THE ACA AND DENTAL COVERAGE“What’s in it for my small business?”January 21, 2014Christine Alibrandi, Esq. Healthcare Reform Project Coordinator
The ACA and Dental Coverage Key ACA provisions related to oral health: • Makes oral health services for children an “essential health benefit” in the individual and small group markets • Stand-alone dental benefit plans can be offered on the public exchanges (Health Insurance Marketplaces)
The ACA and Dental Coverage Essential Health Benefits (10 categories of services): • ambulatory patient services • emergency services • hospitalization • maternity and newborn care • mental health and substance use disorder services, including behavioral health treatment • prescription drugs • rehabilitative and habilitative services and devices • laboratory services • preventive and wellness services and chronic disease management, and • pediatric services, including oral and vision care
The ACA and Dental Coverage Essential Health Benefits (EHBs) • Do not apply to • large group medical plans • self-insured medical plans, or • grandfathered medical plans … • AND, some other existing medical plans, if a carrier opts to allow renewal of a medical plan for another year.
The ACA and Dental Coverage How the Pediatric Dental Benefit (PDB) is available: • PDB can be either embedded in a medical plan or covered in a stand-alone dental benefit plan. • Medical plans do not have to offer the PDB in its plan if a stand-alone dental plan is available on the state’s Marketplace and is offering a plan covering the PDB (“the dental carve out”).
The ACA and Dental Coverage What/who does Maine’s PDB cover? • In Maine, the Pediatric Dental Benefit must mirror the covered services in the dental benchmark plan, the Federal Employee Dental and Vision Insurance Program (FEDVIP) plan. • Dental “pediatric” age on Federally Facilitated Marketplace is up to age 19.
The ACA and Dental Coverage The ACA’s Pediatric Dental Benefit plan design requirements: • No annual plan maximum • (New) Out-of-Pocket Maximum (OOPM) • No deductible applied to preventive services • Out-of-network expenses do not count to the OOPM • Actuarial Values of 70% or 85% • Medically necessary orthodontics
The ACA and Dental Coverage • Adult coverage is not impacted by ACA. • No requirement for adults to purchase dental coverage. • ACA plan requirements do not apply so it will look similar to coverage in existing plans. • Because market reforms only apply to Pediatric Dental Benefit (as an Essential Health Benefit), family plans can have different cost-sharing (co-pays, deductibles, co-insurance, etc.) for kids and adults.
The ACA and Dental Coverage Delta Dental’s ME Marketplace Plans: • Pediatric (only) Low Plan • Pediatric (only) High Plan • Family Low Plan • Family High Plan All four available to individuals or small groups.
The ACA and Dental Coverage Marketplace Dental Benefit Plan Design PEDIATRIC Coverage (ME) • Up to age 19 • 100/80/50/50 (85% actuarial value) or 100/60/50/50 (70% AV) • Office visit co-pay $15 / $30 (high/low); Deductible $50/ $150 • No deductible on any preventive services • OOPM $700, $1400 family maximum for 2+ children • 100/100/100/100 after OOPM reached • Only covered services apply to OOPM • Medically necessary orthodontics; 24 month waiting period
The ACA and Dental Coverage Marketplace Dental Benefit Plan Design ADULT Coverage (ME) • 100/80/50 (High) or 100/60/50 (Low) • Office visit co-pay $15 / $30 (High/Low) • Deductible $50/ $150 (High/Low) • No deductible on any preventive services • No orthodontics covered • Plan annual maximum $1000 • Waiting periods: 3 months Basic, 6 months Major
The ACA and Dental Coverage Delta Dental’s Maine Marketplace Plans’ Network: • Marketplace plans use the Delta Dental PPO network. Services provided by both Delta Dental PPO and Delta Dental Premier dentists are reimbursed at PPO rate, but Premier dentists can balance bill. • Dentists outside of the Delta Dental network are reimbursed at the allowance for non-participating dentists, which is usually lower than the PPO rate, and they can balance bill. • Only costs for such services performed by Delta Dental PPO dentists accrue to the pediatric Out-of-Pocket Maximum.
The ACA and Dental Coverage Considerations When Purchasing PDB Coverage: • Are you required to purchase it? • Provider Network • Monthly Premium • Is the deductible applied to preventive services? Are highly utilized services (preventive services) covered at 100%? • Confirm which deductible and OOPM applies to the pediatric dental benefit (the medical plan’s if the dental is embedded or stand-alone dental benefit plan’s).
The ACA and Dental Coverage Small groups not penalized for non-PDB dental: • The Employer Shared Responsibility Payment does not apply to small employers with fewer than 50 full-time equivalent (FTE). • Thus, small employers can offer whatever dental plan (or plans) they choose to their employees and their employees’ families. Small groups have choices for 2014 dental coverage: • Traditional stand-alone dental coverage for employees and families purchased outside the Marketplace • Dental plans covering the PDB, family or child-only, purchased on or outside the Marketplace
The ACA and Dental Coverage Questions? Please visit Deltadentalcoversme.com (Delta Dental Covers Me)