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Legal Loopholes Leave Some Kids Without Dental Insurance

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If you think buying health insurance under the Affordable Care Act has been complicated, just wait. Buying dental coverage on the health exchanges, it turns out, is even more confusing.

Dental coverage for children is one of the benefits that must be offered under the law. But, it turns out, a loophole in the law means that — in most states — families don't actually have to buy that coverage.

These rules are so confusing that they even tripped me up.

On Monday (as part of a Q and A on the law), I noted the inclusion of the benefit and said it would be part of any plan sold on the exchange.

That turns out not to be the case.

"It's very complex," says Joe Touschner of Georgetown University's Center for Children and Families. He has been tracking implementation of the pediatric dental benefit.

Touschner says the problem is that when Congress wrote the law, the legislators were trying to satisfy two different goals. "On the one hand," he says, "they did make [pediatric dental services] part of the 'essential health benefits package.' "

But at the same time — partly in response to some strong lobbying by providers of dental benefits, Touschner says — Congress also wanted to preserve a market that looked a lot like the one we've had for years. Typically, if you have dental coverage, you get it through an employer and it's offered separately from your health plan. The new exchanges follow roughly that same pattern.

So, some state exchanges offer only stand-alone dental plans. Other states offer stand-alone dental plans, as well as health plans that have children's dental benefits included. (Adult dental benefits always have to be purchased separately — because they're optional, under the law.)

But there's another catch. Or two.

The law contains a loophole, "whereby families can choose not to purchase dental coverage for their children, even though it's part of the 'essential health benefits,' " says Colin Reusch. He's with the Children's Dental Health Project, a nonprofit group based in Washington, D.C.

As Reusch explains it, while the ACA requires that pediatric dental coverage must be offered in each state exchange, families who don't buy it won't be penalized for having substandard coverage.

There's also a disincentive for families to purchase stand-alone coverage for their kids, Reusch says. If a family buys stand-alone dental coverage, they won't get a federal subsidy to help them pay for it. That's true even if they're eligible for help in buying their overall health plan.

"So if that [health] plan doesn't include pediatric dental coverage, then you're getting no subsidy for that dental coverage, period," he says.

Dental coverage can also be downright difficult to find in the exchanges, though a few states make it easy, says Fay Donohue. She's president and chief executive of DentaQuest, a dental benefits company that's offering coverage in about a dozen states.

"In some states, for example — a Maryland or a Massachusetts — you can go onto the exchange and shop just for dental," Donohue says, "and are able to pick a dental plan for yourself that makes sense and is an easy experience."

In other states, she says, "it is extremely difficult, and in others, pretty impossible."

That's not just a problem for the bottom line of dental firms, Donahue says. Unmet oral health needs — particularly those of children — are a serious health problem. It's estimated that 1 in 10 children from low-income families is in pain from untreated dental problems.

"How can you go to school and learn anything when you're in pain?" Donahue asks. "If you care about education, you've got to care about oral health."

That difficulty in finding plans extends to adults, too. Under the health law, any adult who doesn't have dental coverage should, theoretically, be able to just go to the exchange and buy a plan.

But Donohue says that's not always happening, either. "In some [states], you can," she says. "In some, you can only buy dental if you've already purchased a medical. And in some, they're not there at all."

Meanwhile, children's advocates say their first priority is making sure families who do buy stand-alone dental coverage for their kids are getting subsidies if they're eligible.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.

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