Health insurance issuers that offer coverage in the individual or small group markets must provide “essential health benefits.” Essential health benefits include minimum benefits in 10 general categories, including pediatric dental care. The requirement to provide essential health benefits is effective for plan years beginning on or after January 1, 2014.
As a general rule, required pediatric dental benefits include coverage for routine exams, cleaning, fluoride, sealants, fillings, crowns, x-rays, and medically necessary orthodontics. Each state is permitted to select the specific details of its essential health benefits coverage by reference to one of a range of popularly selected plans offered in the state or as part of the federal employees health benefits program. Accordingly, the scope of pediatric dental benefits may vary from state to state. In order to be in compliance with the ACA, a plan must offer essential pediatric dental care to all persons under the age of nineteen; individual states will have the option of extending this requirement to persons beyond the age of 19 as they desire.
The Department of Health and Human Services (“HHS”) offers a limited exception. An insurer is not required to offer pediatric dental coverage if a stand-alone plan with this benefit is available in the marketplace. While this exception applies to plans offered both on and off the marketplace, insurers offering plans off the marketplace, which fail to provide pediatric dental coverage, must receive reasonable assurance that their enrollees have attained coverage through a separate stand-alone plan. The method for obtaining assurance is determined by the insurance issuer.
