Health Care Reform for Dentists

When it comes to health care reform, we’re experienced, knowledgeable and proactive. We’re committed to keeping you informed about the Affordable Care Act1 (ACA).

The key to understanding children’s dental benefits under the ACA is to know the three types of coverage arrangements and how each might affect reimbursement for services.

Three types of pediatric dental coverage

Beginning in 2014, children’s dental benefits under the ACA include three types of arrangements: 1) embedded, 2) bundled and 3) stand-alone. Coverage for each type may differ by state, depending on how regulators and exchanges set their rules and policies.

By knowing the different coverage types, you can help your patients find and choose a Delta Dental plan to meet their family’s needs, as well as understand their coverage and costs.

Embedded

Embedded pediatric dental benefits are included (embedded) in the medical policy. The dental coverage provisions may be different from what you are used to seeing. For example:

  • A single high deductible may apply to both the dental and medical benefits together. For example, a deductible of $2,000 per individual ($4,000 per family) or greater may need to be met before a patient is eligible for coverage. Some medical plan carriers might waive this deductible for all dental services, may only waive it just for diagnostic and preventive services, or may establish a separate smaller deductible for dental; others may not.
  • A contractual out-of-pocket maximum2 could be up to $6,600 per individual ($6,250 in California) and $13,200 for families. As with the deductible, this is a combined maximum that includes both medical and dental out-of-pocket expenses. Once the out-of-pocket maximum is reached, the combined dental/medical policy provides 100% coverage for all additional covered services.
  • Unlike bundled and stand-alone dental plans (see below), embedded dental plans are under no federal requirements to guarantee a pre-set actuarial value of 70% or 85% to enrollees under age 19.

Bundled

Bundled dental and medical coverages are sold together, but as two separate policies. The dental coverage could be administered by the medical insurance carrier or by a separate, stand-alone dental carrier. Delta Dental has partnered with a number of medical carriers to offer bundled coverage.

Federal rules governing the cost sharing3 of bundled dental coverage make it a good option for usable dental benefits:

  • Bundled dental coverage qualifies for separate deductibles and out-of-pocket maximums that are not affected by the medical coverage.
  • The deductibles will generally be low, from around $35 to $130, after which a typical dental benefit plan structure applies.
  • There are no annual benefit maximums for children, but a separate out-of-pocket maximum that can never exceed $350 will determine when the policy begins to pay 100% of covered in-network services.

Stand-alone

Stand-alone dental coverage includes most of the same advantages as bundled coverage described above, offering separate, limited deductibles and out-of-pocket maximums that never exceed $350. Stand-alone coverage can be coupled with a medical policy that does or does not include pediatric dental. Furthermore, ACA-compliant stand-alone (and bundled) dental coverage must offer a guaranteed “actuarial value” of either 70% or 85%. Actuarial value refers to the portion of covered services paid by the dental carrier, and with patient cost sharing (copayments and deductibles).

Please note: Children with dental coverage through a family member's employer are not required to have dental coverage through the ACA.

Provider Tools – your online resource for eligibility, benefits and more

Register for a free Online Services account and you'll have access to Provider Tools – everything you need to obtain detailed eligibility and benefits, free real-time claim submission, claim status, claim history, payment details and more for your Delta Dental Premier® and Delta Dental PPO SM patients in our group of companies4.

  1. 1ACA-compliant health plans include the required 10 essential health benefits (EHBs), one of which is pediatric oral care to age 19.
  2. 2An out-of-pocket maximum is the amount a patient pays for services (a total of annual deductibles and copayment/coinsurance amounts) before the plan begins to pay 100% for covered in-network services. A contractual out-of-pocket maximum with an embedded plan could be up to $6,650 per individual and $13,200 for families. An out-of-pocket maximum is different from an annual maximum because there is no time limit on how long it takes to reach the out-of-pocket maximum.
  3. 3Cost sharing refers to the enrollee's annual out-of-pocket costs for health care. Federal rules set the maximum levels allowed, with stand-alone and bundled plans set at no higher than $350, and embedded plans that combined with medical can be as high as $6,600 per individual, up to $13,200 for a family.
  4. 4Our group of Delta Dental companies includes Delta Dental Insurance Company (AL, FL, GA, LA, MS, MT, NV, TX and UT) and the Delta Dental companies of these states: CA, DC, DE, PA/MD, NY and WV.