Affordable Care Act

What are Pediatric Essential Health Benefits?


In discussions about the Affordable Care Act you may have heard mention of pediatric Essential Health Benefits, but wondered what they are and how do they pertain to health care reform.

Under the ACA, there are 10 Essential Health Benefits (EHBs) that must be offered to most individuals and small employer groups both inside and outside marketplace exchanges, unless the medical plan is grandfathered. One of these EHBs is pediatric dental and vision benefits, which will be offered within state insurance exchanges and to most small employers outside the exchanges.

Medical coverage offered within an exchange must include a pediatric vision and dental benefit. If the same exchange offers a stand-alone dental plan providing the required pediatric dental benefit, the medical plan has the option to exclude that benefit.

In an exchange marketplace, medical plans with dental or vision coverage likely will cover children only. This means that adults who purchase pediatric dental and vision coverage for dependents will need to purchase these benefits separately to maintain their own health. Adults and dependents purchasing dental or vision through an exchange or EHB package could then have different benefit plans than their children.

Here are a few other key points:
• When the pediatric dental benefit is offered in an exchange on a stand-alone basis, employers and individuals are not required to purchase it (by federal law, but a few states may say otherwise).
• 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 that extends beyond 2013 may be impacted significantly if their coverage is moved to an EHB or exchange. Some plans may offer additional wrap-around options with pediatric orthodontia coverage, but benefits and providers may differ from existing plans.
• Costs for services from a dentist outside a particular exchange plan’s network will not apply to a limit on the amount of out-of-pocket costs an insured pediatric member is required to assume before the plan pays in full for covered services.

Benefit selections within an exchange will be limited to set plan designs and selected insurance carriers. Employers will not be able to customize plans.

Learn more about pediatric Essential Health Benefits.