Dental Benefits & the Affordable Care Act

Transcription

1 Dental Benefits & the Affordable Care Act Health Care Reform, Dental Benefits & the Dental Practice Oral Health Coalition Summit Rutgers School of Dental Medicine D. Scott Navarro, DDS, MPH Vice President, Professional Services & Dental Director Delta Dental of New Jersey February 26, 2014

2 Agenda Basics of the ACA Dental Coverage under the ACA Considerations for Dental Practices

3 Basics of the ACA 3

4 4 Basics of the ACA Four Primary Goals of the ACA 1. Expand health insurance coverage 2. Improve coverage for those with health insurance 3. Improve access to and quality of care 4. Control rising health care costs We will focus on goals 1 and 2 and relate them to dental coverage

5 5 Basics of the ACA Goal 1 Expanding Health Insurance Coverage U.S. citizens/legal residents must have qualified health insurance by 2014 or pay a penalty ( Individual Mandate ) Larger employers required to provide coverage or pay penalties (which were deferred to 2015) Expands Medicaid with federal funding Creates exchanges ( Marketplaces ) for individuals and small employers to purchase coverage and obtain reduced premiums based on income qualification

6 6 Basics of the ACA Goal 2 Improve Coverage for those with Insurance Coverage for small employers and individuals must include 10 categories of minimum essential benefits - including pediatric dental Larger employers must offer a minimum value of coverage, but are not required to include pediatric dental coverage Other market reforms were made, including: Prohibit insurers from applying pre-existing condition restrictions Remove annual and lifetime dollar limits Limit out-of-pocket spending for consumers Most market reforms do not apply to dental for large employers

7 7 Basics of the ACA Everyone must be enrolled in one of these plans Individuals or Small Employer Plans Offered in Exchange Offered Outside Exchange Grandfathered Plans* (Individual, Small or Large Employer) Large Employer Plans Government Programs Medicare Medicaid CHIP Tricare Veterans * Existed 3/23/10, with very limited change in benefits. Can add new employees to plan.

8 8 Dental Coverage under the ACA It s Complicated

9 Health Care Reform and Dental Benefits Dental Coverage and the ACA ACA and Dental Benefits The ACA requires coverage for pediatric dental as one of the 10 categories of Essential Health Benefits for individuals and small employers There is no requirement for adults to purchase dental Adult dental benefits are considered excepted benefits are not subject to the ACA s market reforms (such as no annual maximum) Pediatric plans will need to conform to the essential health benefit requirements (individuals and small employers)

10 Essential Health Benefit Requirements - Dental Dental Coverage and the ACA Essential Health Benefits ( EHB ) New Jersey selected NJ Family Care (the State Children s Health Insurance Program- CHIP ) as the benchmark for the scope of covered benefits Applies to children age 18 and under The EHB applies only to plans purchased by individuals & small businesses (50 or less full-time equivalent employees) It requires that plans provide benefits that meet a minimum value requirement

11 General Pediatric EHB Plan Elements Pediatric Dental Benefits Standardized Benefits No Maximums Out of Pocket Limits Prior Authorizations Dental/Medical Necessity Criteria Applies to members under 18 years of age Must be Substantially Equal to NJ State CHIP Plan in terms of coverage and benefits (not fees) No dollar maximums for EHB benefits Once reached, covered services are paid at 100% $700 per child, $1,400 all children in family Required for many procedures, if not performed, service is not covered or benefit reduced Most services have no standard frequency limitations

12 Example of Pediatric EHB Dental Plan (Child Only) Stand-alone High and Low Procedure Categories Low PPO Plan High PPO Plan Diagnostic & Preventive 100% 100% Basic Restorative Services (includes oral surgery) 60% 80% Major Services 50% 50% Orthodontics (Medically necessary) 50% 50% Deductible $75 (all services) $25 (not applied to D&P) Maximum Annual Out of Pocket (1 Child) $700 $700 Maximum Annual Out of Pocket (2 or More Children) $1,400 $1,400 Annual Maximum (per covered person) None None Medically Necessary Orthodontics Maximum No Dollar Maximum No Dollar Maximum Waiting Periods None None Eligibility Age To Age 19 To Age 19

