Delta Dental of Arkansas
ACA Marketplace FAQs
Disclaimer: This information is not intended to serve as legal advice and only constitutes Delta Dental of Arkansas’ opinion on this subject. Please consult your attorney and/or accountant for more information about how the ACA may impact you or
your business.
Most dental plans issued by a stand-alone dental carrier like Delta Dental 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.
The EHB benchmark plan in Arkansas does not require orthodontic coverage.
Fully insured groups
A. No. Fully insured dental plans administered by a stand-alone dental carrier like Delta Dental are “excepted benefits” as long as they are not integral to the group’s medical plan and are, therefore, exempt from the ACA market reforms, including the requirement to offer dependent coverage up to age 26. While it is not required, Delta Dental of Arkansas will continue to offer coverage for dependents up to age 26.
Self-funded groups
A. 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.
A. No. Fully insured dental plans administered by a stand-alone dental carrier like Delta Dental are “excepted benefits” as long as they are not integral to the group’s medical plan and are, therefore, exempt from the ACA market reforms, including the requirement to offer dependent coverage up to age 26. While it is not required, Delta Dental of Arkansas will continue to offer coverage for dependents up to age 26.
Self-funded groups
A. 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.
Self-funded dental plans
A. 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 (groups with 50 or more FTEs)
A. No. A fully insured dental plan covering a group with 50 or more full-time employees or full-time equivalent employees (FTEs) does not need to cover EHBs. Under the ACA, only policies in the small group and individual insurance markets are required to cover EHBs. The small group market is defined as groups that have less than 50 FTEs. (Please note that starting in 2016, the definition of small group will be expanded to include groups with 100 or fewer FTEs.)
Fully insured dental plans (less than 50 FTEs)
A. Technically, a fully insured dental plan covering a group with less than 50 FTEs is not required to offer its employees health coverage under the ACA. However, if the group elects to purchase coverage off the exchange, that coverage must cover all 10 EHBs, including pediatric dental benefits. However, the group does not need to buy all 10 EHBs from its medical carrier but instead may purchase the pediatric dental EHB benefit through a separate dental policy from its stand-alone dental carrier.
A. 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 (groups with 50 or more FTEs)
A. No. A fully insured dental plan covering a group with 50 or more full-time employees or full-time equivalent employees (FTEs) does not need to cover EHBs. Under the ACA, only policies in the small group and individual insurance markets are required to cover EHBs. The small group market is defined as groups that have less than 50 FTEs. (Please note that starting in 2016, the definition of small group will be expanded to include groups with 100 or fewer FTEs.)
Fully insured dental plans (less than 50 FTEs)
A. Technically, a fully insured dental plan covering a group with less than 50 FTEs is not required to offer its employees health coverage under the ACA. However, if the group elects to purchase coverage off the exchange, that coverage must cover all 10 EHBs, including pediatric dental benefits. However, the group does not need to buy all 10 EHBs from its medical carrier but instead may purchase the pediatric dental EHB benefit through a separate dental policy from its stand-alone dental carrier.
No. Despite the fact that your current policy with Delta Dental covers pediatric benefits, it is not compliant with the new ACA requirements. Delta Dental has developed EHB-compliant dental plans and has obtained all necessary federal and state certifications. These plans will satisfy all of the ACA’s requirements with respect to pediatric dental care.
No. Under the ACA, a small group employer is allowed to purchase EHB-compliant pediatric dental coverage from a stand-alone dental carrier like Delta 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.
It depends. If you are an employer with less than 50 FTEs and you have elected to purchase health coverage for your employees, you must offer your employees coverage that includes all 10 EHBs, including pediatric dental coverage.
It depends on your current plan design. Please contact your account manager to further discuss the details of your plan. You may want to consider making changes to your medical and dental plans now so that the dental plan could be considered an excepted benefit and, therefore, not subject to many of the ACA’s requirements. You can also discuss that option with your account manager.
The ACA market reforms have been in effect since 2010.
Some examples of these reforms include:
• Covering dependents up to age 26
• Allowing plan participants to request an external claims review from an independent review organization
• Modifying your plan design to remove applicable pre-existing condition exclusions and annual and lifetime limitations on essential health benefits
• Establishing a patient out-of-pocket maximum for in-network essential health benefits
• Issuing a Summary of Benefits and Coverage to all plan participants
A more comprehensive list and discussion of market reforms is available at: http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/index.html
Delta Dental will have EHB-compliant plans for your group. If you purchase an EHB-compliant plan through Delta Dental, you can be assured of meeting the ACA’s EHB pediatric dental coverage requirement.
Absolutely! If you determine that you must have an EHB-compliant plan, make sure to notify Delta Dental. Once Delta Dental knows of your need to comply, we will offer your group a fully compliant dental plan.
The law regarding this is complex. You should consult an attorney, payroll advisor or other qualified professional to assist with your FTE calculation. More information can be found at http://www.shrm.org/hrdisciplines/benefits/Articles/Pages/Employer-Mandate-Proposed-Rule.aspx
Maybe not. An employer sponsored dental plan is exempt from the ACA market reform requirements as long as the dental plan is an “excepted benefit” under HIPAA.
Under HIPAA, dental benefits generally constitute “excepted benefits” if they are either:
• Offered under a separate policy, certificate, or contract of insurance; or
• Not an “integral part” of the employer-sponsored medical benefit plan.
Because fully-insured plans issued by Delta Dental to employer groups are offered under a separate policy, certificate and contract of insurance from medical plans offered by the employer, Delta Dental’s fully-insured plans are considered “excepted benefits” and are not subject to the ACA’s market reform requirements.
