Pediatric Dental Benefits

Column 13-- Sept 22, 2013  Pediatric Dental Benefits


Q. Are dental or vision plans affected by the PPACA? (Patient Protection and Affordable Care Act, aka Health Care Reform or Obamacare)

A. Stand-alone or separate dental and vision plans are generally not impacted by PPACA requirements. These are plans that are separate from your medical plan.

Q. Doesn't PPACA require Qualified Health Plans (QHPs) to include pediatric oral and

vision care?

A. Yes. For plan years beginning on and after January 1, 2014, small group (under 50 employees)

and individual health plans must be a QHP. In order to be a QHP, the health plan must provide a prescribed set of benefits called Essential Health Benefits (EHB).  These benefits include pediatric services including oral and vision care.


Q. What is the pediatric oral and vision care EHB?

A. The pediatric oral EHB for each state is the pediatric dental benchmark plan for that state.

Generally for pediatric dental, the benchmark is either the Federal Employees Dental Vision

Insurance Plan (FEDVIP) or the state's CHIP plan. The pediatric vision benchmark plan for all

states is the FEDVIP plan.  Covered CA, our states Exchange has two standalone options with rates between $15 and $30 in our area.  The plans have no copayment for preventive services and varying copays for other services.  Be careful of the HMO products.  The provider lists are likely small.


Q. What is the maximum age for the pediatric dental and vision EHB?

A. The pediatric dental and vision EHB applies to children under age 19.


Q. How can health plans and health insurers meet the pediatric dental

EHB requirements?

A. Health plans for small groups and individuals can meet their pediatric dental EHB

requirement by any of three methods:

1. Offering the benchmark pediatric dental plan as part of the overall QHP (on and off a public


2. Offering the QHP without pediatric dental EHB on a public exchange where stand-alone pediatric

dental EHB plan(s) are available.

3. Offering a QHP without pediatric dental EHB outside of the public exchange provided the QHP

can demonstrate that the individual has obtained an exchange-certified stand-alone pediatric

dental EHB coverage.


Q. What does it mean for an individual or small group stand-alone pediatric dental plan

to be ACA compliant?

A. It must meet the following criteria:

• Provide the required pediatric dental EHB

• No lifetime or annual limits

• Reasonable out-of-pocket maximum (defined by the public exchange currently as $700 for one

child, $1,400 for two or more children for the federally facilitated exchange)

• Actuarial value: 85% high/70% low (This means that 85 or 70% of the premium dollars, depending

on the plan, must go back to the insured via benefits.)

Q. Can a small employer still offer stand-alone dental?

A. Yes. Remember, only QHPs are required to offer pediatric dental in order to meet the EHB

requirements. It is important to consider the following situations:

1. For larger groups (over 50 lives), you may offer dental just as you have in the past.

2. For smaller groups (50 or fewer lives), you have three options:

a. If pediatric dental is embedded in your medical plan, you can keep your stand-alone dental

as it is today.

b. If pediatric dental is embedded in your medical plan and you don't want to double cover

children, then you can look at a dental wrap plan that would not duplicate those benefits.

c. If pediatric dental isn't embedded in your medical plan, you can offer a stand-alone

pediatric dental plan.

Q. What does this mean for pediatric vision?

A. Pediatric vision must be included as part of an EHB compliant health insurance plan being offered

on or off a public exchange to individuals and small groups (in most states defined as 50 or fewer

lives for 2014 and 2015).

Q. Can I still offer stand-alone vision?

A. Yes. Remember, QHPs are only required to cover pediatric vision to meet EHB requirements.

Under current guidance, stand alone pediatric vision to meet the EHB requirements is generally not permitted.


Note: All information in this column is provided" to the best of my knowledge" subject to final regulation by the respective agencies.