Washington—Affordable Care Act provisions for pediatric dental services “will improve access to care for consumers who require these benefits,” the administration said in a proposed rule.

Health insurance issuers offering coverage in the individual or small-group market must ensure that coverage includes pediatric dental benefits as an essential health benefit. However, if a stand-alone dental plan is available in the insurance exchanges required by the ACA, qualified health plans offered in the exchange may exclude coverage of the pediatric dental component of the EHB package.

This is the only exception to essential health benefits coverage permitted under the section of the ACA outlining standards for health plans to cover the 10 EHB categories, the regulatory notice said.

The Association is reviewing the 119-page Department of Health and Human Services print notice and expects to respond to the request for comments on proposed standards related to essential health benefits, actuarial value and accreditation.

An issuer of a plan offering essential health benefits “may not include routine non-pediatric dental services…or cosmetic orthodontia as EHB,” the proposed rule said. The proposal would set different age limits for pediatric dental and medical child-only coverage, 19 and 21 respectively.

Stand-alone dental plans would be subject to cost-sharing limitations separate from the annual limitation on other EHB coverage, and the proposed rule sets separate actuarial value standards for stand-alone dental plans.

“We proposed that the plan must demonstrate the annual limitation on cost sharing for the stand-alone dental plan is reasonable for coverage of the pediatric dental EHB,” HHS said. “We request comment on this proposal and what parameters should be considered a ‘reasonable’ annual limitation on cost sharing. We note that the annual limitation on cost sharing would be applicable to in-network services only.”   

HHS discussed various cost sharing alternatives and invited comments on whether the proposed “approach to applying the annual limitations on cost-sharing standard is appropriate for stand-alone dental plans.”

Regulation writers expressed greater certainty in an “accounting statement summarizing HHS’ assessment of the benefits, costs and transfers associated with this regulatory action,” which was offered to satisfy White House Office of Management and Budget requirements in OMB Circular A-4.

“HHS anticipates that the provisions of this proposed rule will assure consumers that they will have health insurance coverage for essential health benefits, and significantly increase consumers’ ability to compare health plans, make an informed selection by promoting consistency across covered benefits and levels of coverage, and more efficiently purchase coverage,” the accounting statement said.

“This proposed rule ensures that consumers can shop on the basis of issues that are important to them such as price, network physicians and quality, and be confident that the plan they choose does not include unexpected coverage gaps, like hidden benefit exclusions. It also allows for some flexibility for plans to promote innovation in benefit design.”

“The specific approach to defining EHB in this proposed rule realizes the benefits of simplicity and transparency by allowing each state to choose a benchmark from a set of plans that are typical of the benefits offered by employers in that state,” HHS said. “The proposed rule allows that EHB in each state reflect the choices made by employers and employees in that state today, and minimizes disruption in existing coverage in the small group market.

“In addition, the proposed provisions addressing specific benefit categories, such as habilitative services and pediatric dental and vision services, will improve access to care for consumers who require these benefits.”