PPACA AND THE PEDIATRIC DENTAL ESSENTIAL HEALTH BENEFIT FACT SHEET FOR HEALTH CARE PROFESSIONALS

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1 PPACA AND THE PEDIATRIC DENTAL ESSENTIAL HEALTH BENEFIT FACT SHEET FOR HEALTH CARE PROFESSIONALS April 2014 New provisions of the Patient Protection and Affordable Care Act (PPACA) became effective January 1, Its Health Insurance Marketplaces ( Marketplaces ) and essential health benefits provisions may affect you and your patients directly. This fact sheet provides an overview of the PPACA and answers common questions about the pediatric dental essential health benefit requirements. Marketplaces What is a Marketplace? A Marketplace, formerly known as a Health Insurance Exchange, has been established in every state as a new option for individuals (including those who work for an employer with 50 or fewer employees) to purchase medical and dental health insurance. What does on-marketplace mean? Individuals have the option to apply for financial assistance, which is based on household income, and have a 90-day grace period to pay their premium. What does off-marketplace mean? These plans are not eligible for subsidies by the government. Individuals have a 31-day grace period to pay their premium. Essential health benefits What are essential health benefits? These are a range of benefits established by the PPACA that non-grandfathered insured individual and small group health plans must cover starting on January 1, What is the pediatric dental essential health benefit? This benefit requires qualified health plans to offer pediatric dental coverage for individuals up to the age of 20 (age 19 in 2015). Plans that offer benefits designated as essential health benefits by the state benchmark plans, including self-funded non-excepted* dental and vision plans, cannot apply calendar-year or lifetime dollar limits on pediatric dental services that are defined as essential health benefits. * Self-insured dental and vision benefits are considered non-excepted when employees who enroll in medical coverage automatically receive dental benefits, vision benefits, or both. Cigna Dental plans offered on-marketplace In which states does Cigna offer dental plans on-marketplace? Cigna offers two dental health insurance plans on-marketplace, which offer the pediatric dental essential health benefit as required by the PPACA, to individuals in the following five states: Arizona Colorado Florida Tennessee Texas The health plan coverage offered on-marketplace in these states cannot have preexisting condition limitations, lifetime maximums, or calendar-year maximums on the dollar amount of their essential health benefits.

2 What dental plans does Cigna offer on-marketplace? Family + Pediatric Provides PPACA-compliant pediatric dental benefits for customers up to the age of 20 (age 19 in 2015). Provides dental PPO benefits for customers of all ages and includes the PPACA-compliant pediatric dental coverage for customers up to the age of 20 (age 19 in 2015). Cigna Dental on-marketplace plans: Features by state See separate chart for Colorado Calendar-year deductible (Refer to each plan column for applicable classes) Pediatric On-Marketplace AZ, FL, TN, TX Family + Pediatric 20*, and individuals age 20* and above Up to age 20:* $50 Classes I-IV Age 20* and above: $50 Classes I-III Up to age 20:* $150 Classes I-IV Age 20* and above: $150 Classes I- III Separate lifetime deductible None None Calendar-year maximum None Up to age 20*: None Age 20* and above: $1000 per person Lifetime maximum None None Class I: Preventive/diagnostic Class II: Basic restorative Class III: Major restorative Up to age 20:* $700 Up to age 20:* $1,400 Up to age 20*: Age 20* and above: Up to age 20:* Age 20* and above: 80% after deductible Waiting period: Six months Up to age 20:* Age 20* and above: Waiting period: 12 months Up to age 20:* Age 20* and above: In-network: 0% Discounts may apply Waiting period: Not applicable Out-of-network: Not covered Page 2 of 7

3 Cigna Dental on-marketplace plans: Features by state Colorado only Calendar-year deductible: Classes I, II, and III only Pediatric On-Marketplace Colorado Family + Pediatric 20*, and individuals age 20* and above Up to age 20:* $50 Age 20* and above: $50 Up to age 20:* $150 Age 20* and above: $150 Separate lifetime deductible None None Calendar-year maximum None Up to age 20:* None Age 20* and above: $1000 per person Lifetime maximum None None Classes I, II, and III only Class I: Preventive and diagnostic Class II: Basic restorative Class III: Major restorative 0% In-network Discounts may apply Out-of-network: Not covered Waiting period: Not applicable Up to age 20:* $700 Up to age 20:* $1,400 Up to age 20:* Age 20* and above: Up to age 20:* Age 20* and above: 80% after deductible Waiting period: Six months Up to age 20:* Age 20* and above: Waiting period: 12 months Up to age 20* and 0% in-network age 20* and above: Discounts may apply Out-of-network: Waiting period: Not covered Not applicable for all ages Page 3 of 7

4 Cigna Dental plans with the pediatric dental health benefit offered off-marketplace MyCigna Dental Pediatric is available off-marketplace to individuals in 10 states either embedded in or bundled with a Cigna medical plan, depending on the state s requirement. Embedded California and Connecticut Bundled Arizona, Colorado, Florida, Georgia, North Carolina, South Carolina, Tennessee, and Texas Embedded means that there is one single policy for medical and dental insurance. Medical and dental deductibles and out-of-pocket maximums are shared and cross-accumulate. Bundled means that there are two separate policies one for medical and one for dental. Medical and dental deductibles and out-of-pocket maximums are not shared, and do not cross-accumulate. Cigna Dental off-marketplace plans: Features by state See separate charts for California and North Carolina Policy type Calendar-year deductible: AZ, FL, GA, SC, TN, TX Bundled in Off-Marketplace CO Bundled in Separate lifetime deductible None None None Calendar-year maximum None None None Lifetime maximum None None None Class I: Preventive and diagnostic Class II: Basic restorative Class III: Major restorative 0% In-network Discounts may apply Out-of-network: Not covered Waiting period: Not applicable CT None 50% Page 4 of 7

