If you’re confused by the new pediatric dental requirements, you’re not alone. Here’s a rundown of how the ACA and HHS regulations impact pediatric dental coverage, with Colorado-specific details:
- The ACA defines pediatric dental coverage as one of the ten essential health benefits (EHBs) that must be covered on all new individual and small group plans in 2014. But the text of the law makes it clear that unlike the other nine EHBs, pediatric dental benefits do not have to be integrated with medical plans (see section 1302 of the ACA, starting on page 59, and specifically page 61).
- If a state exchange allows stand-alone pediatric dental policies to be sold within the exchange, medical policies sold in the exchange are not required to include pediatric dental. Some medical plans will cover pediatric dental, others will not. But as far as the exchange is concerned, all applicants have access to pediatric dental because there are stand-alone plans available that can be purchased in conjunction with a medical plan that does not cover pediatric dental.
- Connect for Health Colorado (the state exchange) does have stand alone pediatric dental plans available. So there are medical plans in the exchange that do not cover pediatric dental.
- If you purchase a stand-alone pediatric dental plan in addition to a medical plan, you’ll have two separate premiums and two separate out-of-pocket maximums. The out-of-pocket costs from your pediatric dental plan will not count towards the total maximum out of pocket on your health plan.
- Colorado chose CHP+ as the benchmark plan for pediatric dental in Colorado. The annual out-of-pocket limit on a stand-alone dental plan in Colorado is capped at $700 for one child and $1400 for all children in a family. Pediatric dental coverage has two actuarial value levels: Low (pays roughly 70% of covered costs) and High (pays roughly 85% of covered costs).
- If your pediatric dental coverage is integrated with your medical coverage, your pediatric dental out-of-pocket amounts count towards the overall out-of-pocket maximum for the policy.
- If you receive a premium tax credit, it is applied first to your medical coverage (which can be a medical plan that has embedded pediatric dental coverage). The credit is only applied to a stand-alone dental plan if there is some left over after paying for the health plan (eg, perhaps you qualify for a subsidy that would pay most of the cost of a silver plan, and you opt instead for the lowest-cost bronze plan).
- You are not required to have pediatric dental coverage on your plan if you buy your coverage through Connect for Health Colorado. Some states are requiring the purchase of pediatric dental within the exchange, but Colorado is not. You can opt to purchase just a medical pl
an that does not have embedded pediatric dental. The exchange will remind you of the availability of pediatric dental coverage when you apply, but you are not required to purchase a plan. - If you shop outside of the exchange, you are required to have pediatric dental coverage. This is true regardless of whether there are children on your policy (see last bullet point for more on this – you can get a zero cost plan if there are no children on your policy). There are off-exchange medical plans available without embedded pediatric dental, but they can only be sold to applicants when the carrier is “reasonably assured” that the applicant has other Exchange-certified (can be purchased off exchange) pediatric dental coverage in place (see page 12853 of this HHS Regulation in the Federal Register).
- If you shop off exchange, carriers are required to ask you whether you have separate pediatric dental coverage (here’s an example questionnaire from Anthem Blue Cross Blue Shield). If you do not, they can only sell you a policy that has embedded pediatric dental coverage.
- There is no penalty for not having pediatric dental. And carriers are compliant with the law as long as they follow the rules described above for on and off exchange purchases.
Stand alone pediatric dental plans are required to comply with some ACA rules: they may not impose annual or lifetime limits, and they must comply with out-of-pocket limits. However, they are not required to cover all dental procedures (for example, orthodontia is generally not covered unless it is “medically necessary” – an example would be orthodontic treatment following surgery to repair a cleft pallet).- Tip: If you enroll off-exchange, everyone on the application is over age 19, and you attest that you do not have pediatric dental coverage from another carrier, your carrier will enroll you in a $0 premium “adult pediatric” dental plan. The coverage on this plan is for children only, so adults enrolled on it will have no dental coverage. But they also will not have to pay premiums for pediatric dental coverage if they have no children on the plan (off-exchange applicants who do have children and do not have pediatric dental from another carrier will have to enroll in a medical plan that has embedded pediatric dental coverage, which includes a higher premium).
