Pediatric Dental with the Affordable Care Act – What does this mean?
Today I will be talking about State Federal and Federally
Facilitated Exchanges (also known as Marketplaces). State Based Exchanges will
come up with their own rules so are not included here.
Pediatric Dental is one of the 10 Essential Health Benefits
required to be on a health insurance plan starting in 2014. Below is what I've been able to figure out so far. As changes happen, this will be changing.
What is Pediatric Dental?
It simply means that all children under the age of 19 will
have coverage for preventative, basic, major/restorative, and most will include
“medically necessary” orthodontics. Picture your current dental plan. It
usually looks like the following (this would be considered a “high plan” under
the new rules):
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Network
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e.g. Delta Dental
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Deductible Individual/ Family
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$50/$150
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In Network/Out Network %
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Preventative Care
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100%/100%
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Basic Care
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80%/80%
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|
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Major Care
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50%/50%
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|
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Orthodontia
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50%
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Annual Maximum
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$1,000.00
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Lifetime Orthodontia Max
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$2,000.00
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Pediatric dental plans can be offered both as a standalone
product (similar to the above) within the exchange or embedded within the medical
plan.
Stand Alone
If the plan is offered as a standalone product, it will look
similar to the above plan (with different percentages). The big difference is
that the annual out of pocket maximum will be $700 for one child and $1400 for
2+ children. This means that if orthodontia is deemed as medically necessary,
the most someone would pay in one year would be $700. Furthermore, there is NO
ANNUAL MAXIMUM for children (not adults). So if a child needs $4000 of covered
work done, then the child’s family would pay only $700 within that year.
Embedded within a Medical Plan
We are still waiting to see how this may look. A health
insurance company can have pediatric dental’s deductible be the same as the medical
deductible or have it be separate.
Do I need to buy Pediatric Dental?
Technically yes. Some states will be including it with all
plans. Most states will offer a standalone dental benefit that can be combined
with a separate medical plan. They will also be offering medical plans with
dental included within the medical plan.
Technically, all states will require “reasonable assurance” that
you own a dental plan that covers children. If you are on a Federally
Facilitated Marketplace (Exchange) website, it will allow you select a medical
only plan and check out without selecting a separate dental plan. It will ask
you whether you have other dental and if you say yes, then you can continue. Currently
there is no verification as to whether you actually have a pediatric dental
plan.
If I don’t have Pediatric Dental, but do have Medical, will I be subject to the Individual Mandate?
Probably not as I believe the question on the tax return
will be whether you have been covered by a health insurance plan and not ask
whether your plan includes pediatric dental. Furthermore, people on
grandfathered plans will not be required to have pediatric dental and will not
be subject to the Mandate.
What if my company offers dental already?
Chances are that pediatric dental will NOT be part of your
company’s medical plan in 2014 as the requirement states that if a company
offers a standalone dental plan that covers children, then they do not need to
include pediatric dental within their medical plan.
