Estimating premium and out of pocket outlays under all child dental coverage options in the federally facilitated marketplace

Estimating Premium and Out of Pocket Outlays Under All Child Dental Coverage Options in the Federally Facilitated Marketplace Estimating Premium and Out of Pocket Outlays Under All Child Dental Covera[.]

ARTICLE IN PRESS THE JOURNAL OF PEDIATRICS • www.jpeds.com ORIGINAL ARTICLES Estimating Premium and Out-of-Pocket Outlays Under All Child Dental Coverage Options in the Federally Facilitated Marketplace Marko Vujicic, PhD, and Cassandra Yarbrough, MPP Objective To estimate premium and out-of-pocket costs for child dental care services under various dental coverage options offered within the federally facilitated marketplace Study design We estimated premium and out-of-pocket costs for child dental care services for 12 patient profiles, which vary by dental care use and spending We did this for 1039 medical plans that include child dental coverage, 2703 medical plans that not include child dental coverage, and 583 stand-alone dental plans for the 2015 plan year Our analysis is based on plan data from the Center for Consumer Information and Insurance Oversight and Data.HealthCare.Gov Results On average, expected total financial outlays for child dental care services were lower when dental coverage was embedded within a medical plan compared with the alternative of a stand-alone dental plan The difference, however, in average expected out-of-pocket spending varied significantly for our 12 patient profiles Older children who are very high users of dental care, for example, have lower expected out-of-pocket costs under a stand-alone dental plan For the vast majority of other age groups and dental care use profiles, the reverse holds Conclusions Our results show that embedding dental coverage within medical plans, on average, results in lower total financial outlays for child beneficiaries Although our results are specific to the federally facilitated marketplace, they hold lessons for both state-based marketplaces and the general private health insurance and dental benefits market, as well (J Pediatr 2016;■■:■■-■■) ental caries is the most common chronic disease among children in the US.1 Routine dental care is important in promoting children’s oral health Child dental care coverage is mandatory in Medicaid and the Children’s Health Insurance Program and is one of 10 essential health benefits under the Affordable Care Act (ACA) Still, disparities in dental care use between children insured publically and privately remain.2 The implementation of the child dental coverage mandate has been a challenge Private dental coverage traditionally has been provided separately from medical coverage through stand-alone dental plans (SADPs) The ACA maintained this separation Medical plans are not required to cover dental care for children if SADPs are available for purchase in the health insurance marketplaces Only 35.7% of medical plans offered in the 2015 marketplace included dental coverage for children.3 Because dental coverage has been separated from medical coverage and the purchase of an SADP typically is not required in the marketplace, dental coverage expansion under the ACA has been limited According to the most recent analysis, only 13.2% of children who obtained a medical plan in the federally facilitated marketplace (FFM) also obtained an SADP.4 Although some states, such as California, only offer medical plans that include dental coverage for children,5 this is not the norm.6 Thus, the number of children obtaining dental coverage is expected to be much lower than those with medical coverage, although no data are available yet Providing dental coverage through a separate plan also has implications for consumer financial protection Several provisions of the ACA limit consumer out-of-pocket spending, including premium subsidies, annual out-of-pocket maximums, and medical loss ratio restrictions on plans Many of these provisions not apply to SADPs For example, when dental coverage is obtained through a medical plan, premium subsidies partly offset the cost of dental coverage When dental coverage is obtained through an SADP, however, often it is not eligible for premium subsidies.7 In contrast, SADPs might be more effective at limiting consumer out-of-pocket spending on dental care because they have dental-only provisions For example, medical plans with embedded dental coverage might use a single medical/dental deductible whereas SADPs, by definition, have a dental-only deductible Depending on what dental care services are exempt from the common medical/dental deductFrom the Health Policy Institute, American Dental ible, this could have a significant impact on out-of-pocket dental care spending.8 Association, Chicago, IL Analysis from 2015 found that 95% of medical plans with embedded dental covResearch for this report is based partly on claims data compiled and maintained by Truven Health Analytics, erage offered