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Pediatric Dental Required?

By on | 35 Comments

Question: Do I have to select a pediatric dental plan for my kids through Covered California? Do I have to select one at all?

Answer: No on both counts (correction). (See very informative and detailed comments on this article)

35 Comments

Alan, I think you are being unduly alarming in warning people about including dental coverage or the IRS will come after us. First, of all the ACA mandate only applies for individuals under the age of 19. Secondly, “pediatric dental” is imbedded in all the aca-compliant plans offered to families with dependents in that age group in California. So you literally can’t opt-out if you are supposed to have it. Finally, folks have enough to worry about what the IRS can do to them without creating problems.

Happy Holidays Everyone!

From the IRS perspective, if you do not have Dental Coverage, then you don’t have all the Essential Health Benefits and, therefore, are not in compliance with the Affordable Care Act law.

Those who come under this category will have to pay the “Shared Responsibility” penalty-tax to the Internal Revenue Service at tax time 2015, and beyond.

Alan Crenshaw

Indeed. For 2014 health plans as enrolled through Covered California, Pediatric Dental coverage was NOT included. Enrollees with children who enrolled in a medical plan were given OPTION to additionally enroll in a separate Pediatric Dental plan, and not necessarily with the same insurance carrier.

There was no “confusion” about this separation, as may be claimed. It was an INTENTIONAL Covered California decision to allow non-medical plan dental insurance companies to participate in Covered California and to offer Pediatric Dental plans.

Covered California decided to interpret this separation as still in compliance with the Affordable Care Act, yet of course, this separation of Pediatric Dental benefits from an ACA-compliant medical plan is NOT compliant with the ACA. Just no one has taken Covered California to court to challenge this forced lack of Pediatric Dental coverage for kids.

New 2015 health plans WILL and DO include Pediatric Dental benefits as PART OF EACH and EVERY health plan. As will be the case for every year thereafter.

Wow! What fun reading all the way back to January on this thread. In retrospect, I think most, if not all, of the CoveredCA health plans ended up including pediatric dental benefits. But even if a plan did not include pediatric dental and a person failed to obtain a stand-alone dental plan for his/her kids, I don’t believe there is a way for the IRS to penalize someone for this minor inconsistency.

As far as I know, the only penalty the IRS can assess is for a failure to obtain/enroll in a QHP in three or more months in 2014. All of the CoveredCA plans are QHPs, so as long as a person had coverage in 9 or more months in 2014, there is no IRS “Shared Responsibility” payment/penalty due.

Apparently, some of the 2014 Covered CA plans did not automatically include Pediatric Dental with the Medical plan for children. I was told from Covered CA that this year, due to the confusion, there will be no penalty. Do you know what the penalty will be next year? Also, can a family enroll the children in standard Individual Dental plans instead of the Pediatric Dental and still avoid the penalty?

There is no law if in fact it is not enforced 100% regardless of it making any sense at all.

You are not listening to the question, though your words are lovely, they fall with lack of common sense.

My partner and I have no children. We have had individual policies with Anthem for many years. Anthem says that we must each pay for pediatric dental and maternity as mandated by the new CA health law. Sure this is incorrect?! No one benefits from this inclusion in our policies! I am beyond child-bearing age and my boyfriend will likely never need maternity care.

I read several of the posts on this topic but did not see any actionable comments. I agree with the reference to the CA laws which should apply but what actions do we need to take to use them to make Anthem take the extra charges off our policies??

The rules I refer to are the Maximums of Jurisprudence in California Civil Code sections 3509-3548 as stated by the poster “freelancer”

Please advise!

Michael wrote:

“Covered California does not follow the mandate and allows a child to OPTIONALLY acquire pediatric dental.”

That’s what the statute says it can do — the exact wording of the statute is that if the stand-alone dental plan “is offered through an Exchange”, then a plan which does not include the dental remains a QHP. The statute particularly does not use the word “mandated”.

I think that’s inherent in the idea of a “stand-alone” plan — a family can opt to buy a subsidized plan on-exchange, while at the same time buying a separate dental plan off-exchange.

Michael wrote:

“And Covered California gives absolutely no option for an adult to include (purchase) pediatric dental along with medical.”

But that’s a nullity — pediatric dental doesn’t offer any benefit to the adult.

You might want to familiarize yourself with the Maximums of Jurisprudence which are codified in California Civil Code sections 3509-3548. These are general, common law rules that all courts follow — but California simply has done us the favor of setting them out as a set of statutory principle as well.

I think that the particular maxims that apply to your apparent expectation that Covered California should offer pediatric dental coverage to childless adults would be:

  1. When the reason of a rule ceases, so should the rule itself.

and

  1. The law neither does nor requires idle acts.

There is no logical reason to force an adult to buy a separate, stand-alone, pediatric dental policy — the adult cannot benefit from it, and because it is stand-alone, it is not included within the actuarial accounting for setting premiums.

Again, I really am baffled by your argument. It seems that you are asserting that the law is being violated because the exchange isn’t offering childless adults the opportunity to buy stand-alone dental plans for children. That makes no sense to me.

I also can’t fathom why this gets you upset — even if you think you’ve spotted some legal loophole, it hurts no one, because you are disturbed by a set of circumstances that cannot possibly benefit the adult buyers on Covered California.

Is the problem with the commission structure for agents? That is, do you lose money if a non-subsidized client chooses to buy an Anthem policy on-exchange to avoid the dental surcharge that Anthem has opted to impose on adults who purchase policies directly from them?

