Recently in Dental Category

By Leigha Basini, National Academy for State Health Policy

The new year brings many new things: new discussions about CCIIO's newly released Essential Health Benefits (EHB) Bulletin and benefit provisions in the seemingly still new Affordable Care Act.  But state CHIP directors may also be thinking about a slightly older benefit provision--the CHIPRA dental mandate.  NASHP, in conjunction with the Children's Dental Health Project, recently completed an issue brief for the National Maternal and Child Oral Health Policy Center on states' dental benefit changes as a result of CHIPRA, and the findings may help state CHIP programs that are still mulling over their options, state officials working on the EHB, and advocates focused on ensuring strong coverage for children.

Prior to CHIPRA, all states voluntarily offered some level of oral health benefit, but benefits varied widely by state.  CHIPRA leveled the playing field by requiring all states to offer dental coverage that meets a minimum level.  Although regulations are still forthcoming, CMS guidance gives states two options.  States may offer a state-defined benefit package with coverage of services in ten distinct categories such as diagnostic and preventive care and orthodontics.  Or, similar to the options the federal government gave states with CHIP and the EHB package, states may offer a benchmark plan.  Benchmark options include:

1. The Federal Employee Health Benefits Program dependent dental coverage that employees selected the most frequently in the past two years;

2. State employee dependent dental coverage that employees selected the most frequently in the past two years; or

3. The state dental plan with the largest commercial, non-Medicaid enrollment.

However, unlike CHIP benefit packages and EHB, benchmark plans must truly be equivalent and not just actuarially equivalent.  States may add benefits to the benchmark plans, but they may not subtract or alter the benefits that the benchmark plan provides.  On the flip side, if the benchmark plan does not cover a certain service, such as orthodontics, the state is not required to cover it in its CHIP plan. 

Of the nine states with CMS-approved State Plan Amendments (SPAs) at the time the brief was written, seven of nine chose to offer state-defined dental benefit packages as opposed to benchmark packages.  This is perhaps surprising because states opting for state-defined coverage must cover costlier services such as orthodontics that may not be required with a benchmark package.  Also, these states must cover medically necessary care that is in excess of annual benefit maximums.  However, it may actually be less costly for states to provide a state-defined package, since the benchmark packages generally require hefty cost sharing, and CHIP cost sharing is limited to five percent of a family's income, including non-dental services, too.  So, it could be rather costly for a state to provide a benchmark plan with very limited cost sharing.

The new EHB guidance gives states two options for providing pediatric dental coverage--the Federal Employees Dental and Vision Insurance Program dental plan with the largest enrollment or the benefit package in the state's CHIP program.  While we don't yet know the nuances of what this means, the apparent possibility of overlap in kids' dental benefits across CHIP and EHB coverage gives state agencies a great opportunity to collaborate and ensure a level of consistency across coverages.  For states that haven't yet selected a CHIP dental benefits package, the EHB bulletin provides an incentive for collaboration, and for CHIP programs that have already implemented their CHIP dental benefits, it gives state officials working on the EHB a great resource to call on!

Benefits are only one part of improving children's dental health, and states are looking forward to the release of the State Health Official letter regarding CMS' oral health strategy to improve utilization rates.  But CHIPRA's dental benefit is a great start for children in CHIP, as it ensures that all CHIP kids have a base level of comprehensive oral health benefits needed for strong dental and physical health and well-being.

As soon as rumors started flying about what would be in the essential health benefits guidelines I thought hmmmm that sounds a lot like CHIP. At first blush the new guidance does sound like the CHIP model - indeed the guidance says as much (p. 8). But as HHS officials and others have pointed out, there are ways in which this new guidance is quite different from CHIP.

As my colleague Joe Touschner blogged about before Christmas, states will now have a choice of choosing from a number of benchmarks that mirror the choices in CHIP i.e. an FEHBP equivalent product, a state employee package or coverage offered through the largest commercial HMO. The Essential Health Benefits (EHB) guidance specifies that any of the three largest state or federal employees plans by enrollment would be acceptable.

But the EHB guidance offers a new option - the three largest plans (by enrollment) in a state's small group market. This option has caused some concern since coverage in the small group market is generally not as good as on the large employer side.

