PPACA plan gotchas

Commentary June 10, 2014 at 11:26 AM

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Your employer clients have to be careful when looking at dental and vision plan options. The Patient Protection and Affordable Care Act (PPACA) now requires every new, non-grandfathered, insured small group health plan to offer an "essential health benefits" (EHB) package that includes pediatric and pediatric vision benefits.

But the PPACA EHB requirements do not apply to grandfathered plans, self-insured plans or large groups, and it's not safe to assume that a medical insurance plan will offer benefits that are the same as, or even similar to, the benefits that stand-alone dental and vision plans provide.

For example, most medical insurance companies offer pediatric dental that is subject to the medical deductible. The child's family typically pays an additional 50 percent after the deductible for services such as fillings.

At most stand-alone dental plans, the participant pays only 20 percent of the cost of a filling.

In other words: There's a 30-percentage-point difference between what a participant in a stand-alone dental plan pays and what patient who has only basic EHB coverage pays. A 30-percentage-point difference!!

The pediatric vision coverage available through a medical plan EHB package typically comes with higher copays and a smaller provider network than what the patient would get from a stand-alone vision plan.

Tell employers who want to provide a competitive benefits package to review the differences between the medical plan EHB benefits and stand-alone plans, to ensure that the dental and vision benefits offered are competitive and appropriate for all plan members, including children under age 19.

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