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Self-funded group health plans and pediatric dental and vision benefit requirements related to the Affordable Care Act (ACA)

Self-funded plans are not required to cover pediatric dental and vision services unless the benefit is considered preventive. While pediatric services, including dental and vision, is one of the ten broad categories of Essential Health Benefits (EHBs) under the ACA, EHBs are only required to be covered under policies issued in the small group and individual insurance markets.

 

Placing dollar limits on pediatric dental/vision benefits
It is important to remember that if a self-funded plan does cover pediatric dental and vision, dollar limits cannot be placed on those benefits unless they are offered separately from the medical plan. Standalone dental/vision plans are considered excepted benefits and dollar limits would be permitted, as these plans are not subject to the ACA. However, if the dental/vision benefits are embedded in the medical plan, the plan would not be able to impose any dollar limits on members under the age of 19.* The pediatric dental/vision benefits can be limited to the services that are offered during the course of a well visit with the primary care provider.

 

Pediatric dental/vision services must not have a dollar limit apply if covered under the medical plan and received from an in-network provider

 
The following dental services cannot have dollar limits apply if offered under a medical plan:

    • Preventive

    • Basic

    • Major

    • Medically necessary orthodontia

 

 The following vision services cannot have dollar limits apply if offered under a medical plan:

    • Routine eye exams

    • Frames and lenses, with contact lenses being covered in lieu of lenses for eyeglasses
        

 *Please note that while all states have adopted the benefit age limit of “to age 19,” it is possible that some states increased the age limit in the state benchmark plan they are offering. Plans should consult the state benchmark plan they have chosen to follow when applying dollar limits on benefits, to confirm the age limit for pediatric vision/dental.

 

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.