Michael wrote:

“there are no ambiguities. The PPACA as written seems quite clear with regard to pediatric dental benefits as a required pediatric service benefit, and a benefit along with pediatric vision benefits, as part of total required Minimum Essential Benefits.”

I think you need to read the STATUTES that Max quoted, particularly 42 USC 18022(b)(4)(F) and 42 USC 18031(d)(2)(B)(ii).

As Max explains, these sections carve out a statutory exception to the broader language of 42 USC 18021(a)(1).

I honestly don’t see any distinction between the wording of the STATUTE (law passed by Congress) and the regulatory interpretation in this case - 45 CFR 155.1065.

LAW: ” if a plan described in section 18031 (b)(2)(B)(ii) [3] of this title (relating to stand-alone dental benefits plans) is offered through an Exchange, another health plan offered through such Exchange shall not fail to be treated as a qualified health plan solely because the plan does not offer coverage of benefits offered through the stand-alone plan that are otherwise required under paragraph (1)(J)”

REGULATION:

” If a plan described in paragraph (a) of this section is offered through an Exchange, another health plan offered through such Exchange must not fail to be treated as a QHP solely because the plan does not offer coverage of benefits offered through the stand-alone plan that are otherwise required under section 1302(b)(1)(J) of the Affordable Care Act”

It looks to me like the regulatory language tracks the statute almost exactly — the only difference is the substitution of the word “must” for “shall” — and I think those words are clearly synonymous.

Could you please point to me where there is a regulation that differs materially from the statute, with respect to pediatric dental?

I really am totally baffled by your posts.

Hi Freelance. You should read my posts more closely.

I don’t suggest or make any claim that people won’t get their subsidies. In fact, I suggest just the opposite from my very first post, in reply to Max’s post. I set it up in reply to Max’s post that it was unlikely people would not get their tax subsidies should they not acquire a pediatric dental plan. Read it again. Max believes otherwise. I then state that the Covered California plans are not PPACA-compliant, by the standard of the PPACA as passed into law, and that the DHHS and the IRS have granted permission for the changes and created the “mess.” The “mess” as the cited health law professor said it is, is the conflicting legal language and negation of the intent of the PPACA in comparison with the then subsequent rule changes by the DHHS and IRS which made once mandated pediatric dental optional (mandated for benefit inclusion or purchase, to be either built-in to medical plans, or as stand-alone pediatric dental plans). In my opinion, the Exchanges and DHHS and IRS changed the rules and intent of the PPACA to pander to the private dental insurance companies which want and wanted to sell stand-alone pediatric dental plans through the Exchanges, dental carriers which do not offer medical insurance.

You state, “The DHHS and IRS are the agencies charged with adopting regulations to implement the law, and that includes resolving any ambiguities within the statutory law.” Yet there are no ambiguities. The PPACA as written seems quite clear with regard to pediatric dental benefits as a required pediatric service benefit, and a benefit along with pediatric vision benefits, as part of total required Minimum Essential Benefits. You even cited the law. The ambiguity has now arisen due to the DHHS and IRS allowance with its ‘interpretation’ and the subsequent pediatric dental benefits rule changes from a benefit requirement to benefit optional.

Have you asked yourself why Anthem and Blue Shield even force an adult to purchase pediatric dental coverage, even when adults can and will never utilize these child-only benefits? (Blue Shield does not charge for the ‘purchase’ and Anthem does). And why Health Net, and Kaiser, and Cigna, and LA Care and Molina Care, and Contra Costa Health Plan, and Western Advantage, and Sharp, and other HMOs have all INCLUDED and built-in pediatric dental as inclusively part of their medical plans, and have also built-in the extra COST for the included pediatric dental benefits into EVERY health plan it offers… even for the medical health plans which adults enroll in and take?

It’s because the PPACA mandates pediatric dental to be an included Minimum Essential Benefit.

PPACA says the Exchange can include it with the medical plan or it MAY offer it as a stand-alone pediatric dental plan. PPACA however STILL REQUIRES that pediatric dental benefits be offered IN CONJUNCTION WITH the Exchange-offered medical health plans. The DHHS and the IRS came in to let the Exchanges off the hook from the mandated requirement to offer/provide included pediatric dental, thereby resulting in making pediatric dental an OPTIONAL benefit for health plans, as offered by the Exchanges. Why? So private dental insurance companies, each with its own pediatric dental plan rates, can and will be able to sell their pediatric dental plans directly through the Exchanges. But wait, that then means the medical plans cannot already also have the included built-in pediatric dental benefits if dental carriers get to offer stand-alone pediatric dental plans, and the enrollee selection of a stand-alone pediatric dental plan would be required. But ooops, look at the extra cost, and the variance in rates for each carrier and/or plan, the bad PR we (the Exchange) will get if we force this extra dental plan on enrollees when everyone knows by now that pediatric dental is an included essential benefit, so we gotta make it optional somehow, which then, as I understand it, the DHHS and IRS gave their blessing in rule changes to make the Exchanges’ decision legit.

So, technically the Exchange plans which split out pediatric dental and do not require purchase of a stand-alone pediatric dental plan are not PPACA-compliant, yet everyone will still get their subsidies because the DHHS and IRS said plans will still be Qualified Health Plans even if the PPACA requirement for Exchanges to include pediatric dental benefits is abolished and replaced with optional inclusion of stand-alone pediatric dental benefits.

