many adolescents. Others have imposed higher dollar caps and copayment requirements that impede access to dental services for adolescents from targeted working-poor families.

The American Dental Association (Edelstein, Schneider, and Laughlin, 2007) reports that 19 states have elected to cover dental services for all SCHIP beneficiaries through separate SCHIP plans, 8 through combination separate SCHIP and Medicaid plans, and 21 through Medicaid expansion or expansion look-alike designs. Medicaid expansion states are required to provide comprehensive EPSDT dental benefits to adolescents through age 19. All 27 states with full or partial separate dental plans cover basic diagnostic, preventive, and reparative services with minor exceptions, but a high proportion of these states do not cover prosthodontic (6 states), periodontic (7 states), and orthodontic services (14 states).

Private insurers About half of privately insured adolescents are likely to have coverage for dental services through employer-sponsored plans (The Kaiser Family Foundation and Health Research and Educational Trust, 2006; U.S. Bureau of Labor Statistics, 2006). Unfortunately, the scope of dental benefits is not documented in either of the referenced surveys, nor is cost-sharing information available.

Cost Sharing and Provider Participation

Out-of-pocket cost sharing, particularly in private plans, may deter individuals and families from seeking needed care. When families face high deductibles and copayments, they may be reluctant to attend to ongoing health care needs, leading to an increase in unmet needs (Buntin et al., 2005; Newhouse, 2004; Newhouse and the Insurance Experiment Group, 1993). Over the last decade, deductibles and out-of-pocket cost-sharing requirements have increased in private plans (Glied and Remler, 2005; Mercer Health and Benefits, 2007). Between 2003 and 2005, the share of firms that offered employees a high-deductible health insurance plan rose from 5 to 20 percent (The Kaiser Family Foundation and Health Research and Educational Trust, 2005).

Historically, public policies have been designed to keep out-of-pocket cost sharing in public programs low, although higher cost sharing is permitted under SCHIP than under Medicaid, and the Deficit Reduction Act of 2005 permitted more cost sharing in Medicaid. To date, no published study has examined the effects on adolescents of different copayment schedules in public programs.

In addition, having benefits with low cost sharing on paper does not always translate into access to services because providers may be unwilling to offer services under that type of insurance coverage. This is a particular

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