Dental Insurance for Some Children Mandated in 2 States

Laird Harrison

January 03, 2013

The states of California and Washington will require people who buy medical insurance through new health plan exchanges to also buy pediatric dental benefits regardless of whether they have children, according to official documents and interviews.

The new requirements will kick in on January 1, 2014, as part of the states' implementation of the federal Affordable Care Act.

Together the 2 states are offering some of the first responses to a conundrum embedded in the new law: Although the law requires everyone to have health insurance or pay a penalty, it exempts dental benefits from this "individual mandate." However, it lists pediatric oral health services among the 10 "essential benefits" that health plans must include when sold to small groups, such as businesses with 50 or fewer employees, and to individuals. In addition, it allows dental plans to be sold separately from medical plans in state health insurance exchanges that the law sets up.

These somewhat contradictory provisions have left dental policy experts wondering whether anyone will be required to get dental benefits at all, and so far, the US Department of Health and Human Services, which is charged with issuing regulations under the new law, has declined to offer guidance.

With only a year to get the new exchanges going, California and Washington have now reached their own decisions about the pediatric benefit.

Andrea Rosen, interim health plan management director for California's benefit exchange, Covered California, told Medscape Medical News that the state statute implementing the Affordable Care Act requires health plans sold to small groups to include all 10 essential benefits, which includes oral health services for children.

"An adult will buy a box of services that includes a pediatric benefit," she said, whether or not that adult has children. By the same token, a single man will have to buy a plan that includes maternity benefits. "That's the way spreading the risk works," she said.

In practical terms, the enforcement will take place through the Web site that consumers will use to purchase insurance in the small group market. All the plans sold through the exchanges will include the other essential benefits as one package, but some may not have pediatric oral health services included. If the consumer selects health plans without pediatric dental benefits, the Web site will prompt the consumer to select a stand-alone pediatric dental plan and will not allow the consumer to complete the transaction without adding one.

The California exchange will also offer optional adult dental benefits.

Rosen dismissed a concern by the National Association of Dental Plans that some consumers will find pediatric benefits too expensive and will choose to drop their own adult dental benefits to pay for them. "I think that's wildly speculative," she said.

The Washington Health Care Authority has posted documents suggesting it will take a similar approach. "It was noted that families and individuals enrolling through the Exchange will be required to shop separately and select a pediatric dental plan," according to notes from a September 28, 2012, meeting.

Colin Reusch, a policy analyst for the Children's Dental Health Project, which has closely tracked the implementation of the law, told Medscape Medical News that he was not aware of any other states that clearly articulated a plan to require consumers to purchase dental benefits.

"It comes down to whether the state has the authority to force the consumer to purchase this coverage," he said. "We would like to see clarification from the federal government. If it ends up being a viable solution for states like California and Washington, then we would like to see it spread."

About half the states have indicated they will not create their own health plan exchanges, said Reusch. Under the Affordable Care Act, the federal government will set up exchanges for any states that do not create their own. It is still not clear whether the federally run exchanges will also force consumers to purchase pediatric dental benefits.

The act is also unclear about whether stand-alone pediatric dental benefits sold to small-group customers outside the exchanges can meet the requirements of the act; one interpretation of the law is that pediatric benefits must be folded into medical plans when the plans are sold in the small-group market outside the exchanges.

There is no requirement that large groups, such as businesses with more than 50 employees, include pediatric oral health benefits, although many already offer such dental plans.