Essential Health Benefits

Adult dental and vision care — The ACA defines ten essential health benefit categories, including ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services, laboratory services, preventive and wellness services, and pediatric services (including pediatric dental and vision). Adult dental and vision are not EHB categories; only the pediatric versions are mandatory.

National insurance concept

Coverage for adult dental and vision services is optional and is not a required essential health benefit for adults. — The ten essential health benefits include pediatric dental and vision care, which must be provided to children, but adult dental and vision coverage is not mandated. Insurers may offer adult dental and vision as optional, separately priced benefits, frequently through stand-alone policies or riders. This optional-versus-mandatory distinction is the exact exam point tested under optional coverages in the individual medical expense section of the A&H outline. A broker should explain that a consumer who wants adult dental or vision benefits must usually purchase them separately, because the qualified health plan's essential benefits stop at the pediatric requirement.

National insurance concept