Many Questions, Now With Many Answers

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This may or may not have been an intended consequence of the Affordable Care Act (ACA), but the ACA is prompting many small-business owners to ask, “Does dental have to be embedded in the medical plan? Should I keep my current dental plan? Am I required to purchase a pediatric oral Essential Health Benefit (POEHB) plan?”

In some states the decision has already been made; small-business owners in these states wanting to offer their employees dental-benefit plans face limited choices on how and for whom to purchase dental benefits, along with limited plan-design options.

Fortunately, in Wisconsin small-business owners still have a choice. They can keep buying the dental benefits that provide the highest value from whomever they trust. Don’t be misled; small-business owners are NOT required to embed POEHB coverage with their medical plan. In fact, employers aren’t required to purchase POEHB at all!

Delta Dental of Wisconsin has always offered easy-to-use, easy-to-implement, and easy-to-understand dental benefit plans that employers have come to trust. They work. There is nothing broken about dental benefits that the ACA could possibly fix, and there’s no need to complicate group dental benefits when Delta Dental plans have always accomplished the goals of the ACA – affordable, transparent, health-enhancing benefits for adults and children.

There are many compelling arguments for keeping a conventional group dental plan in place. First and most importantly, the coverage is better. Let’s define better: Better is not achieved by simply adding an out-of-pocket limit to a child-only dental plan. Better is a dental-benefits plan that is consistent, understandable, provides benefits for every member of the family, is affordable, and gives the customer the chance to save money on most dental procedures.

Second, consider the message that’s being sent to employees. The pediatric oral Essential Health Benefit only covers dependents up to age 19. Children’s oral health is vital, but adult oral health is equally important, especially for individuals who have periodontal disease or health conditions that benefit from regular and preventive oral healthcare. Given that, why would a small-business owner put a plan in place that only covers only the children of employees? What about the employees themselves?

For 50 years, Delta Dental has been working to maintain healthy communities and healthy teeth. As Wisconsin’s first not-for-profit dental-benefits provider, we are proud to support important oral-health causes statewide. Whether you looking for voluntary plans or PPO plans that reduce out-of-pocket costs, Delta Dental is here to help, with carefully designed products that make your benefit dollars go further and deliver the world-class service you’ve come to expect from Delta Dental.

The coming months are sure to be filled with change, disruption, confusion, and uncertainty. Through these trying times, you can continue to trust the Wisconsin dental plan that has advocated for oral-health initiatives and supported Wisconsin businesses and communities for more than 50 years.

Delta Dental of Wisconsin. Simple. Experienced. Trustworthy. Committed.

A reasonable, medically necessary whirlwind

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There’s been a whirlwind of activity around implementation of the Affordable Care Act (ACA), so this seems like a good time to update what’s happening with the ACA and dental.

A lot has happened. Last time, we discussed the “outside-the-exchange” waiver issue (i.e., standalone dental plans providing pediatric dental coverage instead of having it embedded in the medical plan). On April 2, the Wisconsin Office of the Commissioner of Insurance (OCI) clarified how medical plans can be in compliance off-exchange when pediatric dental coverage is excluded from the medical plan.

The OCI bulletin deals with pediatric dental coverage provided through standalone dental plans, and stipulates that all comprehensive small-group and individual health plans sold in Wisconsin (on- and off-exchange) have to disclose prior to sale whether they cover pediatric dental. This means the 98 percent of the market that buys medical and dental separately retains the ability to buy the dental coverage that best meets their family’s oral-health needs.

At the federal level, the Centers for Medicare & Medicaid Services (CMS) clarified some outstanding issues related to standalone dental plans. In past blogs, we’ve discussed what a “reasonable” out-of-pocket (OOP) limit for standalone dental plans might be, and how medically necessary orthodontia will be defined. Now we have answers!