in the state and federal marketplaces use a single medical/dental D ACA CCIIO FFM SADP Affordable Care Act Center for Consumer Information and Insurance Oversight Federally facilitated marketplace Stand-alone dental plan MarketScan Research Databases The views expressed by the authors not necessarily reflect those of the American Dental Association, and Truven Health MarketScan is not responsible for the conduct of the research or for any of the opinions expressed in this article The authors declare no conflicts of interest 0022-3476/$ - see front matter © 2016 Elsevier Inc All rights reserved http://dx.doi.org10.1016/j.jpeds.2016.11.045 FLA 5.4.0 DTD ■ YMPD8830_proof ■ December 15, 2016 THE JOURNAL OF PEDIATRICS • www.jpeds.com deductible.3 Under most of these plans, preventive services have first-dollar coverage and are exempt from the deductible Many other dental care services, such as orthodontia, however, are not exempt In this study, we examine the financial implications of obtaining children’s dental coverage through medical plans compared with SADPs, simulate total financial outlays for various patient profiles, and discuss policy implications of our findings Methods We collected medical plan and SADP data for the 2015 plan year from the Center for Consumer Information and Insurance Oversight (CCIIO)9,10 and Data.HealthCare.Gov.11 We collected data for 31 of the 37 states operating through the FFM in 2015 We restricted our analysis to states that offered medical plans with embedded child dental coverage (embedded plans), medical plans without child dental coverage (unembedded plans), and SADPs (Appendix; available at www.jpeds.com) There are FFM states that not meet these criteria and were excluded from our analysis For each plan, we first assessed which of the dental service categories were covered for children: preventive and diagnostic (ie, “check-up”), basic, major, and orthodontia We then categorized cost-sharing variables within each service category: deductible, out-of-pocket maximum, copayment, and coinsurance These variables have specific values for each of the categories of dental services, with spending applied first toward the deductible, when applicable, and then to applicable costsharing variables if a balance in total spending on a particular service category remains and the out-of-pocket maximum has not been reached (If the plan’s copayment amount is greater than a patient profile’s spending amount in a given service category, we use the copayment amount in full For example, if the patient profile’s basic category spending amount was $5, but the copayment amount was $10, we used the full $10 copayment.) Once a plan’s out-of-pocket maximum is reached, all additional dental services used in that plan year are considered as covered free of charge as long as the service falls under a category covered by the plan We matched data from the CCIIO and Data.HealthCare.Gov data sets by a common variable included in both data sets: Plan ID We drew deductible applicability, copayment amounts, and coinsurance amounts from CCIIO In some cases, the copayment or coinsurance variables contradict the deductible variable (For example, the deductible variable may indicate that the deductible does not need to be met before cost-sharing for a specific service category begins, but the copayment or coinsurance variable may indicate the opposite.) We consequently used the information from the copayment or coinsurance variables instead of the deductible variable, which in our view, is a more conservative approach We drew deductible amounts and out-of-pocket maximum amounts from Data.HealthCare.Gov for both embedded plans and SADPs Some embedded plans had a separate dental deductible and out-of-pocket maximum We conducted levels of review to determine which embedded plans have separate Volume ■■ deductibles and out-of-pocket maximums for child dental coverage First, we reviewed each embedded plan’s statement of benefits and coverage and each plan brochure for information on separate deductibles and out-of-pocket maximums for dental services Second, when we could not find conclusive information through plan documentation, we contacted insurance company personnel directly To estimate children’s dental care use patterns, we use “patient profiles” from previous research Ideally, we would use data on dental care use and spending under medical and dental plans obtained through the FFM, but these data are not yet available publicly We thus relied on previously published research on dental care use among children with private dental coverage12 to categorize children into distinct patient profiles based on age group and dental spending level Age groups include 1-6, 7-12, and 13-18 years as well as a combined category for aged 1-18 years Dental spending levels were grouped into quartiles, plus an additional category of “no dental care use” for those with no dental care use and an additional category of “all,” which averages across all