Study: Pediatric Vision, Dental ACA Coverage In Limbo

California has yet to resolve several key questions about how insurers will provide pediatric dental and vision benefits under the federal Affordable Care Act, according to a new study from the California Health Benefits Review Program.

Recent state legislation helps define essential health benefits for children’s dental and vision care, “but does not clarify which ages are ‘pediatric,’ and thus eligible to use these benefits,” according to the study from CHBRP, a University of California initiative that analyzes public health issues for the state Legislature.

It’s also unclear how benefits will be handled when families purchase separate health coverage and stand-alone dental coverage, the report concludes. “These questions will need to be addressed at some point in the future in order to assist both the regulators and the carriers providing for this EHB to comply with ACA requirements,” it said.

The study raises good questions, said Jenny Kattlove, who coordinates dental access programs for The Children’s Partnership, a nonprofit advocacy group based in Santa Monica and Washington D.C.  “We want to make sure that children of all ages have access to dental coverage,” she said. “We want to make sure families understand that children are eligible for pediatric dental benefits and that enrollment in both health and dental coverage will be coordinated.”

Gov. Jerry Brown (D) signed two bills into law Sept. 30 – Assembly Bill 1453 and Senate Bill 951 – that define some of the treatments, tests and services to be covered as essential benefits for the pediatric dental and vision category. But the laws refer to different sources for the age guidelines, so it’s unclear which age group will be covered, according to the CHBRP report released Monday.

The Affordable Care Act doesn’t specify eligibility guidelines for pediatric benefits, leaving the decision to states. Different health programs in California provide services for children up to ages 19 or 22, but the ACA says  “dependent children” can stay on their parents’ health insurance until age 26.

Pediatric dentistry can refer to the time before children lose their primary teeth, which usually happens by age 12. And the American Academy of Pediatrics defines the period as 21 years or younger.

“Assuming the states have flexibility in determining the eligibility age range for pediatric dental and pediatric vision benefits, there is still a question of which entity has legal authority to define age group eligibility,” the study says.

If the Legislature doesn’t define eligibility, the decision would fall to California’s two state regulators, the Department of Managed Health Care and Department of Insurance, according to the report.

It’s not surprising that California’s response to the Affordable Care Act is missing some technical details, said John Lewis, associate director of CHBRP.

“You expect that,” he said. “The law is brand new. It’s an ongoing process.”

California also has yet to determine how health insurance will be coordinated with stand-alone pediatric dental coverage to meet the ACA mandate, the report said. For plans sold outside the state’s insurance exchange, “the state regulators or some other entity would have to confirm these benefits are being fulfilled in order to comply with ACA requirements,” the study concluded.

Separate health and dental carriers also will need to coordinate tracking of an enrollee’s annual out-of-pocket limit. “Such coordination channels do not currently exist,” the report says.

“We hope the exchange finds a way to offer dental coverage to all individuals, and that children do not experience a gap in dental coverage as they transition to adulthood,” said Kattlove.

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