This document provides an overview of pediatric dental benefits under the Affordable Care Act and how they may impact dental practices. It discusses how pediatric dental coverage is considered an essential health benefit and must be included in certain health plans. It describes the three structures for how pediatric dental benefits can be offered (embedded, stand alone, bundled). It also outlines some pediatric dental plan benefit options and issues dental practices may face in navigating these new benefits, such as deciding whether to credential with dental insurance providers and how to manage claims processing.

1. Pediatric Dental Benefits and the ACA
March 3, 2014
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2. Agenda
Pediatric Dental Benefits And The ACA
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Essential Health Benefits
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Pediatric Dental
Decisions for the Dental Practice
Orthodontia
3 Structures
In/out Connector
Plans
The Dental Practice
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Responsibilities
Questions
Decisions
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3. Benefit Plan Changes 2014
Effective for plans renewing on or after January 1, 2014:
 All health insurance plans have to incorporate essential health
benefits
 Health and Dental Plans will be re-tooled to incorporate
benefits
 Health Insurance Plans are being phased out and or
consolidated - Termination Notices a big confusion for
businesses and Individuals alike
 Alternatives will be available which will require upgrading
benefits for some (most) and decreasing for others
 Cost swings and premium hikes…
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4. Health Plans 2014 and beyond
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Effective January 1, 2014, all coverage sold to individuals and
small groups must comply with EHB standards.
EHB standards specify:
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Covered benefits, including pediatric dental coverage
Cost sharing requirements (the so-called “metal tiers”)
― Platinum
― Gold
― Silver
― Bronze
Deductible limits for small groups
Out-of-pocket maximum limits
All existing plans in market will convert to “metal tiers”
Large groups (>50) generally do not need to comply with EHB
standards, but:
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Must comply with the out-of-pocket maximum limitation
Must offer a plan with a “minimum value” of at least 60% (All Mass Plans Comply)
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5. Essential Health Benefits
Pediatric Dental
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6. Essential Health Benefits
Starting in January 2014, the Affordable Care Act will require all new individual and small group
health plans (for people who don’t have traditional job-based coverage) to cover important health
benefits like maternity, mental health, preventive, and pediatric dental care. These benefits,
considered “essential” by the Department of Health and Human Services fall into 10 categories:
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2.
3.
4.
5.
6.
7.
Ambulatory patient services (outpatient services)
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services (those that help patients acquire, maintain, or
improve skills necessary for daily functioning) and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10.Pediatric services, including oral and vision care
The Affordable Care Act’s requirement that essential health benefits be covered without annual
dollar caps will provide patients with more health benefits and a lesser financial burden.
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7. Essential Health Benefits - Pediatric Dental
Massachusetts Division of Insurance recommended that the plan with the
largest enrollment in the merged market, the Blue Cross Blue Shield of
Massachusetts HMO Blue plan, be selected as the benchmark plan.
As this plan does not include the required category for pediatric dental, the DOI,
following guidance from the Centers for Medicare and Medicaid Services,
recommended that the benchmark plan be supplemented with the pediatric
dental benefit plan from the Commonwealth of Massachusetts Children’s
Health Insurance Program (CHIP)
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8. Essential Health Benefits - Pediatric Dental
All qualified dental plans offering the pediatric dental EHB must adhere to the following rules:
 Preventative, restorative and basic services, major restorative and medically necessary
orthodontics* must be covered
 Coverage for individuals up to age 19
 Waiting periods for benefits cannot exceed 90 days
 No lifetime or annual dollar limits
 Low deductibles on restorative, basic services and major restorative
These plans can be sold on or off the connector (exchange)
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In-network preventive benefits are covered at 100%
Out of pocket maximums of $1,000 per child and $2,000 for two or more children
No referrals required for specialty care
Note: While a child may see an orthodontist without a referral, there is no guarantee that
treatment will be covered. The child’s case will need to be reviewed by the Dental Insurance
Carrier for medical necessity
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9. Orthodontia
All qualified dental plans offering the pediatric dental EHB must adhere to the following rules:
What is Medically Necessary Orthodontics?