beneficiaries Average annual dental spending for each of the patient profiles was estimated by multiplying the average use rate for each procedure by a fee In most cases, the total amount paid to providers was used as the fee For cases in which a dental procedure was not covered by a plan, the market rate was substituted as the fee as there is no payment to providers from the dental plan We estimate out-of-pocket spending and premium payments for our different patient profiles under every child dental coverage option available in the 31 FFM states we analyzed We report results for all ages combined (ie, 1-18 years of age), but results for specific age subgroups (1-6, 7-12, and 13-18 years of age) are available on request It is important to note, however, that the main conclusions from our analysis not vary substantially by age subgroups We report results for each dental spending quartile as well as for children with no dental care use at all We this because 28.8% of children with private dental coverage not have any dental claims within the year.12 We also report results for all children combined Because embedded plans often have a single medical and dental deductible, we must make assumptions regarding patient spending toward deductibles stemming from medical care use We take an extremely simple approach based on scenarios: the deductible is fully reached before the use of any dental care services, or the deductible is not fully reached We focus on 12 patient profiles in our analysis: levels of dental care use (no dental care use, quartiles through 4, and “all,” which is an average across all children regardless of use) and the deductible scenarios We estimated the monthly premium cost for embedded plans, unembedded plans, and SADPs by averaging each plan’s monthly premium across rating areas We annualize all premium amounts by multiplying the monthly amount by 12 We then estimate out-of-pocket spending for each patient profile under every dental coverage option available The options include every embedded plan, as well as every Vujicic and Yarbrough FLA 5.4.0 DTD ■ YMPD8830_proof ■ December 15, 2016 ORIGINAL ARTICLES 2016 unembedded plan paired with every SADP We distinguish “deductible met” and “deductible not met” under each embedded plan option Both CCIIO and Data.HealthCare.Gov data indicate that several SADP copayment amounts for service categories are unusually high.13 For some SADPs, the CCIIO file included an additional explanation that these copayment amounts indicate that certain service categories are exempt from the $350 out-of-pocket maximum In these cases, service categories were “value-added” services with separate payment structures For those plans in which the CCIIO file did not provide an additional explanation about unusually high copayment amounts, we used $100 as the cutoff point If the copayment was $100 or less, we assumed that the service category applied to the $350 out-of-pocket maximum If the copayment was more than $100, we did not apply spending under that service category to the $350 out-of-pocket maximum, treating it instead as a valueadded service category Based on a review of states’ essential health benefits benchmark plans,14 we have reason to believe that some of these high copayment amounts again reflect service categories that are treated as “value-added” service categories Consumers who use such plans are thus responsible for service costs greater than $350 We attempted to contact the companies offering these plans to better understand the cost-sharing facing consumers We also contacted CCIIO about these plans, and they are working to clarify this issue in future plan years (we contacted CCIIO about these plans in January 2016.) In all instances in which we considered a service category “valueadded,” we did not apply spending to the $350 out-of-pocket maximum Rather, we charged the full copayment amount indicated by the plan to the consumer For example, if a plan indicated an orthodontia copayment of $3500, we added $3500 to the consumer’s out-of-pocket total Some plans had orthodontia lifetime spending limits Thus, we created a variable entitled “Orthodontia Lifetime Limit” and applied this limit to the consumer when applicable Once this limit was reached, all additional spending on orthodontia services was charged to the consumer For simplicity, we assumed all services within a category were delivered during one appointment Thus, copayments and coinsurance are only applied once We present results aggregated across the 31 FFM states We also present results for states, Georgia and Pennsylvania, as case studies to illustrate the potential for variation in total financial outlays across individual plans within a particular state Results Overall, we analyzed 1039 embedded plans, 2703 unembedded plans, and 583 SADPs Figure and the Table summarize our main findings Figure shows the distribution of estimated total financial outlays, which are composed of medical and dental plan premiums and