EBIA Weekly Newsletter

Benefit-Specific Waiting Periods for Pediatric Orthodontia No Longer Allowed

   June 9, 2016

Frequently Asked Questions on Health Insurance Market Reforms and Marketplace Standards (May 26, 2016)

Available at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/Waiting-period-FAQ-05262016-Final-.pdf

CMS has issued a single FAQ reversing its position regarding benefit-specific waiting periods for pediatric orthodontia. In a previous FAQ (see our Checkpoint article), CMS excepted pediatric orthodontia from the general rule that health insurers are prohibited from imposing benefit-specific waiting periods in plans that must provide coverage of essential health benefits (generally, fully insured individual and small group plans). After further consideration, CMS has removed the exception for pediatric orthodontia. CMS explains in the new FAQ that waiting periods for specific benefits, including pediatric orthodontia, may discourage enrollment or discriminate against individuals with significant health needs or disabilities. The current guidance supersedes the prior FAQ and applies prospectively to all plans required to provide essential health benefits. Recognizing that it may be difficult to make changes to plans that have already been submitted for certification to state regulators or Exchanges for 2017, CMS indicates that it will take no enforcement action until plan years beginning on or after January 1, 2018, but it expects insurers to make changes at the earliest possible opportunity.

EBIA Comment: The prohibition against benefit-specific waiting periods does not apply to self-insured plans or to fully insured plans in the large group market since those plans are not required to cover essential health benefits. Additional guidance addressing these plans would be welcome. For more information, see EBIA’s Health Care Reform manual at Sections X.C (“Prohibition on Excessive Waiting Periods”) and XIV.F (“Comprehensive Health Coverage Requirement (Essential Health Benefits Package)—Applicable Only in the Individual and Small Group Markets”).

Contributing Editors: EBIA Staff.