Small Groups and Dental Benefits in the ACA

by Jason 9/26/2013 9:20 AM

Health plans for small group employers must meet the same requirements of minimum essential coverage as large groups, as discussed in my previous post, but they also have the additional requirement of offering the Essential Health Benefits.

The Patient Protection and Affordable Care Act states that at least the following 10 categories of benefits and services must be covered: 

1) Ambulatory patient services         
2) Emergency Services
3) Hospitalization
4) Maternity and newborn care
5) Mental health and substance use disorder services, including behavioral health
6) Prescription drugs
7) Rehabilitative and habilitative services and devices
8) Laboratory Services
9) Preventive and wellness services and chronic disease management
10) Pediatric services, including oral and vision care

Although pediatric dental care is one of the 10 Essential Health Benefits, dental is an excepted benefit under the law. That means that the ACA generally does not apply to stand-alone dental benefit plans, such as Delta Dental.

There are three broad categories of excepted benefits, which include:

  •  “Limited scope” dental and vision benefits
  • Certain Health Flexible Spending Accounts (HFSAs)
  •  Fixed indemnity policies or coverage for a specific disease or illness

The pediatric oral essential health benefit can be included in the medical plan, or it can be offered as a stand-alone dental benefit from exchange-certified dental carriers. In Missouri and South Carolina, this dental benefit can be purchased through the Federally Facilitated Marketplace (FFM), an online program that will be operated by the U.S. Department of Health and Human Services, or it can be purchased directly from a stand-alone dental plan that has been certified through the FFM.

When purchasing ACA-certified benefits OFF the exchange, it is the medical plan that carries the responsibility of providing the essential benefit unless the medical carrier is “reasonably assured” that the member has purchased “exchange-certified” pediatric dental coverage from a stand-alone dental plan (SADP), such as Delta Dental.

In Missouri and South Carolina, the scope of the pediatric essential dental coverage is determined by one of the FEDVIP plans. This is the Federal Employees Dental and Vision Insurance Program—and the benchmark plan was selected because it is the most popular dental plan available to federal employees.

The pediatric dental essential health benefit applies to children under the age of 19.

While it must be essentially equivalent with the scope of the selected FEDVIP, member cost-sharing features such as deductibles and coinsurance can – and will – differ by carrier.

Only “medically necessary” orthodontia is covered under the pediatric essential oral health benefit, and “medically necessary” will be defined by each carrier. The expectation is that carriers will default to a narrow definition. For example: orthodontia may only be covered for severe malocclusions for certain designated syndromes such as cleft palate or other genetic disorders.

Additionally, a 24-month waiting period is allowed for orthodontia coverage. And, please note that most traditional orthodontia benefits are not considered medically-necessary, but elective, and therefore not part of the essential health benefit.

Because dental benefits are excepted benefits, for the most part, employers will have several options when determining their dental benefits strategy for their employees.  The dental experts at Delta Dental are prepared to help our small group clients navigate the requirements of the ACA and provide the dental benefits each group needs.

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