According to the guidance, small group coverage is actually very similar to large group coverage - and indeed all of the listed benchmarks according to the guidance (p. 4) - in terms of benefits covered.  Where significant differences may occur it would be more likely to be in the area of cost-sharing - and the EHB guidance does not address the issue of cost-sharing.

We hope that HHS officials will share the data they have on this important question since there are many reasons why states may wind up choosing a small group package as its benchmark. (More on this in a later blog.) And finding out what the top 3 plans are in your state is top of the 2012 to do list for many state readers I suspect. But for now back to the CHIP analogy....

Of course one obvious difference is that the CHIP program allows states to choose to do a Medicaid expansion or a separate state program with a benchmark package. For kids, this means that they have access to the Medicaid EPSDT benefit - which according to the Academy of Pediatrics is the gold standard for kids -- if the state goes the Medicaid route. For EHB, states don't have the option of going the EPSDT route for kids.

Another way in which the EHB guidance is different from CHIP is that the Affordable Care Act included a list of 10 benefits that must be covered. This list includes "pediatric services, including oral and vision care" - so these benefits will need to be added if not covered by the benchmark package. The list of benefit categories may constrain some of the flexibility in the benchmark options that states have in CHIP. On the other hand the EHB guidance may offer more flexibility than the CHIP standard in some respects -- another topic for a future day - what kind of insurer flexibility is really floating around in the EHB guidance?

Finally, unlike CHIP, the ACA includes anti-discrimination provisions with respect to age, disability and expected length of life.

So lots to think about as we all work to prepare comments on the federal proposal AND as states start to think about their choice of benefits package. As with much else in the implementation of the ACA, state action will be critical here. Stay tuned!

Editor's Note:  This is the first in a series of forthcoming blogs focusing on essential health benefits from the perspective of children and families.  We welcome guest bloggers to submit entries on this topic.  Please contact Say Ahhh! editor Cathy Hope if you would like to submit a blog.

By Elisabeth Wright Burak, Arkansas Advocates

The legislative session in Arkansas ended last month with many accomplishments for kids' health on the books.  We spend a lot of time talking about measures to improve access to ARKids First and promising new oral health accomplishments, including better availability of fluoridated water and preventive dental services.  

But one measure that didn't receive as much attention will also be critical for many Arkansas kids, ensuring that more than 400 children don't experience a lapse in coverage.  Rep. Donna Hutchinson, working with the Arkansas Insurance Department, passed a bill, now Act 269, to require private plans to offer child-only plans through an open enrollment period each October, beginning this fall. 

This was an important response to ensure correct implementation of the Affordable Care Act--offering policies regardless of pre-existing conditions. However, the effort was also a direct response to the sale and impending departure of Mercy Health Plans, the only insurance plan in Arkansas selling child-only plans.  This would have left 400 children in Arkansas with no health insurance option.

But Arkansas leaders were faced by another challenge: Mercy was set to leave the state in March, so what would happen to the 400 children between now and the October open enrollment period? The bill allows for these kids to enter the state high risk pool, already an option for adults, until October 2011. 

Finally, the Insurance Department also worked to keep these policies as affordable as possible during the transition. Under the terms of an agreement brokered by Insurance Commissioner Jay Bradford, Mercy will pay up to $3,500 for each former policyholder to enter the state's high risk pool until they can enroll in private plans in the fall.

We thank Rep. Donna Hutchinson, Insurance Commissioner Jay Bradford, Gov. Mike Beebe and the many other lawmakers who worked hard to ensure that these children don't see a lapse in their health coverage. 

By now many of you have probably heard about the big news coming out of the NAIC meeting this week in Orlando.  After seven months of intense debate and negotiation, the NAIC voted in favor of a regulation defining the ACA's required "medical loss ratio" (MLR).  They rejected several amendments that were heavily pushed by insurance companies and brokers, scoring a big win for consumers who deserve better value for their health care dollar.

