Small Groups and Dental Benefits in the ACA (Part 2)

by Jason 9/27/2013 9:29 AM

Employers with 50 or fewer employees do not, by law, have to purchase health insurance for their employees. The new law states that individuals have to be covered by the Essential Health Benefits, (unless covered by a grandfathered large group employer or government program).

If small group employers do chose to offer health care benefits in 2014 – for all the valid reasons of attracting and retaining employees, just as before – they will now have to comply with the new ACA regulations. Small group employers may purchase health benefits from their current markets, or beginning with coverage for 2014, they may purchase benefits through the Federally Facilitated Marketplace (FFM), an online program that will be operated by the U.S. Department of Health and Human Services.

On the FFM:

  • Small groups and individuals must be offered the pediatric oral essential health benefit by either the medical plan or a stand-alone dental plan, like Delta Dental. 
  • However, small groups and individuals do not have to purchase the pediatric oral essential health benefit when purchasing through the Federal Facilitated Marketplace.

Off the exchange small groups and individuals must purchase the pediatric dental essential benefit.

The medical plan is required to provide this benefit unless it is “reasonably assured” that the member has purchased an “exchange certified” pediatric dental plan from a stand-alone dental plan, like Delta Dental.

Exchange-certified plans must align with one of two specified options, based on the actuarial value (AV) of the plan. The actuarial value defines the average cost share that the plan will pay for the essential benefits.

  • A high plan must have an 85% actuarial value for services received in network (85% AV will deliver somewhat similar benefits to the typical current dental plans).
  • A low plan must have a 70% actuarial value for services received in network.

While most required benefits are similar to the traditional plans of today, a couple significant differences in the new law need to be considered:

  • The pediatric essential dental plan design includes an out-of-pocket maximum, which has not traditionally been included in dental benefits.
  •  The pediatric essential dental plan design has no benefit maximum limits, unlike traditional plan designs that typically include annual and lifetime maximum benefit amounts. 

The Pediatric Oral Essential Health Benefit specifies:

  •  A $700 out-of-pocket maximum per child or $1,400 for two or more children in the same family.
  • Deductibles and coinsurance apply towards the maximum out-of-pocket limits, but only when services are received from participating network dentists.
  • Once the maximum is reached, 100% of in-network covered services will be paid in full by the plan.

The pediatric oral essential health benefit is clearly a very rich plan for children. Delta Dental will have several plan options to help our small group clients obtain the dental benefits they need for their employees and family members.

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