pediatric dental coverage in state and federally facilitated marketplaces colin reusch senior policy...
TRANSCRIPT
Pediatric Dental Coverage in State and Federally Facilitated Marketplaces
Colin ReuschSenior Policy Analyst
Children’s Dental Health Project
2
ACA Dental Coverage: The Basics
• Intended to be part of comprehensive pediatric coverage
• EHB category 10: “pediatric services, including oral and vision care”
• Must be offered up to age 19 in marketplaces, small group, & individual coverage
• Accompanied by numerous oral health provisions (most unfunded)
3
How the ACA Changes Dental Benefits
• Makes it part of essential health benefits (EHB)• Attempts to subsidize through tax credits• Limits cost-sharing (out-of-pocket maximums)• Removes annual and lifetime dollar limits on
coverage (children only)• Plans must offer child-only plans (up to age 19)• Limits orthodontic coverage to medically
necessary• Integrates oral health into medical coverage via
preventive services
4
ACA Preventive Oral Health Services
• Must be covered by all qualified health plans (QHPs) at no cost:– Oral health risk assessment by pediatrician
for young children & referral to dentist– Fluoride supplements for children w/out
fluoridated water– Fluoride varnish application by pediatrician for
all children under age 5
5
HOW IS DENTAL COVERAGE DIFFERENT?
6
Marketplaces can offer dental differently
Pediatric Essential
Health Benefits
Qualified Health Plan (QHP)
Stand-Alone Dental
QHP Including Dental
(embedded)
• Stand-alone dental plans must be allowed to offer
• QHPs can be exempt from offering dental
• ACA does not require purchase of stand-alone dental
• States may require purchase• Stand-alone dental not
considered in Premium Tax Credit calculation
7
Dental plans are treated differently
Stand-alone Dental Plan• Optional to purchase (unless
state requires)• Separate insurance policy &
premium• Separate deductible• Separate out-of-pocket
maximum• Adult coverage options
available• No cost-sharing reductions• Some consumer protections
may not apply
QHP w/ Embedded Dental• Dental benefits part of health
plan (QHP)• One premium for health and
dental• May have unified deductible or
separate deductible for dental• Individual or family plan
includes dental for children; some plans may include adult dental
• Cost-sharing reductions apply• All consumer protections apply
8
Affordability measures apply differently
Separate & additional OOP max for stand-alone dental plans.
For 2015 plan year$350 for one child$700 for 2 or more
9
Tax credits sometimes forget dental
Alexandria, VA family of 4 w/ annual income of $70,650
• Premium limit = $6,712 (9.5% of income) • 2nd lowest cost silver plan (includes dental) = $9,636• Tax credit: $9,636 – 6,712 = $2,924
• Dental premium (2 kids) = $0• Total premium obligation = $6,712 (9.5% of income)
10
Tax credits sometimes forget dental
Richmond, VA family of 4 w/ annual income of $70,650
• Premium limit = $6,712 (9.5% of income) • 2nd lowest cost silver plan (no dental) = $8,959• Tax credit amount: $8,959 – 6,712 = $2,247
• Estimated dental premium (2 kids) = $552• Total premium obligation = $7,264 (10.3% of income)
11
WHAT DID THE 2014 PLAN YEAR LOOK LIKE?
12
Pediatric dental offerings: 2014
State-based marketplaces:• CA, NV, WA – must be sold stand-alone• KY, NV, WA – requirement to purchase• CT – all QHP standard plan designs embed dental &
largely protect from high deductibles• DC, RI, VT – all QHPs chose to embed• UT – very limited benefits in dental offerings
FFM & Partnership marketplaces:• No restrictions on plan types• No requirement to purchase stand-alone plans
13
About a third (34%) of all health plans in the federally-facilitated marketplaces include pediatric dental coverage in their products.
Less than 1% include adult dental coverage.
Plan documents aren’t always clear on how cost-sharing & deductibles apply to dental benefits.
Source: CDHP analysis of health plan information data: https://www.healthcare.gov/health-plan-information/
Average Across StatesAlaska
AlabamaArkansas
ArizonaDelaware
FloridaGeorgia
IowaIllinoisIndianaKansas
LouisianaMaine
MichiganMissouri
MississippiMontana
North CarolinaNorth Dakota
NebraskaNew Hampshire
New JerseyOhio
OklahomaPennsylvania
South CarolinaSouth Dakota
TennesseeTexas
UtahVirginia
WisconsinWest Virginia
34%78%
97%0%
67%62%
46%13%
1%53%
26%42%
77%11%
6%12%
0%0%
89%65%
49%18%
0%7%
14%41%
67%20%
82%3%
0%52%
13%100%
QHPs with Embedded Pediatric Dental Coverage by State (FFM & Partnership Marketplaces)
14
Take-Up of Stand-alone Coverage
Adults account for vast majority of take-up but adult dental not part of EHB & not subsidized
No data on embedded pediatric dental take-up.
Data Source: ASPE Enrollment Report: http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Mar2014/ib_2014mar_enrollment.pdf
Age 0-18
Age 18-25
Age 26-34
Age 35-44
Age 45-54
Age 55-64
Age 65+
5.62%
11.77%
22%
19.63%
21.09%
19.58%
0.31%
Stand-alone Dental Take-up by Age Group as % of Total (FFM & Partnership Marketplaces)
15
What Does Coverage Cost?
Embedded in QHP Stand-alone Plan
Average Premium
$5.11 (attributable portion of premium)
$30.98 (70% AV)$38.89 (85% AV)
Average Deductible
When separate: $34.21When unified: $2,935
$41.10
Source: ADA Health Policy Resource Center, “Health Insurance Marketplaces Offer a Variety of Dental Benefit Options.”
16
WV UT NE FL ND AL DE AR PA TX GA TN IN LA KS MS OH MO ME IL WI NH OK IA SC NJ MT SD NC MI VA WY AZ AK$0
$10
$20
$30
$40
$50
$60
$70
$80
$90
Average Child-only Stand-alone Dental Premiums by State & Metal Tier (FFM & Partnership Marketplaces)
Low (70% AV)
High (85% AV)
17
State Policy Changes: 2015 plan year
• CO – requiring purchase of pediatric dental• CA – allowing embedded dental & standardizing
OOP maximums (reducing dental OOP by $350)• CT – including stand-alone adult dental offerings• DC – finalizing standard QHP plan designs &
separate deductibles for pediatric dental
18
Federal Policy Changes: 2015
2015 Notice of Benefit and Payment Parameters:• Stand-alone dental max
OOP reduced:– $350 per child, $700 for
multiple children– Applies to FFM & state-
based marketplaces
19
Priorities moving forward
• Encouraging QHP dental integration• Network adequacy• Risk for duplicative coverage?• Affordability impacting take-up• Tax credit applicability• Transparency/shopping experience• Consumer education• Navigator/assister training• Data!!!
20
A FINAL WORD ABOUT CHIP
21
Children’s Health Insurance Program (CHIP)
• 8+ Million children covered• Funding runs out in September 2015• Millions of children would transition to
marketplace coverage• At least 2 million low-income would kids
without subsidized coverage• Marketplace coverage not comparable –
dental a prime example
