Guidance for Individual and Small Group Stand-Alone Dental Policy Form Filings Offered Inside and Outside the New York State of Health (NYSOH)
Revised: April 17, 2026
Stand-Alone Dental Plans Offered Inside the NYSOH
1. Individual and Small Group Pediatric Dental Essential Health Benefit (EHB)
- Stand-alone individual and small group pediatric dental plans certified to be offered inside the NYSOH are required to cover the pediatric dental essential health benefit. (See 45 CFR 155.1065(a)(2)).
- The pediatric standard dental benefit design includes coverage of only the pediatric dental essential health benefit.
2. Individual Standard Adult Dental Benefits
- Individual stand-alone adult dental plans certified to be offered inside the NYSOH are required to offer an individual family plan with standard adult dental benefits.
3. Individual Non-Standard Dental Benefits
- In addition to the required individual pediatric only EHB plan and standard adult plan discussed above, Insurers may also offer two non-standard stand-alone dental plans inside the NYSOH.
- Non-standard dental benefit designs may provide coverage for additional dental benefits for adults and/or children.
4. Bundling Arrangements
- A “bundled” dental benefit is not permitted inside the NYSOH. The NYSOH currently does not have the IT capability to bundle specific medical qualified health plans with a specific qualified dental plan.
Individual and Small Group Pediatric Dental EHB Certified Plans Offered Outside the NYSOH
1. Pediatric Dental EHB Certified Plans Offered Outside the NYSOH
- Insurers are permitted to offer individual and small group pediatric dental EHB certified stand-alone dental plans outside NYSOH. Pediatric dental EHB certified stand-alone dental plans offered outside the NYSOH are subject to the same standards for pediatric benefits as coverage offered inside the NYSOH.
2. Disclosure
- Dental insurers must place a prominent disclosure on the cover page of the stand-alone dental policy/contract/certificate indicating that the policy/contract/certificate is a pediatric dental EHB certified stand-alone dental plan offered outside the NYSOH.
3. Reasonable Assurance of the Pediatric Dental Essential Health Benefit
- For individual and small group comprehensive health insurance coverage offered outside the NYSOH, insurers, HMOs, and PHSPs are required to provide coverage for the pediatric dental essential health benefit to all insureds (children as well as adults) unless the insurer, HMO, or PHSP is reasonably assured that the individual or group has obtained stand-alone dental coverage through a pediatric dental EHB certified stand-alone dental plan offered outside the NYSOH.
- Insurers, HMOs, and PHSPs that do not embed the pediatric dental essential health benefit in their individual or small group health insurance policies or contracts must place questions on the individual application/enrollment form for individual coverage and the employer application/enrollment form for small group coverage in order to verify whether an individual or group has obtained stand-alone dental coverage through a pediatric dental EHB certified stand-alone dental plan offered outside the NYSOH. Insurers, HMOs, and PHSPs must use the following language on their application/enrollment form:
Have you obtained stand-alone dental coverage that provides a pediatric dental essential health benefit through a pediatric dental EHB certified stand-alone dental plan offered outside the New York State of Health marketplace?
Yes [ ] No [ ]
If you answered “yes”, please provide the name of the company issuing the stand-alone dental coverage.
If you answered “no”, We will provide you (or your group, as applicable) coverage of the pediatric dental essential health benefit.
(This question does not need to be included on the small group application/enrollment form that employees complete, since the responsibility of obtaining dental coverage is on the employer.)
4. “Bundling” Arrangements
- Insurers, HMOs, or PHSPs outside of the NYSOH may provide coverage for the pediatric dental essential health benefit by embedding the benefit or by bundling the benefit.
- A “bundled” pediatric dental benefit is a pediatric dental EHB certified stand-alone pediatric dental plan that an insurer, HMO, or PHSP offers to its policyholders in conjunction with its comprehensive medical coverage in order to satisfy the pediatric dental essential health benefit.
- If the insurer, HMO, or PHSP offers a bundled stand-alone pediatric dental benefit, the following conditions need to be met:
- The bundled dental benefit is offered by a dental insurer that has been approved to offer pediatric dental EHB certified coverage and the dental insurer also offers the dental benefit on a stand-alone basis outside the bundled arrangement at the same premium;
- The policyholder is clearly informed when the dental benefit is being offered by a separate insurer, even if only one entity collects the premiums;
- The policyholder is clearly informed of the medical plan design and the dental plan design and that the two plan designs have different deductibles, cost-sharing and OOP maximums;
- The policyholder is clearly informed that the policyholder can purchase the bundled dental plan or any other pediatric dental EHB certified stand-alone dental plan offered outside the NYSOH;
- The pediatric dental benefit has a $450 out-of-pocket limit for one covered member under the age of 19 (or $900 if more than one family member under the age of 19 is covered, although the out-of-pocket limits may be lower); and
- The stand-alone dental plan complies with all ACA requirements pertaining to stand-alone dental plans.
- The insurer, HMO, or PHSP must specifically describe the legal and business arrangement between the insurer, HMO, or PHSP and the stand-alone dental insurer when submitting the forms and rates to DFS. The medical forms/rates should be submitted separately to DFS from the dental forms/rates for approval.
Dependent Coverage
1. NYSOH Standard Stand-Alone Dental Plans
- The standard pediatric dental benefit design that provides coverage for the pediatric dental essential health benefit must cover members until at least the end of the month in which the member turns age 19 years of age. Individual stand-alone dental plans must cover children of domestic partners in the base policy or contract when dependent coverage is provided. Group stand-alone dental plans may cover children of domestic partners in the base policy/contract/certificate or in a separate rider.
