Thursday, August 1, 2013

Pediatric Dental with the Affordable Care Act – What does this mean? Do I need to Buy it?

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):

e.g. Delta Dental
Deductible Individual/ Family
In Network/Out Network %
Preventative Care
Basic Care
Major Care
Annual Maximum
Lifetime Orthodontia  Max

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.