On January 1, 2014 the Affordable Care Act requires health insurance offered by employers in the small group market must provide Essential Health Benefits. One of these Essential Health Benefits is pediatric oral health for all children up to the age of 19. These oral health services include exams, cleanings, x-rays, fillings, crowns, and medically necessary orthodontia.
Pediatric oral health coverage must be included in all health plans offered on the Exchange unless a standalone dental plan within the Exchange offers the required dental benefit. Outside of the exchange, this pediatric dental coverage can be embedded within the medical plan or offered as a standalone plan. Only the coverage embedded within the medical plan will accumulate towards deductibles and out of pocket maximums.
A standalone dental plan offered on the Exchange must cover pediatric oral health services, but may also offer additional benefits like adult dental coverage. These standalone plans must be certified as a high (85%) or low (70%) plan by an actuary.