Technically the Exchange plans are not PPACA-compliant, because the PPACA clearly says there is a mandate to provide pediatric dental to EVERYONE, adults included (just like maternity benefits must be provided and cost-accounted for within EVERYONE’S health plan, even for men, and older women, and kids health plans); pediatric dental is to be either included and built-in WITH the medical plan, or with the REQUIREMENT to be purchased OUTSIDE the medical plan as a stand-alone pediatric dental benefits plan, if not already built into the Exchange-offered medical plan… but still required.

You state, “NO. This is not correct. The STATUTE specifies that where stand-alone dental is offered, a health plan purchased through an exchange without the dental is a QHP. That is at 42 U.S. CODE § 18021 - QUALIFIED HEALTH PLAN DEFINED; and 42 U.S. CODE § 18022 - ESSENTIAL HEALTH BENEFITS REQUIREMENTS. 42 USC 18022(f) EXPLICITLY says that — that is the STATUTE, not a regulatory determination.”

Yes, you’re right! Correct! “The statute specifies that where stand-alone dental IS offered, a health plan purchased through an exchange without the dental is a QHP.” Yes, correct, but this is in reference to only the health plan… which still REQUIRES purchase of an additional stand-alone pediatric dental plan.

Consider: “Without the dental” means a health plan without dental built-in. And if that’s the case, then for the health plan to still be a Qualified Health Plan (QHP) the Exchange IS STILL REQUIRED to mandate purchase of a SEPARATE stand-alone pediatric dental plan. There is no option to not include the separate stand-alone pediatric dental plan if the Exchange medical plans do not build pediatric dental within. Yet, they’ve done it anyway. This is the “mess.”

“The statute specifies that where stand-alone dental is offered…” Have you noticed that Covered California does NOT OFFER pediatric dental AS A MANDATE PER the PPACA REQUIREMENT? Again, stand-alone does not mean optional. Stand-alone simply means separated from. I think you are concluding that stand-alone means optional, when in fact stand-alone only means not part of the medical plan. The PPACA says there is no option and that pediatric dental IS required; to either include pediatric dental with the medical plans, or to include pediatric dental as a required stand-alone plan… which either way does still mean along with the medical policy. There IS then STILL the mandate for one to acquire pediatric dental. This mandate observed makes a QHP.

Covered California does not follow the mandate and allows a child to OPTIONALLY acquire pediatric dental. And Covered California gives absolutely no option for an adult to include (purchase) pediatric dental along with medical. The PPACA does not provide an option to acquire pediatric dental benefits; PPACA requires it. In fact, it requires these pediatric dental and vision benefits to be inclusive with EVERY QHP. Covered California does not do this. The private insurance carriers do. The private insurance carriers do because they intend to follow the PPACA law and have their medical plans IN COMPLIANCE with the PPACA. Covered California and Exchanges were given an ‘out’ by DHHS and IRS. The out means that the Covered California plans are not PPACA-compliant, but the DHHS and IRS are providing the Covered California QHP status regardless. Subsidies will therefore flow none the less, as I see it. Lawyers and Obama-breaking devotees may be planning otherwise.

Hi Max. You state, “What complicates this is that the IRS does not apportion the Premium Tax Credits between the health plan and the dental plan. All is applied to the health plan premium, leaving the parents to pay 100% of the cost for the pediatric dental plan. It all reconciles in 2015 when 2014 income tax returns are filed.”

Yet, it will not all reconcile in 2015. Tax subsidies are not just based upon income as you recently stated, but rather also in relation to premium cost; think one’s “fare share.” When pediatric dental is taken out of the total premium cost, then subsidies are provided based upon medical (and pediatric vision) benefit plans only. Therefore subsidies do not reconcile at the end of the year inclusive with pediatric dental. Subsidies for pediatric dental plans are simply not provided at all. Subsidies would overall typically be higher subsidies should pediatric dental be taken into account as inclusive of one’s total fair share. The only year-end subsidy reconciliation is an annual income reconciliation.

Max wrote:

“Even though I know we have them in CA, I have not seen any standalone dental plans offered for enrollment anywhere on the CoveredCA site, have you?”

I thought Michael’s complaint was that there was no way for an ADULT to buy a PEDIATRIC dental plan via Covered California?

As I am now a single adult, I didn’t look for dental when I signed up for Covered Cal, but I had assumed that it would have been offered if I had been enrolling a child.

The FAQs on the Covered California site imply that it is offered: “Dental and vision benefits are available for children.” https://www.coveredca.com/FAQs/#faq-21

And here’s a news report from September saying that the pediatric dental is offered via the exchange:

“The contracts offer stand-alone plans for children’s dental coverage in the first year of the new health benefit exchange, which will open for enrollment Oct. 1. Meanwhile, Covered California pledged to work toward embedding pediatric dental coverage in its 2015 portfolio of comprehensive medical insurance products.

Five insurance companies will offer plans to families who buy insurance through Covered California in 2014: Anthem Blue Cross, Blue Shield of California, Delta Dental, Liberty Dental and Premier Access.”

http://yubanet.com/california/Covered-California-Finalizes-Contracts-for-Children-39-s-Dental-Plans-in-2014.php

Are you now saying that even parents can’t buy the pediatric dental for their kids on the exchange, despite public statements to the contrary?

Please clarify.

Since fingers are pointing at STATUTORY LAW, let’s look at the actual text of the relevant sections of the statutes.

