Dental Benefits and the Affordable Care Act

Everyone must enroll in a plan or program This includes… Individual or small group plans Large group Large group plans Grandfathered plans Grandfathered plans (for individual, small or large group) Government Programs 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 offer Pediatric Dental The inside vs outside rules will differ. Dental is exempt 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 Two ways to get there – Inside vs. Outside

A Perfect 10… How To Get There… InsideOutside 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… InsideOutside 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. 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“ 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. W ill 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 often a moving target Benchmark varies state-by-stateBenchmark varies state-by-state Federal states go with FEDVIP Most states select CHIP The Actuarial Value (AV) is keyThe Actuarial Value (AV) is key It drives terms and limits pricing

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…

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”: 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%) HHS approves high (85%) and low (70%) with a separate $350 OOP maximum medically necessary orthodontics (when in the benchmark)

4 QHP Benefit tiers 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!

vary slightly Stand-alone details vary slightly

Sample comparisons for Standalone PPO High and Low* *(in Texas)

Sample Standalone Comparison DHMO High and Low *(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!

embedded, standalone & bundled 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 1 st visit child gets an exam, cleaning, x-ray, fluoride treatment, three sealants and a single, one surface filling. On the 2 nd visit, child gets an exam, cleaning and fluoride treatment

Dental for your “typical kid”: Limits costs range from $101…to $683 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. for High Utilization dental care.

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

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. deltadentalins.com/about/contact