I always tell my kids, don’t forget to brush your teeth! As we gear up for open enrollment in October, that phrase takes on a whole new meaning: Don’t forget to buy your pediatric coverage.

The Affordable Care Act’s (ACA) essential health benefit (EHB) package – or the minimum benefit package offered in both the individual and small group insurance markets beginning in 2014 – includes pediatric dental. Including pediatric dental as one of the 10 categories of benefits was and is tremendous progress for kid’s overall health. Unfortunately, the actual implementation of offering, purchasing and accessing this benefit is fraught with complexity. It is worth touching on what these implementation challenges are and what advocates can do to support a robust pediatric dental benefit that is meaningful for children.

Just offer the benefit and kids get coverage, right?

Well, not really. Currently most of the conversation about coverage is about plans being offered in the Exchange – or the virtual location where consumers can shop for health insurance plans. In Exchanges, pediatric dental can be offered through a stand-alone dental plan (or a plan that is separate from your health insurance plan) and/or be offered as part of your health plan (embedded). It cannot simply be added on to health insurance because it has a long history of functioning independent of health insurance. Structurally, it has traditionally operated outside health insurance. Theoretically, it should not – dental health is health.

States are taking different approaches to how they offer pediatric dental. In Massachusetts, for example, there will only be stand-alone dental plans. In Rhode Island, however, there will be both stand-alone dental plans and health plans with an embedded pediatric dental benefit.

One complexity in offering the dental benefit is linked to how the premium subsidy or tax credit will be calculated. As some may recall, the premium subsidy is tied to the second lowest silver level plan offered in the Exchange. If the silver level plan does not include a pediatric dental benefit – then pediatric dental is left out of the subsidy calculation. In this case, there would be little, if any subsidy value left over to purchase a stand-alone dental benefit that, in turn, has its own premium and associated out of pockets costs (as high as $1400 per family). This raises affordability concerns for families – paying two premiums is complex and burdensome. This is only one complexity of the pediatric dental benefit – but highlights the difficulty in getting it right.

For example, while the law requires that pediatric dental be offered to families, they are not required to purchase this coverage. So if families face affordability hurdles due to the prospect of 2 premiums and 2 out of pocket maximums absent a requirement to hold dental coverage, there is little incentive to purchase dental coverage for their kids. Some states, like Washington State and Kentucky, are considering adding a requirement to purchase pediatric dental. Advocates should be cautious with this type of requirement. If there is not an opportunity to fully subsidize health coverage – from teeth to toes – there is a risk of financially burdening vulnerable families.

Other issues such as how consumer protections are applied to dental plans and robustness of the benefit are equally important, and you can learn more about them here.

What to do?

Many advocates are pondering the question of how to best support a robust dental benefit in such a complex regulatory environment. There are a couple of things that advocates can do now in preparation for October enrollment.

-Talk to your Department of Insurance about the importance of the pediatric benefit. The Children’s Dental Health Project is a great resource for background materials. In these conversations, gain a clear understanding of what your state is doing in terms of the dental offering;

-Engage Exchange staff about the importance of flagging the pediatric dental benefit for families. This may take the form of a check-out flag or an educational reminder of the opportunity to purchase pediatric dental;

-Advocate for strong tracking requirements. It will be important to understand how the pediatric dental is offered and equally important to understand whether or not kids gain coverage. Exchanges are the perfect data collection source for this information and its important data to track and share;

-Continue educating your coalitions about the role of dental health in child health. Many children will continue to go without dental coverage due to its inaccessible structure and it will require continued monitoring and advocacy to realize the promise of its inclusion in the ACA.

National groupsare working to solve the tax credit calculation problem for families – but as it stands currently, the affordability and access problems will persist through 2014. For advocates, this will be an important situation to monitor in hopes of altering implementation in the hopefully, not so distant future.