Waiting periods not permitted for covered benefits, including pediatric orthodontia

Insurers are not permitted to require an enrollee to wait to access covered benefits. Such a policy will be considered a violation of essential health benefits (EHB) requirements. This rule now applies to pediatric orthodontia coverage.

Original warning. In May 2014, CMS’ Center for Consumer Information and Insurance Oversight (CCIIO) expressed concern that implementing waiting periods for EHB services could discourage enrollment or discriminate against certain individuals. Waiting periods for plans required to provide EHB coverage under the Patient Protection and Affordable Care Act (ACA) could be considered a violation of EHB regulations, which hold that an issuer does not provide EHB if the implementation of its benefit design is discriminatory (45 C.F.R. section 156.125).

In 2014, the CCIIO stated that issuers should amend their plans to remove EHB waiting periods, but provided an exception for pediatric orthodontia as long as the waiting periods were reasonable. The updated guidance reverses agency position on pediatric orthodontia after determining that the same risks apply to this category of coverage. The CCIIO expects issuers to make plan changes as soon as possible, but no later than for plan years beginning January 1, 2018. The agency will not take enforcement action until that time.

SOURCE: CCIIO FAQ, May 26, 2016.

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