What is a reasonable OOP limit for standalone dental plans? Price and OOP limit move in opposite directions – the higher the limit the lower the price, and vice versa – so ultimately, “reasonable” needs to balance the two. For federally facilitated exchanges (FFE), CMS has stated that “reasonable” is an OOP limit of $700 or less per child, with a 2x family limit. Since premium is excluded from the OOP limit, the maximum a family will spend annually on dental services for children under 19 is $1,400.

The guidance on medically necessary orthodontia lets each carrier define “medically necessary” as part of the coverage, meaning there will not be a common definition of medically necessary orthodontia. Different plans offered by different carriers could have different definitions of medical necessity. The good news is consumers will have choice; a broader definition will cover more children, albeit at a higher price point, while a narrower definition will cover fewer children but at a lower price point.

Finally, we have clarity on timelines. Wisconsin has a public exchange administered by the federal government, more commonly known as an FFE or FFM (federally facilitated marketplace). The filing deadline is fast approaching for products offered on-exchange in FFE/FFM states. The medical-plan filing window is April 1-May 3, and the standalone-dental filing window is May 15-May 31. Products must be filed during these dates to be available to consumers on the exchange for open enrollment. As you can imagine, this is keeping everyone very busy!

There is a lot of work to do as implementation of the ACA continues. You can count on Delta Dental of Wisconsin to stay engaged and informed, and to be your go-to resource for information on the ACA and the future shape of dental benefits in Wisconsin.

Want to save money? Ask the right questions

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Approaching the right question from the right direction can save you money.

Case in point: Delta Dental’s dentist networks.

Let’s suppose you have Delta Dental and need to go the dentist. In the old days, you might have gone to the Yellow Pages, found some dentists close by, and started calling to find out if they were in your plan’s network.

Even today, out-of-network dentists might reply, “We accept all insurance,” but that doesn’t answer the question. They may accept insurance, but your out-of-pocket costs can be significantly higher when you see an out-of-network dentist. The difference can be hundreds or even thousands of dollars. 

Similarly, a Delta Dental Premier dentist could say, “We’re a network dentist with Delta Dental” – which is true, but if your plan includes a Delta Dental PPO option, you’ll receive your best benefit when you see a Delta Dental PPO dentist.

You can see how calling around is an inconsistent and inefficient way of finding a Delta Dental network dentist.

Here’s a better approach: Use Delta Dental’s website and online dentist finder (www.deltadentalwi.com/provider-search/dental) to find a dentist.

The website tells you your benefits, and helps point out how you can benefit from seeing a Delta Dental PPO provider.

The dentist finder clearly shows the network affiliation(s) or each listed provider, and the maps let you pinpoint their location – and if you supply your street address, they even include driving directions!

This sort of high-quality information helps consumers make good choices.

So let’s segue to Delta Dental’s networks, and the differences between them.

Delta Dental of Wisconsin has two dentist networks to choose from. The Delta Dental Premier network is Wisconsin’s largest dentist network, and the Delta Dental PPO is Wisconsin’s second-largest network. (The situation is much the same nationally.) Together they save Wisconsin-based groups millions of dollars – almost $80 million in 2012 – and deliver the largest effective discount of any Wisconsin dental carrier.

One of the best things about this is that if a dentist isn’t in the Delta Dental PPO network, they’re probably in the Delta Dental Premier network. You save a little less, but you get treatment guarantees — and you don’t get charged more than the agreed-upon fee, no matter what the dentist charges.

Here’s an example of how that translates into dollars and cents: 

PPO Savings, With A “Safety Net”  Delta Dental PPO Dentist  Delta Dental Premier Dentist Out-of-Network Dentist
Dentist’s Normal Fee* $720 $720 $720
Allowed Amount* $590 $680 $680
Dentist Fee Adjustment Due to Delta Dental Agreement* $130 $40 None
50% Benefit Paid by Plan* $295 $340 $340
Patient Responsibility* $295 $340 $380

*Approximate fees and percentages for illustrative purposes

The Delta Dental Premier network (if your plan includes it) is a great safety net.  With other dental-insurance companies, if you don’t see a PPO dentist, you pay more – sometimes a lot more – and it’s a big hassle.

Ninety percent of Wisconsin dentists are in a Delta Dental network, so chances are you’ll save money every time you see the dentist — no matter what dentist you see. But think of the extra you’ll save if you see a Delta Dental PPO dentist.

Being a savvy consumer is more important than ever. And while it starts with asking the right questions, it’s evolved into finding the right answers – and with the new website, it’s easier than ever.

 

Further On Down the Road: the ACA Progresses

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The pieces continue to come together as we work to understand the full impact of the Affordable Care Act (ACA). A big piece fell into place when the Department of Health and Human Services (HHS) released its final rule on the Essential Health Benefits (EHB), Actuarial Value (AV) and Accreditation on Feb. 20. The rule lets us address some of the unknowns raised in past blogs as well as confirm some of the proposed rules.

The most important development for standalone dental is that HHS granted the long-requested “outside the exchange” waiver. Specifically, HHS said the pediatric-oral EHB (POEHB) can be offered on- and off-exchange through a standalone dental plan. Previously, the POEHB could be provided through a standalone dental plan on-exchange, but had to be embedded in the medical plan off-exchange.

This clarification clears the way for the separate choice and purchase of medical and dental coverage on- and off-exchange, meaning the 98 percent of the market that buys medical and dental separately can keep doing so. Standalone dental will be treated the same on- and off-exchange.

The waiver off-exchange also means childless adults who buy medical coverage off-exchange do not have to purchase the POEHB. Previously, any medical plan sold in the small-group or individual market off-exchange had to embed POEHB, meaning childless adults would be paying for coverage they didn’t need and couldn’t use. Now they can buy a medical plan and a standalone dental plan that mirrors their coverage needs.

As part of the final rule, “pediatric” is defined as up to age 19, with flexibility for states to extend pediatric coverage beyond this limit. This matches the definition in the proposed rule released last November.

HHS also confirmed and clarified coordination of benefits between medical and standalone dental plans. The POEHB will have a separate out-of-pocket limit if provided by a standalone dental offering, and will be subject to the medical out-of-pocket limit if it’s embedded in the medical plan.

The out-of-pocket limit for standalone dental plans providing the POEHB must be “reasonable,” but the final rule did not define what “reasonable” means. Instead, the limit will be defined by the exchanges. For states (like Wisconsin) with a Federally Facilitated Exchange (FFE), HHS anticipates issuing further interpretive guidance to define “reasonable.” Delta Dental of Wisconsin recommends an out-of-pocket limit of $1,000 as a balance between coverage affordability and member costs.

HHS confirmed as part of the final rule that only “medically necessary” orthodontia is covered as part of the POEHB. HHS further clarified in the rule that “cosmetic” was intended to mean “non-medically necessary,” meaning that “non-medically necessary” orthodontia is not covered as part of the POEHB.

In its ruling, HHS reaffirmed that standalone dental plans will calculate AV independently of the other EHBs and will be subject to separate AV requirements, whereas a POEHB embedded in a medical plan will be included as part of the medical AV.

The POEHB sold through standalone dental plans will be classified as either a high plan or a low plan. The November proposed rule set the AV of the high plan at 85% and the low plan at 75%, with a variance of +/- 2%. The final rule created more space between the two standalone dental options. The high AV remained at 85%, but the low AV was adjusted to 70%. The standalone dental AV still has an allowed variance of +/- 2%.

There’s still a lot of work to be done to get ready for ACA implementation. Delta Dental of Wisconsin continues to stay on top of all the latest developments; we remain your source for information on the ACA and the future shape of dental benefits in Wisconsin.

D&P, Definitely and Positively

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One of the signs that people’s oral health is improving is a higher percentage of dental claims stemming from diagnostic and preventive (D&P) procedures – cleanings, exams, X-rays, fluoride treatments, and sealants. The greater the percentage of D&P claims, the better the general oral health of your population.

The good news is that according to Delta Dental’s annual book-of-business norms study, in 2012 the company’s claims included a greater percentage of D&P claims than ever before.

