Pediatric Dental Benefits Under the ACA - What Employers (and dentists) Need to Know
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This document provides an overview of pediatric dental benefits under the Affordable Care Act and how they may impact dental practices. It discusses how pediatric dental coverage is considered an essential health benefit and must be included in certain health plans. It describes the three structures for how pediatric dental benefits can be offered (embedded, stand alone, bundled). It also outlines some pediatric dental plan benefit options and issues dental practices may face in navigating these new benefits, such as deciding whether to credential with dental insurance providers and how to manage claims processing.
Pediatric Dental Benefits Under the ACA - What Employers (and dentists) Need to Know
- 1. Pediatric Dental Benefits and the ACA March 3, 2014 LinkedIn: spring-consulting-group-llc Twitter: @SpringsInsight Proprietary and Confidential ©Copyright 2014 Spring Consulting Group, LLC. All rights reserved
- 2. Agenda Pediatric Dental Benefits And The ACA Essential Health Benefits Pediatric Dental Decisions for the Dental Practice Orthodontia 3 Structures In/out Connector Plans The Dental Practice Responsibilities Questions Decisions 2
- 3. Benefit Plan Changes 2014 Effective for plans renewing on or after January 1, 2014: All health insurance plans have to incorporate essential health benefits Health and Dental Plans will be re-tooled to incorporate benefits Health Insurance Plans are being phased out and or consolidated - Termination Notices a big confusion for businesses and Individuals alike Alternatives will be available which will require upgrading benefits for some (most) and decreasing for others Cost swings and premium hikes… 3
- 4. Health Plans 2014 and beyond Effective January 1, 2014, all coverage sold to individuals and small groups must comply with EHB standards. EHB standards specify: Covered benefits, including pediatric dental coverage Cost sharing requirements (the so-called “metal tiers”) ― Platinum ― Gold ― Silver ― Bronze Deductible limits for small groups Out-of-pocket maximum limits All existing plans in market will convert to “metal tiers” Large groups (>50) generally do not need to comply with EHB standards, but: Must comply with the out-of-pocket maximum limitation Must offer a plan with a “minimum value” of at least 60% (All Mass Plans Comply) 4
- 5. Essential Health Benefits Pediatric Dental 5
- 6. Essential Health Benefits Starting in January 2014, the Affordable Care Act will require all new individual and small group health plans (for people who don’t have traditional job-based coverage) to cover important health benefits like maternity, mental health, preventive, and pediatric dental care. These benefits, considered “essential” by the Department of Health and Human Services fall into 10 categories: 1. 2. 3. 4. 5. 6. 7. Ambulatory patient services (outpatient services) Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services (those that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10.Pediatric services, including oral and vision care The Affordable Care Act’s requirement that essential health benefits be covered without annual dollar caps will provide patients with more health benefits and a lesser financial burden. 6
- 7. Essential Health Benefits - Pediatric Dental Massachusetts Division of Insurance recommended that the plan with the largest enrollment in the merged market, the Blue Cross Blue Shield of Massachusetts HMO Blue plan, be selected as the benchmark plan. As this plan does not include the required category for pediatric dental, the DOI, following guidance from the Centers for Medicare and Medicaid Services, recommended that the benchmark plan be supplemented with the pediatric dental benefit plan from the Commonwealth of Massachusetts Children’s Health Insurance Program (CHIP) 7
