Oral Health and the Affordable Care Act: Essential Health Benefits

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The Affordable Care Act – 2010 (ACA) is designed to increase access to health care, including oral health, by providing affordable coverage options through approved Exchanges with essential health benefit (EHB) plans in addition to the plans on the private market.  Subsidized options are provided to ensure increased coverage.   

   

General Status 

The ACA requires each state to identify a benchmark coverage plan that ensures the EHB covers items and services within 10 specified benefit categories including pediatric services including oral and vision care.  Each plan offered in the individual and small group market, whether in or out of the exchange, must cover those benefits. 

In anticipation of the implementation of the Exchanges, there is a nationwide focus on the development of the EHB packages, which are a state-specific baseline of covered health services. 

The scope of benefits provided should be equivalent to a typical employer plan reflecting the small employer market. The federal standard does not define typical.  In all states, this plan also must address in-state health mandates.  

Plans excepted from the EHB include self-funded and large group plans.  Additionally, a stand-alone pediatric dental plan can be offered in the market, and if so, then other dental plans with limited benefits can still participate in the exchange.  

Benchmark plans have been federally-defined and include the largest, by enrollment, of the small group insured products in the state’s small group market, any of the largest 3 state employee health benefit plans, any of the 3 largest national federal employee plans, or the largest insured commercial non-Medicaid HMO operating in the state.  States must show by October 2013 that they can be operational; otherwise a federally-facilitated exchange will be put into place.  

If a state does not exercise its option to choose a plan, then the federal proposal is likely to be the largest plan by enrollment in the largest product in the state’s small group market.  NH Voices for Health has prepared a grid of likely benchmark options which includes 2 Anthem products, Matthew Thornton, the state employee POS and HMO plans, and two federal plans. http://tinyurl.com/VOICESEHG

EHBs must include a children’s dental benefit and state exchanges may permit pediatric and adult dental to be coupled in family plans so that all can be served in the same office.  

If the benchmark plan does not contain the required dental services, then a stand alone dental plan can be offered based on either the Federal Employees Dental and Vision Insurance Program, or the state’s own separate CHIP program.  In New Hampshire, our CHIP program is currently changing from a federally-defined “separate” plan to a Medicaid “expansion” plan.    

 

New Hampshire Status

In NH, we have a legislatively-created, Joint Oversight Committee on Health Care Reform (JCHCR) that will make our EHB decision. http://tinyurl.com/JCHCRO

Per the ACA, they can use federal and state employee plans as well as small market plans already operating within the state.  

The oversight committee was scheduled to consider, and likely make, that decision on August 16, but on Wednesday, August 8, the Executive Council approved a contract with Compass to prepare and provide data and analysis to assist the oversight committee in making an informed decision.  It is expected that the August 15 Committee will be postponed to allow adequate time for Compass to do their work.                                                                                                                         

Within NH we also have state-mandated children’s dental coverage for complex dental procedures.  This is in part due to prior NH litigation around the Hawkins lawsuit.  Thus NH benchmarks already include coverage for children’s dental procedures in both the office and the hospital.  In relation to adult dental coverage, all of the likely NH and federal benchmark plans include some adult services.  The federal influence is leaning towards the use of a “medical necessity” guideline for covered services. 

These NH pediatric oral health mandates are included in all of the state-specific benchmark plans as well as all but one of the federal benchmarks.  With the mandates in place, it is the best choice for NH to choose one of the benchmarks plans that currently contains them as there will be federal funding to assist.  But, if the mandate remains in place, and is not included in the benchmark plan, then the state would assume the costs.  It is unlikely that NH would make that choice for a variety of reasons including our budget limitations, the fact that the date for coverage relating to mandates is for those in place on 1/1/2012, and the ongoing oversight we receive relating to the Hawkins lawsuit.    

 

Key Questions Moving Forward 

  • In NH, how will the medically-based oral health risk assessment and fluoride application fit into the EHB? Is it already covered in any of the benchmarks?
     
  • If a benchmark plan with pediatric dental is chosen, is that adequate to meet the pending federal definition? Is it then possible for a Stand Alone Dental to be substituted for the essential dental benefit or will they be separate products in the broad market?

 

Key Resources 

 

In addition to this provision on the EHBs, the ACA addresses other related oral health issues through nearly 2 dozen provisions aimed at improving oral health including prevention, health promotion, coverage and financing, workforce and training, infrastructure/surveillance and in improved oral health safety net. Not all of these provisions are funded at this time. 

We will follow the development of these provisions as they roll out.

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