Essential Health Benefits: Pediatric Oral and Vision Care

At UnitedHealthcare, we have prepared for the operational and product requirements of the ACA and the Essential Health Benefits. We can help you design dental and vision products that expand your product portfolio, meet minimum state benchmark requirements, manage cost and risk, manage reporting, and provide national network access, all with negotiated discounts for covered services. There are many Essential Health Benefit product and packaging options with various price points to consider. Let us help customize a product portfolio that meets your health plan needs.

Effective January 1, 2014, the Affordable Care Act (ACA) required all fully insured, non-grandfathered small group and individual medical policies inside and outside exchanges to cover 10 categories of Essential Health Benefits (EHB). The tenth category is "pediatric services, including oral and vision care."

Some of the facts:

  • Pediatric age minimum is defined as up to age 19, but may vary by state.
  • Benchmark dental and vision plans vary by state.
  • Small group size: Up to 50 employees, which increases to 100 employees effective 2016.
  • Dental and vision are subject to medical out-of-pocket maximum accumulation when embedded.
  • Annual and lifetime dollar maximums are prohibited.

Dental and vision are subject to ACA provisions when embedded:

  • Expanded appeals and external review rights
  • Summary of Benefits and Coverage (SBC)
  • Medical Loss Ratio (MLR) reporting
  • Insurance industry tax


Essential health benefits product requirements and options

Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates.