Georgetown University Health Policy Institute The Future of Children’s Health Coverage Fulfilling the ABOUT THIS SERIES This issue brief is the second in a series of papers from Georgetown Promise of University Center for Children and Families on the future of children’s health coverage. The first brief, The Future of Children’s Coverage: Children in the Marketplace, focused on Children’s ways to improve marketplace coverage and the associated financial assistance for children. This second brief, written in partnership with the Children’s Dental Health Project, focuses on pediatric Dental dental coverage and ways to improve children’s oral health. Coverage INTRODUCTION Tooth decay remains the most common chronic condition by Colin Reusch and Joan Alker among children and teens, and it disproportionately affects low-income and minority families.1 Failure to identify, treat, and prevent dental disease can result in extremely serious health problems for children as well as costly, long-term Second in a series of briefs on the consequences as it impairs children’s ability to eat, sleep, future of children’s health and perform up their potential in school. However, tooth care coverage decay is largely preventable early in life, and children who have dental coverage are far more likely to receive appropriate services than those who are uninsured.2 Therefore, it is critical to expand dental coverage for children while maintaining and improving coverage options for those who are currently insured. In the years since the passage of the Children’s Health Insurance Program (CHIP) and the Affordable Care Act (ACA), the share of children without dental coverage has been cut by more than half.3 However, that coverage, more than any other aspect of health insurance, varies greatly in terms of comprehensiveness and affordability. There are a number of opportunities to improve how oral health care is delivered to children and adolescents in the health insurance marketplaces, CHIP, and Medicaid. September 2016 2 CCF.GEORGETOWN.EDU CHILDREN’S DENTAL COVERAGE Marketplace Coverage under the ACA The 2010 passage of the ACA represented an additional premiums—with no additional tax credit historic achievement for numerous reasons, not to help cover these costs.8 Children only account least of which was its focus on oral health. As for about 8 percent of the total enrollment in a result of the ACA, for the first time, families marketplace stand-alone dental plans.9 purchasing coverage on their own or receiving it QHPs that embed pediatric dental benefits through a small employer are guaranteed a set provide the full range of consumer protections and of essential health benefits (EHBs) that must be affordability measures to families. Furthermore, offered in all private insurance packages. Congress if they are structured appropriately, QHPs can explicitly included oral health coverage for children provide the same level of coverage as a stand- in the EHBs: “Pediatric services, including oral alone dental plan with little impact on overall and vision care.”4 However, the implementation premiums and out-of-pocket costs for families. of this provision of the law has resulted in a While some QHPs subject dental services to the number of complications affecting both the full medical deductible, an increasing number of comprehensiveness and affordability of dental insurers are exempting pediatric dental services coverage under the ACA. 5 from deductibles altogether, making services more Affordability and Consumer Protection affordable for families.10 The ACA states that pediatric dental coverage can While the law was intended to allow for a variety of be offered “either separately or in conjunction with pediatric dental offerings in the marketplaces, the a qualified health plan [QHP],”6 allowing stand- consequences have been far more complicated: alone dental plans to participate in the health insurance marketplaces to provide that aspect zz Families purchasing their children’s dental of EHB coverage. The regulations implementing coverage through a stand-alone dental the ACA stipulate that if there is at least one plan are not guaranteed the full range of stand-alone dental plan providing pediatric dental consumer protections established by the benefits in the marketplace, QHPs are exempt ACA, such as guaranteed rates and the from the requirement to include such benefits right to an external appeals process.11 in their products.7 As a result, in the federally zz Cost-sharing reductions for low-income facilitated marketplace and in many state-based families do