Plain version: children's teeth and eyes are built into the health plan; adults' are add-ons. Limited pediatric dental and vision benefits are mandatory, while adult dental and adult vision are optional coverages.
Why children's care is mandatory: California's essential health benefits law for individual and small group policies lists pediatric services, including oral and vision care, as an essential health benefit category (Ins. Code §10112.27(a)(1)).
Pediatric oral care equals the dental benefit children received under Medi-Cal as of 2014, including medically necessary orthodontic care (§10112.27(a)(5)).
Pediatric vision care is tied to the federal employee vision plan with the largest national enrollment (§10112.27(a)(4)).
Federal rules require pediatric services until at least the end of the month in which the enrollee turns 19 (45 CFR §156.115(a)(7)). Being an older dependent on a parent's plan does not extend them.
Why adult care is optional: federal essential health benefit rules bar routine non-pediatric dental services, routine non-pediatric eye exams, long-term or custodial nursing home benefits and non-medically necessary orthodontia from essential health benefit status (45 CFR §156.115(d)). Adult dental and adult vision therefore stay optional at every metal level.
Buying adult coverage in California:
Dental through Covered California: an adult cannot enroll in a dental plan only; a Covered California health plan comes first, and dental follows the enrollment windows (open enrollment or a special enrollment period). Covered California's dental HMO plans have no waiting period, while adults in its dental PPO plans wait six months for major services unless proof of prior coverage shortens or waives the wait.
Vision: adult vision is not included in Covered California health plans at any metal level. Adults buy a separate plan directly from a vision insurance company, which handles enrollment and billing, and enrollment is year-round.
Limits and selling rules (Ins. Code §10112.27):
The requirement applies whether the policy is sold inside or outside the Exchange, but not to grandfathered plans or excepted benefits.
An insurer or its agent, producer or representative may not market or sell any product, policy or discount arrangement as compliant with the essential health benefits requirement unless it meets all of the section's requirements. A violation is enforced in the same manner as §790.03.