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 changing?
As of January 1, 2014, dental coverage for children up to age 19 must be offered to everyone in state and federally-facilitated small group and individual exchange marketplaces. Outside health exchanges, this coverage will be automatically provided by most small group and individual health plans.
What are essential health benefits (EHBs)?

Under the provisions of the ACA, 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 coverage (called “essential health benefits”) beginning January 1, 2014.

EHBs are a set of 10 categories of health care services, including one for pediatric oral and vision services.

The ACA requires that all plans offered within state exchanges and outside of exchanges (by private companies) cover these important basic services for individuals and small businesses. Large businesses, by contrast, are required to provide Minimum Essential Coverage (MEC), which may or may not include pediatric oral services.

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 you and/or your spouse and children.

Starting January 1, 2014, if you need to acquire ACA-compliant coverage for children, it can be acquired in one of these ways:

  • Employer-sponsored
  • Government-sponsored
  • Individually purchased through a state health insurance exchange marketplace (state exchange)
  • Individually purchased directly from an insurer or insurance agent

Please note: Inside state exchanges, pediatric oral services will be offered to small groups and individuals. 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).

There are exceptions to ACA requirements. Visit your state’s exchange to determine if any exceptions apply to you, and in many state exchanges, pediatric oral services will be offered on an optional basis, not a mandated one.

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 exchanges open for individuals?
October, 1, 2013. Coverage purchased during this first open enrollment period will be effective January 1, 2014.
How will Delta Dental participate in the exchanges?
Beginning October 1, 2013, Delta Dental will offer stand-alone plans in many state exchanges, 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 adults (separate from medical plans)
  • 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 your own through your state’s exchange marketplace or 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.
What if I can’t afford coverage?
The government may be able to help you pay for medical coverage with a subsidy. Subsidies are determined by a person’s income level and family size. Find out if you qualify for a subsidy by going online or calling your state exchange.
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 would have to change dentists to limit your out-of-pocket costs and receive the benefit levels detailed in that plan’s Evidence of Coverage.
What is a stand-alone pediatric dental plan?
Stand-alone pediatric dental plans are separate, and purchased separately, from medical insurance plans. A Delta Dental 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 called “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 annually, making it difficult to actually use the pediatric dental benefits.
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 will automatically add required pediatric dental benefits, and 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.