not apply to stand-alone dental marketplaces, there is a mixed set of offerings for plans. Subsequent regulations have children: established a separate maximum out- zz QHPs that include or “embed” pediatric of-pocket limit (MOOP) for stand-alone dental services; pediatric dental coverage (on top of the law’s previously established MOOP for zz Stand-alone pediatric dental plans; QHPs). zz Stand-alone family dental plans that zz The IRS ruled that the cost of stand-alone include pediatric dental coverage; and pediatric dental coverage could not be zz QHPs without any pediatric dental services. included in the calculation of premium tax These options vary widely, depending on where credit amounts. families live. In some areas, families looking to Altogether, these factors erect a considerable purchase dental coverage for their children must barrier to affordability for families purchasing do so through a stand-alone dental plan, incurring dental coverage through stand-alone plans in the additional cost-sharing burdens and paying an marketplace.12 average of nearly $30 per child, per month in 3 CCF.GEORGETOWN.EDU CHILDREN’S DENTAL COVERAGE States that stand out as exemplars for how Recognizing that most of these benchmark health to provide children’s dental coverage in the plans did not appropriately cover pediatric dental marketplace include California, Connecticut, benefits, HHS established supplementary EHB Maryland, and the District of Columbia. Each of benchmarks for pediatric dental coverage, namely these states implemented standard plan designs the Federal Employee Dental and Vision Insurance that shield pediatric dental services from high Program (FEDVIP) and the dental services outlined medical deductibles while incorporating them in separate state CHIP programs—many of which into QHPs. While the law allows state-based also use a benchmark approach for covered marketplaces greater flexibility, the federal services. While these supplementary benchmarks government could ensure that families shopping on tend to be fairly comprehensive in terms of the the federally facilitated marketplaces receive more covered services, they are based on a rigid, one- comprehensive and affordable dental coverage for size-fits-all approach to oral health care, largely their children through a similar approach. In fact, ignoring the fact that dental caries, the disease recent guidance from the Department of Health and that causes tooth decay, takes hold early in life and Human Services (HHS) laid out options for standard must be managed as a chronic condition. Children plan designs for QHPs offered on the federally at higher risk for caries (e.g., those with early signs facilitated marketplaces; however, it is unclear how of tooth decay, lack of access to fluoride, or a diet these designs will address pediatric dental benefits high in sugar) may need more frequent dental visits when implemented.13 Including pediatric dental and additional interventions—such as counseling benefits in standard QHP designs and exempting or fluoride treatments—to keep the disease from those services from the medical deductible would progressing. As implemented, the benefits on paper ensure that every child enrolled in coverage through are a stark departure from the benefits envisioned the federally facilitated marketplace would have by the ACA and, certainly, from those required comprehensive dental coverage at no additional under Medicaid. cost to the family, thereby ensuring that all families First, the current benchmark selection process does benefit from the consumer protections and not ensure that all children have comprehensive affordability measures established by the ACA. coverage. For example, as its EHB benchmark, Child-Focused Benefits Utah selected a state employee health plan that Even an ideal approach to dental coverage through covers only basic preventive dental services, such standard plan designs with embedded pediatric as cleanings and x-rays, but that excludes any dental benefits may fall short of ensuring that all medically necessary restorative or orthodontic children receive the care that they need given care.14 Utah was not required to select a existing EHB guidelines. The current benchmark supplementary pediatric dental benchmark approach and lack of specified services for children that would have provided more comprehensive presents families with plans that are not tailored to coverage. As a result, children receiving coverage kids’ needs. on the Utah marketplace are left without the full range of dental services they need to maintain