13 Sample Plan with Pediatric EHB and Adult Benefits Stand-alone High Plan Enhanced High Family Plan Procedure Categories Pediatric Benefits Adult Benefits Diagnostic & Preventive 100% 100% Basic Restorative Services (includes oral surgery for pediatric plan only) 80% 80% Major Services 50% 50% Orthodontics (Medically necessary) 50% Not Covered Deductible $25 (not applied to D&P) $50/$150 (not applied to D&P) Maximum Annual Out of Pocket (1 Child) $700 No Out of Pocket Limit Maximum Annual Out of Pocket (2+ Children) $1,400 No Out of Pocket Limit Annual Maximum (per covered person) None $1,000 Medically Necessary Orthodontics Maximum No Dollar Maximum Not Covered Waiting Periods None None Eligibility Age To Age 19 Age 19+

14 14 Dental Coverage under the ACA A Few More Wrinkles

15 Dental Coverage and the ACA Dental benefits can be provided 3 ways: Embedded in health plan part of medical policy Integrated deductibles and out-of-pocket limits Stand-alone dental plans separate policy Distinct deductibles and out-of-pocket limits Bundled dental paired with medical policy Not part of medical policy - structured like standalone 15

16 Dental Coverage and the ACA Dental can also be purchased on the public exchange or outside the public exchange (the way it is today) Premium reduction subsidies for those with qualifying incomes can only be accessed on the public exchange Subsidies apply to health plans

17 17 Dental Coverage and the ACA Inside and outside are different On-exchange health plans do not have to include the pediatric essential health benefits Off-Exchange Health plans must include pediatric dental, unless reasonably assured that an exchangecertified standalone pediatric EHB dental plan has been purchased for children

18 Comparing Total Dental/Medical Out of Pocket Costs $5,500 in medical expenses must be paid before OOP limit of medical and stand-alone dental are equal Example only plans vary & specific comparisons may produce different results

19 Comparing Total Dental/Medical Deductibles For medical plans that apply deductible to dental, $3,250 in expenses must be paid before there is any dental coverage available (some may make D&P available) Example only plans vary & specific comparisons may produce different results

20 20 Dental Coverage and the ACA Patients are likely to be confused until they adapt to the new forms of coverage Proposed changes have been published for 2015 Regulations will continue to evolve the essential health benefits will be reviewed in 2016 It s still early, but enrollment through the exchanges has been below expectations

21 Dental Practice Considerations 21

22 Dental Practice Considerations Evaluating the Impact For 2014 & 2015, just individual and small employer policies are affected by the pediatric benefit change For many of your patients with dental coverage from larger employers, there will be little change Office staff should be sure to ask if there have been any benefit changes especially for children under age 19 It s especially important to verify benefits with the carrier, preferably in advance of the appointment

23 Dental Practice Considerations Issues to Consider Verify whether your patient s plan is stand-alone dental or embedded in the medical plan -- benefits may be very different The new plans use NJ CHIP as the basis for benefits, but dental offices do NOT have to participate with the CHIP program nor accept the CHIP program fees

24 Dental Practice Considerations Issues to Consider Benefits may be different between adults (age 19 and over) and children (age 19 and under) in the same family Some new plans will require mandatory pre-authorization of certain procedures, so be sure to verify this with the carrier Orthodontics will be subject to medical necessity reviews and must meet certain criteria to qualify for payment

25 Looking Ahead Stand-alone dental plans will seek equal treatment of its coverage inside and outside of the exchange: Required purchase on exchange Separate pricing by the medical carrier The ACA will eventually incorporate quality metrics for dental possibly as early as 2016 but specifics have not been defined

26 Questions 26

27 Contact Information: Mandatory preauthorization requirements HLD (NJ-Mod2) Malocclusion Assessment Form Dentist Handbook Chapter 20 (866)

28 Contact Information Continued: Claims Individual Policy Delta Dental of Wisconsin P.O. Box 103 Stevens Point Wisconsin (888) Claims Group Policy Delta Dental of New Jersey, Inc. P.O. Box 222 Parsippany, NJ (800)