Pediatric Dental FAQ
- When does coverage end for individuals enrolled in pediatric dental coverage?
Coverage ends at age 19. Eligibility for pediatric dental benefits ends at the end month in which the enrollee turns 19 years of age.
- What is the timeline and method for how issuers will be made aware if a stand-alone dental plan will be offered on the Marketplace?
DIFS will annually publish information on its website regarding the availability of stand-alone dental plans that will be sold through the Marketplace when the filing window opens for QHP and stand-alone dental plan issuers. For the 2014 and 2015 plan years, the Michigan Marketplace has an adequate number of pediatric stand-alone dental carriers, enabling Marketplace QHPs to rely on dental issuers to provide the pediatric oral EHB.
- Does every medical plan have to have embedded pediatric dental benefits?
All plans sold in the individual and small group market after January 1, 2014, must include the Essential Health Benefits, including pediatric dental benefits. The only exception in the law is for plans sold on the Marketplace, which can exclude pediatric dental coverage if pediatric coverage is included in a stand-alone dental plan offered on the Marketplace. In such case, it is possible for someone to purchase a QHP on the Marketplace without pediatric dental coverage and then choose not to purchase the stand-alone dental plan.
Under the regulations, the outside market will work a little differently. Plans in the individual and small group market may exclude dental coverage from the plan if they are “reasonably sure” the consumer has purchased a stand-alone dental plan with pediatric dental coverage. The issuer has to offer the coverage, but the pediatric dental coverage may be carved out for a consumer that attests that he/she has purchased the stand-alone coverage elsewhere.
- Can issuers use the following approach to ensure that a consumer has pediatric dental coverage?
Upon applying for major medical coverage, the issuer would ask the purchasers, “Do you have pediatric dental coverage through a certified stand-alone dental provider that will cover you and your dependents along with the medical insurance you are purchasing?”
- If yes, the issuer would sell them a major medical plan without pediatric benefits.
- If no, the issuer would sell them a major medical plan and at the same time have them also purchase a dental plan from a dental partner who is certified as a stand-alone dental provider on the marketplace.
- One premium would be collected for both products and the medical issuer would communicate eligibility to the dental provider.
QHPs must offer all essential health benefits (EHBs) but can omit the pediatric dental EHB in a Marketplace that also offers a certified stand-alone dental plan. Because Michigan has reliable information that pediatric dental benefits would be available on the Marketplace, QHPs for the Marketplace do not have to include dental coverage. The regulation did not allow for the omission of pediatric dental coverage in QHPs marketed off the Marketplace. To reduce market disruption, federal policy makers resolved that if a QHP issuer could get reasonable assurance from the consumer that they had pediatric dental benefits, the QHP issuer could exclude, or carve out, the pediatric dental coverage from the QHP. Some examples of reasonable assurance off the Marketplace include:
- requiring a copy of the dental certificate;
- an attestation of pediatric dental coverage from the consumer;
- enter into issuer partnership agreements that allow for simultaneous issuance of coverage (when the QHP is issued, the dental carrier will be notified and, at that time, the dental certificate will be issued); or,
- marketing agreements between QHP issuers and stand-alone dental carriers.
- If pediatric oral benefits are offered through a stand-alone dental issuer, does the cost sharing on the dental plan accumulate to the out of pocket maximum on cost-sharing associated with the QHP?
The stand-alone dental out of pocket limits are separate from the QHP cost sharing limit. The HHS Notice of Benefit and Payment Parameters for 2015 reduced the cost sharing for stand-alone dental plans. The SADP cost sharing may not exceed $350 for one covered child and $700 for two or more covered children. The reduced cost sharing is intended to provide more benefit design flexibility for dental issuers, meant to reduce the potential impact on premiums and other cost sharing, while also furthering the originally stated goal in the proposed rule of reducing the total annual limit on cost sharing for consumers who are enrolled in both QHPs and SADPs.
- Can dental carriers offer a "greater of" or "better of" benefit if during claim adjudication a claim could be covered under more than one benefit? Will this process affect the AV of the stand-alone, pediatric dental plan?
Dental carriers may use the “greater of” or “better of” claim adjudication process for any benefit that is not an essential health benefit. The actuarial value is based on the essential health benefits only; the claim adjudication process is not affected when EHBs are not subject to this process.
The answers provided are not meant to be a substitute for legal advice.