When it comes to the Health Care Exchange (Marketplace), 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.
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 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:
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:
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.
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.
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