EHB coverage needs child-specific standards

By the CDHP team

Led by Senator Brian Schatz (D-HI), a group of 11 U.S. senators sent a letter last week urging the U.S. Department of Health and Human Services (HHS) to strengthen health benefits for children under the Affordable Care Act (ACA), including dental coverage. While the ACA requires that private insurance packages sold on the state marketplaces — and purchased by individuals and small businesses elsewhere — cover 10 essential health benefits (EHB), the senators’ letter argues that the way HHS has chosen to establish those benefits for children falls short.

Because HHS decided not to outline specific services for children but instead allowed states to choose from existing private insurance benchmarks, the pediatric benefits provided are often based on insurance products originally designed for adults. As such, the senators are calling on HHS to establish child-specific standards for EHB coverage.

Comparing the EHB to truly child-specific benefits like those provided in Medicaid, the letter notes that children have unique needs that exceed the often restrictive treatment limits in many private plans under the ACA. Furthermore, as we have previously noted, the letter points out that HHS refused to certify any marketplace plans as comparable to CHIP in terms of both benefits and affordability.

Currently, the pediatric benefits provided through EHBs are often based on insurance products originally designed for adults.

The senators’ letter also emphasizes the unique complexities associated with oral health care under the ACA, pointing out that often families must pay additional premiums and cost-sharing to get dental coverage for their children.

In addition, ACA regulations do not explicitly require plans to offer first-dollar coverage of the full range of preventive oral health services referenced in the law. In other words, plans can charge families for services like initial dental visits, dental sealants, and caries risk assessments by dental professionals. However, states that manage their own marketplaces do have the flexibility to establish more robust standard plan designs that would require insurers to provide comprehensive preventive care at no cost to families.

CDHP has previously called for HHS to review the EHB with an eye towards child-specific benefits and oral health care. Modifying the current approach to EHB coverage to focus on opportunities to prevent tooth decay and other developmental and health concerns in childhood has a greater potential of ensuring children’s health.

More From CDHP

Stay Updated

Keep updated on the latest news from CDHP.


or Subscribe via RSS ›

Teeth Matter

Read our blog

Click here ›

Did you know?

75% }
of American Indian/Alaskan Native children have experienced caries by age 5.
More on the state of dental health ›