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HHS issues rules on insurance exchanges

March 15, 2012

By Craig Palmer, ADA News staff

Washington—Regulations setting minimum standards for the new marketplace of health insurance exchanges offer guidance on the dental coverage that may be offered. Stand-alone dental plans available in the exchanges must offer child-only coverage, for example.

The Department of Health and Human Services March 12 regulations implement the 2010 health reform law establishing competitive marketplaces for individuals and small employers to directly compare available private health insurance options, including dental benefits, on the basis of price, quality and other factors. The exchanges will become operational in 2014.

"We accept the recommendation of commenters [on proposed regulations] that cost-sharing limits and the restrictions on annual and lifetime limits should apply to stand-alone dental plans for coverage of the pediatric dental essential health benefit," HHS said in a 644-page regulatory statement issued as a final rule with certain "interim final" provisions and promises of further detail later.

"Any issuer covering pediatric dental services as part of the essential health benefits must do so without annual or lifetime limits as defined under the Affordable Care Act and its implementing guidance, even if such issuers are otherwise exempt from the provisions of Subparts I and II of Part A of Title XXVII of the PHS Act (including PHS Act section 2711) under PHS Act section 2722.

"We note that for any benefit offered by a stand-alone dental plan beyond those established under section 1302(b)(I)(J) of the Affordable Care Act, standards specific to the essential health benefits would not apply. We plan to provide more detail in the future regarding how a separately offered pediatric dental essential health benefit would be considered under standards that apply to a full set of essential health benefits."

The regulations also set a standard for exchanges "to ensure sufficient access to pediatric dental coverage. By 'sufficient access' we mean to convey that exchanges should ensure that, when combined, stand-alone dental plans have the capacity (in terms of solvency and provider network) to provide child-only coverage to all potential children enrolling in coverage through the exchange."

The Association offered a summary of the HHS rule and continues to review information pertaining to the exchanges as it is released to determine the effect for individual dental practices once the exchanges are up and running in 2014. The Association offers member information on the exchanges in various venues including ada.connect at http://connect.ada.org, a March 14 and other "issues alerts," the advocacy site at ada.org, the State Legislative Report, annual session, conference calls and webinars and the ADA News in print and online at ada.org.