- The individual standard adult dental benefit design provides coverage for members over the age of 18.
2. NYSOH Non-Standard Stand-Alone Dental Plans
- In addition to the required individual pediatric only EHB plan and standard adult plan discussed above, Insurers may also offer two individual non-standard stand-alone dental plans inside the NYSOH. Non-standard individual stand-alone dental plans that provide coverage for adult dental services in addition to the pediatric dental essential health benefit must cover children through age 25 (to mirror medical plans under federal law) or age 29 (to mirror some medical plans under New York law).
- Non-standard group stand-alone dental plans that provide coverage for adult dental services in addition to the pediatric dental essential health benefit must cover dependent children until at least the end of the month in which the child turns 19. The policy may cover children through age 25 (to mirror medical plans under federal law) or age 29 (to mirror some medical plans under New York law).
- Individual stand-alone dental plans should provide coverage of domestic partners and their children in the base policy/contract. Group stand-alone dental plans may either provide coverage of domestic partners and their children in the base policy/contract/certificate or in the domestic partner rider.
3. Pediatric Dental EHB Certified Coverage Offered Outside the NYSOH
- An individual or group stand-alone dental policy that only provides coverage for the pediatric dental essential health benefit must cover members until at least the end of the month in which the member turns 19 years of age.
- An individual stand-alone dental policy that provides coverage for adult dental services in addition to the pediatric dental essential health benefit must cover dependent children until at least the end of the month in which the child turns 19 years of age and cover full-time students through age 23. The policy may cover all children through age 25 (to mirror medical plans under federal law) or age 29 (to mirror some medical plans under New York law).
- A group stand-alone dental policy that provides coverage for adult dental services in addition to the pediatric dental essential health benefit must cover dependent children until at least the end of the month in which the child turns 19 years of age. The policy may cover all children through age 25 (to mirror medical plans under federal law) or age 29 (to mirror some medical plans under New York law).
- An individual stand-alone dental policy should provide coverage of domestic partners or children of domestic partners in the base contract or policy. A group stand-alone dental policy may either provide coverage of domestic partners or children of domestic partners in the base policy/contract/certificate or in the domestic partner rider.
Model Language
1. NYSOH Coverage
- Model language must be used for all individual and small group stand-alone dental plans offered inside the NYSOH.
2. Pediatric Dental EHB Certified Coverage Offered Outside the NYSOH
- Model language must be used for all individual and small group pediatric dental EHB certified stand-alone dental plans offered outside the NYSOH.
3. Individual and Small Group Dental Coverage that is not Pediatric Dental EHB Certified Coverage Offered Outside the NYSOH
- Model language must be used in its entirety for individual stand-alone dental coverage that is not pediatric dental EHB certified coverage offered outside the NYSOH. Small group stand-alone dental coverage that is not pediatric dental EHB certified coverage offered outside the NYSOH must use the model language provisions identified in the dental checklist, and use of the remaining sections is strongly recommended.
Network Adequacy
- The NYSOH reviews provider networks used with plans offered inside the NYSOH and the Department of Financial Services (DFS) reviews provider networks used with plans offered outside the NYSOH.
- See the “Network Adequacy Standards and Guidance” and “Network Adequacy Submission Instructions” for information on network adequacy requirements and instructions on submitting networks for DFS review.
SERFF Submission Instructions
- Stand-alone dental insurers offering coverage inside the NYSOH or pediatric dental EHB certified coverage outside the NYSOH must use the following Filing Types:
- 2027 Exchange Dental Forms & Rates
- 2027 Off Exchange Certified Dental Forms & Rates
- Stand-alone dental plans are not subject to the rate adjustment process found in Sections 3231(e) and 4308(c) of the Insurance Law and are not required to follow the notice or comment period requirements. Insurers should not use any filing types that reference this process.
- Stand-alone dental insurers also need to select the appropriate Type of Insurance (TOI) and Sub-TOI.
Rating Requirements & Related Rules
1. Out-of-Pocket Limit
- For 2027, the out-of-pocket limit for the pediatric dental essential health benefit is $450 for one member under age 19 and $900 for more than one member under age 19.
2. Plan Year for Stand-Alone Dental Coverage
- Individual stand-alone dental coverage offered inside the NYSOH must use a 12-month calendar year ending on December 31st as a plan year.
- Group stand-alone dental coverage offered outside the NYSOH may use either a 12-month period beginning with the employer’s effective date of coverage or a calendar year ending on December 31st as a plan year.
3. Cost-Sharing
- Coinsurance is expressed as the percentage that represents the insured’s responsibility. Coinsurance values imposed on an insured may not exceed 50%.
4. Rating Factors
- Dental insurers are not required to use the tiered rating factors for stand-alone dental plans that are required for medical plans. An insurer may determine its tier factors based on the insurer’s own population if desired.
5. Rating Regions
- Stand-alone dental insurers in the individual market must use the standardized rating regions for NYSOH and pediatric dental EHB certified coverage offered outside the NYSOH. However, dental insurers are only required to offer coverage in their service area within a standardized region.
6. Rating Tiers
- Stand-alone dental plans in the individual market that offer adult coverage should use a four-tier rating structure of Individual, Couple, Parent + Child(ren), and Family.
See the 2027 Rate Submission Instructions for Pediatric EHB Certified Stand-Alone Dental Plans for additional rate submission requirements.