What is ACA?
The Affordable Care Act. It is also known as Health Care Reform, the Patient Protection and Affordable Care Act, and Obamacare. The measure was signed into law in 2010.
What is EHB?
Essential Health Benefits (EHB). Under the ACA, only policies in the small group and individual markets are required to cover EHBs. There are 10 benefit categories that must be included in EHB-compliant plans.
What are the 10 EHB categories?
- Ambulatory patient 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 and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services including oral and vision care
A patient notices that their children’s benefits have changed. Why did they change?
ACA requires that pediatric dental plans match the state’s benchmark plan and be offered at either an 85 percent or 70 percent actuarial value (high and low). Matching the state’s benchmark only refers to the scope of covered services and associated limitations. Patient cost-sharing levels may vary from plan to plan and carrier to carrier.
Why are children’s benefits different than their parents?
The ACA’s dental plan requirements are only for people under age 19. Adults are able to keep their existing dental plan.
Why do different members of the same family have different benefit levels?
Dental benefits are based on age and plan. Individuals 19 and over maintain standard benefit levels. To eliminate any confusion, it is vital that members and dental offices check benefits on an individual level, not at a family level.
What if a patient has a procedure that is not part of an EHB-compliant plan, but is part of “standard” coverage?
Regardless of the patient’s age, coverage will revert to the standard plan.
What if a patient has a procedure that is covered as both a “standard” benefit and an EHB benefit in a plan?
There is no coordination of benefits (COB) between the standard and EHB benefits. Only one set of benefits will cover the procedure. Having both EHB and non-EHB benefits does not mean the patient will receive complete coverage.
Consider this example: if the procedure code is in the EHB list AND the patient is under the age limit, EHB benefits are used to pay that code. If the procedure code is NOT in the EHB list, the standard benefits are used to pay that code, regardless of the patient’s age.
How long is a patient covered in an EHB-compliant plan once they turn 19?
Small group: To the end of the calendar year of the 19th birth date.
Individuals: To the end of the calendar year after the 19th birth date.
How does the out-of-pocket maximum work?
Certain costs paid by your patient for in-network EHB-covered services apply to the out-of-pocket maximum. All in-network, EHB services covered in an EHB-compliant plan are paid at 100 percent after the out-of-pocket maximum has been reached.
What is included in the out-of-pocket maximum?
Deductibles, coinsurance and copayments for in-network, EHB-covered services are applied to the out-of-pocket maximum in an EHB-compliant plan.
Is the out-of-pocket maximum different for a policy covering one individual under 19 or two or more individuals under 19?
Yes. The out-of-pocket limit for pediatric dental essential health benefits is $350 for families with one covered member under the pediatric age limit and $700 for families with two or more covered members under the pediatric age limit.
What happens if a patient goes to an out-of-network provider?
If the patient is under the age limit for an EHB-compliant plan, the services are still paid using the EHB copayments, but the patient’s payment does not apply to the out-of-pocket maximum.
If a service is denied under EHB due to a time limitation, will it automatically revert to the standard plan to pay (if payable)?
No. EHB covered services are only payable under the EHB benefits, using the limitations applicable to EHB covered services. Standard plan benefits only apply to the non-EHB covered services.
If a patient exceeds their limitations for covered services in the EHB-compliant plan, does that count toward their out-of-pocket maximum? Why?
No. Only those services actually covered under the EHB-compliant plan will count toward the out-of-pocket maximum.
If Mom has a standard plan through a large employer that does not have to be EHB-compliant and Dad has an EHB-compliant plan with benefits through a small group; and Mom’s date of birth is first, how will this work with EHB?
The EHB-compliant plan will pay secondary just like any other plan. If there is any patient payment after the secondary payment, it will apply to the out-of-pocket maximum.
What if Dad is primary and we pay the EHB benefit out; will Mom’s coordinate in this instance?
Yes. When the EHB-compliant plan is primary, any patient pay amount that would apply to the out-of-pocket maximum in the absence of COB will still apply to the out-of-pocket maximum, even if the secondary carrier pays that amount.
Will there be any impact on Delta Dental’s maximum approved fee?
No.
Will there be any change regarding submission of claims?
No.
How can I verify a patient’s eligibility?
Patient eligibility verification has not changed. Verification can still be accomplished through the IVR, Toolkits or ID cards.
Do I need to take any additional action to change my participation status?
No. As a Delta Dental Premier® and/or a Delta Dental PPOSM participating provider you are considered in-network for EHB.
What should I do if there’s any doubt about a patient’s eligibility or coverage?
Submit a pre-treatment estimate.