Dental & Vision Coverage under the ACA
It is important for agents to understand the impact of the ACA as it relates to dental and vision coverage so they can pass on reliable information to clients.
Under the ACA, there are 10 Essential Health Benefits (EHB) that must be a part of every plan offered to individuals and small business groups regardless if the plan is being purchased in or out of the Exchange. Pediatric dental and pediatric vision benefits are considered EHBs.
Medical coverage offered within an Exchange must include a pediatric dental and pediatric vision benefit. Adults will need to purchase their own dental or vision coverage separately and may or may not have the same coverage as their dependent.
According to the National Association of Dental Plans, 98% of dental benefits are provided through stand-alone dental policies for individuals. Dental and vision benefits sold in stand-alone policies are not subject to most ACA provisions. This could be a selling point for being able to provide an advantage in retaining and expanding business with clients.
Traditional pediatric orthodontia care may not be covered unless considered medically necessary. A condition such as a cleft palate may be considered medical necessary and coverage can be available as an EHB.
When evaluating marketplace plan options, refer to the following guidelines:
• Identify covered dental or vision services, copayments and reimbursement percentage levels.
• Know the deductible that must be met before non-preventive services are covered.
• Review the network to see whether changes in providers may be needed.
• Understand whether there is a waiting period that must be met before using the benefits.
• Know whether there are exclusions or conditions for coverage.
• Know whether the out-of-pocket maximum applies separately to dental or if the medical out-of-pocket applies.
Individuals who decide not to purchase health benefits may be assessed a small penalty. It is not clear at this time if the penalty extends to the purchase of pediatric dental or pediatric vision benefits in the small-group market.