Everyone talks about how healthcare reform affects medical benefits, but what about the impact on dental benefits? Find out how dental could be changing because of the Affordable Care Act.

1. Dental Benefits and the
Affordable Care Act

2. 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)

3. 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

4. Individual/Small Group Plans
must offer Essential Benefits
Individual and Small Group
plans must include
Pediatric Oral Health Services
(up to age 19)

5. Standalones can offer
Pediatric 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.

6. A Perfect
Two ways to
get there –
Inside vs. Outside

7. 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

8. 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 markets
must 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“

9. 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)

10. 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

11. Dental coverage is often
a moving target
• Benchmark varies state-by-state
• Federal states go with FEDVIP
• Most states select CHIP
• The Actuarial Value (AV) is key
It drives terms and limits pricing

12. Dental coverage is often
a moving target
ACA does not define cost sharing,
e.g., copays, deductibles, frequency and
other limitations.
Benefits do not define cost sharing…

13. 3 Dental Options
• Stand-alone
• Bundled
• Embedded
DETAILS…
THE DEVIL IS IN THE

14. 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

15. 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

16. 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

17. 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)

18. 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!

19. Stand-alone details vary slightly

20. Sample comparisons for
Standalone 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)

21. Sample Standalone Comparison
DHMO High and Low
PROCEDURE 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)

22. 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.

23. FACE OFF!

24. 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

25. 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

26. Dental for your “typical kid”:
Limits costs range from $101…to $683
$205
$113
$683
$479
$570
$0
0
100
200
300
400
500
600
700
800
Standalone
Low
Standalone
High
Embedded
Child Pays
Plan Pays
This example illustrates how separate deductibles, versus one QHP deductible.
can affect OOP costs.

27. 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.

28. Dental for kids that need braces:
Limits cost $350…to $700!!!
This chart demonstrates how separate dental OOP pays
for High Utilization dental care.
$350 $350 $700
$3,650 $3,650
$7,300
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
Year 1 Year 2 Total
Child pays
Plan pays

29. Embedded plans pay 50%...
ONLY after $2,000+ deductible
$3000 $3000
$6000
$1000 $1000
$2000
0
1000
2000
3000
4000
5000
6000
7000
Year 1 Year 2 Total
Child Pays
Plan Pays

30. 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

31. 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.
deltadentalins.com/about/contact