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Form Review Checklist – Stand Alone Dental Plans
Updated: May 1, 2013
Company Name:
Product Name:
Plan:
☐ Stand Alone Dental Plan
YES: Check this box if all contract provisions in the section meet minimum requirements.
NO: Check this box if any of the contract provisions do not meet minimum requirements, restrict coverage in a way not allowed by law, or for any other reason
are inconsistent with the law.
N/A: Check this box if a contract does not have to meet this requirement
Category
☐ No lifetime limits on the dollar value of Essential Health Benefits
(EHB):
☐ Stand alone dental plans must cover at least the pediatric dental
EHB.
Federal &
State Law
Tips (including problematic sample contract
language)
PHSA §2711
(75 Fed Reg
37188,
45 CFR
§147.126); 45
§155.1065(a)(
2)
Issuers are not prohibited from using lifetime limits for
specific covered benefits that are not EHB; issuers are not
prohibited from excluding all benefits for a non-covered
condition for all covered people, but if any benefits are
provided for a condition, then no lifetime limit requirements
apply.
Yes
No
N/A
☐
☐
☐
☐
☐
☐
Tip: Check benefit maximums and service limitations to
ensure no dollar limits for EHBs.
Problematic contract language/example: EHB-eligible
pediatric dental services limited to $100,000. This violates
the prohibition on lifetime limits on EHB.
Explanation:
☐ No annual limits on the dollar value of EHB:
☐ Stand alone dental plans must cover at least the pediatric dental
EHB
PHSA §2711
(75 Fed Reg
37188,
45 CFR
§147.126); 45
§155.1065(a)(
Tip: If there are maximum dollar limits, check to ensure that
these are not for benefits within one of the EHB categories.
Problematic contract language/example: EHB-eligible
pediatric dental limited to $100,000 annually. This violates
prohibition on annual dollar limits on EHB.
1 | ACA Implementation Toolkit for Departments of Insurance
©Georgetown University Health Policy Institute 2013
Federal &
State Law
Category
Tips (including problematic sample contract
language)
Yes
No
N/A
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
2)
☐ Provides Essential Health Benefits (Pediatric Dental Services) –
☐ Form reviewer: complete EHB form review
Explanation:
PHSA §2707
☐ Special enrollment period
45 CFR §
156.260
*further
guidance
needed*
45 CFR §
156.260
*further
guidance
needed*
45 CFR §
156.150(a)
☐ Open enrollment period(s) required
[If no state standard, issuers may determine the number and length of
open enrollment periods].
☐ Annual Limitation on Cost Sharing
☐
A stand-alone dental plan covering the pediatric dental EHB
must demonstrate that it has a reasonable annual limitation on
cost-sharing as determined by the Exchange. Such annual limit is
calculated without regard to EHBs provided by the QHP and
without regard to out-of-network services.
☐ Minimum actuarial value
Note: Stand-alone dental plans are only required to provide
coverage for pediatric dental essential health benefits.
For the 2014 coverage year in the FFE, CMS interprets the
word “reasonable” to mean any annual limit on cost sharing
that is at or below $700 for a plan with one child enrollee or
$1,400 for a plan with two or more child enrollees.
45 CFR §
156.150(b)
☐ Must demonstrate that the stand-alone dental plan offers the
pediatric dental essential health benefit at either:
☐ A low level of coverage with an AV of 70 percent; or
☐ A high level of coverage with an AV of 85 percent; and
☐ Within a de minimis variation of +/−2 percentage points.
☐ The level of coverage must be certified by a member of the
American Academy of Actuaries using generally accepted actuarial
2 | ACA Implementation Toolkit for Departments of Insurance
©Georgetown University Health Policy Institute 2013
Federal &
State Law
Category
Tips (including problematic sample contract
language)
principles.
For more information, contact: Max Farris, [email protected]
3 | ACA Implementation Toolkit for Departments of Insurance
©Georgetown University Health Policy Institute 2013
Yes
No
N/A
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