Delta Dental of Ohio

Home / Dentists / Affordable Care Act / Affordable Care Act FAQs

Affordable Care Act FAQs

PAGE LAST UPDATED 9/30/16


Note: This material is not intended to serve as legal advice and only constitutes Delta Dental's opinion on the subject matter contained herein based on its own review of available guidance.


Questions:

  1. What is ACA?
  2. What is EHB?
  3. What are the 10 EHB categories?
  4. A patient notices that their children’s benefits have changed. Why did they change?
  5. Why are children’s benefits different than their parents?
  6. Why do different members of the same family have different benefit levels?
  7. What if a patient has a procedure that is not part of an EHB-compliant plan, but is part of “standard” coverage?
  8. What if a patient has a procedure that is covered as both a “standard” benefit and an EHB benefit in a plan?
  9. How long is a patient covered in an EHB-compliant plan once they turn 19?
  10. How does the out-of-pocket maximum work?
  11. What is included in the out-of-pocket maximum?
  12. Is the out-of-pocket maximum different for a policy covering one individual under 19 or two or more individuals under 19?
  13. What happens if a patient goes to an out-of-network provider?
  14. If a service is denied under EHB due to a time limitation, will it automatically revert to the standard plan to pay (if payable)?
  15. If a patient exceeds their limitations for covered services in the EHB-compliant plan, does that count toward their out-of-pocket maximum? Why?
  16. If Mom has a standard plan through a large employer that does not have to be EHB compliant and Dad has an EHB-compliant plan with benefits through a small group; and Mom’s date of birth is first, how will this work with EHB?
  17. What if Dad is primary and we pay the EHB benefit out; will Mom’s coordinate in this instance?
  18. Will there be any impact on Delta Dental’s maximum approved fee?
  19. Will there be any change regarding submission of claims?
  20. How can I verify a patient’s eligibility? 
  21. Do I need to take any additional action to change my participation status?
  22. What should I do if there’s any doubt about a patient’s eligibility or coverage?
  23. Is orthodontics covered as part of the Essential Health Benefits?

1. What is ACA?

The Affordable Care Act. It is also known as Health Care Reform, the Patient Protection and Affordable Care Act and Obamacare. The measure was signed into law in 2010.
Return to top

2. What is EHB?

Essential Health Benefits (EHB). Under the ACA, only policies in the small group and individual markets are required to cover EHBs. There are 10 benefit categories that must be included in EHB-compliant plans.

Return to top

3. What are the 10 EHB categories?

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services including oral and vision care
Return to top

4. A patient notices that their children’s benefits have changed. Why did they change?

ACA requires that pediatric dental plans match the state’s benchmark plan and be offered at either an 85 percent or 70 percent actuarial value (high and low). Matching the state’s benchmark only refers to the scope of covered services and associated limitations. Patient cost-sharing levels may vary from plan to plan and carrier to carrier.

Return to top

5. Why are children’s benefits different than their parents?

The ACA’s dental plan requirements are only for people under age 19. Adults are able to keep their existing dental plan.

Return to top

6. Why do different members of the same family have different benefit levels?

Dental benefits are based on age and plan. Individuals 19 and over maintain standard benefit levels. To eliminate any confusion, it is vital that enrollees and dental offices check benefits on an individual level, not at a family level.

Return to top

7. What if a patient has a procedure that is not part of an EHB-compliant plan, but is part of “standard” coverage?

Regardless of the patient’s age, coverage will revert to the standard plan.
Return to top

8. What if a patient has a procedure that is covered as both a “standard” benefit and an EHB benefit in a plan?

There is no coordination of benefits (COB) between the standard and EHB benefits. Only one set of benefits will cover the procedure. Having both EHB and non-EHB benefits does not mean the patient will receive complete coverage.

Consider this example: if the procedure code is in the EHB list AND the patient is under the age limit, EHB benefits are used to pay that code. If the procedure code is NOT in the EHB list, the standard benefits are used to pay that code, regardless of the patient’s age.

Return to top

9. How long is a patient covered in an EHB-compliant plan once they turn 19?

Small group: To the end of the calendar year of the 19th birthdate.

Individuals: To the end of the policy year after the 19th birthdate.
Return to top

10. How does the out-of-pocket maximum work?

Certain costs paid by your patient for in-network EHB-covered services apply to the out-of-pocket maximum. All in-network, EHB services covered in an EHB-compliant plan are paid at 100 percent after the out-of-pocket maximum has been reached.
Return to top

11. What is included in the out-of-pocket maximum?

Deductibles, coinsurance and copayments for in-network, EHB-covered services are applied to the out-of-pocket maximum in an EHB-compliant plan.

Return to top

12. Is the out-of-pocket maximum different for a policy covering one individual under 19 or two or more individuals under 19?

Yes. The out-of-pocket limit for pediatric dental essential health benefits is $350 for families with one covered member under the pediatric age limit and $700 for families with two or more covered members under the pediatric age limit.

Return to top

13. What happens if a patient goes to an out-of-network provider?

If the patient is under the age limit for an EHB-compliant plan, the services are still paid using the EHB copayments, but the patient’s payment does not apply to the out-of-pocket maximum.
Return to top

14. If a service is denied under EHB due to a time limitation, will it automatically revert to the standard plan to pay (if payable)?

No. EHB covered services are only payable under the EHB benefits, using the limitations applicable to EHB covered services. Standard plan benefits only apply to the non-EHB covered services.

Return to top

15. If a patient exceeds their limitations for covered services in the EHB-compliant plan, does that count toward their out-of-pocket maximum? Why?

No. Only those services actually covered under the EHB-compliant plan will count toward the out-of-pocket maximum. 

Return to top

16. If Mom has a standard plan through a large employer that does not have to be EHB compliant and Dad has an EHB-compliant plan with benefits through a small group; and Mom’s date of birth is first, how will this work with EHB?

The EHB-compliant plan will pay secondary just like any other plan. If there is any patient payment after the secondary payment, it will apply to the out-of-pocket maximum. 
Return to top

17. What if Dad is primary and we pay the EHB benefit out; will Mom’s coordinate in this instance?

Yes. When the EHB-compliant plan is primary, any patient pay amount that would apply to the out-of-pocket maximum in the absence of COB will still apply to the out-of-pocket maximum, even if the secondary carrier pays that amount. 
Return to top

18. Will there be any impact on Delta Dental’s maximum approved fee?

No.
Return to top

19. Will there be any change regarding submission of claims?

No.  
Return to top

20. How can I verify a patient’s eligibility? 

Patient eligibility verification has not changed. Verification can still be accomplished through the IVR, Toolkits or ID cards.
Return to top

21. Do I need to take any additional action to change my participation status?

No. As a Delta Dental Premier and/or a Delta Dental PPO participating provider you are considered in-network for EHB.

Return to top

22. What should I do if there’s any doubt about a patient’s eligibility or coverage?

Submit a pre-treatment estimate.

Return to top

23. Is orthodontics covered as part of the Essential Health Benefits?

Whether orthodontic services are treated as Essential Health Benefits may depend on the state in which your policy was issued. Certain states do not mandate orthodontic services as Essential Health Benefits, and even in those states that do, orthodontic services may be limited to those that are “medically necessary.”