Following the passage of the ACA, instead of optimal oral health. outlining specific EHB services, HHS allowed states to choose from a set of predetermined benchmark Second, the oral health needs of individual children plans as a means of identifying which services must vary greatly, just as their need for many pediatric be covered by private health and dental insurers in services do. Clinical guidelines from the American the new health insurance marketplaces. Academy of Pediatric Dentistry (AAPD) and the American Academy of Pediatrics (AAP) recommend 4 CCF.GEORGETOWN.EDU CHILDREN’S DENTAL COVERAGE that oral health services be tailored to each child’s Data and Evaluation individual risk level for disease, based on the The ACA holds great promise for expanding findings of an oral health risk assessment.15 Higher- affordable, comprehensive, and age-appropriate risk children may need to receive fluoride varnish or oral health coverage to nearly all children other dental services numerous times within a given nationwide. However, at this point, it is difficult to plan year, while lower-risk children may only need to evaluate the success of the law because relatively visit the dentist once or twice a year. Unfortunately, little data have been made available by HHS. the current plan structures in both the EHB Current enrollment reports do not provide detailed benchmarks and actual insurance plans offered on information about pediatric dental coverage the marketplace typically apply a one-size-fits-all enrollment. Although the percentage of QHPs approach—relying on the outdated model of care with embedded pediatric dental coverage in the by which every child receives services every six marketplaces increased during the 2015 plan year, months, regardless of the child’s risk level for dental no data have been released to help assess the disease. impact of this trend. This major gap in available In addition, the ACA established a set of preventive data makes it difficult—if not impossible—to services that must be covered by all private health determine whether and how families are purchasing plans at no cost to enrollees. Included in this list dental coverage for their children and, more are all “A” and “B” recommendations by the U.S. importantly, what factors may be influencing their Preventive Services Task Force, as well as the choices. Future marketplace enrollment reports comprehensive guidelines supported by the Health should provide detailed information on dental Resources and Services Administration, which insurance enrollment in both state-based and are known as the AAP Bright Futures Guidelines. federally facilitated marketplaces, including QHPs Unfortunately, the final regulations for preventive that embed pediatric dental coverage. services under the ACA referred only to the Bright While enrollment data offer a good starting Futures periodicity schedule, leaving out the full point to assess whether children have access range of oral health services recommended for to dental coverage, such data are not a proxy children.16 for measuring the extent to which children are receiving the services they need. The Marketplace What Does the Affordable Care Act Enrollee Experience Survey should—but does not Require for Children? currently—include questions about children’s dental The ACA requires that private health insurers services.17, 18 Moreover, only one dental-related cover certain oral health services with no out- performance measure—the percent of children of-pocket costs for children and families. These between the ages of 2 and 20 who received an services include the following: fluoride varnish annual dental visit—is included in the criteria used application for all children through the age in the star quality rating system (QRS) that is under of 5 by a physician, fluoride supplements for development to assist consumers in evaluating children living in areas without community water different QHPs.19 However, child-only plans and fluoridation, and oral health risk assessment by stand-alone dental plans are excluded from the a physician and referral to a dentist. Consumer Experience Survey and the QRS. The federal marketplace should consider following However, these services are only a small the lead of California’s state-based marketplace, piece of what children should be receiving. Covered California, which has adopted the pediatric The AAP’s Bright Futures guidelines outline a dental measures starter set developed by the comprehensive set of oral health services that Dental Quality Alliance, an organization initiated by should be