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Stand-Alone Pediatric vs. In a Medical Plan

September 30, 2013

Employers will have several options to help employees meet the requirements for the pediatric oral essential health benefit: from a stand-alone dental plan to dental benefits embedded in the medical plan, with many options between these two extremes. 

Let’s compare these two wide-ranging options.  As you can see in the example, stand-alone pediatric dental plans will provide high/low plans with one of the two actuarial value requirements:  85% or 70%. The medical plans must comply with the four actuarial value levels. When part of a medical plan, the pediatric oral essential health benefit is not considered in the calculation of the medical actuarial values, so the dental benefits could be very lean and still be exchange-certified.

Two other elements really stand out in this comparison:  How the out-of-pocket limits and the deductibles are treated.

  • In a stand-alone plan, the out-of-pocket limit is separate from that of the medical plan, rather than subject to a single, combined medical and dental out-of-pocket limit as shown in the embedded example. This may significantly dilute the value of the dental benefit since the member must reach the higher combined out-of-pocket limit before the plan pays 100% for dental services.
  • The deductible in a stand-alone dental plan again is separate from the medical deductible. When embedded, the dental benefits may be subject to the combined medical/dental deductible, which would be a much higher amount that members must pay before the dental benefits begin.

Comments (1) -

Craig White
Craig White United States
11/27/2013 9:03:31 AM #

Simply put, dental care must be kept separate. It’s too important not to be. Oral health is extremely important to our overall wellbeing, dentists can not only look after our teeth but spot early signs of diseases such as cancer developing.


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