out-of-pocket spending on dental care, under the alternative channels through which children Figure Distribution of total annual financial outlays (premiums plus out-of-pocket spending on dental care) under alternative child dental coverage options available in the FFM Total financial outlays are calculated for every plan and then averaged across plans within each of the options Analysis is for children aged 1-18 years and includes children assumed to have no dental care use within the year Estimating Premium and Out-of-Pocket Outlays Under All Child Dental Coverage Options in the Federally Facilitated Marketplace FLA 5.4.0 DTD ■ YMPD8830_proof ■ December 15, 2016 THE JOURNAL OF PEDIATRICS • www.jpeds.com Volume ■■ Table Average total annual financial outlays (premiums plus out-of-pocket spending on dental care) under alternative child dental coverage options 31 FFM states Embedded plan, deductible not met before use of dental care services Embedded plan, deductible met before use of dental care services Unembedded plan + SADP Georgia Embedded plan, deductible not met before use of dental care services Embedded plan, deductible met before use of dental care services Unembedded plan + SADP Pennsylvania Embedded plan, deductible not met before use of dental care services Embedded plan, deductible met before use of dental care services Unembedded plan + SADP All No dental spending First quartile Second quartile Third quartile Fourth quartile $2158 $2010 $2352 $1881 $1881 $2101 $1971 $1929 $2212 $1985 $1899 $2251 $2075 $1920 $2297 $2795 $2196 $2564 $2213 $1956 $2167 $1876 $1876 $2032 $1976 $1917 $2064 $2067 $1928 $2072 $2206 $1945 $2109 $3062 $2079 $2328 $2244 $2179 $2359 $1526 $1526 $2139 $1927 $1907 $2243 $2140 $2101 $2272 $2198 $2133 $2314 $2704 $2483 $2488 can obtain dental coverage in the FFM The Table summarizes average total financial outlays for various patient profiles Under the embedded plan option, assuming the deductible is not met before the use of dental care services, total financial outlays averaged across all plans in all 31 states are estimated at $2158 per year Assuming the medical deductible is met before the use of dental care services, estimated total financial outlays under the embedded plan option average $2010 per year Under the option of purchasing an unembedded plan plus an SADP, estimated total financial outlays average $2352 per year In aggregate, regardless of whether the deductible is met before the use of dental care services, estimated financial outlays are, on average, lower under the embedded plan option Decomposing financial outlays under the embedded plan option, the average annual premium is $1881 Under the unembedded plan plus SADP option, the average annual premium is $2101 Estimated out-of-pocket spending on dental care averages $277 per year under the embedded plan option when the deductible is not met before the use of dental care Under the assumption that the deductible is met, this drops to $130 per year Under the unembedded plus SADP option, estimated out-of-pocket spending on dental care averages $227 per year Figure also shows that there is considerable variation in estimated total financial outlays within each dental coverage option Figure shows the distribution of estimated total financial outlays separated by patient profile The patterns are consistent across patient profiles (ie, “low” dental care users and “high” dental care users) and are in line with aggregate findings in Figure Financial outlays are predicted to be greatest under the unembedded plan plus SADP option The exception is for the fourth quartile of dental care users, in which financial outlays are estimated to be greatest under the embedded plan option when the deductible is not met before the use of dental care (Table) In other words, for very high dental care but low medical care users, the unembedded plus SADP option has, on average, lower estimated total financial outlays Similar to the aggregate results, there is also considerable variation in estimated financial outlays across plans for the same patient profile Figure shows data specific to states: Georgia and Pennsylvania The pattern of total financial outlays is different in these states For example, in Georgia, there is much less variation in estimated financial outlays across plans compared with Pennsylvania Another difference is that in Georgia, financial outlays are greatest, on average, under the embedded plan option when the deductible is not met before the use of dental care (Table) This means that for moderate or high dental care users and low medical care users, it is less expensive, on average, to obtain dental coverage via SADPs In contrast, in Pennsylvania, the unembedded plus SADP option is, on average, most expensive for all patient profiles In both states, however, for children expected to use little or no dental care within the year, or for children expected to meet their deductible before the use of dental care, estimated financial outlays are