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Affordable Care Act FAQs

While the Affordable Care Act (ACA) is already bringing a new direction for health benefits in 2014 and beyond, Renaissance Dental would like to educate small business owners about how their dental benefits may be impacted by the ACA. Below are a series of frequently asked questions and answers focused on changes to dental coverage in the new ACA world.

Note: This material is not intended to serve as legal advice and only constitutes Renaissance Dental’s opinion on the subject matter contained herein based on its own review of available guidance. Published October 2013.

  1. What are Essential Health Benefits?
  2. Are dental benefits subject to Affordable Care Act requirements?
  3. How do I determine if my dental plan is structured in a way that exempts it from most ACA requirements, such as the market reforms?*
  4. Does my group's dental plan need to include EHB-compliant pediatric dental benefits?
  5. If my group has part-time employees, how do I determine whether my group is in the small or large group market?
  6. Up to what age are EHB-compliant pediatric dental benefits covered?
  7. Does my group dental plan have to provide dependent dental coverage up to age 26?
  8. I am an employer in the small group market and I want to provide my employees with EHB-compliant pediatric dental coverage. My current plan already covers pediatric dental services. Is my current policy's coverage sufficient to meet the ACA's requirements?
  9. I have an employee who does not have children. Will he or she still have to purchase pediatric dental coverage?
  10. I am an employer in the small group market. My broker (or medical plan carrier) told me that if I elect to purchase coverage for my employees I have to purchase EHB-compliant pediatric dental benefits from my medical plan carrier. Is that true?
  11. Must all employees covered by an employer that needs an EHB-compliant plan enroll in an exchange-certified pediatric dental plan, even if they're currently waiving the group dental plan? What if the member doesn't have a spouse or dependent under age 19? What if the member is waiving the group dental plan currently and their dependents under age 19 are covered under a spouse's exchange-certified pediatric dental plan?

1. What are Essential Health Benefits?

The ACA mandates that all policies issued in the small group and individual insurance markets provide coverage for certain benefits, which are commonly referred to as Essential Health Benefits (EHBs). Those benefits include the following:

  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 treatment
  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

The specific services that must be covered under each of the 10 general categories identified above vary on a state-by-state basis.
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2. Are dental benefits subject to Affordable Care Act requirements?

Most dental plans issued by a stand-alone dental carrier are exempt from many of the ACA’s requirements. A complete answer, however, depends on how your dental plan is structured. This FAQ document may help you determine the ACA’s impact on your dental plan.
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3. How do I determine if my dental plan is structured in a way that exempts it from most ACA requirements, such as the market reforms?* 

The answer depends on whether your plan is fully insured or self-funded.

Fully insured dental plans administered by a stand-alone dental carrier are “excepted benefits” and are therefore exempt from ACA requirements. However, if your group is part of the small group insurance market, you will only be able to purchase health coverage off the exchange that includes all 10 Essential Health Benefits, including pediatric dental services. In most states, an employer is considered part of the small group market if the employer has 50 or fewer employees.

Self-funded dental plans are "excepted benefits" if the dental benefits are not "integral" to the medical benefits.
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4. Does my group's dental plan need to include EHB-compliant pediatric dental benefits?

Self-funded dental plans
No. A self-funded dental plan does not need to cover EHBs. Under the ACA, only policies in the small group and individual insurance markets are required to cover EHBs.

Fully insured dental plans in the large group market (in most states, groups with more than 50 employees)
No. A fully insured dental plan covering a group in the large group market does not need to cover EHBs. Under the ACA, only policies in the small group and individual insurance markets are required to cover EHBs. In most states, the small group market is defined as groups that have 50 or fewer employees.

Fully insured dental plans in the small group market (in most states, groups with 50 or fewer employees)
Technically, a fully insured dental plan in the small group market is not required to offer its employees health coverage under the ACA. However, if the group elects to purchase coverage off the exchange, it will only be able to purchase coverage that contains all 10 EHBs, including pediatric dental coverage. The group does not need to buy all 10 EHBs from its medical carrier but instead may purchase an EHB-compliant policy from its stand-alone dental carrier. In most states, the small group market is defined as groups that have 50 or fewer employees.

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5. If my group has part-time employees, how do I determine whether my group is in the small or large group market?

You should consult an attorney, payroll advisor or other qualified professional.
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6. Up to what age are EHB-compliant pediatric dental benefits offered?

Generally, EHB-compliant pediatric dental benefits are provided up to age 19 unless a state selects a higher age. For example, the state of Kentucky mandates that EHB-compliant dental coverage must be provided up to age 21.
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7. Does my group dental plan have to provide dependent dental coverage up to age 26?

Fully insured groups
No. Fully insured dental plans administered by a stand-alone dental carrier are “excepted benefits” and are therefore exempt from the ACA market reforms, including the requirement to offer dependent coverage up to age 26.

Self-funded groups
So long as your dental plan is not “integral” to your medical plan, you will not have to provide dependent coverage up to age 26. However, if your dental plan is integral to your medical coverage, the group may have to comply with the ACA’s market reforms, which includes a requirement that groups offer dependent coverage up to age 26.
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8. I am an employer in the small group market and I want to provide my employees with EHB-compliant pediatric dental coverage. My current plan already covers pediatric dental services. Is my current policy’s coverage sufficient to meet the ACA’s requirements?

Most likely no. Despite the fact that your current policy covers pediatric benefits, it is likely not compliant with the ACA’s requirements.
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9. I have an employee who does not have children. Will he or she still have to purchase pediatric dental coverage?

It depends. If you are an employer in the small group market and you have elected to purchase health coverage for your employees, you will only be able to offer your employees coverage that contains all 10 EHBs, including pediatric dental coverage. However, if your employee is purchasing coverage through the exchange, he or she will have the option of not purchasing pediatric dental coverage.
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10. I am an employer in the small group market. My broker (or medical plan carrier) told me that if I elect to purchase coverage for my employees I have to purchase EHB-compliant pediatric dental benefits from my medical plan carrier. Is that true?

No. Under the ACA, a small group employer is allowed to purchase EHB-compliant pediatric dental from a stand-alone dental carrier like Renaissance Dental. Medical carriers are not required to sell pediatric dental coverage to a small group employer so long as the carrier is reasonably assured that EHB-compliant pediatric dental coverage has been obtained from a stand-alone dental carrier.
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11. Must all employees covered by an employer that needs an EHB-compliant plan enroll in an exchange-certified pediatric dental plan, even if they’re currently waiving the group dental plan? What if the member doesn’t have a spouse or dependent under age 19? What if the member is waiving the group dental plan currently and their dependents under age 19 are covered under a spouse’s exchange-certified pediatric dental plan?

Currently, there is no clear and concise guidance on how these issues are to be addressed. It appears that, under the ACA, a medical carrier may only issue coverage that does not contain pediatric dental to an individual or small group employee if that carrier is “reasonably assured” that the individual or small group employee obtained certified pediatric dental coverage from a stand-alone dental carrier. However, because it is the medical carrier who is ultimately responsible for ensuring that appropriate coverage has been issued to an individual or small group employee, consulting with your medical carrier is the best way to determine how it is answering the specific questions above.

Each medical carrier may handle these situations slightly differently. Regardless of how your medical carrier chooses to address the above scenarios, rest assured that Renaissance Dental is ready and able to assist by providing you and your employees with the dental coverage you need.

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