Understanding Pediatric Essential Benefits

child at dentist office

The U.S. Department of Health and Human Services has mandated that as of January 1, 2014, insurance plans must include 10 categories of essential health care or services, and one of the core elements is pediatric oral and vision care for dependents.

These essential health benefits (EHBs) must be offered to individuals and small groups both inside and outside the new health insurance exchanges. The following are several important points to know about the requirements for vision and dental care for children:

  • Pediatric dental and vision benefits are required for state insurance exchange plans and plans offered to small employers with non-grandfathered medical plans outside exchanges. Both state health insurance exchanges and private medical carriers must offer pediatric dental and vision benefits to small employers (groups with fewer than 50 employees).
  • Medical coverage offered within an exchange must include a pediatric dental benefit, unless the same exchange offers a standalone dental plan providing the required pediatric dental benefit. In that case, the medical plan has the option to exclude the pediatric dental benefit. When the pediatric dental benefit is offered in an exchange on a standalone basis, employers and individuals do not have to purchase the pediatric dental benefit.
  • Traditional orthodontia coverage may not be available through pediatric dental benefits offered in state insurance exchanges or essential health benefit packages (EHBP). Currently only orthodontia declared medically necessary will be covered, if at all. This means that children involved in an orthodontia treatment program that extends beyond 2013 may be impacted significantly, as their care will not be covered through the exchange. Some exchanges may offer additional wrap-around dental options with pediatric orthodontia coverage, but the benefits may be different from existing plans.
  • Individuals who choose not to purchase health benefits, which may include pediatric dental or vision benefits for their dependents, may be assessed a small penalty.

At this time, all states’ medical plans also must contain pediatric vision benefits sufficient to satisfy the EHB requirements.

What are the 10 essential benefits within the Affordable Care Act?

The Act defines certain categories of benefits as Essential Health Benefits. The categories are:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care