HHS Releases EHB Rule: Implications for Oral Health

On Monday, November 26, the Department of Health and Human Services (HHS) published guidance on the Affordable Care Act's (ACA) standard set of benefits that must be offered in the new state health insurance exchanges as well as the small group and individual insurance markets outside the exchanges. The proposed rule on Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation solidifies the approach outlined in the December 2011 bulletin on essential health benefits (EHB), which allows states the flexibility to choose from a variety of benchmark plans in order to establish which specific services must be covered by their EHB. In addition to providing more details on the benchmark selection process, the rule proposes several standards for how dental coverage fits into the range of pediatric benefits that will be available to children up to age 19.

CDHP's preliminary analysis examines some implications of the dental-specific issues in the rule. CDHP will provide further analysis and comment in the coming weeks.

Essential Health Benefits Benchmark Supplementation
The rule clarifies that any EHB benchmark plan that is lacking pediatric dental coverage must supplement with either the set of oral health services outlined in the Federal Employees Dental and Vision Insurance Program (FEDVIP) or those in the state's separate Children's Health Insurance Program (CHIP). This ensures that insurance plans providing the EHB will cover a broad range of dental services.

The same benefit standard will also apply for states that do not elect an EHB benchmark or establish a state-based exchange and instead allow the federal government to set one up.

Cost-sharing Limits
The rule proposes a separate cost-sharing (out-of-pocket) limit for stand-alone dental plans but only specifies that this limit be "reasonable." Without further clarification, this proposal is problematic for two reasons. Not only does it create a separate out-of-pocket limit for services provided through a stand-alone dental plan in addition to the "medical" out-of-pocket limits already established by the law but it also does not set a clear limit, leaving the definition of "reasonable" to be determined by each state. 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 access, thereby breaking the fundamental promise of the underlying law. Further complicating this proposed requirement is the fact that states are permitted to operate exchanges in which families are required to purchase their dental benefits separately; this could result in families being forced to purchase an essential health benefit when it may not be affordable.

Actuarial Value (AV) Standard
The rule also proposes a separate actuarial value standard for stand-alone dental plans. Instead of calculating the overall value of the benefits package purchased by a family, families purchasing medical and dental coverage separately would choose between "high" and "low" options where "high" and "low" represent actuarial values of 85% and 75% respectively. Such a requirement may complicate the cost-sharing reductions guaranteed to low-income families.