42 USC 18021(a)(1) states:(a) Qualified health plan In this title: (1) In general The term “qualified health plan” means a health plan that— (A) has in effect a certification (which may include a seal or other indication of approval) that such plan meets the criteria for certification described in section 18031 (c) of this title issued or recognized by each Exchange through which such plan is offered; (B) provides the essential health benefits package described in section 18022 (a) of this title

42 USC 18022(b)(4)(F) states: (F) provide that if a plan described in section 18031 (d)(2)(B)(ii) of this title (relating to stand-alone dental benefits plans) is offered through an Exchange, another health plan offered through such Exchange shall not fail to be treated as a qualified health plan solely because the plan does not offer coverage of benefits offered through the stand-alone plan that are otherwise required under paragraph (1)(J)

[NOTE: The original text of this section erroneously refers to “(b)(2)(B)” — I have changed the reference to subsection (b) to the correct subsection (d)]

42 USC 18031(d)(2)(B) states: (B) Limitation (i) In general An Exchange may not make available any health plan that is not a qualified health plan. (ii) Offering of stand-alone dental benefits Each Exchange within a State shall allow an issuer of a plan that only provides limited scope dental benefits meeting the requirements of section 9832 (c)(2)(A) of title 26 to offer the plan through the Exchange (either separately or in conjunction with a qualified health plan) if the plan provides pediatric dental benefits meeting the requirements of section 18022 (b)(1)(J) of this title).

Now that we have the law in front of us, let’s decipher what it says.

Section 18021 requires a QHP to offer all ten EHBs listed in 18022(b)(1) [(A) through (J), and (J) is pediatric benefits], but there is no mention of stand-alone dental plans anywhere in this statute.

Section 18022 carves out an exception for a QHP that does not offer pediatric dental benefits IF an exchange offers standalone dental plans that provide those benefits.

Section 18031 states that states SHALL allow standalone dental plans that offer pediatric dental benefits to make those plans available through the exchange.

So, having read and said all that, what is happening in CA?

Even though I know we have them in CA, I have not seen any standalone dental plans offered for enrollment anywhere on the CoveredCA site, have you? Is CoveredCA in violation of federal law? The word SHALL is unambiguous … where has CoveredCA met its statutory responsibility?

If those standalone dental plans are not available on the exchange for enrollment as required by statute, and a health plan does not offer pediatric dental as required by statute, then as I read the statutes, a health plan necessarily fails the statutory requirements to be a QHP because it fails to include all ten of the EHBs.

Do you read it differently than that?

I’m not going to play this game with you Max. You are looking at a public opinion poll that did not even ask the question that you are citing it for.

(Keep in mind that Gallup said that Mitt Romney would win the election in 2012 — http://www.gallup.com/poll/158519/romney-obama-gallup-final-election-survey.aspx )

Freelancer …

56 percent of the American public DO NOT WANT the government involved in their health care, according to the most recent Gallup Poll:

http://www.gallup.com/poll/4708/healthcare-system.aspx

Not sure if that includes Medicare, but I kind of doubt it, for obvious reasons. Those who have it don’t want to give it up. And they won’t have to worry about the $110+ TRILLION unfunded liability Medicare and the Part D PDP currently have incurred.

A single payer system for the “younger” folks would completely bankrupt America.

Max wrote: [quote]If (B) ends up being the natural outcome of the PPACA, then we will end up with a de facto single-payer system of health care (that Congress did not have the gonads to create, and which most of the American public does not want) [/quote]

I’d disagree with you there— I think that the majority of the American public does want and would prefer single payer — or at least single payer with the option to purchase supplemental private insurance for those with the funds to do so. I don’t see very many people volunteering to give up their Medicare.

Max wrote:

” It could certainly have simplified things (or made them infinitely worse).”

Well that’s the crux of the problem. Covered California decided to forego the potential benefit to avoid the potential disaster.

Given the state of the Covered Cal. web site roll out, I don’t think it was a bad decision.

Freelancer wrote: “I think ACA is complicated enough without the US government mandating major changes in the industry — like forcing all health insurance companies to sell dental insurance, or closing the market to dental-only providers.”

You’re absolutely right! But the changes Congress and HHS have forced on the health insurance industry will do one of two things: (A) make the health insurance industry stronger because the number of insureds increases and it actually results in profits, or (B) put the commercial health insurance industry out of business because the number of insureds increases, but they cannot make a profit because they cannot underwrite health status and are required to provide unlimited mandated coverage.

If (B) ends up being the natural outcome of the PPACA, then we will end up with a de facto single-payer system of health care (that Congress did not have the gonads to create, and which most of the American public does not want) which will ultimately put America out of business.

Free insurance? You know that’s prohibited under the Insurance Code. Of course there is a premiums (I even said so). Blue Shield includes pediatric dental benefits in all of its health plans, but adults would have to purchase dental benefits as separate coverage. Anyone may purchase a Blue Shield Dental PPO or HMO plan, whether they have a BSCA health plan or not.

The whole business of pediatric dental and vision has be so screwed up by HHS and its regulations, that it’s no wonder people are confused.

In my understanding of the PPACA, when a person purchases a “QHP” that covers a child under age 19, but that “QHP” does not include pediatric dental benefits (because standalone plans are available), the parent(s) is required by the PPACA to obtain the pediatric dental plan or face the Shared Responsibility Payment for failing to do so, because a QHP must include all ten Essential Health Benefits in order to maintain it qualification.

This requirement is evident in the fact that the dental plan must coordinate its deductibles and out-of-pocket expenses with the health plan, so that the insured receives full credit for both.

What complicates this is that the IRS does not apportion the Premium Tax Credits between the health plan and the dental plan. All is applied to the health plan premium, leaving the parents to pay 100% of the cost for the pediatric dental plan. It all reconciles in 2015 when 2014 income tax returns are filed.