provided to children by a combination CMS and tasked with developing quality measures of medical and dental professionals. for oral health.20 5 CCF.GEORGETOWN.EDU CHILDREN’S DENTAL COVERAGE CHIP: Bridging the Gap More than 8 million children have dental coverage benefits based on private insurance benchmarks financed through the Children’s Health Insurance typically do not adequately tailor care to the needs Program (CHIP). In November 2015, the Centers for of individual children and may not meet the statutory Medicare and Medicaid Services (CMS) released standard above. Furthermore, in contrast to Medicaid a long-awaited certification report comparing and EHB coverage, CHIP rules still allow for annual health plans in the ACA’s health insurance dollar limits on dental services, which may pose a marketplaces to the coverage offered by separate financial barrier to obtaining necessary oral health care CHIP programs, and in May 2016, the Assistant and thus fall short of the statutory standard. Secretary for Planning and Evaluation (ASPE) In order to ensure compliance with the statutory released a related background paper providing standard and current best practices in dental coverage more detail on the certification report. Both reports design, CMS should issue regulations that clearly concluded that children’s coverage under CHIP outline the coverage options for states. First, CMS is more comprehensive and far more affordable should allow for a benefit design that creates greater than coverage under plans available through the flexibility in providing care according to each child’s marketplaces.21 Dental benefits were cited as a key needs in order to better align separate CHIP programs area of disparity between the two coverage options. with Medicaid and Medicaid Expansion CHIP This finding supported analyses by the Medicaid and programs, which adhere to Early Periodic Screening, CHIP Payment and Access Commission (MACPAC), Diagnosis, and Treatment (EPSDT) requirements, and the Government Accountability Office (GAO), and with current best practices.23 Second, CMS should members of the children’s health community.22 eliminate dollar limits on dental coverage in order If funding for CHIP is extended, there will be to adhere to the statutory standard and place CHIP opportunities to improve how dental care is provided families on an equal footing with those enrolled in in the program. The 2009 reauthorization of CHIP Medicaid or marketplace plans. Third, CMS should defined a new statutory standard that requires clearly define how states may adopt a benchmark separate CHIP programs to cover dental services plan while maintaining compliance with the statutory “necessary to prevent disease and promote oral health, standard. Finally, CMS should improve data reporting restore oral structures to health and function, and in order to ensure that there are reliable data on treat emergency conditions.” States can demonstrate access to dental care in separate CHIP programs, compliance with this definition by covering a pre- enabling stakeholders to evaluate consumer defined range of dental service categories or they experience in CHIP compared to Medicaid and private can adopt a dental benchmark plan. However, dental insurance coverage. Medicaid: The Need to Align Policies Nearly 37 million children rely on Medicaid to Medicaid programs on par with private insurance in cover needed dental services, and there are some terms of annual dental visits for children. However, indications that access to basic oral health services on their own, annual preventive dental visits are has improved in recent years.24 Over the last decade insufficient to prevent tooth decay or manage caries and a half, most state Medicaid programs have been as a chronic condition, and Medicaid could do more to able to increase the proportion of kids receiving at provide a comprehensive approach to oral health care. least one preventive dental service.25 In addition, CMS Medicaid programs are required to provide dental recently finished a five-year-long Oral Health Initiative services “both (1) at intervals that meet reasonable during which improving access to preventive dental standards of dental practice and (2) at other intervals care was a priority.26 These efforts have put some state 6 CCF.GEORGETOWN.EDU CHILDREN’S DENTAL COVERAGE as indicated by medical necessity.” However, process that can start in infancy, not receiving a dental a recent report by the HHS Office of Inspector visit until the age of 4 or later means the disease may General (OIG) suggests that access to