HHS releases final rule regarding essential health benefits

The U.S. Department of Health and Human Services (HHS) has released the final rule on standards related to essential health benefits (EHB), actuarial value, and accreditation.

The rule solidifies the Obama administration's approach to EHBs, the standard set of services that must be covered by insurance plans offering coverage on the new health insurance exchanges, as well as in the individual and small group insurance markets in each state, according to an update from the Children's Dental Health Project (CDHP).

There are significant implications for the affordability of children's dental benefits; however, these issues may still be addressed at the state level, the group said.

The CDHP is concerned that the rule's provision related to cost-sharing limits in standalone dental plans may pose a significant affordability barrier for many families. The rule establishes a separate, "reasonable" cost-sharing (out-of-pocket) limit for standalone dental plans.

This creates an additional out-of-pocket expense for dental services provided through a standalone dental plan beyond the "medical" out-of-pocket limits already established by the law. The rule also leaves the state-based exchanges to determine what a reasonable limit would be. It is unclear how this aspect of the rule will be implemented in the 26 states that plan to allow the federal government to set up their exchanges, the CDHP said. Requiring families to meet a separate out-of-pocket limit for expenses related to their children's dental care will increase their costs and could create significant barriers to accessing affordable dental care, the CDHP said.

Proposals by some dental insurers recommend that families purchasing their children's dental coverage through a standalone plan be required to meet an additional out-of-pocket maximum of up to $1,000 per child. The impact on families is further compounded by the fact that states are permitted to operate exchanges in which the only option for pediatric dental coverage is through a standalone dental plan.

If states pursue high out-of-pocket maximums for pediatric dental coverage, families may forgo the purchase of this coverage altogether, which the rule clarifies is not in violation of the law, the CDHP said.

Fortunately, states have wide flexibility in setting their own standards for how pediatric dental coverage must be offered. States may decide that families are only required to meet the cost-sharing limits established by the Patient Protection and Affordable Care Act so that no family is unnecessarily burdened by additional costs simply for purchasing their child's dental coverage separately from their medical insurance.

States may go further in ensuring equitable treatment by applying the same consumer protections to medical and dental plans or by requiring that all insurers be responsible for tracking families' out-of-pocket expenses and notifying them when they've reached their limit, the CDHP said.

The CDHP said it will continue to work with HHS to clarify how out-of-pocket limits will apply to dental plans in the federally facilitated exchanges and urge advocates to engage exchange staff in their states to establish rules that ensure affordable dental benefits for all families.