Dental Benefits and theAffordable Care Act

Everyone must enroll in a plan or program

This includes…• Individual or small group plans• Large group plans• Grandfathered plans (for individual, small or large group) • Government Programs (Medicare, Medicaid, CHIP, Tricare & Veterans)

Individual/Small Group Plans must offer Essential Benefits

Individual or Small Group plans must offer “qualified” plans

• with essential benefits• including pediatric oral health

services.

New incentives and penalties • Premium and cost-sharing

assistance• Assistance to small group

employers• Penalties for failure to participate

Individual/Small Group Plans must offer Essential Benefits

Individual and Small Group plans must include Pediatric Oral Health Services

(up to age 19)

Standalones can offerPediatric Dental

YAY!

• The inside vs outside rules will differ.

• Dental is exempt from major market reforms (when purchased as a separate or stand-alone policy in the large group market).

• Pediatric EHB is subject to some market reforms, but not all.

A Perfect

10Two ways to

get there –

Inside vs. Outside

A Perfect 10… How To Get There…

10.0

9.5+0.5

Inside Outside

Inside most state exchanges consist of:

• A 9.5 EHB Qualified Health Plan (QHP)

• A stand-alone “.5 EHB” pediatric dental plan that can be coupled with any 9.5 QHP - or –

• A 10.0 QHP with dental embedded

…Inside vs Outside

A Perfect 10… How To Get There…

10.0

9.5+0.5

Inside Outside

Outside most state exchanges:

• A 9.5 EHB health plan without pediatric dental can, depending on state, provide “reasonable assurance” that a purchased .5 exchange-certified stand-alone plan is received.

• All health plans in small group or individual marketsmust offer

-either a 10.0 EHB health plan with dental embedded-or a 9.5 health plan with a .5 dental plan bundled.

• The .5 bundled dental plan must be “exchange certified“

There are new taxes on dental insurers too!

Tax-exempt carriers count ½ of the net premium. This will have a:

• +1% premium impact for Delta Dental, and a • +2% impact for Delta Dental Insurance Company

The tax assessment is based on market share. Will be calculated from net premium risk business

(with no assessment of ASO business)

There are new taxes on dental insurers too!

Beginning in 2018, there will be an excise tax on high cost benefit plans - dental is exempt.

• 40% tax coverage for over-stated limits• Still some questions about ASO dental

Dental coverage is oftena moving target

• Benchmark varies state-by-state• Federal states go with FEDVIP• Most states select CHIP

• The Actuarial Value (AV) is keyIt drives terms and limits pricing

Dental coverage is oftena moving target

ACA does not define cost sharing, e.g., copays, deductibles, frequency and

other limitations.

Benefits do not define cost sharing…

3 Dental Options

• Stand-alone• Bundled• Embedded

DETAILS…

THE DEVIL IS IN THE

3 Dental Options

Stand-alone, Bundled and Embedded

True “Stand-alone”:

• True stand-alone is one policy, separate from a medical policy • Policy can be coupled with any QHP/health plan • OOP maximum, Actuarial Value (AV) and deductibles are separately accumulated and not part of the QHP cost sharing limits. • In 2015, all standalone plans have a $350 out-of-pocket maximum. • AV of 70 or 85

3 Dental Options

“Bundled stand-alone” consists of:

• Two policies • One medical and one dental that is technically standalone • Though “stand-alone,” bundled dental policies can be coupled with

only a specific medical partner • OOP maximum, AVs and deductibles are separately accumulated and not part of the QHP cost sharing limits • FFM and most state exchanges cannot mandate bundled medical-

dental policies

3 Dental Options

‘Embedded’ Dental in a QHC plan:• ONE Combined medical-dental policy• The ACA permits for a “combined” medical-dental $2,000 or higher

deductible• These policies vary on how OOP max, deductibles and AV for dental will

work

Standalone doesn’t leave anyone out in the cold…

Dental is handled differently when Standalone.

HHS approves high (85%) and low (70%)• with a separate $350 OOP maximum

• medically necessary orthodontics (when in the benchmark)

4 QHP Benefit tiers

PLATINUM

GOLD

SILVER

BRONZE 60%70%80%90%

• There are four QHP Benefit Tiers: Bronze, Silver, Gold and Platinum

• Embedded dental is not included in actuarial value.

• Dental is NOT required to conform!