Adding together diagnostic and preventive claims, 46.7 percent of Delta Dental’s claims fell into these categories. Compare that to 2002, when the total was 39.5 percent, or even 2008, when the total was 43.5 percent.

You can really see what’s happening in the graph below. There’s been a small amount of movement — a negative two-tenths of 1 percent — in the percentage of fillings (the green bar) since 2002. The percentage of claims coming from orthodontics (the rose-colored bar) has slipped 1.3 percent. The percentage of cast crowns (the blue bar) has slipped a substantial 3 percent — and D&P (the yellow and orange bars) has picked up the slack:

These movements may not seem huge from year to year; for instance, the 2011 D&P total was 46.4 percent, meaning the year-over-year movement was 0.3 percent. But when you consider that this is a 0.3 percent movement over millions of claims, suddenly the impact becomes clearer: More and more people are seeing their dentist for preventive care, and not the generally more expensive procedures like root canals and gum-disease treatment.

There are several reasons for this shift, according to Dr. Fred Eichmiller, vice president and science officer at Delta Dental of Wisconsin. Namely:

  • Dentists are doing a better job getting their patients on a maintenance schedule. Especially during the economic downturn, when demand fell for whitening and other cosmetic procedures, many dentists adapted by getting more of their patients on regular schedules for checkups and cleanings. As the economy improved, the schedules remained.
  • People are more aware of the value of oral health. Increased press coverage surrounding the passage and implementation of the Affordable Care Act has placed the spotlight on oral health and the value of dental benefits.
  • Younger workers who have grown up taking advantage of their parents’ dental benefits and understanding the value of oral health are a larger part of the workforce. People are more accustomed to having and using dental benefits. More often than not, they use their benefits on D&P care.
  • Dental benefits themselves have guided people toward preventive treatment. Most plan designs are weighted toward D&P coverage, meaning there’s a built-in incentive for seeing the dentist and having these procedures done. This has a spillover effect on the more costly, more involved procedures that aren’t done as a result.

All of which is very good news for health care and dental benefits.

Looking for a great quote? Check the details

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When it comes to getting an accurate rate quote on your dental benefits, the devil truly is in the details. The more details we get, and the better the quality of those details, the more accurate our quote can be. And accurate quotes usually deliver the best rates over time.

Here is some of the information we need, and a brief explanation of why we need it.

The legal name of the group helps tie a proposal to a group application, which normally asks for a legal business name.  The legal business name and DBA are used in the group-benefits documents.

The DBA name of the group, if different from the group’s legal name, helps personalize the quote. A DBA name can also help distinguish companies within a corporate entity.

The physical address/location of the group helps identify whether or not the group can be “covered” under a Delta Dental of Wisconsin plan. It also helps distinguish companies with similar DBA names.

The SIC code or the nature of business ensures that we are providing accurate rates on the proposal, and eliminates the frustration of having to go back to a group and explain why the rates that were sold aren’t valid.  SIC is one of the most important pieces of information in calculating an accurate rate.

The # of eligible employees helps determine the product that can be offered. This number is also used in the participation percentage and rating formula.

The # of employees enrolled in the incumbent plan is one data point that determines the final rate by factoring in the percentage of employees that participate in the dental plan currently in place.  If there isn’t a current plan in place, it’s safe to estimate 30% to 40% of eligible employees will participate in a new dental plan.

The employer contribution to the premium, if any, is a key determinant of a final rate, when combined with the number of participating employees. A group with high participation and employer contribution percentages usually gets the best rate.

If you have questions on any of the information needed to deliver a quote, please contact any member of our Sales Team. We’re here to help!

Guidance on healthcare reform, with more guidance in the forecast

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Thanksgiving week was busy on the healthcare-reform front. The Department of Health and Human Services (HHS) released its proposed final rule on Standards Related to Essential Health Benefits (EHB), Actuarial Value (AV), and Accreditation. While there are still questions outstanding, this proposed final rule answered several dental-related questions raised in past blogs.

