Access to Pediatric Oral Health Benefits offered through Health Insurance Exchanges

Health Reform GPS reports:


This Implementation Brief examines current Administration policy regarding access to children’s oral health benefits among families who qualify both for Exchange coverage and for advance premium tax credits and cost-sharing reduction assistance. The Brief identifies an emerging set of policy issues that in turn may be creating a policy misalignment between children’s oral health coverage and the premium credits and cost-sharing reduction assistance to which their families are entitled.


One of the most important health policy advances under the Affordable Care Act is the inclusion of pediatric oral health benefits as part of the Essential Health Benefits (EHB) package.[1] The importance of Congress’s decision to include this benefit for all children can hardly be overstated: The CDC recognizes the oral health of children as one of the nation’s leading public health indicators and also has identified rising rates of caries (tooth decay) among children over the past decade, which suggests ongoing and serious access problems, especially among lower income children. Thus, inclusion of pediatric oral health benefits in the EHB package represents not only a major step forward in pediatric health care quality, but also a major public health advance in a health insurance coverage context. The EHB coverage standard applies to all health plans sold in state-regulated individual and small group health insurance markets.[2] In addition, the EHB package must be offered by all Qualified Health Plans (QHPs) sold in health insurance Exchanges.[3]

Where pediatric oral health coverage is concerned, the Act offers two possible approaches to organizing coverage in the case of QHPs sold in Exchanges. Under the first approach, a QHP can operate as a comprehensive plan; that is, it can include pediatric oral health benefits as part of its EHB offering, along with all of the other EHB items and services it covers and furnishes through its network. Under this comprehensive approach, the QHP would act as the single source of coverage for all EHBs, including pediatric oral health benefits, and families would enroll in one QHP. In the case of those families who also are entitled to premium assistance and cost-sharing subsidies, the QHP would receive the payments and apply them across the entire benefit package.

The second approach actually might be thought of as one approach with two variations that take into account the existence of a “stand-alone” dental plan market, also authorized under the ACA. The Act specifies that in Exchanges in which a stand-alone dental plan is in operation, QHPs do not have to offer the pediatric oral health coverage; instead, the pediatric oral health benefit can be offered “either alone or in conjunction with a qualified health plan.”[4]Presumably, QHPs and dental plans might enter into joint partnerships to offer their products as a package. In other cases, State-Based and State Partnership Exchanges (SBEs and SPEs) presumably will make decisions about what types of “packaging” to use in order to ensure that where a separate dental plan market is in operation, families picking less than comprehensive QHPs also are automatically enrolled in the pediatric component of the stand-alone dental plan.

This state ability to link products is key, not only for purposes of ensuring that children receive their full EHB coverage but also so that in calculating premium credits and cost-sharing reduction assistance, the full scope of benefits to which financial subsidies apply is taken into account, with adjustments by the IRS across all EHBs, as needed. The provisions of the ACA appear to contemplate both types of results. QHPs that are comprehensive or that enter into a joint venture with a stand-alone dental plan to offer full coverage in one package presumably will receive the premium credit and cost sharing reduction assistance for the full EHB package and then would reconcile with their partner. In cases in which the Exchange packages two independently offered products (a stand-alone dental plan plus a separate QHP), premium assistance would be divided, as reflected in the terms of the Act itself.[5] Furthermore, under the Act’s terms, cost-sharing reduction assistance also would be allocated across two separate products. For this reason, the Act bars an independent QHP not offering pediatric oral health benefits from receiving that portion of the cost-sharing reduction assistance that is “properly allocable to pediatric dental benefits.”[6]

Recent Agency Action

On March 1, 2012, the Center for Consumer Information and Insurance Oversight (CCIIO) issued a Letter to Issuers on Federally-facilitated and State Partnership Exchanges. In the letter, CCIIO, amplifying on its earlier EHB regulations, states that:

Section 1402(c)(5) of the Affordable Care Act, as codified in 45 C.F.R. §156.440(b), excludes stand-alone dental plans from the cost-sharing reduction (CSR) requirements placed on medical QHP issuers. The provision states that any CSRs that would be applied to the pediatric dental EHB in a comprehensive medical QHP will not be applied if the pediatric dental benefit is provided through a stand-alone plan.

The CCIIO policy appears to be at direct odds with the terms of the statute, which does not in any way diminish families’ entitlement to cost-sharing reduction assistance, but instead simply bars QHPs that do not offer pediatric oral health benefits (either comprehensively or through a partnering arrangement) from receiving any cost-sharing reduction assistance that should be properly allocated to the stand-alone plan.

Key Questions

Is CCIIO policy consistent with the terms of the statute? The statute’s limitations on payment of cost sharing reduction assistance for pediatric oral health coverage appear to be designed to ensure simply that QHPs that do not offer pediatric oral health benefits also do not receive cost-sharing reductions that instead are properly allocable to pediatric oral health services. Nothing in the provision of law cited by CCIIO appears to limit the entitlement itself, only the manner in which the entitlement is operationalized. Yet the CCIIO policy appears to suggest that in cases in which children must be enrolled in two different plans, their cost-sharing entitlement will be reduced.

What organizational options (such as linked offerings) can states – and the FFE  use to overcome the potential issues that arise when one EHB package is offered through two separate plans? CCIIO’s policy does not address the strategies that states might utilize – or that the FFE will use – in order to assure that proper QHP/stand-alone dental packaging occurs so that children receive the full benefits to which they are entitled and premium credits and cost-sharing reduction assistance to which families are entitled are allocated properly across both plans. Having the Exchange play this role is parallel to the one played by employer plans that offer their participants and their families a menu of both medical and dental benefit plan choices. The only difference is that Exchanges automatically would enroll the children in such families in the dental plan as well as in the QHP, while adult dental plan enrollment would remain purely optional and without financial assistance. CCIIO has not yet indicated what flexibility SBEs, SPEs, or the FFE will have to package offerings and coordinate enrollment in order to ensure that children secure full EHB-level coverage, while their families receive the full premium assistance and cost-sharing subsidy protection to which they are entitled.”