CoveredCA has done no one any favors by not including dental plan options as enrollment choices, and by not acting as the central payment hub for IFPs in the same manner as SHOP handles premium payments for small business groups. Had CoveredCA chosen to act as (or hired a TPA to act as) a central payment facility, we might not have had all the billing issues that have plagued this first year of implementation. It could certainly have simplified things (or made them infintely worse).

Michael wrote:

“as Freelance has pointed out, the health plan is still a Qualified Health Plan giving eligibility for premium tax credit. The Dept of Health and Human Services, and the IRS, have arbitrarily let Covered California off the hook on this one because without pediatric dental included or optionally available through its Marketplace, its health plans are not ACA-compliant.”

NO. This is not correct.

The STATUTE specifies that where stand-alone dental is offered, a health plan purchased through an exchange without the dental is a QHP. That is at 42 U.S. CODE § 18021 - QUALIFIED HEALTH PLAN DEFINED; and 42 U.S. CODE § 18022 - ESSENTIAL HEALTH BENEFITS REQUIREMENTS. 42 USC 18022(f) EXPLICITLY says that — that is the STATUTE, not a regulatory determination.

A QHP by definition is ACA-compliant.

No one has “let Covered California” off the hook — the same federal rules apply to all exchanges in all states, although states can adopt their own more stringent policies if they choose.

A different interpretation would likely undermine the exchanges, either by shutting out participation from insurance companies that do not offer their own dental programs, or disrupting the system whereby the second lowest-cost Silver plan is used to calculate subsidy amount. (We can assume that Delta Dental doesn’t want to write policies with -0- premiums, and the exchanges probably don’t want the headache of administering 0 premium policies that offer 0 benefits to the adults who sign up for them).

Michael wrote:

“But you did not mention the important (as I consider it) point I raised which is the simple decision of interpretation by DHHS and the IRS which radically affects whether pediatric dental MUST be offered by an Exchange or not, either as part of the medical plan, or as a stand-alone pediatric dental plan. The DHHS and IRS decisions (easily seen as arbitrary) directly counter the PPACA as passed into law.”

The DHHS and IRS are the agencies charged with adopting regulations to implement the law, and that includes resolving any ambiguities within the statutory law. That’s how it works for PPACA, and that’s how it works for every other law on the books — it’s simply the way that laws are implemented in our system of government.

It is not an “arbitrary” process — it is an open process which involves publication of proposed regulations, a period for public comment, and issuance not only of the final regulations but of explanatory material related to those regulations (available in the Federal Register reports).

Just because you don’t agree with the outcome doesn’t make it “arbitrary.” On the contrary, these decisions are the result of extensive review and consideration of multiple factors, via a system that arguably is more transparent than the process by which the underlying statutes were enacted.

Again, I’m really not interested in debating pros and cons. But it is a disservice to put out a claim that the exchange is doing something unlawful or that people might lose their subsidies when in fact the exchange is doing something expressly authorized by federal regulation — and federal regulations have the force of law unless and until some court says otherwise.

A good example of this ambiguity is the wording of the statute that can be interpreted to mean that only policies purchased via state exchanges are eligible for subsidies — that led to a lawsuit aimed at preventing the advance tax credit subsidies from being spent via the federally-managed exchange (healthcare.gov). A literal reading of the statute might support that interpretation, but the regulations say otherwise, and a recent federal court decision has upheld the regulations.

There still are quite a few other unresolved ambiguities within the law — and I would hope that regulations would be issued to resolve them. I’d rather be dealing with a regulatory decision I don’t like than having no answer at all, especially when dealing with issues like financial planning.

Michael wrote:

“Think of pediatric dental for adults as a silent rider. It is required to be built into the medical plan, or be offered as a stand-alone benefits policy. This is why both Anthem and Blue Shield mandate the addition of pediatric dental for adult plans purchased directly from each carrier. Blue Shield does not charge adults for it, Anthem does.”

But my point is that that whether or not the customer is charged for the silent rider that does not benefit them is a BFD. You seem to be miffed that the exchange does not provide a way for shoppers to select the worthless (to them) rider to their policy and add to their monthly costs — I’m saying that I don’t see the point. It would only make an already confusing process even more confusing, and would not in any way benefit the customer. The Covered Cal. telephone agents are already overwhelmed without having to field phone calls from childless adults asking why they are being forced to choose a pediatric dental plan — much easier all around to leave that part off.

I don’t like Anthems’ choice to charge adults extra for that add-on. It is not the same as the other benefits included within the plan when stand-alone dental policies are used, because historically dental coverage represents a separate market industry — that is, Delta Dental has never sold regular health insurance, just dental. Many health insurance companies have never sold dental. I think ACA is complicated enough without the US government mandating major changes in the industry — like forcing all health insurance companies to sell dental insurance, or closing the market to dental-only providers.

It might be nice if the exchange offered me the ability to buy an adult stand-alone dental plan — (I actually don’t remember if it did nor not, since I didn’t want one) — but that would certainly be a nice option. However, if the dental plan wouldn’t be subsidized, then there is no particular advantage to buying it via the exchange rather than direct through the company — so I still don’t see a particular reason for the exchange to tack that on.

Hi Max.

Are you saying that adults can ‘purchase’ and acquire at no-cost a pediatric dental plan from Blue Shield or Delta Dental?

I assume not, and that you’re saying adults can optionally pay for a stand-alone pediatric dental plan. This option, of course, thwarts any motivation to do so as there is no resulting benefit.