One of the basic issues with the pediatric oral EHB is the definition of “pediatric.” HHS is proposing that “pediatric” be defined as under age 19, with flexibility for states to extend pediatric coverage beyond this limit.

This is reasonable; while the clinical definition of pediatric is closer to age 13, under age 19 is consistent with social programs, including CHIP.

The proposed rule also clarifies coordination of benefits between medical and standalone dental plans. The 10 EHBs are subject to an out-of-pocket limit, but coordinating this between medical and standalone dental carriers would be complicated and expensive. As a result, standalone pediatric oral dental will have a separate limit from the medical plan. This eliminates the complexity of coordinating these limits and makes it much easier for the consumer to understand. The rule was not clear on what the separate limit will be, but the rule specifies it must be “reasonable” and is requesting comments.

The exact mix of dental benefits included in the EHB is critical. Wisconsin has defaulted to the FEDVIP plan to outline the pediatric oral-health EHB, but this decision won’t be final until the end of the 30-day comment period, or Dec. 26, 2012. Wisconsin could still go with the state’s CHIP plan — a plan we prefer as a benchmark because it’s designed specifically for children. Either way, the benchmark will be finalized by the end of December and we will be ready.

A key clarification in the released rule was that cosmetic orthodontia will not be part of the EHB. Going forward, orthodontia will remain a choice and not a requirement — great for consumers, since cosmetic orthodontia adds significant cost.

The benchmark plan defines only the specific procedures covered, not the coverage level for these procedures (except that preventive must be covered at 100%). The coverage level is defined through the AV. The proposed final rule outlines how AV will be applied to standalone dental plans satisfying the pediatric-oral-EHB requirement.

Standalone dental plans will calculate AV independently of the other EHBs and will be subject to different AV requirements. Under the standalone dental EHB, a high plan will have an AV of 85% and a low plan an AV of 75%.

Similar to the medical AV calculation, the dental AV calculation has an allowed variance of +/- 2%. Unfortunately, unlike medical, there will not be a standard calculator, so challenges remain. Plans with the same benefit design could have different AV, or plans with different benefit designs could have the same AV, making AV an inexact comparison measure for dental plans. Additionally, if the pediatric oral EHB is embedded in the medical plan, it does not appear the dental AV will be calculated separately, making it very difficult to compare the dental EHB benefit embedded in a medical plan to the EHB offered through a standalone dental plan.

There is a lot of work to do over the next several months to get ready for HCR, but clarification on these core issues goes a long way in keeping the process moving. You can count on us to stay engaged and informed on dental issues, and we will continue to be your go-to HCR resource for dental.

The Value of a Healthy Smile

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So what is the actual value of good oral health? We live in a time and place that likes to put dollar signs on everything, so let’s try to put a dollar sign on a healthy smile. It’s not too hard.

Value to the Individual

You’ve heard the adage that a picture is worth a thousand words? Well, a smile can be worth thousands of dollars. A recent study shows that more than half of respondents said a healthy smile made them more likely to be hired and receive a larger salary offer.

So let’s say the larger salary offer is in the range of 5 percent. AOL puts the average starting salary for 2012 college graduates at $44,259. Five percent of that is more than $2,200. Extrapolating that salary differential over 30 years and accounting for a 3.5 percent raise each year produces a big number.

Payoff to the individual: $114,238 over 30 years.


Value to the Employer

Dental-related work absences account for an annual loss of 164 million hours in productivity. The Bureau of Labor Statistics puts the average hourly wage at $23.58. You can do the math from here.

Payoff to all employers: $3.867 billion annually.


Value to our Future – Children and Communities

Poor oral health among children has been linked to lower academic performance, so let’s suppose that poor oral health keeps two kids per class per year from going to college. The $44,000 annual average salary for college grads drops to $21,000 for high-school grads.

The BLS estimates the income differential between high-school grads and college grads at more than $900,000 over a working lifetime. Take that figure, multiply it by 3 million kids who don’t go to college because of poor oral health, throw in a couple of billion dollars in social costs stemming from lower levels of education, and you begin to understand why Delta Dental of Wisconsin donates hundreds of thousands of dollars each year to improve kids’ oral health.