- 8. Essential Health Benefits - Pediatric Dental All qualified dental plans offering the pediatric dental EHB must adhere to the following rules: Preventative, restorative and basic services, major restorative and medically necessary orthodontics* must be covered Coverage for individuals up to age 19 Waiting periods for benefits cannot exceed 90 days No lifetime or annual dollar limits Low deductibles on restorative, basic services and major restorative These plans can be sold on or off the connector (exchange) In-network preventive benefits are covered at 100% Out of pocket maximums of $1,000 per child and $2,000 for two or more children No referrals required for specialty care Note: While a child may see an orthodontist without a referral, there is no guarantee that treatment will be covered. The child’s case will need to be reviewed by the Dental Insurance Carrier for medical necessity 8
- 9. Orthodontia All qualified dental plans offering the pediatric dental EHB must adhere to the following rules: What is Medically Necessary Orthodontics? Medically Necessary Orthodontics means the patient must have a severe and handicapping malocclusion. This means the child’s condition must be severe enough to impact their ability to function such as having trouble eating and/or speaking. How is it determined if a child has met the criteria for “medically necessary” orthodontics? A clinical evaluation using the Handicapping Labio-Lingual Deviations (HLD) Form must be performed to assess if the child has met the criteria. The minimum HLD score to be considered for approval of medically necessary orthodontic treatment is 28. The HLD assess the following: • • • • • • • • • • Upper and lower anterior impactions Ectopic Eruption Overjet Overbite Severe traumatic deviations Mandibular Protrusion Open Bite Posterior unilateral crossbite Labio-lingual spread Cleft palate deformities 9
- 10. Essential Health Benefits – 3 Structures 1. Embedded – Pediatric Dental benefits are included in the medical benefits – all deductibles are made up of Dental and Medical charges. 1. BCBS of Massachusetts 2. United Health Care 2. Stand Alone – Pediatric Dental Benefits are sold separately and administered separately from the health insurance carrier. 3. Bundled – Where a Pediatric Dental Benefit is sold together with the medical plan but have separate policies. Therefore, there are separate deductibles for the Pediatric Dental Benefits from the medical plan deductibles and benefit maximums (none for Ped Dental Benefits). 1. 2. 3. 4. 5. 6. Harvard Pilgrim – Paired with United Dental Fallon Community Health Plan – Paired with Dental Benefit Providers (DBP) Minuteman Health Plan – Paired with Delta Dental of Massachusetts Celtic Care – Paired with Delta Dental of Massachusetts Tufts Health Plan - Paired with Altus Dental Health New England – Paired with Altus Dental 10
- 11. Essential Health Benefits – In/Out Connector In the Connector: • Qualified medical plans do not need to include pediatric dental EHB if there are stand alone plans offering that coverage (Confirmed 9-9-2013 as 6 dental providers offered Pediatric Essential Health Benefit Plans) • Some have debated over whether there is mandated availability or mandated purchase (in Connector – mandated availability ) of all 10 EHBs in the Exchange as long as 1 Pediatric EHB was offered Outside the Connector: • All plans would need to cover the pediatric dental EHB – Mandated Purchase or waiver attestation • Accomplished through a rider to the plan and or as a integrated benefit within health insurance (Extra cost estimated, but not confirmed at approximate 1% to include) 11
- 12. Essential Health Benefits - Pediatric Plans Pediatric EHB Standard Plan Plan Year Deductible - $50 Deductible for – Major/Minor Restorative Plan Year Max (>=19 Only) – NA Plan Year Max (<=19 Only) – $1,000 Preventative and Diagnostic Co-insurance In/OON – 0%/20% Minor Restorative Co-insurance – In/OON – 25%/$45% Major Restorative Co-insurance – In/OON – 25%/$45% Medically Necessary Orthodontia <19 only, In/OON – 50%/70% Non Medically Necessary Orthodontia <19 only, In/OON – N/A Definition of “Medically Necessary Orthodontia” would apply Premiums range from $6.41 to $41.79 (average $26) 12
- 13. Essential Health Benefit - Pediatric Plans High Plan Plan Year Deductible - $50/$150 Deductible for – Major/Minor Restorative Plan Year Max (>=19 Only) – $1,250 Plan Year Max (<=19 Only) – $1,000/$2,000 Preventative and Diagnostic Co-insurance In/OON – 0%/20% Minor Restorative Co-insurance – In/OON – 25%/$45% Major Restorative Co-insurance – In/OON – 25%/$45% Medically Necessary Orthodontia <19 only, In/OON – 50%/70% Non Medically Necessary Orthodontia <19 only, In/OON – 50%/70% Ind Premiums range from $24 to $42 Fam Premiums range from $102 to $156 13