However, for employers with self-funded plans, the analysis is more complex. The following excerpt from a question and answer document provided by the U.S. Departments of Health and Human Services (HHS), Labor and the Treasury on October 8, 2010, provides guidance on whether dental benefits are “integral” to medical benefits:
“For dental (or vision) benefits to be considered not an integral part of the plan (whether insured or self-insured), participants must have a right not to receive the coverage and, if they do elect to receive the coverage, must pay an additional premium. Accordingly, if a plan provides its dental (or vision) benefits pursuant to a separate election by a participant and the plan charges even a nominal employee contribution toward the coverage, the dental (or vision) benefits would constitute excepted benefits, and the market reform provisions would not apply to that coverage.”
Not automatically. Self-funded groups are not issued “a separate policy, certificate, or contract of insurance” by their dental benefits administrator. (True, Delta Dental does have a “contract” with its self-funded groups, but that is a contract for administrative services, not a “contract of insurance”.) Because Delta Dental does not underwrite the risk for our self-funded groups and instead administers their dental benefits pursuant to an administrative services agreement, a self-funded group cannot qualify for the exception.
If, however, a self-funded group’s dental benefits are “not integral” to its medical benefits, the group’s dental benefits may constitute an “excepted benefit” and, therefore, be exempt from the ACA’s market reforms.
If, however, a self-funded group’s dental benefits are “not integral” to its medical benefits, the group’s dental benefits may constitute an “excepted benefit” and, therefore, be exempt from the ACA’s market reforms.
EHB-compliant pediatric dental benefits are provided up to age 19 in Arkansas.
The ACA includes four new taxes/fees that may generate numerous questions. They are the Health Insurance Industry Fee, Medical Device Excise Tax, Comparative Effective Research Fee and the Transitional Reinsurance Fee.
Here is a summary of these four new taxes/fees:
Health Insurance Industry Fee (also called the ACA Tax):
This fee assesses the health insurance industry for the money that will ultimately be used to pay the premium subsidies for eligible low-income individuals purchasing coverage on Health Insurance Exchanges. Beginning in 2014, those with incomes between 133 percent (138 percent with a 5 percent disregard) and 400 percent of the Federal Poverty Level (FPL) will be able to access this newly available money. The Health Insurance Industry Fee DOES apply to stand-alone dental. The good news is that it only applies to fully-insured business. This tax will not appear as a separate line item on clients’ monthly invoices.
Medical Device Excise Tax:
This is a 2.3 percent excise tax on the sales price (that’s gross sales, not profit) of taxable medical devices. As a result, some dentists may ask for slightly higher fees on services with lab charges attached (crowns, bridges, dentures, implants, etc.) because the lab may be passing on a portion, or the full amount, of the tax to those dentists using their services. There have been multiple calls to repeal the Medical Device Excise Tax over the past several years. The U.S. Senate, in an amendment to the Senate Democrats’ budget, even voted 79–20 to repeal the Medical Device Excise Tax in March of this year. While that budget didn’t pass, it shows growing bipartisan disapproval of the revenue raising measure. Most dental plan sponsors will not need to worry about this tax.
Comparative Effectiveness Research Fee (CERF), also called the Patient-Centered Outcomes Research Institute (PCORI) Fee:
This fee is intended to fund a research institute that will look into various issues around comparative effectiveness (for example, should patients with heart disease be treated with drugs or have surgery, and when does it make sense to shift from one treatment to another). The annual fee is $1 per covered life for policy years ending between 10/1/12 and 9/30/13. The fee increases to $2 annually for policy years ending between 10/1/13 and 9/30/14. The fee is indexed for policy years between 10/1/14 and 9/30/19. If a group is fully insured, its medical carrier will pay the fee on behalf of the plan. If the medical plan is self-insured, regulation requires the plan itself to perform the calculation and make the payment (that is, the carrier will not make the payment on behalf of the group). This fee does not apply to stand-alone dental as long as the dental plan retains its excepted benefit status.
Transitional Reinsurance Fee:
This fee is intended to help offset the anticipated higher costs health plans will experience when health policies become “guaranteed issue” policies with no pre-existing condition exclusions. Essentially, many uninsured people (some with pre-existing conditions) are about to become insured. To help carriers partially offset this cost and let their rates and claims data catch up with the “new normal,” the ACA establishes a fund which will effectively act like stop-loss reinsurance for medical plans. In 2014, the fee is $5.25 per member (not per subscriber) per month, which is a significant cost. The assessment declines over time (and is slated to disappear after 2016), but will be a noticeable hit in 2014. For fully insured medical plans, the carrier will make the payment. For self-insured medical plans, the carrier most likely will make the payment, but the plan itself is ultimately legally liable for the fee. This fee does not apply to stand-alone dental as long as the dental plan retains its excepted benefit status.
Generally, 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). However, when a stand-alone dental plan is available, federal regulators allow medical carriers not to include pediatric dental in their EHB policies, which allows groups to purchase these benefits from Delta Dental as they currently do. Even if medical carriers embed pediatric dental coverage into the medical policy, the group can still retain traditional dental coverage through Delta Dental for the adults and children participating in the plan. EHB 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 (dental) 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.
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 (dental) 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.
Yes. Delta Dental will continue to offer group vision coverage just as we do today. However, the required pediatric vision EHB will be covered under group and individual medical plans.
Yes. Delta Dental of Arkansas will offer plans with EHB coverage for individuals and families on the individual exchange (Health Insurance Marketplace) including a dental pediatric-only option.