Health Care Reform

Market Reforms

The Affordable Care Act applies a number of new market reforms/consumer protections to comprehensive major medical insurance. Some of these reforms took effect in September 2010 while others will begin to apply in 2014. Congress believed that these market reforms were necessary to provide consumers with health care packages that would meet their needs on a more complete basis than are available today. For a complete list of reforms, see http://www.healthcare.gov/law/about/order/byyear.html.

HHS clarified in its final Exchange rule that a stand-alone dental benefit plan offering the essential pediatric dental benefit in an Exchange must meet Qualified Health Plan (QHP) certification standards including requirements for annual submission of benefit and rate information. The agency notes the need for a "consistent" level of consumer protections.

Importantly however, a general exception is also provided for any certification requirement "that cannot be met" because the plan covers only the pediatric dental essential health benefit. Here the agency makes an important distinction between stand-alone dental plans and QHPs, but leaves it up to each state Exchange to determine what "cannot be met" because a dental benefit is provided and not a medical benefit.

For example, the agency notes that if accreditation standards specific to standalone dental do not exist then those standards would not apply. The agency also notes that an Exchange may establish certification standards specific to the "unique nature" of stand-alone dental plans, such as network adequacy standards that are specific to the provision of the pediatric dental benefit.