Health Care Reform FAQ for Individuals

How are health care reform and the Affordable Care Act related?
The term “health care reform” refers mainly to the Affordable Care Act (ACA), which sets in law an overhaul of our health care system, intended to make health coverage more comprehensive and available to more Americans.
How is dental coverage affected?
Effective January 1, 2014, dental coverage for children up to age 19 was made available in state and federally-facilitated small group and individual exchange marketplaces. Outside health exchanges, this coverage must automatically be provided by most small group and individual health plans, except when “reasonable assurance” is offered by the purchaser. (Ask your Delta Dental advisor about how reasonable assurance works in your state.)
What are essential health benefits (EHBs)?
Under the provisions of the ACA, coverage for individuals and small groups (defined as businesses with 50 or fewer employees, until 2016 when this rises to under 100 employees) must have a basic level of health benefits (called “essential health benefits”) as of January 1, 2014.
What am I required to do about dental coverage?
If you already have a medical plan that includes pediatric dental coverage, you will not have to do anything, though you can add supplemental dental coverage to get more comprehensive benefits for your children, and to add coverage for you and/or your spouse, which generally will not be included in your medical plan.

As of January 1, 2014, dental ACA-compliant coverage for children can be acquired in one of these ways:
  • From your employer, if offered as a part of their benefits package;
  • Individually purchased through a state health insurance exchange marketplace (state exchange)
  • Individually purchased directly from a dental insurer or insurance agent

Please note: Inside state exchanges, pediatric oral services will be offered to small groups and individuals, but are not a mandated purchase, except in CA, DC, MD and WV. Outside exchanges, all health plans approved to sell EHBs will automatically include pediatric oral services (unless “reasonable assurance” is provided to certify that an individual has purchased a separate exchange-certified stand-alone pediatric dental plan).

What’s a state exchange?
It is a state-facilitated (or federally-facilitated) store (also called a health care exchange or exchange marketplace) where you can explore coverage options and apply for insurance plans. In addition:
  • Exchanges are primarily online with telephone and other channels also available.
  • Exchanges are open to anyone without employer-provided coverage who wants to purchase a health insurance plan.
  • The health plans are offered by private insurance companies.
  • People who work for a small business can purchase plans through the Small Business Health Insurance Options Program (SHOP) section of their state’s exchange marketplace.
When do state and federal exchanges open for individuals?
The exchange marketplace open enrollment period for individuals began on November 15, 2014. Please note, coverage purchased by December 15, 2014, will be effective January 1, 2015. Small business owners can purchase benefits any time throughout the year.
How will Delta Dental participate in the exchanges?
As of November 15, 2014, Delta Dental will offer dental plans in 15 state exchanges, plus D.C., including products for children only, as well as for entire families.
Why should I choose a Delta Dental plan?
No matter your situation, we have an ACA-compliant dental plan for you:
  • We offer large dentist networks so you may not have to switch dentists.
  • You can fill the gaps in embedded individual or small group policies, which often come with a high deductible.
I want adult Delta Dental coverage. How can I get it?
In these ways:
  • Enroll through your state exchange where dental is offered as stand-alone coverage for families, including children as well as adults (separate from medical plans). You are not required to purchase children’s coverage in order to purchase stand-alone coverage for you or your adult family members.
  • Purchase bundled medical and dental coverage within or outside your state exchange from one of our medical plan partners.
  • Purchase Delta Dental coverage through an insurance agent.
  • Enroll directly from our Individual and Family Plans site
I have Delta Dental insurance through my employer. What do I need to know?
If you are already a Delta Dental enrollee, you can keep your current coverage. There’s probably nothing that you need to do to comply with the ACA.
  • If you work for a large company (100+ employees), your employer handles most of what needs to be done. You should get more details during your next open enrollment period.
  • If you work for a small business (under 50 employees through 2015, then under 100 employees thereafter), speak to your employer about any changes to your insurance plans. If necessary, you can find Delta Dental coverage on our website.
I have dental insurance on my own. What do I need to know?
You can keep your current plan. Or, you can explore new plans and pediatric dental coverage, if necessary, through your state’s exchange and on our website.
If I purchase medical benefits through the exchange marketplace, can I still purchase separate dental benefits?
Yes. The ACA allows you the flexibility to purchase dental coverage for yourself and your dependents separately from your medical coverage. Check first to see if pediatric dental coverage was automatically included in your small group or individual health policy.
Will I have to change my dentist if I buy a plan through my state exchange?
If your current dentist does not participate in the plan you select, you will have to change dentists in order to limit your out-of-pocket costs and receive the benefit levels detailed in that plan’s Evidence of Coverage, or if selecting a dental health maintenance organization (DHMO), then you must choose a dentist who participates in the network to receive any covered benefits.
What is a stand-alone pediatric dental plan?
Stand-alone pediatric dental plans are separate, and they are purchased separately, from medical insurance plans. A Delta Dental PPO stand-alone plan makes it easier for your dependents to stay with their current network dentist. A stand-alone pediatric dental plan would be coupled with a qualifying medical health plan to meet ACA requirements.
What is a bundled pediatric dental plan?
A pediatric dental plan is “bundled” when it is purchased as a stand-alone plan and then joined with a qualifying medical plan, creating a bundled policy that meets ACA requirements. Within bundled coverage, the out-of-pocket maximums and deductibles are accumulated separately, making it easier for you to have meaningful and useful dental benefits. This type of coverage is not available in all states.
What is embedded pediatric dental coverage?
Pediatric dental coverage is “embedded” when it is included in a single policy along with medical coverage. Often with an embedded policy, a combined medical-dental deductible applies, which can be as high as $2,000 per person or more annually, making it difficult to actually use the pediatric dental benefits. Furthermore, most embedded dental plans have a much higher out-of-pocket maximum (up to $6,600 combined with medical), making it very unlikely that children will ever obtain 100% coverage unless they have unusually high medical expenses.
I already have Delta Dental coverage for my children; will I need to change my plan?
If you receive your coverage through a large employer, there is nothing you need to do. If you receive benefits from a small employer, your health plan probably already contains the required pediatric dental benefits, and your current Delta Dental plan can still provide adult coverage as well, helping to fill the gap of a large medical-dental deductible in your health plan. If you purchase your health and dental benefits individually, most medical policies automatically will add required pediatric dental benefits. You should check the terms of that coverage to see if you still need your existing Delta Dental coverage, or only want to maintain it for the adults (19 and older) in your family.
Where can I get more information?
Visit your state exchange or talk to your Human Resources department representative about Delta Dental benefits.