Affordable Care Act (ACA) Policies

The ACA mandates that all policies issued in the small group and individual insurance markets provide coverage for certain benefits, which are commonly referred to as Essential Health Benefits (EHBs). Those benefits include the following:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

Typically, the out-of-pocket maximum is the maximum amount that the individual will pay in a given benefit year for in-network EHB covered services. Out-of-pocket expenses that count towards the out-of-pocket maximum include your deductible, co-pay, and co-insurance. This may vary slightly depending on your state.

No, there are no annual or lifetime limits on covered services described as EHB.

Individual who are at or below 400% of the poverty level will only receive subsidies (Premium Tax Credits) to help with insurance premiums when they purchase in the Individual Marketplace. They will not receive subsidies if they purchase through their employer. Also, these subsidies will apply to medical coverage first and may not be large enough to cover pediatric dental benefits. Subsidies cannot be used to purchase adult dental benefits. Note that if an employer covers part of the cost of an employee’s benefits, the employee is not eligible for a subsidy through the Individual Marketplace.

Dental benefits may be embedded in a medical plan. However, medical deductibles are often much higher than dental, and non-preventive dental expenses may not be covered until the medical deductible is reached. Even if benefits are embedded, you may want to check your options with a supplemental individual dental plan.

Adults may have different benefits than their children/dependents who are under age 19 and enrolled in an EHB-compliant plan.

Orthodontia is covered as an EHB in most states. However, it may only be covered to the extent it is “medically necessary.”

Generally, EHB-compliant pediatric dental benefits are provided up to age 19 unless a state selects a higher age.

To the extent that you have one of the below scenarios or you have purchased medical coverage that meets minimum essential coverage requirements your policy may not need to be EHB compliant.

• Employer-sponsored coverage (including COBRA coverage and retiree coverage);
• Medicare Part A coverage and Medicare Advantage;
• Most Medicaid coverage;
• Children’s Health Insurance Program (CHIP) coverage; and
• Certain types of veterans health coverage administered by the Veterans Administration

If you are 65 or older and have Medicare coverage, you are not required to purchase an EHB-compliant plan for yourself. The ACA will have no impact on your dental plan offering.