Insurance marketplaces offer many options, limited information

The new health insurance marketplaces offer a variety of dental benefits, but figuring out which ones are best for consumers and pediatric coverage is complicated, according to a new ADA research brief.

Recognizing the importance of oral health, the Patient Protection and Affordable Care Act (ACA) includes pediatric dental care as one of the 10 essential health benefits that all small group and individual market health plans must cover. Early estimates predict that almost 9 million children could gain dental benefits coverage due to the ACA, with 3 million gaining such coverage through the insurance marketplaces.

How dental benefits are offered within the insurance marketplaces varies considerably among the states, according to researchers Cassandra Yarbrough, MPP; Marko Vujicic, PhD; and Kamyar Nasseh, PhD, in their comprehensive and informative 17-page research brief released on March 27 by the ADA Health Policy Resources Center. But they explain how information is limited on the key attributes of the dental plans, making it challenging for consumers to make meaningful comparisons and informed decisions.

In some states, pediatric dental benefits can be purchased only through standalone dental plans (SADPs); in others, all medical plans include embedded pediatric benefits.

SADPs and medical plans with embedded dental benefits differ in several ways, including out-of-network coverage, deductibles, and premiums.

Health plans may still offer adult dental coverage, but they are not required to do so. Therefore, the estimated number of adults who could potentially get private dental coverage through the marketplaces is much smaller, the study authors noted.

Health plans sold through the marketplaces are not required to include pediatric dental benefits as long as SADPs are available. But all SADPs in the marketplaces must include pediatric dental benefits.

Marketplaces can offer pediatric dental benefits in three ways:

1. Standalone dental plans
2. Dental plans that are bundled with a medical plan
3. Medical plans that have embedded pediatric dental benefits

Since no bundled dental plans are offered through marketplaces for 2014, consumers now have only SADPs and medical plans with embedded pediatric dental benefits to get dental coverage for their children.

Subsidies

Premium subsidies also are complicated when it comes to dental benefits, the researchers noted. To help offset the cost of health insurance, the ACA established premium assistance for low-income groups via tax credits for plans purchased through the marketplaces. How premium assistance applies to SADPs, however, is complex.

Consumers can apply their premium tax credits toward pediatric SADP premiums, but it probably won't be enough to offset the cost of the pediatric SADP, they pointed out.

Also, adult dental insurance purchased through an SADP is not eligible for premium assistance because it is not considered essential under the ACA.

"As a result of the absence of a true requirement to purchase pediatric dental benefits under the ACA, the structure of a state's marketplace plays a crucial role in the expansion of dental benefits coverage for children," the study authors wrote.

Specifically, buying pediatric dental coverage is only guaranteed if a state either only offers medical plans that embed or bundle pediatric dental benefits, or requires consumers who purchase pediatric medical benefits to also purchase pediatric dental benefits. Currently, only Kentucky, Nevada, and Washington require consumers to purchase pediatric dental benefits.

With so much variability, the researchers said it remains to be seen how and if the marketplaces will increase access to dental care for children.

"This ultimately depends on how effective the marketplaces are at expanding dental benefits coverage for children, and how effectively this expansion of coverage increases access to dental care," the researchers said.

SADPs, federally and state-based marketplaces

The study analyzed key attributes of all medical plans and SADPs offered through both the federally facilitated and state-based marketplaces, focusing on pediatric dental benefits.

In 2014, 34 states are participating in the federally facilitated marketplace, while the remaining 17 states (including the District of Columbia) have established their own marketplaces.

Data available through the federal marketplace list all medical plans and SADPs offered in the area.

Of the 15 state marketplace websites evaluated in the study, five states provided extensive data on their available medical plans and SADPs. The analysis includes 50 randomly picked medical plans with embedded pediatric dental benefits and 50 SADPs. SADPs are offered in all states analyzed in the report.

The researchers analyzed medical plans and SADPs by actuarial value -- the percentage of the total average costs that a plan will pay for the benefits it covers. There are four medical plan actuarial values: platinum, gold, silver, and bronze. The percentage of costs that a plan pays ranges from 60% (bronze) to 90% (platinum).

Results

Among the 41 states analyzed in the study, there were 3,180 medical plans and 697 SADPs. The number of medical plans offered by the states ranges from 11 in New Hampshire to 257 in Wisconsin. The number of SADPs ranges from two in Vermont to 51 in Michigan.

Some 26% of the medical plans have embedded pediatric-only dental benefits, according to the study. Another 7% have embedded pediatric and adult (i.e., family) dental benefits. Only 4% of the medical plans have embedded adult-only dental benefits, and all these plans are offered in Ohio.

Among the SADPs, 42% offer pediatric-only dental benefits, and 58% offer family dental benefits. Family SADPs can be purchased for children only, adults only, or a mix of children and adults. In accordance with the ACA, no SADPs offer adult-only dental benefits, the study authors noted.

In seven states, none of the medical plans offered has embedded pediatric dental benefits. In contrast, all the medical plans in two states include embedded pediatric dental coverage.

While none of the states reviewed in the study requires medical plans to have embedded pediatric dental benefits, some states chose to not allow medical plans to include embedded pediatric dental coverage. For example, for 2014, California's marketplace chose not to allow medical plans to embed pediatric dental benefits. But this decision has been reversed for 2015.

Silver medical plans are the most common plans being offered in the marketplaces, the study authors said, and have an actuarial value of 70%.

Just over half of SADPs are low actuarial value, which is how much a plan will typically pay. But it varies. In Arkansas, 44% of the SADPs have low actuarial value compared with 100% of the SADPs offered in Washington, the researchers said.

Coverage

In the majority of medical plans with embedded pediatric dental benefits, it's unclear whether they cover anything beyond preventive dental care, according to the study authors. And information on co-insurance levels and co-payments is even more limited.

Also, it's often unclear how the deductible applies to pediatric dental benefits within medical plans. Only 20% of the medical plans analyzed in the report clearly stated that there was a separate dental deductible and, even then, the amount of that deductible was not always available, they noted.

"Consumers may assume that the medical deductible is applicable to pediatric dental benefits, but this is one area where transparency is a major issue," the researchers wrote.

In part 2, DrBicuspid.com will look at dental deductibles and networks, and compare costs of dental coverage for standalone dental plans with medical plans with embedded dental benefits.