The Affordable Care Act (ACA) has brought with it sweeping changes to benefits for small employers with 50 or fewer lives. One of the lesser highlighted changes made includes mandated requirements dental insurance.
Essential Health Benefits (EHB) must include pediatric services, including oral and vision. “Qualified” health plans for small groups must include 10 Essential Benefits in order to be deemed compliant. One of the Essential Health benefits includes pediatric oral care for children up to age 19.
The pediatric oral care EHB requirement can be fulfilled on and off exchange by a stand-alone dental plan. EHB requirements for pediatric oral care include:
- Separate, “reasonable” OOP maximum per child for stand-alone dental plans (federal is set at $700)
- Must include medically necessary orthodontia
Medical carriers can exclude pediatric oral care from the list of EHBs, as long as there is an exchange-certified dental plan covering the requirements.