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Benefit-Specific Waiting Periods for Pediatric Orthodontia No Longer Allowed

On May 26, 2016, the Centers for Medicare and Medicaid Services (CMS) released an FAQ which reversed CMS’ position on benefit-specific waiting periods for pediatric orthodontia. Pediatric orthodontia had been previously excluded from the prohibition of placing benefit-specific waiting periods on essential health benefits in plans that are required to cover EHB.


To whom does this change apply?
The change applies to fully insured individual and small group plans. It does not apply to self-insured plans or to fully insured plans in the large group market since they do not need to cover essential health benefits.


Why are waiting periods for pediatric orthodontia no longer allowed?
CMS has reversed its position due to the fact that placing benefit-specific waiting periods may discriminate against those with significant health needs or disabilities.


When must plans be in compliance with this change?
CMS expects insurers to make changes to comply as soon as possible; however, CMS will take no enforcement action until plan years beginning on or after January 1, 2018.


If you have any questions, please contact your Client Solutions team.


This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.