Reform Alert - News from the Blues' Office of National Health Reform

Stand-Alone Dental on the Exchange

May 31, 2012

Will stand-alone dental be offered on the Exchange? 

The Department of Health and Human Services released a final rule on Exchanges on March 12, 2012. The rule codified that Exchanges must allow limited scope dental benefit plans to be offered through the Exchange, so long as the plan covers at least the pediatric dental essential benefit. The final rule clarified that stand-alone dental plans offered through an Exchange must offer the pediatric dental essential benefits without annual or lifetime dollar limits.

Who is responsible for certification of stand-alone dental plans? 

Exchanges will also be responsible for developing the certification standards that dental plans must adhere to.

Is stand-alone dental an essential health benefit? 

All qualified health plans, and all individual and small group market health insurance, either on or off the Exchange, must provide essential health benefits*. While the Affordable Care Act defines pediatric oral care as an essential benefit, more guidance is needed on what types of services are included in pediatric oral care.

Who can receive the benefit? 

Stand-alone dental benefits can be offered through Exchanges if:

  • The stand-alone dental plan covers the pediatric oral care essential benefit AND 
  • The stand-alone dental plan qualifies as a limited scope dental benefit per the excepted benefits rules**. 

QHPs operating under the Exchange do not have to offer the pediatric dental essential benefit as long as there is at least one stand-alone dental plan on the Exchange that offers the pediatric dental essential benefit.

Do tax credits apply? 

Cost-sharing reductions for lower income beneficiaries do not apply to stand-alone dental plans. However, the ACA stipulates that premium tax credits apply to the portion of stand-alone dental plans that qualify as essential benefits. The ACA states that if an individual who is eligible for premium tax credits chooses a stand-alone dental plan that covers the pediatric dental essential benefits, the portion of the dental premium that is allocable to the pediatric dental essential benefits must be considered part of the premium to which the individual's premium tax credit applies. However, it is unclear how this will work in practice. It is also unclear how employees purchasing coverage through a SHOP Exchange will apply employer contributions to pediatric dental coverage.

HHS indicated that future guidance will give more detail on how pediatric dental benefits should interact with adult dental coverage. Blue Cross Blue Shield of Michigan will continue to monitor regulations and updates will be provided as soon as they become available.

* Adult dental is not considered an essential benefit.

** Dental benefits that qualify as limited scope dental are considered "excepted benefits" in federal rules, and have not been subject to health insurance reforms, including, but not limited to, the elimination of lifetime and annual limits, and the expansion of coverage to dependent children up to age 26.

The information on this website is based on BCBSM's review of the national health care reform legislation and is not intended to impart legal advice. Interpretations of the reform legislation vary, and efforts will be made to present and update accurate information. This overview is intended as an educational tool only and does not replace a more rigorous review of the law's applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice. Analysis is ongoing and additional guidance is also anticipated from the Department of Health and Human Services. Additionally, some reform regulations may differ for particular members enrolled in certain programs such as the Federal Employee Program, and those members are encouraged to consult with their benefit administrators for specific details.