Payoff to society: $60 billion-plus annually.


Total Value

The total value is, as you might guess, a very large number.

Through its charitable contributions and its innovative employee-benefits plans, Delta Dental of Wisconsin is working hard to help protect the healthy smiles of millions of Wisconsin residents, all across the state. We understand what’s at stake.

So the next time someone tells you that a healthy smile is priceless, you may want to correct them. It’s not exactly priceless, but it is very, very valuable.

The Actual Value of Actuarial Value

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Actuarial value (AV) is being talked about a lot as part of the Affordable Care Act (ACA) and healthcare reform (HCR). Here’s the information we promised on AV and how it affects dental.

Let’s start by defining two key terms used in the HCR discussion: actuarial value and actuarial equivalence.  Actuarial value refers to the average share of covered services paid by a plan for a given population relative to the total average spending for the same population on the same covered services. Plans with the same AV are actuarially equivalent.

Here’s what that means: For an average population, if the total claims expense was expected to be $100 and the plan was expected to pay $80 on average, then the AV would be 80 percent.

You can see how actuarially equivalent plans may not necessarily have the same benefit designs or the same premiums, or how plans with the same benefit design from different companies could have different AV. AV is simply a measure of what portion of the total claims expense, on average, is expected to be paid by the plan.

At this point you may be wondering why you should care about AV. The reason is that AV is the main approach for comparing plans and determining the relative richness of benefits under the ACA.

The ACA requires small-group and individual health plans to meet certain levels of coverage whether they are on or off the exchange. These coverage levels are often called “metal tiers” because they have been defined as bronze (60% AV), silver (70% AV), gold (80% AV), and platinum (90% AV).

The Department of Health and Human Services, in conjunction with organizations like the American Academy of Actuaries, is developing a publically available AV calculator that will standardize population and utilization patterns, minimizing the issue of plans with the same benefit design having different AV.

This sounds great. So what’s the catch?

The catch is dental. Pediatric oral care is part of the required Essential Health Benefits (EHB), and AV applies to the total EHB, not each separate benefit that goes into the EHB.

This creates challenges when the pediatric oral EHB is satisfied with a standalone dental plan. First, there is no accepted way of combining and recalculating AV among dental and medical plans. Second, combining AV across these plans could create a situation where a consumer picks separate medical and dental plans that best meet their needs, but their combined AV no longer fits into one of the metal tiers.

Couldn’t each plan meet the AV requirement separately? Yes for the medical plan, but not for the dental plan. Dental plan designs are very different than medical plans; a typical dental plan in today’s market has an AV of about 86 percent.

Dental’s preponderance of preventive services paid at 100 percent and limited use of deductibles makes it hard to design a dental plan at the 70% AV silver tier (the tier used for premium subsidies) without requiring unusual amounts of cost-sharing. This sets up a situation where the coverage would be out-of-step with today’s market and consumer costs would be much too high.

Additionally, the AV calculator currently being developed only includes medical data, so it’s not appropriate for calculating dental AV. Dental AV would not be based on a standardized data set like medical, so plans with the same benefit design could have different AV; this would make it hard to compare plans across companies.

What’s the solution? Delta Dental of Wisconsin recommends exempting the pediatric oral EHB from the AV requirement. AV is a great tool for comparing complex medical plans, but it doesn’t translate well to simpler dental plans.

Whether pediatric oral benefits are embedded in the medical plan or satisfied through a standalone plan, excluding them from AV avoids market confusion and gives consumers the flexibility to choose coverages that best meet their needs.

For more detailed information on AV and actuarial equivalence, check out the following links:

http://www.actuary.org/files/publications/Health%20Reform%20glossary%20080310.pdf

http://www.actuary.org/pdf/health/equivalence_may09.pdf

http://www.actuary.org/pdf/health/Actuarial_Value_Issue_Brief_072211.pdf

 

Healthcare Reform, Known and Unknown

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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.