Pediatric Dental FAQ

Coverage ends at age 19. Eligibility for pediatric dental benefits ends at the end month in which the enrollee turns 19 years of age.

All plans sold in the individual and small group market after January 1, 2014, must include the Essential Health Benefits, including pediatric dental benefits. The only exception in the law is for plans sold on the Marketplace, which can exclude pediatric dental coverage if pediatric coverage is included in a stand-alone dental plan offered on the Marketplace. In such case, it is possible for someone to purchase a QHP on the Marketplace without pediatric dental coverage and then choose not to purchase the stand-alone dental plan.

Under the regulations, the outside market will work a little differently. Plans in the individual and small group market may exclude dental coverage from the plan if they are “reasonably sure” the consumer has purchased a stand-alone dental plan with pediatric dental coverage. The issuer has to offer the coverage, but the pediatric dental coverage may be carved out for a consumer that attests that he/she has purchased the stand-alone coverage elsewhere.

Upon applying for major medical coverage, the issuer would ask the purchasers, “Do you have pediatric dental coverage through a certified stand-alone dental provider that will cover you and your dependents along with the medical insurance you are purchasing?”

• If yes, the issuer would sell them a major medical plan without pediatric benefits.
• If no, the issuer would sell them a major medical plan and at the same time have them also purchase a dental plan from a dental partner who is certified as a stand-alone dental provider on the marketplace.
• One premium would be collected for both products and the medical issuer would communicate eligibility to the dental provider.

QHPs must offer all essential health benefits (EHBs) but can omit the pediatric dental EHB in a Marketplace that also offers a certified stand-alone dental plan. Because Michigan has reliable information that pediatric dental benefits would be available on the Marketplace, QHPs for the Marketplace do not have to include dental coverage. The regulation did not allow for the omission of pediatric dental coverage in QHPs marketed off the Marketplace. To reduce market disruption, federal policy makers resolved that if a QHP issuer could get reasonable assurance from the consumer that they had pediatric dental benefits, the QHP issuer could exclude, or carve out, the pediatric dental coverage from the QHP. Some examples of reasonable assurance off the Marketplace include:

• requiring a copy of the dental certificate;
• an attestation of pediatric dental coverage from the consumer;
• enter into issuer partnership agreements that allow for simultaneous issuance of coverage (when the QHP is issued, the dental carrier will be notified and, at that time, the dental certificate will be issued); or,
• marketing agreements between QHP issuers and stand-alone dental carriers.

Dental carriers may use the “greater of” or “better of” claim adjudication process for any benefit that is not an essential health benefit. The actuarial value is based on the essential health benefits only; the claim adjudication process is not affected when EHBs are not subject to this process.