Filling cavities in children's teeth is designated by law as one of 10 "essential benefits" in next year's federal health care overhaul.
But children's advocates say that the fine print shows that it's not all that essential after all.
Unlike other key medical services, California families considering the purchase of pediatric dental insurance next year:
Will not be fined for failing to acquire it.
Will not be eligible for federal subsidies to ease costs to low-income households.
Will not find an insurance policy on California's new health care exchange that combines kids' dentistry with coverage for the nine other essential health benefits, including hospitalization and prescription drugs.
The bottom line is that low-income families buying pediatric dental insurance through the state's online exchange, Covered California, will pay an extra monthly premium and potentially more out-of-pocket expenses.
Children's advocacy groups are pushing the state exchange to switch gears and embed medical care and kids' dental care into a single policy, with premiums cut by charging the same price to families with children and without.
Failure to do so would result in higher costs and less dental care to vulnerable youth who need it badly, according to Kathleen Hamilton of the Children's Partnership, a coalition of advocacy groups.
"The consequences of not getting dental care for kids run the gamut from missed school days and inadequate diets because children can't chew well to secondary infections and social malaise," Hamilton said. "It's chronic, it's serious and it's unfair."
Anthony Wright, director of Health Access California, said that dental problems as a child can lead to attention problems in school and medical problems that can last a lifetime.
"A little bit of coverage and care can go a long way," he said.
Pediatric dental care should be no different than other essential health services that not every age group or gender uses such as mammographies or prostate tests but whose costs are blended into premiums charged to all, Hamilton said.
"That's what drives affordability," she said.
But Assemblyman Dan Logue, R-Marysville, said that many older people with no children have a hard enough time paying for their own health care, much less subsidizing pediatric dental care.
"If we continue to ask people to pay for health care for everybody, I think you're going to see the system collapse," he said.
Children's dental insurance covers office visits, X-rays, exams, cleanings, oral surgery and services ranging from filling cavities to installing crowns until age 19. Deductibles will vary.
Covered California recently announced that it had chosen five firms to sell "stand-alone" pediatric dental coverage and one firm to sell a "bundled" plan that separately provides dental and health care coverage beginning Oct. 1.
Monthly premiums will range from about $10 to $40 per child, but purchase is not mandatory. Policyholders will pay separately for the dental plan and will incur up to $1,000 in annual out-of-pocket expenses per child.
For medical insurance, the exchange provides federal subsidies on a sliding scale to Californians with annual incomes ranging up to $45,960 for an individual and $94,200 for a family of four.
No subsidies are available for stand-alone or bundled pediatric dental coverage.
State Insurance Commissioner Dave Jones contends that Covered California is exceeding its authority by requiring insurers not to embed pediatric dental care into health care policies it sells on the exchange or in mirror proposals for the private market.
"What they're doing is contrary to the law and not in the best interests of children's access to dental care," Jones said.
Federal law requires that pediatric dental care be provided as one of 10 essential benefits, but it also allows firms offering medical-only coverage to sell on public exchanges if a stand-alone pediatric dental plan is available.
"The exchange has gone 20 steps further than that and has directed the health insurers and HMOs to pull embedded pediatric dental out of their health plans and health insurance, which is not allowed under federal or state law," Jones said.
Covered California has agreed to discuss concerns but not necessarily to change course.
Covered California spokesman Dana Howard said that requiring insurers to embed pediatric dental care would force families to buy such coverage, which the exchange cannot do unless Congress passes a mandate, he said.
Conversely, to accept insurance policies with and without embedded dental care would eliminate uniformity and make it more difficult for consumers to comparison shop, he said.
The California Dental Association supports Covered California's position not to embed pediatric dental care.
More than 90 percent of Californians who currently have dental coverage receive it through dental plans, not medical plans, CDA said.
Covered California's "decision offers the least disruption for families purchasing coverage for their children in the exchange and will allow parents to maintain their existing relationship with their dentist," CDA said in a written statement.
Insurance industry officials say that firms have a long history of offering separate plans for dentistry and health care, with separate tracking systems.
"Our biggest concern is that if the exchange changes the structure of how care is going to be delivered next year, insurers would have to reopen their entire offering and restructure it," said Nicole Kasabian Evans of the California Association of Health Plans. "They may not be able to make open enrollment" by Oct. 1.
Covered California has attracted a broad array of pediatric dental policies without requiring embedding, Howard said. "We're not certain whether we would have had that much choice trying to go the other way having all plans include a pediatric dental component," he said.
Stand-alone dental plans will be available at monthly prices as low as $9 per child in Los Angeles and $10 elsewhere. Separate rates may be set for families with multiple kids.
"We believe that's affordable, and that people will go ahead and purchase dental coverage because it's not going to be a heavy burden on them," Howard said.
But Hamilton and Jones said they were told by insurers that pediatric dental care could be embedded into medical coverage for much less: $6 per month for each child covered.
"What the exchange has done is take away that choice from families," she said.
Editor's Note: This story has been updated from print and online versions to clarify that the health exchange believes Congress, not the Legislature, would have to act for the health exchange to require insurers to include pediatric dental coverage in all offered medical plans. Updated at 6:05 p.m. July 10, 2013.
Call Jim Sanders, Bee Capitol Bureau, (916) 326-5538. Follow him on Twitter @jwsanders55.