Understanding Your Affordable Care Act Coverage
As part of the Affordable Care Act (ACA), Delta Dental has outlined the following transparency in coverage information for members enrolled in dental plans purchased through healthcare.gov.
Balance billing occurs when a dentist bills a member for charges—other than copayments, coinsurance or any amounts that may remain on a deductible—following Delta Dental's payment on a claim. Our network dentists agree to accept Delta Dental’s
contracted fees as full payment and not to bill the member above that amount. Balance billing is not allowed within the Delta Dental network.
If the submitted amount for an out-of-network dentist is more than the allowed amount, the member is not only responsible for paying the dentist that percentage listed in the policy, but is also responsible for paying the dentist the difference between the submitted amount and the allowed amount. Nonparticipating dentists are under no obligation to limit the of their fees and the member will be responsible for paying the amount that is charged.
If an in-network dentist is not readily available within a reasonable period of time or driving distance, it may be possible for a member to receive covered services from an out-of-network dentist and be reimbursed at the same benefit level as if the covered services were provided by an in-network dentist. If this situation occurs, the member should call customer service to discuss options prior to visiting the out-of-network dentist.
If a member requires emergency treatment and receives covered services from an out-of-network dentist, covered services for the emergency care rendered during the course of the emergency will be treated as if they had been provided by an in-network dentist.
One benefit of staying in the Delta Dental network is that our participating dentists will submit claims on your behalf. If you choose to visit a nonparticipating dentist, you will need to submit your own claims within 12 months of the date of service to:
PO Box 9085
Farmington Hills, MI 48333-9085
PO Box 15965
Little Rock, AR 72231
You can download the claim forms here.
A claim is pending when it has been submitted to Delta Dental and is still being processed by the claims department.
- If the member fails to pay the full amount of the premium by the date it is due, a grace period will apply. The grace period allows the member additional time to pay the premium without losing coverage. The grace period refers to either a 3-month grace period for members receiving advance payments of tax or a general grace period for members not receiving advance payments of tax credit.
- The general grace period is a 31-day grace period. This means that if a premium, other than the initial premium, is not paid by the date it is due, it may be paid during the following 31 days. Your policy will remain in force during this grace period. The grace period will not apply if, at least 30 days before the due date, Delta Dental has delivered or mailed to your last known address a written notice of our intent not to renew your policy.
- The 3-month grace period applies to members receiving advance payments of the premium tax credit who have previously paid at least one full month's premium during the benefit year. Your policy will remain in force during this grace period. If payment is not received within the 3-month grace period, your coverage will terminate on the last day of the first month of the grace period.
- During the 3-month grace period, Delta Dental will pay all appropriate claims for services rendered to the member during the first month of the grace period and may pend claims for services rendered to the member in the second and third months of the grace period.
A retroactive denial is the reversal of a previously paid claim, as a result of which the member then becomes responsible for payment. A claim can be denied retroactively, for example, if Delta Dental pays a claim during the grace period and it is discovered that the member has terminated the policy prior to covered services being rendered.
The best ways to prevent retroactive denials are to:
- Pay your premium on time online or by phone
- Ensure you have provided us with the correct information
- Ensure you are covered when services are performed.
To update your individual account information, you can visit the Individual Account Manager.
If an overpayment occurs, it will automatically be given as a credit toward the next month's premium.
The Essential Health Benefits requirement for pediatric oral care services (for children up to age 19) may limit certain covered services, including orthodontia, to those that are medically necessary. In the case of orthodontia, this means that only orthodontic treatment that is assessed as being reasonable, necessary and/or appropriate, based on evidence-based clinical standards of care may be considered an essential health benefit. Medically necessary orthodontia was not specifically defined by federal law or regulation and may vary by state.
COORDINATION OF BENEFITS
Coordination of benefits occurs when a member has dental coverage from more than one dental plan. When the claim is submitted, special criteria helps determine which dental plan is primary and which is secondary. The primary plan must pay its portion of the claim before the secondary plan pays its portion. When Delta Dental is primary, the claim is processed normally. When Delta Dental is secondary, the claim is processed, so that the combined payments provide maximum coverage without exceeding 100% of the total claim amount.
Some dental plans include a non-duplication clause for coordination of benefits. In this case, Delta Dental is the secondary carrier, and payment is determined by deducting the primary carrier's payment from the amount that Delta Dental would have paid if there had not been of benefits.
A predetermination informs you and your dentist, before the procedure is if it is a covered procedure and what the reimbursement for the covered procedure will be. A predetermination, or pre-approval, is recommended for any non-emergency treatment plan of $300 or more. You will receive an estimated dollar amount of how much Delta Dental will cover for the planned procedure. A predetermination is valid 12 months from the issue date, and is subject to eligibility, benefit maximums, coordination of benefits (if applicable) and group and dentist status at the time services are provided.
EXPLANATION OF BENEFITS
After you visit your dentist, you will receive an Explanation of Benefits. The Explanation of Benefits will display the fee your dentist submitted, the amount Delta Dental will cover and the amount you owe for the service. If you owe any amount, you will need to pay your dentist the remaining balance. You may also access your Explanation of Benefits when you to the Member Connection section of this website.