Medically Necessary Orthodontics means the patient must have a severe and handicapping malocclusion. This
means the child’s condition must be severe enough to impact their ability to function such as having trouble eating
and/or speaking.
How is it determined if a child has met the criteria for “medically necessary” orthodontics?
A clinical evaluation using the Handicapping Labio-Lingual Deviations (HLD) Form must be performed to assess if
the child has met the criteria. The minimum HLD score to be considered for approval of medically necessary
orthodontic treatment is 28. The HLD assess the following:
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Upper and lower anterior impactions
Ectopic Eruption
Overjet
Overbite
Severe traumatic deviations
Mandibular Protrusion
Open Bite
Posterior unilateral crossbite
Labio-lingual spread
Cleft palate deformities
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10. Essential Health Benefits – 3 Structures
1. Embedded – Pediatric Dental benefits are included in the medical benefits – all deductibles are
made up of Dental and Medical charges.
1. BCBS of Massachusetts
2. United Health Care
2. Stand Alone – Pediatric Dental Benefits are sold separately and administered separately from
the health insurance carrier.
3. Bundled – Where a Pediatric Dental Benefit is sold together with the medical plan but have
separate policies. Therefore, there are separate deductibles for the Pediatric Dental Benefits
from the medical plan deductibles and benefit maximums (none for Ped Dental Benefits).
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6.
Harvard Pilgrim – Paired with United Dental
Fallon Community Health Plan – Paired with Dental Benefit Providers (DBP)
Minuteman Health Plan – Paired with Delta Dental of Massachusetts
Celtic Care – Paired with Delta Dental of Massachusetts
Tufts Health Plan - Paired with Altus Dental
Health New England – Paired with Altus Dental
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11. Essential Health Benefits – In/Out Connector
In the Connector:
• Qualified medical plans do not need to include pediatric dental EHB if there are stand
alone plans offering that coverage (Confirmed 9-9-2013 as 6 dental providers offered
Pediatric Essential Health Benefit Plans)
• Some have debated over whether there is mandated availability or mandated purchase
(in Connector – mandated availability ) of all 10 EHBs in the Exchange as long as 1
Pediatric EHB was offered
Outside the Connector:
• All plans would need to cover the pediatric dental EHB – Mandated Purchase or waiver
attestation
• Accomplished through a rider to the plan and or as a integrated benefit within health
insurance (Extra cost estimated, but not confirmed at approximate 1% to include)
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12. Essential Health Benefits - Pediatric Plans
Pediatric EHB Standard Plan
 Plan Year Deductible - $50
 Deductible for – Major/Minor Restorative
 Plan Year Max (>=19 Only) – NA
 Plan Year Max (<=19 Only) – $1,000
 Preventative and Diagnostic Co-insurance In/OON – 0%/20%
 Minor Restorative Co-insurance – In/OON – 25%/$45%
 Major Restorative Co-insurance – In/OON – 25%/$45%
 Medically Necessary Orthodontia <19 only, In/OON – 50%/70%
 Non Medically Necessary Orthodontia <19 only, In/OON – N/A
 Definition of “Medically Necessary Orthodontia” would apply
Premiums range from $6.41 to $41.79 (average $26)
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13. Essential Health Benefit - Pediatric Plans
High Plan
 Plan Year Deductible - $50/$150
 Deductible for – Major/Minor Restorative
 Plan Year Max (>=19 Only) – $1,250
 Plan Year Max (<=19 Only) – $1,000/$2,000
 Preventative and Diagnostic Co-insurance In/OON – 0%/20%
 Minor Restorative Co-insurance – In/OON – 25%/$45%
 Major Restorative Co-insurance – In/OON – 25%/$45%
 Medically Necessary Orthodontia <19 only, In/OON – 50%/70%
 Non Medically Necessary Orthodontia <19 only, In/OON – 50%/70%
Ind Premiums range from $24 to $42
Fam Premiums range from $102 to $156
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14. Essential Health Benefit - Pediatric Plans
Low Plan
 Plan Year Deductible - $75
 Deductible for – Major/Minor Restorative
 Plan Year Max (>=19 Only) – $1,000
 Plan Year Max (<=19 Only) – $1,000/$2,000
 Preventative and Diagnostic Co-insurance In/OON – 0%/20%
 Minor Restorative Co-insurance – In/OON – 50%/70%
 Major Restorative Co-insurance – In/OON – 50%/70%
 Medically Necessary Orthodontia <19 only, In/OON – 50%/70%
 Non Medically Necessary Orthodontia <19 only, In/OON – 50%/70%
Ind Premiums range from $19 to $37
Fam Premiums range from $81 to $140
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15. The Dental Practice
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16. The Dental Practice
Responsibilities
 Dental practices and staff must be able to understand not only the health insurance
plans (and their renewal date in 2014) but the pediatric dental benefits. They have to
ask the critical questions of their patients:
 What is the name and insurance carrier of your Health Insurance Plan and your
Dental Plan?
