Dental Coverage and the Affordable Care Act

Laird Harrison


December 05, 2012

In This Article

Dental Benefits and ACA

Expansion of Medicaid

The answer comes from 2 other parts of the law. One provision expands the number of people eligible for Medicaid from those living under 100% of the federal poverty line to those living under 133% of the federal poverty line. But the effects of this requirement on oral health may be fairly modest for a couple of reasons. First, another program, the Children's Health Insurance Program (CHIP), already picks up where Medicaid leaves off (in most cases up to 200% of the poverty line),[6] and it includes dental benefits for children. So children may not be affected directly by the expansion of Medicaid. (Medicaid and CHIP vary from state to state and have different names; for example, in California, Medicaid is known as Medi-Cal and CHIP is known as Healthy Families.)

Second, the federal rules for Medicaid don't require states to provide dental benefits for adults. In a 2011 survey by the American Dental Association (ADA), only 12 states provided "comprehensive" benefits, meaning at least 100 out of 600 services recognized by the ADA. Twenty-two states provided no dental benefits for adults or only emergency pain relief. The others provided something in between.

On the other hand, not all children who are eligible for Medicaid are enrolled in the program. As more adults sign up for Medicaid, some may sign their children up for the first time. With these services in flux and varying from state to state, it's hard to project how many adults would gain dental benefits from the expansion of the Medicaid program.

Essential Benefits

The ACA could also expand oral health coverage because it requires many insurance plans to include dental benefits starting in 2014.[1] The ACA lists "essential benefits" that insurance plans must include when they are sold to individuals or small groups. (Large group plans, such as those offered by big companies, don't have to provide all these benefits, and neither do health plans purchased on or before March 23, 2010.) It specifically lists "pediatric services, including oral and vision care" among these benefits.

That's the provision that has led so many people to expect a significant increase in coverage. The thinking is that people who don't already have health insurance will get it in order to comply with the individual mandate. Most of these people will acquire coverage through the small group and individual market, and dental benefits for children will be included.

Insurance Exchanges

This is logical enough. But there is a catch. The law also sets up exchanges through which insurance plans will be bought and sold. The idea is to foster competition and help individuals and small groups make good choices by assembling the information on various plans in one place where their costs and benefits can be compared more easily. Each state must set up its own exchange by 2014; if any states decline, the federal government will do it for them. An ADA document cites an estimate that about 3 million children will gain dental benefits through the exchanges.[7]

When the act was being drafted, the dental insurance industry lobbied for a clause allowing dental insurance plans to be sold separately from medical plans within the exchanges. This allowed the dental insurance companies to keep selling products more or less like those they had been selling. They argued that consumers would benefit because they could find coverage that allowed them to keep the dentists they already had.

Colin Reusch of the Children's Dental Health Project argues, on the other hand, that uniting dental and medical plans could foster communication among a patient's healthcare providers. "Requiring separation makes coordination of care more difficult," he said. And with dental plans sold separately from medical plans, it's not clear whether adults will be obligated to buy dental plans for their children. "You run the risk of a family going and just purchasing a medical plan and saying, 'If I have to purchase dental separately, I'm going to forego that cost,'" said Reusch.

When I called the Department of Health and Human Services (HHS) to ask this question, I was told that no one would be available to discuss it for the public record. Instead, a spokesperson gave me this terse statement: "The department will issue further guidance on essential health benefits through the rulemaking process."

In other words, the department hasn't figured it out yet. In her conversations with federal rule makers, National Association of Dental Plans (NADP) Executive Director Evelyn Ireland said that they seemed to be leaning towards making sure that everyone who gets a health plan within the exchange also gets a dental plan. "When we met with the HHS general counsel, one of the questions they asked us was how we can be sure that individuals have purchased essential benefits," she said. "We said we would issue some kind of certificate of coverage."

But more recently the rule makers have given indications that they will let each state decide whether to require people buying medical plans within the exchanges to also buy dental plans, Ireland and Reusch both said.

Individual and small group insurance can also be sold outside the exchanges. The NADP is now lobbying for rules that would allow dental and medical plans to be sold separately there as well, but in its most recent round of rules, the HHS showed no signs of allowing that separation, and Ireland said the regulators told her they don't think they have the authority to make such a rule.

Another perplexing question is whether people who have medical coverage through an employer -- but don't have dental benefits -- will be eligible for a subsidy to purchase dental benefits because they will already have "affordable" healthcare by the law's definition. Reusch estimated that as many as 2 million children could be in that situation.