The Ten Essential Health Benefits
What are essential health benefits? Well, part of the Affordable Care Act (ACA) was to set a standard of health care services (or benefits) that must be included in the design of all "certified" private health plans in 2014 offered through Covered California for individuals, families and small groups - as well as plans offered outside of Covered California. In order to be one of the "certified" plans (i.e. Anthem, Blue Shield) the ten benefits below must be included, which you will notice that dental and vision for kids are both included as an essential health benefit:
1. ambulatory patient services
2. emergency services
4. maternity and newborn care
5. mental health and substance use disorder services, including behavioral health treatment
6. prescription drugs
7. rehabilitative and habilitative services and devices
8. laboratory services
9. preventive and wellness services and chronic disease management
10. pediatric services, including oral and vision care
So, all the plans include these benefits, but they may have different coverage levels for each benefit on a specific plan. Also, it's important to note that pediatric dental and vision will be offered as a stand-alone option through Covered California. The dental plan benefits will include a few different options, with a High option providing richer benefits. Here is a sample of the High option benefit highlights. Make sure to double check with your dentist to see how the plan works with them.
Pediatric Dental Plan - High Option
Waiting Periods Before Receiving Services/Benefits: NONE
Annual Maximum Per Child: NONE (most current dental plans include $1000 to $2000 maximum benefit, now there is no cap)
Out-of-Pocket Maximum Per Child: $1000 (now after a child reaches $1000 out-of-pocket, for eligible services, the cost would be covered)
Deductible: $50 (waived for preventive visits)
Preventive Services (i.e. X-rays, exams, cleanings): You pay 0%
Basic Services (i.e. Fillings): You pay 20%
Major Services (i.e. Crowns, oral surgery): You pay 50%
Orthodontics (Braces): You pay 50%
Garrett Viggers is a Northstate employee benefits specialist (Viggers Benefits) and Affordable Care Act (ACA) & Health Insurance Marketplace consultant. He has spent 11 years in the industry as a broker for large and small employers. He helped launch pioneer CDH company Veritas Health Systems (HRAs / HSAs) in 2002 and the spin-off technology company, Inovius, in 2006.
Most recently, in July 2013, Garrett founded Windfall App Technologies with the launch of the first-to-market, Health Insurance Marketplace cross-platform Affordable Health App to find affordable coverage with a health premium tax credit in the Marketplace (Covered California). Windfall App Technologies is a team of ACA insurance experts and technology (App & Web) experts committed to providing relevant solutions in the new world of ACA and Health Insurance Marketplace Exchanges.