Insurance Broker Blog

Pediatric Dental and Non-Grandfathered Stand Alone Dental Plans...and More

As a dental insurance broker, you must be in-the-know about where dental requirements fall under the Affordable Care Act (ACA). Your clients likely have a lot of questions. 
Essential Health Benefits (EHB)
The 10 EHBs required to be covered under the ACA include:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care   

Pediatric Dental Services to be Covered

Secific services covered within the broader category vary state-to-state.

If the state didn’t make a selection between the state’s Children's Health Insurance Plan (CHIP) plan or the Federal Employee Dental and Vision Plan (FEDVIP), the pediatric plan automatically went to FEDVIP.  This chart lays out exactly how each state fell.

What about Non-Grandfathered Stand Alone Plans?

Must non-grandfathered stand alone dental plans include pediatric dental EHB? Check out our more guide, which provides a chart to answer this question.

In the meantime, here are some details: 

  • Small groups don't have to offer health insurance (through an exchange or not). But if a group elects to purchase health coverage outside of the exchange, the ACA requires that it contain all 10 EHBs.
  • Groups may offer a health insurance policy that does not include the pediatric EHB, but in order to meet ACA requirements, employers will need to “reasonably assure” the health plan issuer that all employees (and their dependents) have purchased ACA-compliant pediatric dental EHB coverage in the form of an exchange-certified Qualified Dental Plan (“QDP”). 
  • Individuals who purchase health coverage without an embedded pediatric dental EHB off-exchange must reasonably assure the medical carrier that they have such coverage through an exchange-certified QDP.

The information in this blog is based on Solstice's review of the national health care reform legislation and is not intended to provide legal advice. While we make every effort to present and update accurate information, interpretations of the reform legislation vary. The overviews provided here are intended as an educational tool only and should not be relied upon as legal or compliance advice.

The Ins-and-Outs of the ACA: Free Downloadable Broker Guide