January 7, 2013
Starting in 2014, consumers may be paying for pediatric health services as part of their insurance plans – regardless of if they have children or not.
The U.S. Department of Health and Human Services published a proposed rule under the Affordable Care Act in an effort to promote consistency across plans and ensure that they “cover a core package of items and services.”
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The rule outlines a list of “essential health benefits” that must be covered in insurance plans as part of the Affordable Care Act, and the items and services they refer to must be in at least the following 10 categories:
- Ambulatory patient services
- Emergency services
- Hospitalization
- 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, including oral and vision care
Like much regarding the ACA, it has already been met with much controversy and confusion. While HHS is still involved in the rulemaking process and some questions remain unanswered for now, we know that the rule only applies to those with individual or small group (companies with fewer than 50 employees) plans.
In the meantime, the ADA has identified four goals that it believes HHS should stress with state officials:
- The federal and state officials involved in establishing exchanges must ensure that consumers know the full value of what they will be paying for.
- Stand-alone dental plans and medical plans with dental benefits must be able to compete on an equal footing both inside and outside the exchanges to ensure consumers have an wide selection of dental plans.
- The pediatric dental essential health benefit should be a required purchase for all families with children who buy their coverage in the individual or small group market.
- Children up to age 21 should be covered by a dental benefit and there should be adult dental coverage for emergencies as part of state essential health benefit packages.
Much of the fear surrounding the ambiguous rule has been created by the National Association of Dental Plans, which argued that around 11 million adults would drop their dental coverage in an effort to avoid paying for pediatric dental services. So far, the NADP remains alone in this prediction.
Experts in the field of dental coverage have asserted that pediatric dental benefits have proven to be inexpensive in the past, and the option would likely not be unaffordable.
So far, Washington and California are the only two states to respond to this rule. In the next year, we can expect some of the ambiguous issues to be cleared up,says a spokesperson for HHS.
