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

Children’s dental benefits under the ACA beginning in 2014 will include three types of arrangements: embedded, bundled and 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) may have to be met before a patient is eligible for coverage. Some medical plan carriers might waive this deductible for dental, or establish a separate smaller deductible for dental; others may not.
  • A contractual out-of-pocket maximum2 could be up to $6,350 per individual and $12,700 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.

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, but a separate out-of-pocket maximum of $700 to $1,000 (depending on the state) 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. Stand-alone coverage can be coupled with a medical policy that does or does not include pediatric dental.

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

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  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 $6,350 per individual and $12,700 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. Each state determines what it considers to be a reasonable amount.
  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.