5 Cigna Dental off-marketplace plans: Features by state California only Policy type Cigna medical plan bronze, silver, gold and platinum Off-Marketplace California CA-mandated medical plan bronze and silver Calendar-year deductible None $60 per person None Separate lifetime deductible None None None Calendar-year maximum None None None Lifetime maximum None None None Class I: Preventive and diagnostic Class II: Basic restorative Class III: Major restorative 50% CA-mandated medical plan gold and platinum 80% after deductible Cigna Dental off-marketplace plans: Features by state North Carolina only Off-Marketplace North Carolina Policy type Bundled in Calendar-year deductible: Separate lifetime deductible None Calendar-year maximum None Lifetime maximum None In-network Out-of-network Class I: Preventive and diagnostic Class II: Basic restorative Class III: Major restorative 95% after deductible 45% after deductible 45% after deductible 45% after deductible Page 5 of 7

6 Caring for your patients with Marketplace dental coverage Will I be able to tell when a patient has coverage through a Marketplace plan? No. You will not be able to distinguish between patients with coverage through an individual Marketplace policy or an employer-sponsored plan. However, the way a patient obtained coverage does not change the tools and resources available to you to manage patient care. You can verify eligibility, benefits, and claim status on the Cigna for Health Care Professionals website (CignaforHCP.com), through the electronic data interchange (EDI) eligibility and benefit inquiry and response (270/271), or by calling Cigna. Are there a dedicated phone number and claims mailing address for Marketplace customers? No. There are not a separate phone number and claim mailing address for these customers. You may continue to call Cigna24 ( ) for information such as eligibility and benefits. Submit all claims as you always have. What network do the Cigna Dental Marketplace plans use? The Cigna Dental Marketplace plans use the Cigna Dental PPO network. Your services will be reimbursed based on your currently contracted fees. What happens if I provide services to a Marketplace customer who has not paid the plan premiums? Subsidized plans Arizona, Colorado, Florida, Tennessee, and Texas: During the first 31 days of the grace period, Cigna will continue to pay claims and not seek reimbursement, even if the policyholder s coverage is later terminated. For days 32-90, Cigna will pend claims until the total premium owed is paid. If the premium is paid in full, then all pended claims will be paid. If the premium is not paid in full, then all pended claims will be denied. Texas-specific note: Claims for premium-subsidized customers in Texas with unpaid premiums will be paid during the extended grace period (days 32-90). If the premium remains unpaid after the extended grace period, Cigna will seek to recover payment to the extent the law allows. Non-subsidized plans Arizona, Florida, Tennessee, and Texas: Cigna will continue to pay claims during the first 31 days. If the premium is not paid, the customer's coverage will be terminated back to the paid-thru date and the customer is responsible for payments of claims incurred during the 31 day period. Colorado: Claims will be paid for customers in Colorado with unpaid premiums during the first 31 days. If the premium remains unpaid after 31 days, the customer s coverage will be terminated back to the end of the 31 days and no further claims will be paid. Cigna is not allowed to seek reimbursement of claims paid during the 31 days. How can I ensure that services provided will be reimbursed by Cigna? You should always verify a patient s eligibility at the time of service. This can be done on the Cigna for Health Care Professionals website (CignaforHCP.com), through the electronic data interchange (EDI) eligibility and benefit inquiry and response (270/271), or by calling Cigna at Cigna24 ( ) to determine whether a patient is covered based upon the eligibility information available to Cigna at that time. The following information will be provided on CignaforHCP.com or through the 271 transaction alerting you that your patient is within the extended grace period: Eligibility pending for verification of premium payment will appear on the Details screen of CignaforHCP.com S1 remark code will appear for claims pended in the claim details screen with Suspend Missing Information Letter to Insured noted 5 is the code that will be passed on 271 transactions which has the definition of Active Pending Investigation Page 6 of 7

7 What if I provide service to an individual whose eligibility is pending due to failure to pay the premium? If you provide service to an individual who is within his or her grace period, you accept the risk of nonpayment. If this individual s plan is terminated for non-payment of the premium, you will not be reimbursed by Cigna for the services rendered during the grace period and Cigna is not liable for the payment. It is recommended that you establish a policy on how to handle patients who are in the premium payment grace period. Questions? For more information about Marketplaces, the pediatric dental essential health benefit, and other aspects of the PPACA, visit the Cigna health care reform website InformedonReform.com. There you will find information and tools, designed with you and your patients in mind, to explain the provisions and impacts of the law. You can also contact the Cigna Dental Provider Services Unit at Cigna24 ( ). At the prompts, say Health Care Professional, Contract, and Dental. Your Cigna Dental Professional Relations Manager is also available to assist you. Cigna and the Tree of Life logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. 04/2014 Cigna 2014 Page 7 of 7