So how are dental benefits being impacted by healthcare reform, and how will dental benefits change as the healthcare landscape shifts? There’s plenty to ponder in how everything dental, from copays to crowns, relates to the Affordable Care Act.

And we’ve been doing plenty of pondering. Delta Dental of Wisconsin is actively engaged in the state and national healthcare-reform discussions, and we’ve learned enough about the process where we can be your go-to source for information about dental under healthcare reform.

Let’s start with one important thing we know. Pediatric oral care is one of the 10 essential health benefits (EHB) required to be included as part of health coverage sold in the small-group and individual markets beginning Jan. 1, 2014.

So to the extent that pediatric oral care is part of most dental plans, two important aspects of the dental landscape — your current benefits and the dental-benefits marketplace — have been or will be altered at least to some degree by healthcare reform.

What does that really mean? Great question. Unfortunately, the answer is unclear. We’re still waiting for guidance from the federal Department of Health and Human Services (HHS).

And when we say “guidance,” we mean a lot of guidance, on things that might seem obvious. For example, the term “pediatric” has not yet been defined. From a clinical standpoint, age 12 or 13 is commonly considered the transition away from pediatric care, because that’s when adult teeth have typically replaced baby teeth. Social programs typically cover children to age 19 (the Children’s Health Insurance Program, or “CHIP”) or 21 (Medicaid), and medical plans are now required to cover dependents to age 26.

The final definition of pediatric has pricing and plan-design implications, making it hard to determine impacts on dental until the definition is set.

The exact mix of dental benefits included in the essential health benefits also needs to be determined. HHS gave states flexibility to choose a plan upon which the essential health benefits could be based. Many potential benchmark plans did not include dental coverage, so HHS allowed either the state’s CHIP plan or the Federal Employees Dental and Vision Insurance Program (FEDVIP) dental plan to serve as the benchmark.

We prefer that the Wisconsin CHIP plan be used to define the dental essential health benefits. This is a Wisconsin-developed, tried-and-tested, child-only dental plan that minimizes disruption and balances affordability with appropriate coverage for children. But without clear guidance on what procedures are included in the essential-health-benefits definition, it’s hard to determine exactly how dental is impacted.

While many of the ACA’s market reforms don’t apply to dental, a few key provisions apply to the dental essential health benefits. Preventive services under the essential health benefits must be covered at 100% with no deductible, and while non-preventive services can have deductibles and cost-sharing, no annual or lifetime limits can be applied. Also, annual deductible and out-of-pocket limits apply to all 10 essential health benefits, including dental. We don’t know how these limits will be coordinated, but those decisions will impact both the design and price of the dental essential health benefits.

With healthcare reform, what we know is almost always balanced by what we don’t know. For instance, we know that the ACA will allow standalone dental plans on the insurance exchanges if they provide the pediatric dental essential health benefits and meet other criteria; however, we don’t know whether carriers that embed dental coverage in a medical plan will have to show the dental cost separately. (DDWI supports showing breaking out the dental costs because it lets consumers easily compare plans, increases choice and drives down costs.)

We also don’t know if standalone dental plans that include more than just the essential health benefits will be allowed on the exchange. We think it’s critical to allow expanded dental coverage on the exchange because it will improve access to dental care, increase competition among dental carriers, build on existing coverage, and let parents and children keep their coverage combined.

So summing up, there’s a lot we know about dental’s place in healthcare reform, but there’s also a lot we don’t know – and we haven’t even touched on actuarial value (those pesky bronze, silver, gold, and platinum-level plans). Look for details on actuarial value in a future blog.

What does all this mean? Stay tuned. More updates are coming.