Health care reform expands coverage in private dental market

There is still much uncertainty regarding the overall and long-term impacts of the Affordable Care Act (ACA) on the health and dental care delivery systems.  What we do know, however, is that the ACA will usher in access to dental care for many more children outside of the ACA-created online insurance marketplaces – including coverage through most private health insurance plans. 

Pediatric dental benefits are listed as one of the 10 Essential Health Benefits (EHBs) that many more  health plans will now have to offer. All health plans sold in the private individual and small group markets (that did not receive a waiver from the federal government) are required to provide all 10 EHBs, including pediatric dental benefits, as of Jan. 1, 2014. Although other plans (large group or self-funded plans, for example) are not required to provide the 10 EHBs, which means many more children (those under 19 years old) will access dental coverage through health plans sold to individuals and small businesses. This coverage could be offered either through dental plans or through dental provider networks “embedded” within a health plan itself.

In California, those benefits are generally being offered by traditional standalone dental plans in partnership (or “bundled”) with health plans. California law states that the pediatric dental benefit offered must be comprehensive – equal to the benefit design offered by the former Healthy Families Program (now folded into Medi-Cal). It includes prevention services, restorative services and medically necessary orthodontic services. 

Controversy remains, however, over the fact that the pediatric dental benefit is a required purchase regardless of whether the person buying it has children. Some advocates argue that this required purchase demonstrates the importance of dental benefits and treats dental benefits just as it treats other health care services that are only used by certain populations (maternity care or mental health treatment, for example). Others argue that their health insurance premiums should not have to pay for services that they will never use and do not want. 

Both of these arguments have merit. Regardless, however, the end result of this rule will be that more children will have access to dental benefits than ever before.

One of the key questions that is still unanswered is what level of access to care children with these benefits can expect to receive. Dental plans participating in the non-exchange market – like all other standalone dental plans sold in California – are subject to the network adequacy requirements set forth in state law and the oversight of the State Department of Managed Health Care. However, concerns remain among many in the dental community about whether these dental plans will establish a network of dental providers sufficiently robust to cover the needs of these new consumers.  

CDA remains actively engaged in all of the ACA implementation efforts, advocating on members’ behalf with the Legislature, administration – including the state agencies charged with regulating dental plans – Covered California and the federal government. 

CDA is a resource to members interested in finding out more about the new law and how it may impact dentists and dentistry. 

For more information, please contact CDA’s Manager of Legislative Affairs Nicette Short at nicette.short@cda.org or 916.554.4970.