What hasn't been reported so widely is all the other work NAIC did this past week, from advancing model state laws on major consumer protections required by the ACA, developing a model law on state insurance exchanges,  and defining how an insurer must justify an "unreasonable" rate increase.  Here are a few highlights:

• A key NAIC task force adopted model state laws implementing three market reform provisions of the ACA: rescissions, young adult coverage up to age 26, and choice of health professional.  These now will be reported up to the NAIC's "B" Committee, which is the umbrella committee for health issues.  The same task force is also developing model laws on: lifetime/annual limits, elimination of pre-existing condition exclusions for children under 19, access to preventive benefits, and grievances and appeals, all of which are ACA provisions that went into effect on September 23, 2010. 
• Consumer representatives are urging changes to the model law on the kids' "pre-ex" provision to encourage states to prevent "child only" health plans from withdrawing from the marketplace.  We also made formal presentations applauding Commissioner Sevingy from New Hampshire and Commissioner Kreidler from Washington for their leadership and toughness in requiring their states' insurers to offer coverage to kids.  

• Coordination with Medicaid.  My impression is that the model law will probably not delve into the tricky issues of how the exchanges will coordinate with state Medicaid agencies.  When one of the Commissioners asked about this, the chair of the work group, Commissioner McRaith from Illinois, said that they have not been working with Medicaid Directors, and emphasized that it would be a "NAIC Model" and therefore would focus on insurance-related issues. 
• Dual regulation.  The members of the work group were very concerned about exchanges potentially usurping their traditional role regulating health insurance through rate review, market conduct exams and grievances.  They'll probably add new language to the model that will have a more clear delineation of regulatory roles between state insurance departments and the exchange.
• Pediatric dental.  The current draft model doesn't have any language reflecting the ACA's provision allowing the inclusion of stand-alone dental plans that offer pediatric dental benefits in the exchange.  A representative from Delta Dental pointed that out to the group and Commissioner McRaith asked him to submit legislative language.  The consumer reps will keep an eye on this issue as it develops.
• Another key NAIC task force has been working for many months to develop the form that insurance companies will have to fill out if they are proposing an "unreasonable" rate increase.  This form will provide unprecedented transparency on rate increases, and will include essential information for consumers and employers to better understand the factors driving proposed increases.  The task force finalized the form this week and reported it to the "B" Committee, in spite of last-minute opposition from America's Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association.  Even in the face of many hours of open and inclusive conference calls and meetings, both trade associations claimed that the form had been developed without sufficient industry input.
• Last but not least, the NAIC has created a new working group to tackle the issue of limited benefit plans, or "mini-meds."  A joint effort of the "B" Committee and an anti-fraud committee, the group will investigate whether plans are making misrepresentations about their products and whether they are being sold by unlicensed brokers.  Because many of these plans provide little or no real coverage if someone actually gets sick, the group will also be looking into the "utility" of these products for consumers.

Mom: "Did you brush your teeth?"

Child: "Yep."

Mom: "How come your toothbrush isn't wet?"

This is an excerpt from the script of the bedtime drama performed live nightly in the comfort of my own home.  Just between you, me and the tooth fairy ... after battling on the nutrition, hygiene and homework fronts, I don't have a lot of energy left to wage the toothbrush wars.  That's why I'm always a bit nervous about dragging my children to their 6-month dental check-ups.  Luckily, we have good dental benefits and an understanding dentist.  With the help of the dentist and dental hygienists, we've managed to get through with only a couple of cavities between all three kids.  (The nightly drama slacks off a bit after a good "education session" from the dentist.)

Other parents are facing the same obstacles to ensuring their kids have healthy teeth and gums but not all of them are able to rely on a dentist.   Even children with excellent brushing and flossing habits need to see a dentist because untreated dental disease and tooth decay can have devastating health consequences.  However, about one in five children in the U.S. do not receive dental care each year according to a new report The Cost of Delay: State Dental Policies Fail One in Five Children, by the Pew Center on the States.  The report points out that states play a key role in ensuring that low-income children have access to basic, preventive dental care and that more than two-thirds of the states are doing a poor job in this area.

The good news is that the Children's Health Insurance Program Reauthorization Act  provided states with new tools to help improve the oral health of children.  All CHIP programs are now required to cover comprehensive dental benefits. CHIPRA also allows states with separate CHIP programs to offer a dental-only plan for children who have other health insurance, but lack adequate dental benefits. Other oral health improvements include education for new parents, better access to benefit and provider information, and enhanced reporting on the quality of dental health services in Medicaid and CHIP.  CCF, the Kaiser Commission on Medicaid and the Uninsured, and the Children's Dental Health Project just released a "CHIP Tip" on CHIPRA's oral health provisions which is a good resource for those who want to see children receive better oral healthcare coverage.