greatest under the unembedded plus SADP option The Table summarizes average total financial outlays by patient profile in Georgia and Pennsylvania Discussion Our analysis yields main conclusions First, total estimated financial outlays are, on average, greater when child dental coverage is purchased through a SADP compared with when it is obtained through a medical plan Obtaining dental coverage through medical plans is less expensive This finding holds even in the case in which the deductible is not met before the use of dental care Furthermore, in only of 12 patient profiles, SADPs entail lower financial outlays than embedded plans: for high dental care users when the deductible is not met before dental care use Second, there is wide variation in estimated financial outlays across individual plans within a particular state This is true for all patient profiles and whether dental care is obtained by embedded plans or SADPs Variation is driven both by differences in premiums as well as out-of-pocket payments for dental care services Further research is needed to understand the extent to which this variation can be explained by plan characteristics beyond those we have analyzed Third, and most important in our view, information on dental coverage options is difficult to navigate within the FFM Vujicic and Yarbrough FLA 5.4.0 DTD ■ YMPD8830_proof ■ December 15, 2016 ORIGINAL ARTICLES 2016 Figure Distribution of total annual financial outlays (premiums plus out-of-pocket spending on dental care) under alternative child dental coverage options available in the FFM by patient profile Total financial outlays are calculated for every plan and then averaged across plans within each of the options for each quartile Analysis is for children aged 1-18 years First quartile does not include children with no dental care use within the year It would be difficult for consumers to make well-informed decisions regarding the purchase of dental coverage because transparent, simple, easy-to-navigate information is not available Research from the consumer perspective confirms this.15 There could be systematic differences between embedded plans and SADPs with respect to nonfinancial aspects, such as choice of dental care providers and quality of services, which are important to consumers We not examine these issues in our analysis, and we are not aware of research in this area Other research suggests that premium arrangements could be a key driver of our findings One study found that embedding dental coverage within medical plans is estimated to increase premiums, on average, by about $7 per month per child.5 SADP premiums, in comparison, are 3-4 times greater.16 There are important policy implications stemming from our analysis The implementation of the child dental coverage mandate under the ACA has been complicated substantially by allowing SADPs in the marketplace This approach essentially separated insurance coverage and allowed medical plans to exclude coverage of child dental services There is compelling evidence that this has limited the expansion of dental coverage under the ACA.4 Our analysis indicates that from the consumer perspective, total financial outlays are on average, lower under embedded plans than SADPs Taken together, this strongly suggests that including dental care services within medical plans would not only address the dental coverage expansion issue but also could lower total financial outlays on dental care for most consumers We reviewed deductible arrangements under embedded plans These provisions impact out-of-pocket dental spending significantly For example, in cases in which there is a single deductible for medical and dental care services, a high dental care but low medical care user will experience relatively high out-of-pocket dental costs For a high dental care, high medical Estimating Premium and Out-of-Pocket Outlays Under All Child Dental Coverage Options in the Federally Facilitated Marketplace FLA 5.4.0 DTD ■ YMPD8830_proof ■ December 15, 2016 THE JOURNAL OF PEDIATRICS • www.jpeds.com Volume ■■ Figure Distribution of total annual financial outlays (premiums plus out-of-pocket spending on dental care) under alternative child dental coverage options available in Georgia and Pennsylvania Total financial outlays are calculated for every plan and then averaged across plans within each of the options for each state Analysis is for children aged 1-18 years and includes children assumed to have no dental care use within the year care user, the opposite effect is expected: out-of-pocket spending on medical care can be thought of as “consuming” the deductible, limiting out-of-pocket spending on dental care If embedded plans use a separate dental deductible, however, the link between medical care use and out-of-pocket spending on dental care is broken Thus, if more embedded plans had a separate dental deductible, our results would change to favor embedded plans over SADPs even more We believe that policymakers should