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ACA dental coverage: must offer, may purchase

February 26, 2013

By Craig Palmer, ADA News staff

Washington—Insurers must offer pediatric dental coverage as an essential health benefit beginning in 2014, but consumers shopping through the new insurance exchanges won't necessarily have to buy it.

The final rule on standards related to essential health benefits mandates the offer of benefits defined by the Affordable Care Act as essential, including dental coverage, but does not require the purchase of the pediatric dental essential health benefit if the purchase is made through an exchange.

“This rule outlines standards to be applied both to the exchanges and insurance companies,” said an Association analysis of the regulations. “It also finalizes a timeline for qualified health plans to be accredited in federally facilitated exchanges (FFEs). Finally, the rule amends regulations providing a process for the recognition of additional accrediting entities. These standards apply only to the individual and small group markets, both inside and outside the exchange.”

• Issuers of qualified health plans are permitted to exclude the pediatric dental essential health benefit if a stand-alone dental plan is offered in the exchange, and nothing in the rule requires purchase of the full set of benefits. Consumers may purchase a medical plan that does not cover the pediatric EHB without buying a stand-alone dental plan;

• On the other hand, outside the exchange the rule requires the offer of all 10 benefit categories and purchase of the pediatric dental EHB by everyone in the individual and small group markets. Qualified health plans may offer a product that excludes the pediatric dental EHB if they are “reasonably assured” that such coverage is sold only to consumers who purchase pediatric dental coverage through an exchange-certified stand-alone dental plan.

Additional information and the Association's initial analysis of Patient Protection and Affordable Care Act Standards Related to Essential Health Benefits, Actuarial Value and Accreditation are posted at ADA Advocacy.

The insurance exchanges are scheduled to begin enrolling beneficiaries for federally subsidized coverage on October 1.