Affordable Care Act

Pediatric Essential Health Benefits (EHB)

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Under the Affordable Care Act, there are 10 categories of Essential Health Benefits that medical carriers must offer to most individuals and small employer groups both inside and outside public exchanges. One of these categories includes pediatric dental and vision benefits for those up to age 19.

Medical coverage must include pediatric vision benefits.

Within the exchange the medical plan can exclude dental benefits if the exchange offers a stand-alone dental plan providing exchange-certified pediatric dental benefits.
In the private market the medical plan can exclude dental benefits if the medical carrier is reasonably assured that individuals have obtained exchange-certified pediatric dental benefits through a stand-alone dental plan.

Things to Keep in Mind

  • Adult coverage—In a public exchange, medical plans with dental coverage likely will cover only those under age 19 (in most states). Adults who purchase pediatric dental coverage for their kids will need to purchase their own dental plan separately. This means adults and dependents with dental through an exchange or EHB package could have different benefit plans, dental networks and insurance carriers.
  • No purchase required—If the pediatric dental benefit is offered in an exchange on a stand-alone basis, separate from the medical plan, employers and individuals are not required to purchase it (by federal law, but a few states may say otherwise).
  • Orthodontia treatment changes—Traditional pediatric orthodontia coverage may not be available in state exchanges or EHB packages. Currently only orthodontia declared medically necessary (for example, coverage related to a cleft palate condition) would be covered as an EHB. Children undergoing a traditional orthodontia treatment program may be impacted significantly if their coverage is moved to an EHB or exchange plan. Some plans may offer additional options with pediatric orthodontia coverage, but benefits and providers may differ from existing plans.
  • Out-of-network treatment fees impacted—Costs for services from a dentist outside a particular exchange plan’s network will not apply to the plan’s out-of-pocket maximum, which is the amount of out-of-pocket costs an insured pediatric member is required to assume before the plan pays in full for covered services.
  • No customization of plans—Benefit selections within an exchange will be limited to set plan designs and selected insurance carriers. Employers will not be able to customize plans.

Additional Information

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