Bcbs Small Group Pediatric Dental Ehb Attestation Form
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1
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3Important information
regarding Pediatric Dental
for accounts with a plan year
beginning on or after 1/1/2015
ACA generally requires non-grandfathered insured small group benefit plans to include coverage for
pediatric dental services that are considered essential health benefits (“EHBs”). For applicable small
group coverage sold “off-exchange,” pediatric dental EHBs may either be embedded in the medical plan,
or provided through a stand-alone dental plan that has been certified by an exchange (also known as a
health insurance marketplace) called “Dental Qualified Health Plans” or “Dental QHPs.” If these benefits
are not embedded in your Blue Cross and Blue Shield of Texas (BCBSTX) medical plan(s), ACA requires
us to be reasonably assured that all your participants (enrolled in the applicable BCBSTX
medical plan) have pediatric dental EHB coverage through another policy.
ACA requires that each participant (enrolled in an applicable medical plan) must have pediatric dental
EHB coverage even if that participant is not eligible for these services. However, participants who are
not eligible for these services will not pay a premium for the coverage of the pediatric dental EHBs.
In order to comply with the requirements described above, all employers are required to complete the
attached attestation form to confirm whether its participants (enrolled in the applicable BCBSTX medical
plan) have coverage of the pediatric dental EHBs. Please use the following attestation form to provide
us with that confirmation. Low Child Only Dental Plan, our limited dental qualified health plan (QHP),
which provides pediatric dental EHBs, will be added to your BCBSTX coverage at an additional premium
cost for any participants under age 19 (up to a maximum of three dependents) unless you tell us that all
your participants (enrolled in the applicable BCBSTX medical plan) have pediatric dental EHB coverage
through another policy.
IMPORTANT: Please complete, digitally sign, and submit the Pediatric Dental EHB Attestation Form.
For renewing groups, submit the Pediatric Dental EHB Attestation Form to .
You may also download the form to print and fax it back to 1-972-231-6931.
For new groups, submit the form with other documents required for new group enrollment.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
728363.0914
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