And as Freelance has pointed out, the health plan is still a Qualified Health Plan giving eligibility for premium tax credit.
The Dept of Health and Human Services, and the IRS, have arbitrarily let Covered California off the hook on this one because without pediatric dental included or optionally available through its Marketplace, its health plans are not ACA-compliant.

Michael wrote “As a man I have maternity benefits built into my medical plan, and I pay for these maternity benefits as part of my ‘ACA-compliant’ health plan each month, yet I will never be delivering a baby, or needing pre-natal care, etc.”

Not just us men, but women who are no longer capable of bearing children, too.

This is one of the wonderful unintended consequences of trying to carve something that is inherently an individual thing into a one-size (and premium)-fits-all conglomeration.

The PPACA has turned health insurance into the camel-equivalent of a horse.

Michael …

I concur wholeheartedly with your observations of the modus operandi of CoveredCA. Don’t try to get anything in writing from them, either, confirming anything you are told by a CSR or supervisor (if you can get to one).

However, your observation concerning the unavailability of pediatric dental in the private market is incorrect. A person may obtain a standalone plan from Delta Dental or Blue Shield (and surely there are others I am unaware of) without having purchased a QHP on or off the exchange. Blue Shield’s HMO plan, for example, is less than $17 per month per person, statewide, and there is no requirement to insure all of the persons in a household.

Everything else you discuss … 100% on target.

Hi Freelance.

Think of pediatric dental for adults as a silent rider. It is required to be built into the medical plan, or be offered as a stand-alone benefits policy. This is why both Anthem and Blue Shield mandate the addition of pediatric dental for adult plans purchased directly from each carrier. Blue Shield does not charge adults for it, Anthem does.

Think of it this way too. As a man I have maternity benefits built into my medical plan, and I pay for these maternity benefits as part of my ‘ACA-compliant’ health plan each month, yet I will never be delivering a baby, or needing pre-natal care, etc. Same with pediatric dental, it is required to be built in or added as a separate policy.

Think of it also that we are already paying for pediatric vision benefits, built in and accounted for in the total premium costs of the medical plan, yet these are vision benefits no adult can or will use.

Sure, the amendment thing, I agree. This is fairly minor. This specific amendment simply allows other dental carriers to participate in the Exchanges. But you did not mention the important (as I consider it) point I raised which is the simple decision of interpretation by DHHS and the IRS which radically affects whether pediatric dental MUST be offered by an Exchange or not, either as part of the medical plan, or as a stand-alone pediatric dental plan. The DHHS and IRS decisions (easily seen as arbitrary) directly counter the PPACA as passed into law.

Michael, I’m not here to debate pros and cons — I just want to clarify the source of the law and regs.

The people answering the phone at Covered California are not the ones who set policy. The policy is set by the board, and that is in line with the explicit laws and regulations that authorize the choices they have made.

You wrote, “per the articles you posted, it’s not the wording or intent of the actual PPACA law, but rather a subsequent congressional amendment which allows stand-alone dental carriers to offer stand-alone pediatric dental plans on the Exchanges”. The Congressional amendment IS the law. There is no “actual” PPACA separate and apart from the law that is on the books today.

Congress can amend laws at any time and it is likely that there will be further amendments to PPACA — and if and when that happens, the law will change. Yes, there was an act of Congress called the PPACA, and you can read the original statute if you are interested in legislative history — but that bill added or amended dozens of different statutes, and it is the current wording of those statutes that governs. And right now there law pretty much says that the exchanges need to offer dental insurance, but parents aren’t obligated by law to buy it, and that stand alone plans won’t be subsidized by the advanced tax credit.

I really am baffled by your reference to their being no way for an adult to purchase a pediatric dental plan on the exchange. (“It makes absolutely no pediatric dental plan available for inclusion to the adult medical plan or as an added stand-alone pediatric dental plan option.”)

Why would an adult want such a plan? By definition, it wouldn’t cover any needed services for adults — pediatric means that the plan can only benefit a child.

What I find confusing is the requirement that Anthem has imposed on off-exchange adult buyers, forcing them to pay an extra premium for plans from which they cannot possibly receive any sort of benefit. That has the impact of creating disparate pricing for identical plans — off-exchange plans have a built-in pediatric dental surcharge. (I’d note that Anthem seems to stand alone in that interpretation).

I think it’s reasonable to assume that no matter how the law is worded, Congress never intended to force childless adults (or those of us whose children have long since reached adulthood) to buy coverage for non-existent children.

Hi Freelancer, I thought you might chime in.

Well, interesting. I disagree with you per the actual wording, and actual intent, of the Patient Protection & Affordable Care Act (PPACA).

First off, Covered California does make things up they go along; give them a call and you will quickly realize and likewise conclude from your firsthand experiences per the answers they provide to your questions; sometimes to relatively simple questions too.

Thanks for clarification on QHP, that essential dental benefits do not need to be included as part of the plan for the plan to be considered a Qualified Health Plan.

As I concluded when I wrote, I did say that “This is unless Pediatric Dental is indeed optional for medical plans…”
You make this more clear, and thanks for citing the text of the law and the related articles you provided.

However, in this same PPACA section of the written law, and as you also clearly state, “the exchanges must offer pediatric dental, EITHER as a “stand-alone dental plan” OR “in conjunction with a QHP.”“

One of the points I made previously here is that Covered California does not provide adults ANY option for or access to pediatric dental at all, and therefore Covered California is in violation of the PPACA. Additionally so, in that adults who have purchased health plans through Covered California have no option in the direct private insurance market to purchase pediatric dental either.

