Mouths of babes: the essential health benefits debate

Confederate and Union forces once fought in Kansas over the laws governing slavery and the nature of the relationship between U.S. states.

Now, commenters are battling in Kansas over just what pediatric oral health benefits ought to go into the "essential health benefits" (EHB) package required by the Patient Protection and Affordable Care Act of 2010 (PPACA).

The Kansas Insurance Department held a hearing on the PPACA EHB requirements earlier this month. The department has posted a hearing transcript and written comments on the Web.

Employers and insurers are arguing that Kansas should make any EHB pediatric oral health requirements as narrow and inexpensive as PPACA allows.

William Tracy, chief executive officer of UnitedHealth's UnitedHealthcare plan, said in a written comment that the Kansas EHB pediatric dental benefits and vision benefits should consist primarily of preventive services and screening services.

"Any additional pediatric dental or vision benefits should utilize treatment limitations based on current industry standards, such as a maximum number of cleanings per year, to maintain affordability for these services," Tracy wrote.

Tonya Dorf Brunner, executive director of Oral Health Kansas, a group that represents dentists and nonprofit dental plans, said at the hearing that her group wants the EHB package to include "all pediatric dental services necessary to prevent disease and to promote oral health, to restore oral structures to health and function and to treat emergency conditions for the attainment and maintenance of oral health."

Kansas Insurance Commissioner Sandy Praeger is developing a package of EHB recommendations for the state's governor, Sam Brownback. PPACA gives the U.S. Department of Health and Human Services (HHS) the authority to develop an EHB package for a state does not develop its own package.

HHS officials have indicated that, in states that fail to choose their EHB packages, HHS will use the small group plan with the highest enrollment as the basis for creating the state's package, Praeger said at the EHB hearing.

The EHB Program

PPACA opponents continue to fight in the courts, in Congress, in state legislatures and at the polls to repeal part or all of PPACA and block implementation of the act.

If the law takes effect on schedule and works as drafters expect, it will require all individual and small group major medical plans to offer the standardized EHB package by 2014.

PPACA supporters say the EHB package system help consumers compare plans on an apples-to-apples basis.

HHS has asked each state to design its own EHB package.

A state is supposed to start by looking at the benefits offered by the three largest Federal Employee Health Benefits Program plans offered in the state, the three largest state employee benefit plans, the three largest small group commercial health plans, and the largest commercial health maintenance organization (HMO) plan.

The EHB benchmark plan chosen is supposed to provide benefits in 10 different areas, including ambulatory patient services, emergency services, hospitalization services and pediatric services.

The pediatric services provisions must include oral health and vision health services for children.

Commenters in many states are going through the same kind of debate that's now taking place in Kansas.

In Tennessee, for example, some commenters are still questioning whether their states should make any efforts at all to cooperate with the federal agencies in charge of implementing PPACA.

Kansas

In Kansas, consultants at Milliman have analyzed the EHB candidate plans. The consultants found that the candidate plans are similar and meet most of the PPACA EHB requirements.

One exception is that most of the candidate plans are less likely to cover the "habilitative services" that PPACA requires.

The term "habilitative services" refers to speech therapy, occupational therapy, and other services for children or others who have been born with handicaps, as opposed to rehabilitative services for patients who have lost abilities due to illnesses or accidents.

The candidate plans also lack pediatric oral health and pediatric vision benefits, in part because many employers provide oral health and vision benefits through separate dental plans and vision plans, the Milliman consultants said.

A Middle Way

One witness who spoke at the Kansas EHB hearing, Scott Farmen, a representative for Ameritas Life Insurance Group, suggested that the state could come up with a pediatric oral health standard by looking at what many small employers already provide through small group dental plans.

The EHB requirements apparently will apply both to plans sold through new PPACA "exchanges," or Web-based health insurance market supermarkets aimed primarily at low-income and moderate-income individuals who are eligible for Medicaid, the Children's Health Insurance Program (CHIP), or federal health insurance purchase subsidies.

PPACA will let stand-alone dental plans sell coverage through an exchange, Farmen noted.

The only EHB candidate plans that offer pediatric dental benefits today or the federal employees' benefit plan and the state CHIP plan, Farmen said.

"Neither of these are considered typical of small employer group plans," Farmen said.

HHS has been suggesting that states should keep solid, affordable small group plans in mind, rather than deluxe benefit plans, when developing EHB packages.

"Therefore, Ameritas recommends utilizing the small employer 14 model for the pediatric dental benefit," Farmen said. "Although many dental policies cover similar clinical procedures, costs vary greatly to the level of cost sharing and cost containment features. Kansas will need to balance coverage and affordability. A small employer benchmark stretches delivery between the two."

Kansas also should find a way to provide pediatric dental coverage waivers for medical plans when consumers will be buying stand-alone dental coverage, especially outside the exchanges, Farmen said.

"If medical plans are required to cover the pediatric dental outside the exchanges, there's potential for additional and unnecessary costs for dual coverage of these services," Farmen said.

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