- 14. Essential Health Benefit - Pediatric Plans Low Plan Plan Year Deductible - $75 Deductible for – Major/Minor Restorative Plan Year Max (>=19 Only) – $1,000 Plan Year Max (<=19 Only) – $1,000/$2,000 Preventative and Diagnostic Co-insurance In/OON – 0%/20% Minor Restorative Co-insurance – In/OON – 50%/70% Major Restorative Co-insurance – In/OON – 50%/70% Medically Necessary Orthodontia <19 only, In/OON – 50%/70% Non Medically Necessary Orthodontia <19 only, In/OON – 50%/70% Ind Premiums range from $19 to $37 Fam Premiums range from $81 to $140 14
- 16. The Dental Practice Responsibilities Dental practices and staff must be able to understand not only the health insurance plans (and their renewal date in 2014) but the pediatric dental benefits. They have to ask the critical questions of their patients: What is the name and insurance carrier of your Health Insurance Plan and your Dental Plan? When did or does your health insurance plan renew? The start date in 2014 will help to identify whether or not the Pediatric Benefits are in force at the time of service or not. The Dental Staff , depending on the health insurance plan, may have to submit each claim to the insurance company for processing. Each plan is different and if a patient has a deductible plan, claims paid for these pediatric dental benefits will have to be calculated after taking into account where the deductible use is at that time. Coordination of payment will have to be handled depending on the health plan and whether or not there is a Dental Plan in the picture of not. 16
- 17. ACA Impact on Pediatric Dental Benefits and Dental Practices Questions: Will your practice want to contract with ALL, some or NONE of the players; Your answer will impact your ability to get reimbursed for your services. Is a “Wait and see approach optimal? If you are, for instance, a Central Mass Dental Provider, you may think very carefully about being a Fallon Health Plan provider (Credentialed with United Dental) as there are so many people in the Worcester area that utilize Fallon for their health benefits. Does your practice have a pediatric dental component? If you are an adult only practice, your thought process may be a little bit different. Will your practice be able to adjust to accommodate the potentially millions of additional children that will obtain dental benefits under the ACA through insurance exchanges and the additional millions who will obtain coverage via Medicaid eligibility expansion. 17
- 18. ACA Impact on Pediatric Dental Benefits and Dental Practices Questions Con’t: There are potentially millions of new members into Dental Insurance via the exchanges but will it happen? How will the exchange enrollment issues locally and nationally affect Dental benefits? Orthodontia benefits – could there be a surge of cases with ACA Pediatric Dental Benefits or is the benefit so restrictive that there won’t be many that will be eligible? If employers drop dental coverage – how likely would employees buy dental insurance and what type of plans would they buy? Low priced, preventative care? 18
- 19. ACA Impact on Pediatric Dental Benefits and Dental Practices Decisions - Is the juice worth the squeeze? Should Dentists and their practices get credentialed or not? Is a wait and see approach better? If so how long to credentialed? What is the reimbursements for each of the networks? Is there potential lost business if you DON’T sign up into the networks? How much admin investment is required to navigate this benefit for your patients? What questions do you have to ask your patient each time they come for care? Who is the primary payor and who is secondary? Will patients really know enough about it? Will they lean on you to know these benefits inside and out for all insurance companies and Dental providers? 19
- 20. Contact Information Corporate Office: 30 Federal St – 4th Floor, Boston MA 02110 Operations Office: 200 Friberg Parkway – Suite 2006, Westborough, MA 01581 George W. Gonser, Jr. MBA, CHDC, LIA Partner Spring Consulting Group, LLC – Spring Insurance Group [email protected] Phone: 617-589-0930 Fax: 617-589-0931 w w w . s p r i n g g r o u p . c o m 20