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Posted by on Dec 26, 2013 in Healthcare Reform

Pediatric Dental and Pediatric Vision Essential Health Benefits

Pediatric Dental and Pediatric Vision Essential Health Benefits

Starting on January 1, 2014, the Patient Protection and Affordable Care Act of 2010 (ACA) will require many forms of health insurance to cover essential health benefits (EHBs).  Among the new EHBs is the category of “pediatric services, including oral and vision care.”  Because many health plans and policies either do not offer or offer limited dental and vision coverage, the implementation of this requirement has raised a number of issues for policymakers and stakeholders in California to consider. This brief describes the choices California has made to comply with the ACA’s pediatric dental and pediatric vision EHB requirement.

What Specific Tests, Treatments, and Services Will Be Covered by the Pediatric Dental and Pediatric Vision EHB Category?

Federal guidance issued after passage of the ACA suggested that a state select supplemental benefits from its Children’s Health Insurance Program (CHIP) or from the largest (by enrollment) Federal Employee Dental and Vision Insurance Program (FEDVIP).  Following this federal guidance, California law has selected Healthy Families (the state CHIP program) as the source for defining EHB pediatric dental benefits, and selected the Blue Cross Blue Shield (BCBS) FEP BlueVision FEDVIP as the source for defining EHB pediatric vision benefits.

The dental benefits for Healthy Families include coverage for preventive care (cleanings, fluoride treatments), fillings, sealants, diagnostic services, and certain major procedures (root canals, oral surgery, crowns, bridges, and dentures).

The vision benefits for BCBS FEP BlueVision include coverage for routine eye examinations, glasses, and contact lenses.

What Age Group Will Be Eligible for Pediatric Dental and Pediatric Vision Benefits?

A federal rule, originally issued on November 26, 2012, and finalized on February 25, 2013, recommended coverage for both pediatric dental and pediatric vision benefits for individuals up to age 19, with a state option to provide coverage beyond age 19.  Covered California, the health insurance marketplace in California, is following this guidance and offering pediatric dental and pediatric vision benefits to enrollees up to age 19.

 How Will Stand-Alone Health Insurance be Coordinated with Stand-Alone Dental Insurance to Fulfill the Pediatric Dental EHB Requirement?

The ACA allows the pediatric dental benefit to be covered either through a stand-alone dental insurance carrier or through an enrollee’s health insurance carrier.  This allows two different carriers to jointly fulfill the EHB requirement (one covering all other benefits and a second covering pediatric dental benefits), and raises the following compliance-related questions.

What entity will confirm that an enrollee has full EHB-compliant coverage?

Inside Covered California: For products sold in the state’s health insurance marketplace, Covered California will confirm whether an enrollee has EHB-compliant coverage, but it will not require coverage of pediatric dental benefits in 2014. According to federal law, enrollees in products sold in a state’s health insurance marketplace are not required to purchase pediatric dental coverage, but there is a requirement that such coverage be offered by the state’s health insurance marketplace starting in 2014. Covered California has not currently determined whether it will require the purchase of pediatric dental benefits in the future. This policy will be re-evaluated for 2015. According to federal law, the pediatric dental EHB can also be offered in different ways, either as an embedded benefit in a health plan, in a bundled arrangement, or as a separate stand-alone dental plan.  Covered California chose not to accept bids for the embedded option from qualified health plans (QHPs) for open enrollment in 2014.  This decision allows QHPs without pediatric dental coverage to participate in Covered California and offer what are called “9.5” plans, which are basically health plans that offer the nine other categories of EHBs along with pediatric vision. In such cases, these plans could be supplemented by “.5” plans, offering pediatric dental coverage only, to fulfill EHB requirements.

Outside Covered California: For DMHC-regulated plans and CDI-regulated policies sold outside of Covered California that are subject to EHB coverage requirements, all 10 categories of essential health benefits must be offered to all enrollees. It is currently unclear whether the state regulators or some other entity would be responsible for confirming that these benefits are being fulfilled to comply with ACA requirements for insurance purchased outside of Covered California.

How will annual out-of-pocket limits be coordinated by two insurance carriers?

Along with defining EHBs, the ACA requires plans and policies that cover EHBs to have an annual limitation on out-of-pocket spending. The February 2013 federal rule resolved the need to coordinate annual out-of-pocket limits between two different carriers (for health and dental insurance) by stating that stand-alone pediatric dental insurance should have a separate annual limit from the annual limit for health insurance. This means that both carriers will separately calculate and track their respective out-of-pocket limits. State law has confirmed these two separate out-of-pocket limits, but this is subject to change in the future.

According to state law, the out-of-pocket limit for an embedded plan would be $6,350 for an individual for both health and dental benefits. Since Covered California chose to offer stand-alone dental plans alongside QHPs in bundled arrangements, there are currently two separate out-of-pocket limits ($6,350 for medical, $1,000 for dental) in California.  In future plan years, Covered California is considering offering embedded plans that would include pediatric dental alongside comprehensive health benefits, and such a decision could result in a single out-of-pocket limit for both sets of benefits.


As policymakers in California work toward full implementation of health reform, questions around the pediatric dental and pediatric vision EHB category will continue to present new challenges. CHBRP will provide updates on this topic as new rules and regulations are issued by the state Legislature and regulators, and by the federal government.

The full policy brief can be found on the California Health Benefits Review Program (CHBRP) website at