“Effective on plan/policy years beginning on or after Jan. 1, 2014, the Affordable Care Act (ACA) will require non-grandfathered fully insured small group (2-50) metallic benefit plans to include pediatric dental coverage as an Essential Health Benefit (EHB), regardless of whether there are any eligible employees or dependents for these services.
For small group off-exchange products, this means that the pediatric dental EHB requirement may be met either by:
- Including benefits in the medical plan, or
- Purchasing a stand-alone pediatric dental plan.
Additionally, the coverage must be certified as a Dental Qualified Health Plan (Dental QHP) by the standards of the exchange (also known as the health insurance marketplace).
To provide pricing transparency in our small group, off-exchange products, Blue Cross and Blue Shield of Illinois (BCBSIL) will not include pediatric dental benefits within our off-exchange metallic medical plans. We know that groups may already provide dental coverage through another carrier. This gives our groups the opportunity to choose the best approach for their employees and dependents.
ACA calls for health insurance carriers to receive “reasonable assurance” if a group already has coverage that meets the EHB need for pediatric dental. To receive this “reasonable assurance,” BCBSIL has created the “Small Group Pediatric Dental EHB Attestation Form” (This Form is no longer available.) This form will be included within:
- Impact Analysis (for those groups with renewal dates of February 2013 through October 2013), or
- Renewal mailings (for those groups with renewal dates of November 2013 through January 2014)
The form will provide groups the opportunity to confirm that they are enrolled in other dental coverage that meets ACA requirements.
Unless the group confirms and returns the form to BCBSIL, a new, stand-alone pediatric dental plan will automatically be added at an additional premium cost for employees or dependents under the age of 21 (up to a maximum of three dependents). This form must be returned by Oct. 15, 2013, to ensure that an added cost is not included.
Our goal is to provide groups that already offer a Dental QHP the opportunity to let us know, so that we don’t unnecessarily add this coverage to their current plan.
Small Group FAQs
What are Essential Health Benefits? Under ACA, effective on the first plan year beginning on or after Jan. 1, 2014, a package of minimum “essential benefits” falling into 10 general categories must be included in non-grandfathered small group plans offered on and off the exchange (also known as the health insurance marketplace). The essential health benefit categories are:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services
What if I don’t have anyone that needs pediatric dental coverage? ACA regulations require that all employees and dependents covered under the small group’s medical plan must have the pediatric dental Essential Health Benefit (EHB), even if no one is eligible for these services.
I already have dental coverage through BCBSIL. Will I need pediatric dental coverage, too? No. BCBSIL stand-alone dental products are considered a “dental qualified health plan” and meet the EHB pediatric dental requirements, so you don’t need to add a stand-alone pediatric dental plan.
I have dental coverage through another carrier. Do I need to have stand-alone pediatric dental coverage, too? No. As long as you can provide confirmation (using the “Small Group Pediatric Dental EHB Attestation Form”) to BCBSIL that you already have coverage for pediatric dental EHBs through another carrier, you don’t need a stand-alone pediatric dental plan. But this form must be received by Oct. 15, 2013, to ensure that pediatric dental coverage is not added.
Why doesn’t BCBSIL just put pediatric dental coverage into medical plans like other health insurance carriers are doing? We realize that groups may already be enrolled in dental coverage through another carrier. Automatically adding this benefit to medical plans may add extra costs.
How much does pediatric dental coverage cost? Information regarding pediatric dental rates will be included in the group’s Impact Analysis (for those groups with renewal dates of February 2013 through October 2013), or upcoming November 2013 through January 2014 renewal mailings. Rates will be added to your coverage at an additional premium cost for employees or dependents under age 21 (up to a maximum of three dependents).
Will ACA fees apply to pediatric dental coverage? Yes, the Annual Fee on Health Insurers (Health Insurer Fee) and the Transitional Reinsurance Program Contribution Fee (Reinsurance Fee) will apply to pediatric dental coverage.
Are grandfathered plans impacted by pediatric dental? No. Grandfathered plans are not required to provide EHBs, which include pediatric dental coverage.
I don’t offer any type of dental coverage. What does this mean for me and my group? If you do not offer any coverage that meets the pediatric dental EHB requirements, a stand-alone pediatric dental plan (BlueCareDental 4 KidsSM) will automatically be added to your group’s coverage and will appear as an additional premium cost, effective on plan/policy years beginning on or after Jan. 1, 2014.”