necessary have already progressed to form cavities.29 Dental services is still lacking, especially with regard to the disease that starts in childhood may have long-term comprehensiveness and appropriateness of care. impacts. Both children and adults report impaired The OIG report focused on four states (California, social functioning, such as avoiding laughing or Indiana, Louisiana, and Maryland) and exposed smiling, due to perceived poor appearance of teeth. significant issues: 27 Additionally, untreated dental disease leads to tooth loss of both primary and permanent teeth, which zz 78 percent of children enrolled in Medicaid can hamper the ability to eat a varied diet that meets across these four states did not receive nutritional guidelines.30 dental care in accordance with the states’ periodicity schedules; State Medicaid programs can take advantage of a zz 28 percent of enrolled children did not have a new opportunity to better meet the needs of children dental visit at all during that time period; and by aligning their policies with established clinical zz Two of the four states had reimbursement guidelines and incentivizing clinical approaches that policies that were in direct conflict with will prevent and manage tooth decay. HHS created their Medicaid dental periodicity schedule, this opportunity and increased flexibility for state preventing them from paying for certain Medicaid programs when the agency approved the outlined services. new caries risk assessment codes allowing states to receive federal matching funds for a wider range HHS encouraged the formation of the Dental Quality of oral health services. This new policy is based on Alliance (DQA), an initiative of the American Dental the latest research in evidenced-based clinical care Association, to advance quality measurement for and the premise that services should be based on children’s oral health services. The DQA, which individual needs. involves a broad group of pediatric stakeholders, has fostered the creation of a 10-measure starter set of In addition, because many children do not see the pediatric dental measures.28 Yet, the Child Core Set dentist in the first few years of life—especially those of Health Care Quality Measures for children enrolled with lower incomes who are enrolled in Medicaid— in Medicaid and CHIP includes only one of the DQA’s the engagement of primary care and non-dental measures—dental sealants for 6- to 9-year-old providers is almost certainly an opportunity to provide children at elevated caries risk, which is new for the preventive care outside of the dental office before 2015 reporting period. The other dental measure in the tooth decay becomes a problem. Furthermore, child core set is the percentage of eligible children who CMS can incentivize innovation in oral health care received a preventive dental service, which is drawn by restructuring the next iteration of its Oral Health from state-required reporting on EPSDT. In looking Initiative so that state programs are measured in a forward, HHS should encourage the development of a manner that reflects appropriateness of care. measure that evaluates whether children are receiving a risk-based oral health assessment as recommended Recommendations by the AAPD and AAP. Since enactment of the Children’s Health Insurance Children from low-income and minority families are Program and the Affordable Care Act, millions of disproportionately affected by tooth decay. Given American children have gained dental coverage. But that Medicaid serves a population with greater need, that coverage varies from state to state: Coverage is it is troubling that even when children see a dentist, not always as comprehensive as it ought to be and is many of them do not receive the range of services too often unaffordable for families. Policymakers at the recommended by professional guidelines. Moreover, state and federal levels have options available to them children under the age of 3 are the least likely to that could vastly improve the delivery of children’s oral receive dental care. Because tooth decay is a disease health care. 7 CCF.GEORGETOWN.EDU CHILDREN’S DENTAL COVERAGE Policy Options to Strengthen Children’s Dental Coverage Options for Federal Agencies zz HHS should establish a standard plan design for QHPs in federally facilitated and partnership marketplaces. This standard plan should be similar to those of states like California, Connecticut, and Maryland, and the District of Columbia, which include comprehensive pediatric dental coverage and protect children’s dental services from high