consider putting provisions in place that encourage embedded plans to provide a separate dental deductible According to the most recent data, only 5% of embedded plans have a separate dental deductible.3 Our analysis has several limitations At the time of this review, we were unable to ascertain conclusively why some SADPs have copayment amounts for some service categories that exceed $350 Thus, we created assumptions about how these plans work and their impact on consumer out-of-pocket costs Second, our dental care use and spending profiles are based on dental claims data among children with employer-sponsored private dental coverage in 2014 Children with private dental coverage may have different oral health needs than children obtaining dental coverage through the FFM Although dental claims data from plans sold through the FFM are not yet publicly available, there is strong evidence to suggest those enrolling in health insurance through the FFM are poorer17,18 and sicker19 than those with employer-sponsored coverage Thus, children obtaining dental coverage through the FFM may have greater dental care needs, on average, than children with employer-sponsored private dental coverage who are the basis for our patient profiles Finally, in several cases we could not confirm whether an embedded plan had a separate deductible and out-of-pocket maximum for child dental services; in these cases, we assumed that the embedded plan had neither Thus, we may have overstated the out-of-pocket costs to the consumer This conservative approach likely underestimated the potential cost savings under an embedded plan Urgent for policymakers to address is the need for some type of choice assistance tool, such as an online calculator, within the FFM to help consumers navigate dental coverage choices There is evidence that consumers are confused by dental coverage options in the FFM.15 Our analysis shows significant variation in expected financial outlays across plans for the same patient profile A consumer choice tool that helps predict outof-pocket dental spending for each dental coverage option would inform decision making Such a tool could be precalibrated to the “average” patient profile or could be designed to allow consumers to select from different patient profiles ■ We thank Krishna Aravamudhan, BDS, MS (American Dental Association), for input on the methodology and overall guidance; and Brittany Harrison (American Dental Association) for editorial assistance Submitted for publication Aug 30, 2016; last revision received Oct 24, 2016; accepted Nov 10, 2016 Reprint requests: Cassandra Yarbrough, MPP, Health Policy Institute, American Dental Association, 211 E Chicago Avenue, Chicago, IL 60611 E-mail: yarbroughc@ada.org References Clark M, Slayton R; Section on Oral Health Fluoride use in caries prevention in the primary care setting Pediatrics 2014;134:626-33 Nasseh K, Vujicic M Dental care utilization steady among working-age adults and children, up slightly among the elderly Chicago (IL): American Dental Association; 2016 http://www.ada.org/~/media/ADA/ Science%20and%20Research/HPI/Files/HPIBrief_1016_1.pdf Accessed October 18, 2016 [Internet], Health Policy Institute Research Brief Vujicic and Yarbrough FLA 5.4.0 DTD ■ YMPD8830_proof ■ December 15, 2016 ORIGINAL ARTICLES 2016 Yarbrough C, Vujicic M, Nasseh K More dental benefits options in 2015 health insurance marketplaces Chicago (IL): American Dental Association; 2015 http://www.ada.org/~/media/ADA/Science%20and%20 Research/HPI/Files/HPIBrief_0215_1.ashx Accessed August 9, 2016 [Internet], Health Policy Institute Research Brief American Dental Association 2016 take-up rate of stand-alone dental plans in healthcare.gov Chicago (IL): The Association; 2016 http://www.ada.org/ ~/media/ADA/Science%20and%20Research/HPI/Files/HPIgraphic _0416_3.pdf?la=en Accessed August 9, 2016 [Internet], Health Policy Institute Infographic Nasseh K, Yarbrough C, Vujicic M Including child dental benefits in medical plans in California had limited impact on premiums Chicago (IL): American Dental Association; 2015 http://www.ada.org/~/media/ ADA/Science%20and%20Research/HPI/Files/HPIBrief_0515_1.ashx Accessed August 9, 2016 [Internet], Health Policy Institute Research Brief Whitener K, Volk J, Miskell S, Alker J Children in the marketplace Washington (DC): Georgetown University Health Policy Institute Center for Children and Families; 2016 http://ccf.georgetown.edu/wp-content/ uploads/2016/06/Kids-in-Marketplace-final-6-02.pdf Accessed August 10, 2016 [Internet] Reusch C A rule change that would make dental coverage more affordable Washington (DC): Children’s Dental Health Project; 2016 https:// www.cdhp.org/blog/403-a-rule-change-that-would-make-dental-coveragemore-affordable Accessed August 10, 2015 [Internet] Reusch C Greater transparency needed on dental coverage provided by health plans Washington (DC): Children’s Dental Health Project; 2014 https://www.cdhp.org/blog/261-greater-transparency-needed-on-dentalcoverage-provided-by-health-plans