SAA Webinar: Oral Health Policy Update

Smiles Across America Webinar Series

Oral Health Policy Update

August 24, 2016

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Oral Health Policy Update

Colin Reusch Senior Policy Analyst Children’s Dental Health Project

Children’s Dental Health Project Created in 1997 in response to the lack of a CHIP dental benefit, Children's Dental Health Project is an independent non-profit organization working to: » Prevent childhood tooth decay, because cavities are the result of a disease that is overwhelmingly preventable

» Promote innovative, cost-effective solutions grounded in science and support exploration where evidence is lacking » Engage decision-makers to address oral health disparities to improve our nation's health

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Today’s Presentation • Recap of ACA dental coverage • Update on IRS Proposed Rule Change • Update on CHIP

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ACA Dental Coverage: The Basics • Intended to be part of comprehensive pediatric coverage • EHB category 10: “pediatric services, including oral and vision care” • Must be offered up to age 19 in marketplaces, small group, & individual coverage • Accompanied by numerous oral health provisions (most unfunded) 12

How the ACA Changes Dental Benefits • • • •

Makes it part of essential health benefits (EHB) Attempts to subsidize through tax credits Limits cost-sharing (out-of-pocket maximums) Removes annual and lifetime dollar limits on coverage (children only) • Plans must offer child-only plans (up to age 19) • Limits orthodontic coverage to medically necessary • Integrates oral health into medical coverage via preventive services

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ACA Preventive Oral Health Services • Must be covered by all private health insurance plans at no cost: – Oral health risk assessment by pediatrician for young children & referral to dentist – Fluoride supplements for children w/out fluoridated water – Fluoride varnish application by pediatrician for all children under age 5

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HOW IS DENTAL COVERAGE DIFFERENT?

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Marketplaces can offer dental differently Pediatric Essential Health Benefits QHP Including Dental (embedded)

Qualified Health Plan (QHP)

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Stand-Alone Dental

• Stand-alone dental plans must be allowed to offer • Qualified health plans (QHPs) can be exempt from offering dental • ACA does not require purchase of stand-alone dental • States may require purchase • Stand-alone dental not considered in Premium Tax Credit calculation

QHPs with Embedded Pediatric Dental Coverage by State (FFM & Partnership Marketplaces, 2015) Average Across States Alaska Alabama Arkansas Arizona Delaware Florida Georgia Iowa Illinois Indiana Kansas Louisiana Maine Michigan Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey Ohio Oklahoma Pennsylvania South Carolina South Dakota Tennessee Texas Utah Virginia Wisconsin West Virginia Wyoming 17

34% 78% 97% 0% 67% 62% 46% 13% 1% 53%

About a third of all health plans in the federally-facilitated marketplaces include pediatric dental coverage in their products.

26% 42%

Only about 1% include adult dental coverage.

77% 11% 6% 12% 0% 0%

Plan documents aren’t always clear on how cost-sharing & deductibles apply to dental benefits.

89%

65% 49%

18% 0% 7% 14%

41%

Source: 2016 CDHP analysis of health plan information data: https://www.healthcare.gov/healthplan-information/

67%

20% 82%

3% 0% 52% 13% 100% 61%

Dental plans are treated differently Stand-alone Dental Plan • Optional to purchase (unless state requires) • Separate insurance policy & premium • Separate deductible • Separate out-of-pocket maximum • Adult coverage options available • No cost-sharing reductions • Some consumer protections may not apply 18

QHP w/ Embedded Dental • Dental benefits part of health plan (QHP) • One premium for health and dental • May have unified deductible or separate deductible for dental • Individual or family plan includes dental for children; some plans may include adult dental • Cost-sharing reductions apply • All consumer protections apply

Affordability measures apply differently Separate & additional OOP max for stand-alone dental plans.

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Tax credits sometimes forget dental St. Louis, MO family of 4 w/ annual income of $72,000

• Premium limit = $6,883 (9.6% of income) • 2nd lowest cost silver plan (no dental) = $9,399 • Tax credit: $9,399 – 6,883 = $2,516 • Dental premium (2 kids) = $432 • Total premium obligation = $7,315 (10.2% of income)

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What Does Coverage Cost?

Embedded in QHP

Stand-alone Plan

Average Premium

$16.21 (attributable portion of premium)

$27.61 (70% AV) $35.95 (85% AV)

Average Deductible

When separate: $50 When unified: $2,884

$63.93

Source: ADA Health Policy Resource Center, “More Dental Benefits Options in 2015 Health Insurance Marketplaces.�

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Take-Up of Stand-alone Coverage 2016 Stand-alone Dental Take-up by Age Group as % of Total (FFM & Partnership Marketplaces) Age 0-18

8%

Age 18-25

11%

Age 26-34

23%

Age 35-44

19%

Age 45-54

19%

Age 55-64

Age 65+

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20%

1%

Adults account for vast majority of take-up but adult dental not part of EHB & not subsidized No data on embedded pediatric dental take-up.

