Idaho Clarifies Pediatric Dental EHB Rules for Individual and Small Group Plans

Idaho — To Disability/Health Insurance Carriers in Individual and Small Group Markets. Pediatric Dental Coverage and Reasonable Assurance (Reissuance of Bulletin 14‑02)

This guidance applies to all essential health benefits (EHB) compliant individual and small group health benefit policies whether sold through Your Health Idaho (YHI), the Idaho health insurance exchange, or sold outside of YHI.

Section 1302 of the Affordable Care Act (ACA) requires all comprehensive health insurance plans to cover the ten EHB categories, which include pediatric oral (dental) care. Section 1302(b)(4)(F) of the ACA provides an exception for qualified health plans (QHPs) to exclude pediatric oral care, only if at least one exchange-certified stand-alone dental plan (SADP) is available in the service area of the QHP.

The final federal rule on the Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation, issued February 25, 2013, confirms that the pediatric dental care exception applies only to QHPs. It states that “the [ACA] does not provide for the exclusion of a pediatric dental EHB outside of the Exchange as it does in section 1302(b)(4)(F) of the Affordable Care Act for QHPs.” The rule further states that QHPs purchased outside an exchange may exclude coverage of the pediatric dental care EHB only if, prior to issuance, the QHP carrier is “reasonably assured that an individual has obtained such coverage through an Exchange-certified stand-alone dental plan… [which] ensures full coverage of EHB.” See 78 Fed. Reg. at 12853.

With the intent to ensure overall fairness and efficiency of the individual and small group health insurance markets, the Idaho Department of Insurance (Department) will apply these provisions as follows.

Applicable to QHPs when sold through Your Health Idaho

Section 1302(b)(4)(F) of the ACA allows the exclusion of pediatric dental care EHB as long as there is at least one SADP available through YHI in the rating area where the plan is being offered. Consequently, there is no additional reasonable assurance requirement for QHPs purchased through YHI. The consumer is not required to purchase separate pediatric dental care EHB coverage, and the QHP’s carrier must not delay enrollment in the plan due to lack of pediatric dental care coverage.

Applicable to QHPs when sold outside of Your Health Idaho

The final EHB rule allows for a carrier selling a QHP off-exchange to exclude the pediatric dental care EHB in its QHP if it is reasonably assured that the consumer has an exchange-certified SADP. See 78 Fed. Reg. at 12853. To meet this standard, the Department will consider the inclusion of clear disclosure language on enrollment forms/application for individuals, employers, and employees as evidence that the carrier is reasonably assured of other exchange-certified SADP coverage. The Department recommends disclosure language similar to:

“The policy you are applying for does not include coverage for pediatric dental care, which is considered an essential health benefit under the Affordable Care Act. Pediatric dental care is available in the market and can be purchased as a stand-alone product. Please contact your insurance agent, your health insurance company, or Your Health Idaho if you wish to purchase a stand-alone dental care product.”

Without the disclosure, a QHP purchased outside of YHI which excludes the pediatric dental care EHB would not meet the requirement to offer all ten EHB categories. A carrier should not ask consumers to inform them of other pediatric dental coverage, and a carrier must not require that the consumer purchase such coverage.

Applicable to non-QHPs

Under the final 2013 Program Integrity Rule, “a [non-SADP] plan sold to consumers exclusively outside of the Exchange could not obtain QHP certification,” therefore, a plan sold only outside of YHI is a “non-QHP.” See 78 Fed. Reg. at 37044. Neither the ACA nor the EHB rule provides an allowance for non-QHPs to exclude the pediatric dental care EHB. Non-QHPs must provide coverage of all EHB categories, and non-QHPs are not eligible for the “reasonable assurance” allowance.

This Bulletin is not new law but is an agency interpretation of existing law, except as authorized by law or as incorporated into a contract. Requests for additional information or other inquiries regarding this Bulletin can be directed to the Market Oversight section at 208-334-4315.