Accessed August 10, 2016 [Internet] Center for Consumer Information and Insurance Oversight Health insurance marketplace public use files Baltimore (MD): Centers for Medicare & Medicaid Services; 2015 https://www.cms.gov/CCIIO/Resources/ Data-Resources/marketplace-puf.html Accessed November 18, 2015 [Internet] 10 Center for Consumer Information and Insurance Oversight Benefits and cost sharing public use file data dictionary Baltimore (MD): Centers for Medicare & Medicaid Services; 2015 https://www.cms.gov/CCIIO/ Resources/Data-Resources/Downloads/2014-Benefits-Cost-Sharing-DataDictionary.pdf Accessed October 21, 2016 [Internet] 11 Centers for Medicare & Medicaid Services Data.HealthCare.gov Baltimore (MD): Centers for Medicare & Medicaid Services https:// data.healthcare.gov Accessed November 23, 2015 [Internet] 12 Yarbrough C, Vujicic M, Aravamudhan K, Schwartz S, Grau B An analysis of dental spending among children with private dental benefits Chicago (IL): American Dental Association; 2016 http://www.ada.org/~/media/ ADA/Science%20and%20Research/HPI/Files/HPIBrief_0316_3.pdf? la=en Accessed February 16, 2016 [Internet], Health Policy Institute Research Brief 13 HealthCare.Gov Out-of-pocket maximum limit Baltimore (MD): Centers for Medicare & Medicaid Services; 2016 https://www.healthcare.gov/ glossary/out-of-pocket-maximum-limit/ Accessed October 21, 2016 [Internet] 14 Center for Consumer Information and Insurance Oversight Information on essential health benefits (EHB) benchmark plans Baltimore (MD): Centers for Medicare & Medicaid Services; 2016 https://www.cms.gov/ cciio/resources/data-resources/ehb.html Accessed October 21, 2016 [Internet] 15 American Dental Association Millennials struggle to navigate the dental options on healthcare.gov Chicago (IL): American Dental Association; 2016 http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/ Files/HPIgraphic_0516_1.pdf?la=en Accessed August 9, 2016 [Internet], Health Policy Institute Infographic 16 National Association of Dental Plans 2014 state of the dental benefits market Dallas (TX): NADP; 2015 17 Office of the Assistant Secretary for Planning and Evaluation Health insurance marketplaces 2016 open enrollment period: final enrollment report Washington (DC): U.S Department of Health and Human Services; 2016 https://aspe.hhs.gov/health-insurance-marketplaces-2016-open-enrollmentperiod-final-enrollment-report Accessed October 18, 2016 [Internet] 18 The Henry J Kaiser Family Foundation Employer-sponsored coverage rates for the nonelderly by federal poverty level (FPL) Menlo Park (CA): KFF; 2015 http://kff.org/other/state-indicator/rate-by-fpl-2/ ?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22, %22sort%22:%22asc%22%7D Accessed October 18, 2016 [Internet] 19 Blue Cross Blue Shield Newly enrolled members in the individual health insurance market after health care reform: the experience from 2014 and 2015 Washington (DC): BCBS; 2016 https://bluehealthintelligence com/engine/files/Newly_Enrolled_Individuals_After_ACA.pdf Accessed October 18, 2016 Estimating Premium and Out-of-Pocket Outlays Under All Child Dental Coverage Options in the Federally Facilitated Marketplace FLA 5.4.0 DTD ■ YMPD8830_proof ■ December 15, 2016 THE JOURNAL OF PEDIATRICS • www.jpeds.com Volume ■■ Appendix States operating through the FFM and included in our analysis Number of plans by state States Alabama Arizona Delaware Florida Georgia Illinois Indiana Iowa Kansas Louisiana Maine Michigan Mississippi Missouri Nebraska Nevada New Hampshire New Jersey North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania South Dakota Tennessee Texas Utah Virginia Wisconsin Wyoming Embedded medical plans Unembedded medical plans SADPs 19 82 15 78 43 58 19 57 15 11 20 16 12 60 26 50 19 110 30 84 10 51 99 21 10 106 10 155 116 200 70 82 56 12 50 153 45 68 30 58 32 53 30 174 89 121 118 11 21 335 107 45 316 22 13 22 11 32 25 14 16 15 51 12 15 22 29 12 12 22 20 19 25 30 15 36 26 20 16 12 States were included in our analysis if all plan types were available to consumers for purchase The states operating through the FFM in 2015 and excluded from our analysis are Alaska, Arkansas, Montana, New Mexico, South Carolina, and West Virginia 7.e1 Vujicic and Yarbrough FLA 5.4.0 DTD ■ YMPD8830_proof ■ December 15, 2016 ... medical Estimating Premium and Out- of- Pocket Outlays Under All Child Dental Coverage Options in the Federally Facilitated Marketplace FLA 5.4.0 DTD ■ YMPD8830_proof ■ December 15, 2016 THE 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Estimating Premium and Out- of- Pocket Outlays Under All Child Dental Coverage Options in the Federally Facilitated Marketplace FLA 5.4.0 DTD ■ YMPD8830_proof ■ December 15, 2016 THE JOURNAL OF PEDIATRICS... https://bluehealthintelligence com/engine/files/Newly_Enrolled_Individuals_After_ACA.pdf Accessed October 18, 2016 Estimating Premium and Out- of- Pocket Outlays Under All Child Dental Coverage Options in the Federally