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.