“155.1065 (b) Offering options. The Exchange may allow the dental plan to be offered— ..(1) As a stand-alone dental plan; or ..(2) In conjunction with a QHP.”

Per the wording of the PPACA law, per Sub-Section 155.1065 (b) (as above), an Exchange IS still required to offer pediatric dental, and it MAY do so either as a stand-alone pediatric dental plan or in conjunction with a QHP.

Additionally, “155.1065 (c) Sufficient capacity. An Exchange must consider the collective capacity of stand-alone dental plans during certification to ensure sufficient access to pediatric dental coverage.”

Covered California does not do this. It makes absolutely no pediatric dental plan available for inclusion to the adult medical plan or as an added stand-alone pediatric dental plan option. This lack of offering IS therefore is in violation of the PPACA.

Yet per the articles you posted, it’s not the wording or intent of the actual PPACA law, but rather a subsequent congressional amendment which allows stand-alone dental carriers to offer stand-alone pediatric dental plans on the Exchanges, in addition to the IRS’s subsequent interpretive rule resulting in no tax credit subsidies for pediatric dental plans (even though there ARE tax credit subsidies for pediatric vision, which is part of the minimum essential benefit requirement for a Qualified Health Plan to include pediatric services, found and defined in Section 1302 (b)(1)(J).

Yet MAINLY it’s the Department of Health and Human Service’s interpretative rule which after-the-fact changes the original PPACA intent and allows pediatric dental to be optional, where the DHHS deconstructs the PPACA mandate that an Exchange be required to offer pediatric dental alongside or with the QHP. This DHHS decision, along with the IRS “guidance” which reinforces the DHHS separation of pediatric dental out of the mandate for minimum essential benefits = cheating/fudging where you can, to make things work out the way you want them to after the fact; an official turn your head and look the other way.

It’s why, per one article you list, Seton Hall University health law professor John V. Jacobi, described the pediatric dental coverage situation as “a mess.”

Illegitimately legitimate; the new American norm, full force since about Q4, 2001.

Here are some other resources on the pediatric dental issue:

http://www.kaiserhealthnews.org/Stories/2013/November/12/kids-pediatric-dental-care-insurance-ACA-Obamacare.aspx

http://www.njspotlight.com/stories/14/01/20/change-in-aca-rules-means-fewer-kids-will-have-dental-coverage/

http://ccf.georgetown.edu/all/emerging-policies-on-dental-coverage-for-kids/

And here’s a link to the PDF with the volume of the Federal Register that explains why the HHS department decided on these rules:

http://www.gpo.gov/fdsys/pkg/FR-2013-02-25/pdf/2013-04201.pdf

Michael, Covered California is not just making things up as they go along. They are following the FEDERAL REGULATIONS — specifically, 45 CFR 155.1065 - which says that http://www.law.cornell.edu/cfr/text/45/155.1065 the exchanges must offer pediatric dental, EITHER as a “stand-alone dental plan” OR “in conjunction with a QHP.”

The regulation also says:

“(d) QHP Certification standards. If a plan described in paragraph (a) of this section is offered through an Exchange, another health plan offered through such Exchange must not fail to be treated as a QHP solely because the plan does not offer coverage of benefits offered through the stand-alone plan that are otherwise required under section 1302(b)(1)(J) of the Affordable Care Act.”

Rough translation: all plans offered through the exchanges are QHP’s. If some plans on the exchange have pediatric dental and some don’t, the ones without pediatric dental still qualify as QHP’s.

Parents are not required to buy dental in order to get a subsidy; they are require to buy a QHP. By definition, if they buy on an exchange, they are getting a QHP.

Here’s a report from NPR that might help make sense of this: http://www.npr.org/blogs/health/2014/01/09/260771998/legal-loopholes-leave-some-kids-without-dental-insurance

Michael …

Not only does CoveredCA “mislead” concerning pediatric dental coverage, even more egregious is its nutshell description of basic medical benefits when one looks at HMO or PPO plans the same message is displayed which says,

“Going to a health care provider who is ‘in the network’ can cost you less than going to a provider who is ‘outside the network.’

Yes, you can go to doctors, hospitals or other providers ‘outside the network.’ If you do, that usually means your care will cost you more than if you went to an ‘in network’ provider.”

The use of the words “can” and “usually” is patently deceptive, leading the unknowledgable person to believe that their HMO provides coverage outside the network, when it does not. As a licensed agent, if I were to use those exact same words to describe how an HMO works, I could lose my license for misrepresentation.

With no accountability, and only limited oversight from the CDI/DMHC, CoveredCA acts with impugnity in these and other ways … to the detriment of Calfornia residents who may lack the understanding necessary to make the most appropriate decisions for their family health care needs and requirements.

The one most important issue surrounding the standalone pediatric dental benefits, however, is the coordination of deductibles and out-of-pocket maximums. HIPAA generally prevents communication between insurance companies not under common control without patient consent. In the absence of such consent, it becomes the patient’s/insured’s responsibility to keep track of billings and payments and report that information to their health insurer for compilation. Think most people realize that?

Hi Max.

This is quite interesting.

Yes, Pediatric Dental is optional for medical plans purchased through Covered California. Qualified Health Plans must have 10 Minimum Essential Health Benefits, Pediatric Dental and Vision being ‘one’ of them.

You make a strong point about IRS tax credit subsidy eligibility based upon having a Qualified Health Plan.

