Like most 3-year-olds, Mariah Venable is a climber and a jumper. And sometimes she lands on her face instead of her legs.
Her acrobatic attempts have cost her two baby teeth already — and have left her mother thankful she has good dental insurance.
"You have to start on their teeth early so they don't have issues when they get older," said Cheryl Venable, who recently took her daughter — smiling wide through the gaps — to a city clinic that offers dental care to low-income and uninsured families.
Health advocates are concerned that new guidance from the Obama administration could make it more expensive for some low- and middle-income parents to pay for dental insurance for their children once the new health care law takes effect next year.
The rules could add up to $2,000 a year in out-of-pocket costs — which, advocates say, could lead some parents to forgo the coverage.
The possibility that some families could be priced out of the dentist's chair is a particularly raw issue in Maryland, where state and local officials have worked to improve pediatric access to dental care since a Prince George's County boy died in 2007 from an untreated tooth infection.
"This could cause a serious burden to families and may deny people affordable pediatric dental coverage," said Sen. Ben Cardin, a Maryland Democrat who for years has sought to improve access to dental care for children and who is leading an effort to alter the administration's guidance.
Insurance trade groups — including those that represent health and dental insurers — say the federal guidance reflects the reality of the way insurance is sold. One industry spokesman said changing the rules the way Cardin and some advocates hope would represent an "administrative nightmare."
About 25 percent of children in the U.S. have untreated tooth decay, according to the Kaiser Family Foundation. While Medicaid and government insurance programs for children do provide dental benefits, nearly one-third of children whose parents have private health insurance are not covered.
The proposals, from the Department of Health and Human Services, would affect only families who buy insurance through exchanges, or marketplaces, created by President Barack Obama's health care law.
The president signed the Affordable Care Act into law three years ago Saturday, but the exchanges — a centerpiece of the controversial act — don't begin until next year.
As many as 25 million people nationwide are expected to buy insurance through the exchanges by 2022.
Congress, responding in part to the death of 12-year-old Deamonte Driver, included pediatric dental coverage as an "essential health benefit" that insurance companies must provide for policies sold in the exchanges.
Prescription drugs, emergency services and newborn care were also included in those minimum requirements.
The law sets a maximum out-of-pocket cost for health plans sold in the exchanges — $5,590 for an individual, for instance — that can be reduced depending on a patient's income.
But the law also allows separate, stand-alone dental plans to be offered in the exchanges. If those separate plans are offered, the companies selling regular health insurance do not have to include dental coverage as part of their own policies.
The problem for advocates is that federal officials have determined that those separate pediatric dental plans may charge a maximum of $1,000 per child and up to $2,000 for a family in out-of-pocket costs, in addition to the cost of the health plan.
That added expense, Cardin says, was not what lawmakers intended.
Advocates are concerned that the structure provides no incentive for health insurance companies to provide dental coverage and that consumers choose not to buy an expensive stand-alone plan.
"Most will not take the insurance because they're going to see it as an additional cost, " said Dr. Patricia L. Bell-McDuffie, the director of oral health services for the Baltimore City Health Department. "From a professional point of view, it's a no-brainer to have pediatric dental as part of regular health insurance."
Katie Bradford, a 31-year-old Baltimore woman, brought her daughter into the city clinic Thursday for a regular checkup — exactly the kind of preventive effort Bell-McDuffie and other dentists say staves off the potential for bigger, more expensive problems down the line.
Bradford has dental coverage for herself and her daughter, Karmen, who is 1.
"It's needed," Bradford said. "Good dental care starts early."
But insurance industry officials say most health and dental policies already are sold separately, which lets people choose whether they want to pay for additional coverage. And they argue that it would be too complicated to combine two different plans under one set of premiums, deductibles and co-pays.
Evelyn F. Ireland, executive director of the National Association of Dental Plans, said in an e-mail that her group, too, is concerned about keeping dental coverage affordable. She was not available to answer questions about the federal guidance.
In a December letter to the federal health department, Ireland said the group supports the separate out-of-pocket costs for dental plans. Combining health and dental plans under one price tag, she argued, "is administratively complex and cost¿prohibitive and should be avoided to keep premiums low."
Robert Zirkelbach, a spokesman for America's Health Insurance Plans, the health insurance trade group, described the idea of merging health and dental plans on a broad scale as a nightmare.
The group also sought the $1,000 per-child maximum, arguing that the threshold was actuarially "reasonable and achievable."
Advocates worry the price might be too high and the process too complicated. Leigh Cobb, health policy director for the Maryland-based Advocates for Children and Youth, said legislation pending in the General Assembly would require a study to determine how many people are buying pediatric dental coverage.
If enrollment is low, state health officials could adjust the out-of-pocket maximums, Cobb said.
"The first mistake was saying there could be plans without pediatric dental coverage — it was a slippery slope," Cobb said. "We're very concerned …that this is really going to cost too much."
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