3 Important Reminders of ACA and Essential Dental Benefits
Important healthcare reform facts on dental coverage.
Navigating the waters of ACA and its ever-changing regulations can be intimidating for your clients. Here is a high-level overview of ACA and dental benefits for you and your clients.
Something New in 2016
In 2016, the small group definition and the employer mandate changed to the following:
- Small groups are now defined as 100 or less full-time equivalent employees. For small groups, health insurance carriers and issuers are required to sell Qualified Health Plans (QHPs).
- The employer mandate includes 50 or more employees. These groups are required to offer plans with at least Minimum Essential Coverage (MEC) or face penalties.
ACA and Dental Benefits Recap
Although the government acknowledges dental services as an important aspect of an individual’s health and wellness, ACA does not define adult dental coverage as an essential health benefit. Therefore, QHPs and MEC do not have to include adult dental benefits.
However, ACA considers child or pediatric dental as an essential health benefit under new healthcare reform. Therefore, QHPs include pediatric dental benefits. Medical carriers are responsible for ensuring pediatric dental coverage is provided either by one of the following:
- Pediatric dental coverage is embedded in the medical plan.
- The carrier has “reasonable assurance” that pediatric dental coverage is obtained, such as through a standalone dental plan.
The new healthcare reform regulations have given the states the authority to decide when the new definitions of small and large groups take place, as well as how to count the number of full-time employees. Moreover, the states also decide how reasonable assurance will be defined for each state.
States are taking one of four different approaches to help define reasonable assurance and guide health carriers.
- Notification – Requires the medical issuers to notify enrollees that the policy does not include pediatric dental benefits.
- Attestation – The medical issuer can forgo embedding pediatric dental if enrollees attest to obtaining pediatric dental coverage through a different policy.
- Proof of Coverage – The least popular approach by the states. (Washington and Maine are the only two states that have adopted this approach.) This requires medical carriers to obtain proof of pediatric dental coverage from the enrollee during the medical coverage application.
- Issuer Determination – The most popular approach for states, and used by states that have not made any type of formal ruling or decision about how to interpret reasonable assurance beyond the federal government’s definition. These states place the responsibility on the medical issuer to define and obtain assurance of pediatric dental coverage.
As we move forward with health care reform, your clients will continue to need your expertise to help translate shifting and evolving federal mandates. And, they will need your advice on finding plans that best meet their needs. When it comes to dental care plan regulations and changes, keep AlwaysCare on top of your short list of sources for reliable updates.
NOTE: This article is intended to provide a high-level summary. Groups should get definitive advice regarding their specific circumstances with input from their legal counsel and/or accountant.