deductibles. In addition, future marketplace enrollment reports should provide detailed information on dental insurance enrollment in both stand-alone and embedded plans. zz HHS should not exempt child-only plans and stand-alone dental plans from the QRS and QHP Enrollee surveys. Additionally, the federal marketplace should incorporate the DQA pediatric measures in the QRS. zz The IRS should revisit the regulations on Health Insurance Premium Tax Credits and allow for the inclusion of all pediatric dental coverage options as part of the tax credit calculation. This would enable all families to receive the full tax credits to which they should be entitled. zz HHS should expand the preventive services regulations to add all oral health services included in the guidelines supported by the Health Resources and Services Administration (i.e., Bright Futures). This will help ensure that tooth decay is treated like any other chronic condition. zz CMS should issue regulations implementing the dental coverage standard in CHIP as outlined in the Children’s Health Insurance Program Reauthorization Act of 2009. zz CMS should encourage state Medicaid programs to align policies and care delivery with established clinical guidelines and should facilitate states’ ability to refine their Medicaid programs to strengthen oral health among preschool-age children. For example, CMS could enhance its Oral Health Initiative to measure appropriateness of care through receipt of services based on risk assessment. zz CMS should foster the development of a measure that evaluates whether children are receiving a risk-based oral health assessment, as recommended by the AAPD and AAP. Such a measure, along with other DQA pediatric dental measures, should be considered for inclusion in the child core set. Moreover, reporting on the child core set should become a mandatory requirement for states. Options for Congress zz Congress should direct HHS to conduct a review of the EHB in 2016 with specific attention to pediatric services and professional guidelines on pediatric oral health care. zz Congress should instruct HHS to release detailed enrollment data for pediatric dental coverage, including enrollment in stand-alone dental plans and QHPs that embed pediatric dental coverage, by age, state, plan, race and income. Options for States zz States should adopt a dental periodicity schedule for their Medicaid/CHIP programs that requires caries risk assessment and treatment plans that reflect a child’s risk for dental disease. Furthermore, states should align their payment policies and contracting arrangements with these guidelines. zz States should refine Medicaid/CHIP policies to encourage and incentivize the use of oral health risk assessments and fluoride varnish by pediatricians. Moreover, states should adopt the American Dental Association’s dental billing codes for caries risk (CDT codes D0601, D0602, and D0603) and reimburse these services. zz States should work to report accurately on the new dental sealant Core Set measure and consider adopting additional Dental Quality Alliance measures for performance indicators in oral health moving forward. 8 CCF.GEORGETOWN.EDU CHILDREN’S DENTAL COVERAGE Endnotes C. Yarbrough, M. Vujicic, and K. Nasseh, “More Dental 10 Benefits Options in 2015 Health Insurance Marketplaces,” 1 Centers for Disease Control and Prevention, “Hygiene- (Chicago: American Dental Association Health Policy Related Diseases: Dental Caries (Tooth Decay),” revised Institute, February 2015), available at http://www.ada. in 2014, available at http://www.cdc.gov/healthywater/ org/~/media/ADA/Science%20and%20Research/HPI/ hygiene/disease/dental_caries.html. Files/HPIBrief_0215_1.ashx. 2 K. Nasseh and M. Vujicic, “Dental Care Utilization Rate 11 Center for Consumer Information and Insurance Continues to Increase among Children, Holds Steady Oversight, “Affordable Exchanges Guidance,” p. 29 among Working-Age Adults and the Elderly,” Figure 6 (Washington: Centers for Medicare and Medicaid (Chicago: American Dental Association Health Policy Services, April 5, 2013), available at https://www.cms. Institute, October 2015), available at http://www.ada. gov/CCIIO/Resources/Regulations-and-Guidance/ org/~/media/ADA/Science%20and%20Research/HPI/ Downloads/2014_letter_to_issuers_04052013.pdf. Files/HPIBrief_1015_1.ashx. 12 “Reduced cost-sharing for individuals enrolling in 3 M. Harrington et al., “CHIPRA Mandated Evaluation of qualified health plans,” Affordable Care Act(Public Law the Children’s Health Insurance Program: Final Findings,” 114-38), 42 U.S. Code § 18071(c)(5) and 45 C.F.R. p. 28, Figure III.4 (Ann Arbor: Mathematica Policy 156.150, available at https://www.law.cornell.edu/uscode/ Research and Urban Institute, August 2014), available text/42/18071. at http://www.urban.org/sites/default/files/alfresco/ 13 U.S. Department of Health and Human Services, publication-pdfs/413276-CHIPRA-Mandated-Evaluation- “Patient Protection and Affordable Care Act; HHS Notice of-the-Children-s-Health-Insurance-Program-Final- of Benefit and Payment Parameters for 2017,” Federal Findings.PDF. Register, December 2, 2015, available at https://www. 4 “Essential Health Benefits Requirements,” Affordable federalregister.gov/articles/2015/12/02/2015-29884/ Care Act (Public Law 111-148), 42 U.S. Code § 18022(b) patient-protection-and-affordable-care-act-hhs-notice-of- (1)(J), available at https://www.gpo.gov/fdsys/granule/ benefit-and-payment-parameters-for-2017. USCODE-2010-title42/USCODE-2010-title42-chap157- 14 A list of all states’ benchmark plans was created and subchapIII-partA-sec18022. published by the Centers for Medicare and Medicaid 5 K. Whitener, J. Volk, S. Miskell, and J. Alker, “The Services, available at https://www.cms.gov/CCIIO/ Future of Children’s Health Coverage: Children in the Resources/Data-Resources/Downloads/Final-List-of- Marketplace” (Washington: Georgetown Center for BMPs_4816.pdf; more information on Utah’s Public Children and Families, June 2016), available at http://ccf. Employees Health Program can be found in “PEHP Health georgetown.edu/wp-content/uploads/2016/06/Kids-in- and Benefits: State of Utah, 2016-17,” available at https:// Marketplace-final-6-02.pdf. www.pehp.org/mango/pdf/pehp/pdc/state%20book%20 2015-16_sw_ff78e5a0.pdf. 6 “Affordable Choices of Health Benefits Plans,” Affordable Care Act (Public Law 111-148), 42 U.S. Code § 15 American Academy of Pediatric Dentistry, “Guideline 18031(d)(2)(B)(ii), available at https://www.gpo.gov/fdsys/ on Caries-Risk Assessment and Management for Infants, granule/USCODE-2010-title42/USCODE-2010-title42- Children, and Adolescents,” Clinical Practice Guidelines chap157-subchapIII-partB-sec18031. 37, no. 6, pp. 132-139, available at http://www.aapd. org/media/policies_guidelines/g_cariesriskassessment. 7 “Essential Health Benefits Requirements,” Affordable pdf; American Academy of Pediatrics, Bright Futures: Care Act (Public Law 111-148), 42 U.S. Code § 18022(b) Guidelines for Health Supervision of Infants, Children, (4)(F), available at https://www.gpo.gov/fdsys/granule/ and Adolescents, 3rd edition (Elk Grove Village, IL: 2007), USCODE-2010-title42/USCODE-2010-title42-chap157- pp. 155-168, available at https://brightfutures.aap.org/ subchapIII-partA-sec18022. Bright%20Futures%20Documents/8-Promoting_Oral_ 8 Unpublished Children’s Dental Health Project analysis Health.pdf. of dental plan data provided by federal health officials. 16 Coverage of preventive services, Affordable Care Act, For more information, see U.S. Department of Health and 45 CFR Part 147, Human Services, “FFM QHP landscape files: Health and dental datasets for researchers and issuers,” available 17 There are no questions relating to access and use at https://www.healthcare.gov/health-and-dental-plan- of dental services in the QHP Enrollee Survey. In fact, datasets-for-researchers-and-issuers/. respondents are instructed not to include dental care in their responses to questions. For more information on 9 U.S. Department of Health and Human Services, “Health the survey, see 2017 Quality Assurance Guidelines and Insurance Marketplaces 2016 Open Enrollment Period: Technical Specifications,available at https://qhpcahps. Final Enrollment Report,” ASPE Issue Brief, March 11, cms.gov/sites/default/files/upload/2016_QHP_EES_ 2016, available at https://aspe.hhs.gov/sites/default/files/ QAG_508.pdf. pdf/187866/Finalenrollment2016.pdf. 9 CCF.GEORGETOWN.EDU CHILDREN’S DENTAL COVERAGE 18 The QHP Enrollee Survey was fielded by CMS in 2015 February 2013), available at http://www.ada.org/~/ and 2016 to provide information to marketplaces and media/ADA/Science%20and%20Research/HPI/Files/ QHPs. Results of the survey will not be publicly available HPIBrief_0213_3.pdf?la=en. until 2017. 