Stand-alone details vary slightly

Sample comparisons forStandalone PPO High and Low*

PPO/PPO HIGH PLAN LOW PLAN

Diagnostic & Preventive (D&P): X-Rays, Exams, Cleanings, Sealants

100% 100%

Basic Services: Basic Restorative 80% 50%

Major Services: Crowns & Casts, Prosthodontics, Endodontics, Periodontics, Oral Surgery

50% 50%

Orthodontics (Medically Necessary) 50% 50%

Deductible $40 (not applied to D&P) $50 (applied to all services)

Annual Maximum None None

Orthodontics Maximum None None

Waiting Periods (Medically-necessary ortho) 12 months 12 months

Out of Pocket Maximum (PPO Dentists only)

Per child $350 $350

Per 2+ children $700 $700

Annual Premium for individual $346.92 $277.44

*(in Texas)

Sample Standalone ComparisonDHMO High and LowPROCEDURE CATEGORIES 85% AV 70% AV

Average Copayment: Average Copayment:

Diagnostics: X-Rays, Exams, Cleanings $0 $0

Preventive: Sealants $0 $0

Basic Services: Basic Restorative $40 $90

Major Services: Crowns & Casts, Prosthodontics, Endodontics, Periodontics, Implants, Oral Surgery

$310 $310

Orthodontics (Medically Necessary) $700 $700

Office Visit Copay $0 $20

Deductible None None

Out of Pocket Maximum $350/child & $700/multi child OOP

max

$350/child & $700/multi child OOP

max

Orthodontics Maximum (Lifetime) No Maximum No Maximum

Waiting Periods (Major & Ortho) None None

Actuarial Value (AV) 87% 71%*(in Texas)

Embedded Pediatric Dental

These plan designs are all over the board.

No guaranteed AV

A typical “looking” 100/80/50 plan could be subject to a high $2,000+ combined deductible.

D&P might be carved out from deductible.

The MOOP is $6,600 combined/integrated with medical.

Basic and major outside of California often limited to just 50%.

Copays can be required with every office visit.

FACE OFF!

Understand how the plan designs vary between embedded, standalone & bundled.

A single deductible and OOP maximum when embedded could have:• Up to a $2,000+ deductible• Up to $6,600+ OOP maximum

A separate deductible and OOP maximum, when stand-alone or bundled, has: • Up to $65 deductible• $350 OOP maximum

Dental for your typical kid

A typical child utilization scenario would be:

Child goes to an urban area dentist twice in a year, covered under a PPO

• On the 1st visit child gets an exam, cleaning, x-ray, fluoride treatment, three sealants and a single, one surface filling.

• On the 2nd visit, child gets an exam, cleaning and fluoride treatment

Dental for your “typical kid”:Limits costs range from $101…to $683

Standalone Low

Standalone High

Embedded0

100

200

300

400

500

600

700

800

$205$113

$683

$479$570

$0

Child PaysPlan Pays

This example illustrates how separate deductibles, versus one QHP deductible.can affect OOP costs.

Dental for kids that need braces

A child with high utilization analysis assumption might be:

• Child’s needs meet medically necessary ortho definition based on 26-HCD index. used in some state’s Medicaid dental programs.

• Anticipated costs for appliances and treatment is $8,000, spread evenly over two years.

Dental for kids that need braces: Limits cost $350…to $700!!!

This chart demonstrates how separate dental OOP pays for High Utilization dental care.

Year 1 Year 2 Total$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$350 $350 $700

$3,650 $3,650

$7,300

Child pays

Plan pays

Embedded plans pay 50%...ONLY after $2,000+ deductible

Year 1 Year 2 Total0

1000

2000

3000

4000

5000

6000

7000

$3000 $3000

$6000

$1000 $1000

$2000

Child PaysPlan Pays

Bottom Line – Whatever you do:

Stay informed on what the kids’ dental in a medical plan does and does not cover

Help make dental policy transparent

Understand how the dental piece is being provided, and by whom

Work with your Delta Dental account executive to make an informed choice regarding which Delta Dental product or combination of products is available in your state

Get savvy! Our account execs are here to help!

Our Delta Dental enterprise includes these companies in these states: Delta Dental of California — CA, Delta Dental of Pennsylvania — PA & MD, Delta Dental of West Virginia, Inc. — WV, Delta Dental of Delaware, Inc. — DE, Delta Dental of the District of Columbia — DC, Delta Dental of New York, Inc. — NY, Delta Dental Insurance Company — AL, FL, GA, LA, MS, MT, NV, TX and UT.

Delta Dental of California, Delta Dental of New York, Inc., Delta Dental of Pennsylvania, Delta Dental Insurance Company and our affiliated companies form one of the nation's largest dental benefits delivery systems, covering more than 26 million enrollees.All of our companies are members, or affiliates of members, of the Delta Dental Plans Association, a network of 39 Delta Dental companies that together provide dental coverage to 60 million people in the U.S.

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