If what you say is correct, then it seems that Covered California, in clearly stating that Pediatric Dental is optional, is leading 10s of 100s of thousands of people directly into a situation where, should each enrollee child (through parent) and adult have optionally not selected and not enrolled into a Pediatric Dental plan, and yet were (through the household) still provided advance premium tax credit, that each enrollee and/or household will not ultimately be eligible to claim their tax credit subsidy at the end of the year after all, because their Covered-California-purchased health plan would have been and will be out of Qualified Health Plan compliance, therefore disqualifying the household for premium tax credits. And thus any and all monthly advanced tax credit subsidies would have to be paid back.

I would think likely the IRS will forego mandating such requirement, after all, the federal government is currently providing such advanced tax credit subsidy funds now, with full knowledge that Covered California (the leading state Marketplace nationwide) is offering such non-compliant plans to its 100s of thousands of applicants and enrollees, is not informing its applicant enrollees of the PPACA requirement to acquire Pediatric Dental, is then misleading its applicant enrollees that such Pediatric Dental coverage is optional, and ‘worse’ is determining that applicant enrollees ARE tax credit eligible in contrast to its real-time knowledge that its applicant enrollees are without the mandated Pediatric Dental coverage. Otherwise it would appear and be actual that Covered California is leading people on, where it first deems enrollees eligible for provision of advanced tax credit subsidies, which most enrollees will exercise, yet where then each enrollee will actually have to pay back all their advanced tax subsidy at the end of the year when she or he files taxes; as each will in fact not be provided a Qualified Health Plan.

Most to all enrollees do not know the difference, nor are they informed by Covered California to know the difference. As the providing and governing body, Covered California does provide and has provided its applicant enrollees with OPTION to enroll in Pediatric Dental, AND, AT THE SAME TIME Covered California does provide and has provided each applicant enrollee with Covered-California-established eligibility for actual material advanced tax credit subsidy (APTC as supplied by the federal government) even when Covered California clearly has intent for and knows each enrollee’s health plan is technically out of federal compliance for such federal tax credit subsidy. Covered-California-provided health plans do not include Pediatric Dental, which Covered California deems as a completely optional benefit.

Additionally, the PPACA mandates adults are also required to have pediatric dental built into their ACA-compliant health plan. Yet, Covered California gives absolutely NO OPTION for adults to add Pediatric Dental to their selected health plans. This then creates a situation where adult medical plans ARE Non-Qualified Health Plans. This technically means that all Covered California adult health plans are out of compliance for tax credit subsidy eligibility. Additionally further, adults with Covered California acquired health plans are provided and have no option to go to their selected medical carrier or any other dental carrier to purchase or add-on Pediatric Dental so as to obtain PPACA-required Minimum Essential Coverage (under their medical plan or generally so) and Qualified Health Plan compliance. Therefore, both Covered California and the federal government are in current and ongoing collusion to provide health plans along with advanced tax credit subsidies which do not meet PPACA compliance, and which technically do not and will not allow each enrollee and/or household to claim any tax credit subsidy for 2014, when he or she files taxes in 2015.

It seems Covered California, along with the federal government may be leading people into a subsidy payback mess, and/or no financial tax credit assistance at all, which, of course, completely counters the stated intent of the Patient Protection and Affordable Care Act.

This is unless Pediatric Dental is indeed optional for medical plans as purchased through Covered California, where households will still be able to maintain and obtain tax credit subsidy eligibility, and their actual tax credit.

‘Probably best to just turn the other way and let this one go by this year.’ Such action, or inaction, is the new foundation of much of legal theory and action these days, it seems. ‘Don’t prosecute and let it slide’ is the new norm when it comes to financial and legal improprieties for the higher-ups and governmental bodies.

Which letter of the law is and will be legitimate for health plans as purchased through Covered California?

With all the strangeness in the ACA rollout, attorneys can throw darts blindfolded backwards over their shoulder on a handstand, and easily hit a legitimate Claim straight on.

There are several confusing statements here. First, the ACA mandates Pediatric Dental Care as an ESSENTIAL HEALTH BENEFIT, which means that a health plan is not “qualified” unless it includes pediatric dental benefits. However, the states were given the latitude to not require participating health plans from including it if “stand alone” plans are made available.

In CA, we have several stand-alone dental plans, including those from Delta Dental and Blue Shield.

Theoretically, the standalone dental plan is supposed to coordinate benefit payments with the health insurance plan insofar as the Annual Out of Pocket limit is concerned … but don’t count on it. This will most likely require extra effort on the part of insureds to send copies of children’s dental bills to their health insurer.

As for having to purchase a dental plan through CoveredCA, that isn’t necessarily a requirement. The pediatric dental premium is eligible for tax credits, but they will not be applied to any standalone dental plan. The total tax credit is not dependent on having a dental plan, it is dependent on income.

So it is not a requirement to purchase a pediatric dental plan through CoveredCA. But it IS A REQUIREMENT that you provide your children under age 19 with dental benefits, otherwise you run the risk of losing your tax credits for failing to have a Qualified Health Plan, even though you had 90% of one the entire year. And even if your kids didn’t need to go to the dentist.

Yes, it sucks. But that’s the way Congress grafted the various elements of Essential Health Benefits together.

Good morning, I’m confused, I spoke wit a coveredca representative on the same questions and to advised me that pediatric Dental is not mandatory. Can I get something in writing where is says that Pediatric dental is a mandatory requirement.

Maribelle Garrido (909)481-7222

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