26 U.S. Department of Health and Human Services, 19 Centers for Medicare and Medicaid Services Health Centers for Medicare and Medicaid Services, “Use of Insurance Marketplace, “Quality Rating System and Dental Services in Medicaid and CHIP,” January 2015, Qualified Health Plan Enrollee Survey: Technical Guidance available at https://www.medicaid.gov/medicaid-chip- for 2016, Version 2.0,” January 2016, available at https:// program-information/by-topics/benefits/downloads/ www.cms.gov/Medicare/Quality-Initiatives-Patient- secretarys-report-dental-excerpt.pdf. Assessment-Instruments/QualityInitiativesGenInfo/ 27 U.S. Department of Health and Human Services, Office Downloads/QRS-and-QHP-Enrollee-Experience-Survey- of Inspector General, “Most Children with Medicaid in Technical-Guidance-for-2016-V20.pdf. Four States Are Not Receiving Required Dental Services,” 20 K. Soderlund, “Covered California Adopts DQA January 2016, available at http://oig.hhs.gov/oei/reports/ Measures,” ADA News, August 17, 2015, available at oei-02-14-00490.pdf. http://www.ada.org/en/publications/ada-news/2015- 28 For more information on the Dental Quality Alliance, go archive/august/covered-california-adopts-dqa-measures. to http://www.ada.org/en/science-research/dental-quality- 21 Centers for Medicare and Medicaid Services, alliance/. “Certification of Comparability of Pediatric Coverage 29 American Academy of Pediatric Dentistry, “Early Offered by Qualified Health Plans,” November 25, 2015, Childhood Caries (ECC),”available at http://www. available at https://www.medicaid.gov/chip/downloads/ mychildrensteeth.org/assets/2/7/ECCstats.pdf; for certification-of-comparability-of-pediatric-coverage- more information, see the Early Childhood Caries offered-by-qualified-health-plans.pdf; Assistant Secretary Resource Center (Elsevier), available at http:// for Planning and Evaluation, “Background Paper: earlychildhoodcariesresourcecenter.elsevier.com/. Financial Protections of CHIP and QHPs,” May 2016, available at https://aspe.hhs.gov/pdf-report/background- 30 World Health Organization, “Dental Diseases and Oral paper-financial-protections-chip-and-qhps. Health,” 2003, available at http://www.who.int/oral_health/ publications/en/orh_fact_sheet.pdf; see more at http:// 22 Medicaid and CHIP Payment and Access Commission www.ncqa.org/report-cards/health-plans/state-of-health- (MACPAC), Report to the Congress on Medicaid and care-quality/2015-table-of-contents. CHIP, June 2014, available at https://www.macpac.gov/ wp-content/uploads/2015/01/2014-06-13_MACPAC_ Report.pdf; Government Accountability Office (GAO), “Children’s Health Insurance: Information on Coverage of Services, Costs to Consumers, and Access to Care in CHIP and Other Sources of Insurance,” November 2013, available at http://www.gao.gov/assets/660/659180.pdf; GAO, “Children’s Health Insurance: Coverage of Services and Costs to Consumers in Selected CHIP and Private Health Plans in Five States,” February 25, 2015, available at http://www.gao.gov/products/GAO-15-323. 23 Medicaid and Medicaid Expansion CHIP programs provide care to children in accordance with Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements, which are designed to ensure that each child receives all services deemed necessary by his or her medical and dental providers and at appropriate intervals. 24 Centers for Medicare and Medicaid Services, “FFY 2015 Number of Children Ever Enrolled in Medicaid and CHIP,” May 2, 2016, available at https://www.medicaid.gov/chip/ downloads/fy-2015-childrens-enrollment-report.pdf. 25 M. Vujicic, “Dental Care Utilization Declined among Low-Income Adults, Increased among Low-Income Children in Most States from2000 to 2010,” (Chicago: American Dental Association Health Policy Institute, 10 CCF.GEORGETOWN.EDU CHILDREN’S DENTAL COVERAGE The authors would like to thank Tricia Brooks, Kelly Whitener, Cathy Hope, Matt Jacob, and Peggy Denker for their contributions. Design and layout provided by Nancy Magill. The Georgetown University Center for Children and Families (CCF) is an Center for Children and Families independent, nonpartisan policy and Health Policy Institute research center founded in 2005 with a Georgetown University mission to expand and improve high quality, Box 571444 affordable health coverage for America’s 3300 Whitehaven Street, NW, Suite 5000 children and families. CCF is part of the Washington, DC 20057-1485 Health Policy Institute at the McCourt Phone (202) 687-0880 School of Public Policy. Visit www.ccf. Email childhealth@georgetown.edu georgetown.edu. ccf.georgetown.edu/blog/ facebook.com/georgetownccf twitter.com/georgetownccf The Children’s Dental Health Project (CDHP) has served as the voice for children’s oral health for nearly two decades. Based in Washington D.C., CDHP’s focus is on identifying and advancing solutions to preventing and managing tooth decay in our youngest population—solutions that are grounded in the best available research. Visit www.cdhp.org.