 When did or does your health insurance plan renew? The start date in 2014 will
help to identify whether or not the Pediatric Benefits are in force at the time of
service or not.
 The Dental Staff , depending on the health insurance plan, may have to submit
each claim to the insurance company for processing. Each plan is different and if
a patient has a deductible plan, claims paid for these pediatric dental benefits
will have to be calculated after taking into account where the deductible use is
at that time.
 Coordination of payment will have to be handled depending on the health plan
and whether or not there is a Dental Plan in the picture of not.
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17. ACA Impact on Pediatric Dental Benefits and
Dental Practices
Questions:
 Will your practice want to contract with ALL, some or NONE of the players; Your
answer will impact your ability to get reimbursed for your services. Is a “Wait and see
approach optimal?
 If you are, for instance, a Central Mass Dental Provider, you may think very carefully
about being a Fallon Health Plan provider (Credentialed with United Dental) as there
are so many people in the Worcester area that utilize Fallon for their health benefits.
 Does your practice have a pediatric dental component? If you are an adult only
practice, your thought process may be a little bit different.
 Will your practice be able to adjust to accommodate the potentially millions of
additional children that will obtain dental benefits under the ACA through insurance
exchanges and the additional millions who will obtain coverage via Medicaid
eligibility expansion.
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18. ACA Impact on Pediatric Dental Benefits and
Dental Practices
Questions Con’t:
 There are potentially millions of new members into Dental Insurance via the
exchanges but will it happen?
 How will the exchange enrollment issues locally and nationally affect Dental
benefits?
 Orthodontia benefits – could there be a surge of cases with ACA Pediatric
Dental Benefits or is the benefit so restrictive that there won’t be many that
will be eligible?
 If employers drop dental coverage – how likely would employees buy dental
insurance and what type of plans would they buy? Low priced, preventative
care?
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19. ACA Impact on Pediatric Dental Benefits and
Dental Practices
Decisions - Is the juice worth the squeeze?
 Should Dentists and their practices get credentialed or not?
 Is a wait and see approach better? If so how long to credentialed?
 What is the reimbursements for each of the networks?
 Is there potential lost business if you DON’T sign up into the networks?
 How much admin investment is required to navigate this benefit for your patients?
 What questions do you have to ask your patient each time they come for care?
 Who is the primary payor and who is secondary?
 Will patients really know enough about it?
 Will they lean on you to know these benefits inside and out for all insurance
companies and Dental providers?
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20. Contact Information
Corporate Office: 30 Federal St – 4th Floor, Boston MA 02110
Operations Office: 200 Friberg Parkway – Suite 2006, Westborough, MA 01581
George W. Gonser, Jr. MBA, CHDC, LIA
Partner
Spring Consulting Group, LLC – Spring Insurance Group
george.gonser@springgroup.com
Phone: 617-589-0930
Fax: 617-589-0931
w w w . s p r i n g g r o u p . c o m
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