The ACA and Dental Coverage

1. THE ACA AND DENTAL COVERAGE“What’s in it for my small business?”Portland Regional Chamber / Maine Health Access FoundationDecember 10, 2013Christine Alibrandi, Esq. Healthcare Reform Project Coordinator

2. The ACA and Dental Coverage Key ACA provisions related to oral health: • Makes oral health services for children an “essential health benefit” in the individual and small group markets • Stand-alone dental benefit plans can be offered on the public exchanges (Health Insurance Marketplaces)

3. The ACA and Dental Coverage Essential Health Benefits (10 categories of services): • ambulatory patient services • emergency services • hospitalization • maternity and newborn care • mental health and substance use disorder services, including behavioral health treatment • prescription drugs • rehabilitative and habilitative services and devices • laboratory services • preventive and wellness services and chronic disease management, and • pediatric services, including oral and vision care

4. The ACA and Dental Coverage Essential Health Benefits (EHBs) • Do not apply to • large group medical plans • self-insured medical plans, or • grandfathered medical plans … • AND, some other existing medical plans, if a carrier opts to allow renewal of a medical plan for another year.

5. The ACA and Dental Coverage How the Pediatric Dental Benefit (PDB) is available: • PDB can be either embedded in a medical plan or covered in a stand-alone dental benefit plan. • Medical plans do not have to offer the PDB in its plan if a stand-alone dental plan is available on the state’s Marketplace and is offering a plan covering the PDB (“the dental carve out”).

6. The ACA and Dental Coverage What/who does Maine’s PDB cover? • In Maine, the Pediatric Dental Benefit must mirror the covered services in the dental benchmark plan, the Federal Employee Dental and Vision Insurance Program (FEDVIP) plan. • Dental “pediatric” age on Federally Facilitated Marketplace is up to age 19.

7. The ACA and Dental Coverage The ACA’s PediatricDental Benefit plan design requirements: • No annual plan maximum • (New) Out-of-Pocket Maximum (OOPM) • No deductible applied to preventive services • Out-of-network expenses do not count to the OOPM • Actuarial Values of 70% or 85% • Medically necessary orthodontics

8. The ACA and Dental Coverage • Adult coverage is not impacted by ACA. • No requirement for adults to purchase dental coverage. • ACA plan requirements do not apply so it will look similar to coverage in existing plans. • Because market reforms only apply to Pediatric Dental Benefit (as an Essential Health Benefit), family plans can have different cost-sharing (co-pays, deductibles, co-insurance, etc.) for kids and adults.

9. The ACA and Dental Coverage Delta Dental’s MEMarketplace Plans: • Pediatric (only) Low Plan • Pediatric (only) High Plan • Family Low Plan • Family High Plan All four available to individuals or small groups.

10. The ACA and Dental Coverage Marketplace Dental Benefit Plan Design PEDIATRIC Coverage(ME) • Up to age 19 • 100/80/50/50 (85% actuarial value) or 100/60/50/50 (70% AV) • Office visit co-pay $15 / $30 (high/low); Deductible $50/ $150 • No deductible on any preventive services • OOPM $700, $1400 family maximum for 2+ children • 100/100/100/100 after OOPM reached • Only covered services apply to OOPM • Medically necessary orthodontics; 24 month waiting period

11. The ACA and Dental Coverage Marketplace Dental Benefit Plan Design ADULT Coverage(ME) • 100/80/50 (High) or 100/60/50 (Low) • Office visit co-pay $15 / $30 (High/Low) • Deductible $50/ $150 (High/Low) • No deductible on any preventive services • No orthodontics covered • Plan annual maximum $1000 • Waiting periods: 3 months Basic, 6 months Major

12. The ACA and Dental Coverage Delta Dental’s Maine Marketplace Plans’ Network: • Marketplace plans use the Delta Dental PPO network. Services provided by both Northeast Delta Dental PPO and Northeast Delta Dental Premier dentists reimbursed at PPO rate. • There is no coverage for services provided by dentists outside the Delta Dental network, and costs for such services will not accrue to the pediatric Out-of-Pocket Maximum.

15. The ACA and Dental Coverage Considerations When Purchasing PDB Coverage: • Monthly Premium • Provider Network • Embedded in a medical plan or stand-alone dental plan • Is the deductible applied to preventive services? • Confirm which deductible and OOPM applies to the pediatric dental benefit (the medical plan’s or stand-alone dental benefit plan’s).

16. The ACA and Dental Coverage Questions?