Data Source: ASPE Enrollment Report: https://aspe.hhs.gov/healthinsurance-marketplaces-2016-openenrollment-period-final-enrollmentreport

IRS PROPOSED RULE CHANGE

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IRS Proposed Rule Change • Premium Tax Credit NPRM VI – IRS recognizes that unequal treatment of standalone dental – Proposes to change tax credit calculation – Would allow tax credit benchmark to include cost of stand-alone pediatric dental coverage – Ensures that families get tax credit regardless of how dental is offered 24

IRS Proposed Rule Change Example A Silver-Level Qualified Health Plans (QHPs)

Includes Pediatric Dental?

Stand-alone Dental Plan Pediatric Premium

QHP 1 - $1,250

Yes

Dental Plan 1 - $40

QHP 2 - $1,200

Yes

Dental Plan 2 - $25

QHP 3 - $1,180

Yes

Example B Qualified Health Plans (QHPs)

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Includes Pediatric Dental?

Stand-alone Dental Plans

QHP 1 - $1,250

Yes

Dental Plan 1 - $40

QHP 2 - $1,200

Yes

Dental Plan 2 - $25

QHP 3 - $1,180

Yes

CHIP UPDATE

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What’s Happening with CHIP? • CHIPRA: reauthorized the program (and included dental) • ACA: continued CHIP funding until October 2015 • Medicaid and CHIP Reauthorization Act of 2015: continued CHIP funding until October 2017 • No legislation proposed yet to extend CHIP further • National organizations seeking input from statelevel advocates and governors 27

If nothing is done, October 1, 2017: • Federal CHIP funds will end.

• Separate CHIP programs: no further budget obligation to CHIP children. Many would roll into marketplace coverage – About 59% would be eligible for employer-sponsored coverage vs. 41% eligible for subsidized marketplace coverage – An estimated 1.1 millions kids would remain uninsured

• Medicaid Expansion programs: fall back to Medicaid matching rate (until 2019) 28

Source: Medicaid and CHIP Payment and Access Commission (MACPAC)

What’s at stake for dental?

• Dental benefits not a guarantee in employer-sponsored coverage • Dental coverage not always integrated into marketplace plans • Additional cost-sharing, deductibles, & premiums • Marketplace cost-sharing (not including premiums) is 6 to 13 times higher than CHIP* 29

*Source: Medicaid and CHIP Payment and Access Commission (MACPAC)

Pediatric Dental: CHIP vs Marketplace CHIP

QHP w/ Dental

QHP + Dental

Guaranteed coverage

Yes, as of CHIPRA 2009

Yes

No

Premium

Varies (18 states no premiums)

Max. 9.5% family income (<400% FPL): due to tax credit

Add dental premium avg. $30/mo. per child

Cost Sharing

Yes, allowed

Yes

Yes

often set $ per visit Benefits

Benchmark

Benchmark

Benchmark

Annual/Lifetime Caps

Yes

No

No

Varies by income

Add $350/child or $700/2+ kids

Annual: $0-$1,500

Lifetime: $0-$5,200

Out-of-Pocket Max

5% family income

2015 Max: $13,700 family

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Comparison of Cost Family of 4 at 250% FPL ($60,625/yr.)

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CHIP

QHP w/ Dental

QHP + Dental

Premium

None

Max $4,959 (8% w/ subsidy)

Max $4,959 (8% w/ subsidy) + $720 ($30 x 2 x 12 mo.) = 9%

Cost Sharing

$5.00 non-preventive visit

Co-insurance typically 100/80/20

Co-insurance typically 100/80/20

Benefits

Benchmark

Benchmark

Benchmark

Annual/Lifetime Caps

$1,200/$5,200

No

No

Out-of-Pocket Max

$2,950 (includes premium & cost-sharing)

$13,700 (not including premium)

$14,400 $13,700 + $700 (not including premium)

Pediatric Dental: CHIP vs Marketplace • CHIP is far more affordable and less complicated for families • Utilization in public insurance (Medicaid & CHIP) is comparable to private insurance • Evaluations point to parent satisfaction • But better data is needed to protect CHIP

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Opportunities for Action • Submit comments in support of IRS rule change (due Sept 6) • Ask HHS for better data on marketplace dental coverage • Urge members of Congress to extend funding for CHIP

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Questions?

Colin Reusch, MPA creusch@cdhp.org 202.417.3595 www.cdhp.org

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Thank you!

Colin Reusch, Presenter creusch@cdhp.org 202.417.3595 Jada Harrison Program Coordinator, Children and Youth jada.harrison@oralhealthamerica.org 312.836.9986