Children's dental coverage included in health law - but questions remain

photo Celina Smith, 13, of Chattanooga, gets her teeth cleaned at Children's Dentistry of Chattanooga.

FAST FACTS• From 2008 to 2011, 662 visits to Tennessee hospital emergency rooms were children needing help for preventable dental conditions.• More than 19 percent of Tennessee's population is underserved in dental services, as are 11 percent in Georgia.Source: Agency for Healthcare Research & Quality

Editor's note: This is the second in an occasional series on the 10 essential health benefits required by the Affordable Care Act.

A child's poor dental health can start a domino effect of decay.

It is not uncommon for chronic toothaches to hurt children's school performance, says Dr. Jonathan Jackson, a pediatric dentist and executive director of the Georgia Academy of Pediatric Dentistry.

And oral decay can create larger health problems.

"That's why it's so important to get these kids access to care," Jackson said. "It's just not a luxury."

Tooth decay is the most common childhood disease -- five times more prevalent than asthma.

But until this year, pediatric dental insurance coverage had to be purchased on separate health plans, at additional cost.

"We still have a situation where about half the kids entering kindergarten experience tooth decay," said Colin Reusch, the senior policy analyst at the Children's Dental Health Project, a Washington, D.C., nonprofit organization. "Oral health is integral to overall health. The mouth is part of the body. If you don't have coverage for that part of the body, your coverage is lacking."

The Affordable Care Act is intended to help cover that particular gap -- but questions remain about how that coverage will fit in with other benefits.

Pediatric dental insurance, together with children's vision coverage, is listed as one of the 10 "essential health benefits" new health insurance plans must include as of 2014. The coverage includes basic or preventive services, like teeth cleaning, X-rays and fillings.

Major plans in Tennessee and Georgia are now offering pediatric dental insurance bundled with new medical plans being offered both on and off the new health insurance marketplace, which could pave the way for thousands of children in both states to have dental insurance for the first time.

But not all insurance plans are offering the coverage in the same way, Reusch explains.

Unlike the other essential benefits like maternity care and pediatric vision care, children's dental coverage can be sold on the marketplace as a stand-alone plan. That means not all insurers will package the benefit in their new medical plans after all.

While the law requires insurance companies to offer the benefits, it does not require families to purchase them-- effectively making the "essential" benefit an optional one.

"A family can purchase a plan that doesn't include dental, and still not be able to purchase stand-alone coverage," Reusch said.

The loophole means stand-alone coverage may not be eligible for the tax credits and cost-sharing offered for plans bought on the new marketplace.

States have been given leeway to determine how the dental benefit is handled. Several have required families with children to purchase the coverage. Other states have required insurers not to bundle it with their other medical coverage.

But most states, including Tennessee and Georgia, are allowing insurers to offer both, state officials said.

"As long as there is one stand-alone pediatric dental plan, insurers do not have to embed pediatric dental into their policies to fulfill that benefit," said Kate Abernathy, spokeswoman for the Tennessee Department of Commerce and Insurance.

Though the state does not require it, BlueCross BlueShield of Tennessee opted to embed children's dental insurance in all of its new individual and small group plans.

Cigna, the other Tennessee insurer offering insurance on the marketplace in the Chattanooga area, also is offering a "bundled pediatric dental benefit," as well as stand-alone dental plans. Across state lines, Blue Cross Blue Shield of Georgia is doing the same.

Alliant Health Care, the other North Georgia insurer on the marketplace, did not return requests for comment.

David Yoder, vice president of Chattanooga insurance broker American Exchange -- which specializes in the new marketplace and has national reach -- said the majority of the plans his company has encountered include pediatric dental coverage bundled in the regular health plan.

"We don't have people who call seeking it out specifically, but when I tell them it's included in their health plan, they are often very excited," Yoder said. "It is fantastic for parents who previously faced paying $13.50 or more a month for dental insurance for their kids, and they just couldn't afford the extra expense."

But Yoder also hears from people who complain that pediatric dental is included on their prospective plans. They don't need it, they say, and they don't want it included in their costs.

The law does not change how dental and vision insurance works for adults. Those services will still require supplemental insurance.

And grandfathered plans -- purchased before March 23, 2010 -- do not have to include the essential benefits like pediatric dental care.

Current plans that are nongrandfathered do not include the added benefits at this time -- but members will "eventually need to switch to a new plan with benefits and coverage to meet the law's requirements," said BlueCross BlueShield of Tennessee spokeswoman Mary Danielson.

It's still too early to make a call on how the changing coverage structure will impact children's dental health across the nation, said Reusch.

The American Dental Association had originally estimated that 8.7 million children could gain dental coverage through the Affordable Care Act -- about a third of those through marketplace plans, a third through Medicaid, and a third through employer-provided plans.

But that was before it was determined that the benefit would be mandatory; now that number is not so clear.

"We expect that we'll see a significant expansion in dental coverage for kids under the ACA despite these complications," Reusch said. "But it's hard to say until we start seeing enrollment numbers."

Contact staff writer Kate Harrison at or 423-757-6673.