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ADA answers questions on ACA in the dental practice

April 21, 2014

If they already haven't, patients with dental benefits under the Affordable Care Act will soon begin visiting dental offices. This is a continuation of a Q&A series on how the ACA affects dentists in their practices. The questions are based on ones the ADA Practice Institute has received in its call center.

What do I need to know about pediatric dental benefits now that they are considered an essential health benefit under the law?

In general, the dental benefits children will have when visiting your practice will be very similar to commercial dental benefits you have seen in the past. The difference is that the ACA marketplace must make sure that pediatric dental benefits are offered to consumers, and nonmarketplace health plans must either cover pediatric dental benefits or be reasonably assured that children enrolled in their health plan have dental benefits from a different source. Two other important features of the pediatric dental essential health benefit relate to cost-sharing and out-of-pocket maximums. Unlike many medical preventive services, preventive pediatric dental services may be subject to cost sharing. This means that the patient may need to meet a deductible, provide a copayment or pay a coinsurance percentage for preventive dental services. Additionally, the out-of-pocket limit for children enrolled in stand-alone dental plans is $700 for one child and $1,400 for multiple children. State exchanges, however, may set their own out-of-pocket limits for stand-alone dental plans. These out-of-pocket maximums are not applicable to dental benefits purchased for adults through the marketplaces.

A patient came in with dental benefits purchased through the ACA Marketplace, and I noticed that the insurer looked like a medical plan. Am I automatically a nonparticipating dentist?

It is very likely that a medical plan offering the dental benefit is doing so through a subcontract with a typical dental benefit company. In these cases, you may already have a contract with the dental benefit company and would be considered an in-network dentist. If you do not have a contract you are considered an out-of-network dentist, as usual.

How are dental offices supposed to bill medical insurance plans for dental procedures?

Typically, dental offices will still submit the ADA dental claim form with CDT procedure codes. Billing using the electronic claim form through the patient management software also remains the same. However, this is all very new and everything is not yet known. The ADA is monitoring how medical plans with embedded dental benefits are processing claims and will provide additional information as it becomes available.

I came to know that although the medical carrier is listed on the card, the benefit is being provided by a dental company and I already have a contract with them. My current contract with the dental company hasn't been modified to indicate that it also applies to the patients enrolled with the medical carrier; can I charge my usual fee?

Normally, you are bound by the terms and conditions of the signed participating provider agreement including the agreed upon fee schedule with the company providing the dental benefit. As we noted, it is very likely that a medical plan offering the dental benefit is doing so through a subcontract with a typical dental benefit company and you might have an agreement with this company.

Some children are presenting with two dental plans now or, in some cases, even more. How can I determine which plan is primary or secondary?

Since the implementation of the ACA, nothing has changed when it comes to coordination of benefits. The plan in which the patient is enrolled as an employee or as the main policyholder is primary. The plan in which the patient is enrolled as a dependent is secondary. The typical rules for dependents with parents who have overlapping coverage rely on the birthday rule, that is, the parent with the earliest birthday in a calendar year is primary. In the case of divorced/separated parents, the court's decree would take precedence. If both policies were issued to the same parent on the same day (as they might have been through an exchange), the model act on coordination of benefits requires the carriers to work out the issue or share equally in the claim. Discussions on this topic are beginning in the insurance industry and there may be new guidance soon. We will keep you informed of changes.

My patient's dental benefits are embedded in a medical plan. What does this mean in terms of deductibles and out-of-pocket costs for dental services?

Each medical plan is different. Some medical plans will use the medical deductible and out-of-pocket maximum for dental benefits, while others will have a separate dental deductible and out-of-pocket maximum. To ensure that you and your patient understand what will be paid by the medical plan, call the insurance company to find out: a.) how much deductible does the patient need to meet before receiving exams, prevention or restorative treatment and b.) what the out-of-pocket maximum is for dental services.

Do I need to buy dental benefits for my own children?

Medical plans offering individual or small group coverage outside an ACA health marketplace will be required to be "reasonably assured" that the enrollee has also purchased an ACA Marketplace certified pediatric dental benefit package. The "reasonably assured" standard is determined by state law or regulation. This final regulation issued on the essential health benefits by the Department of Health and Human Services requires all individual and small group plans offered outside of the health insurance marketplaces to provide all 10 essential health benefits, but allows limited flexibility for consumers looking to maintain or purchase separate dental policies to do so. If you purchase through an exchange, you are less likely to have to purchase pediatric dental coverage. Except in four states (Washington, Nevada, Colorado and Kentucky) where the purchase of the pediatric dental essential health benefit is mandatory, the health marketplaces are only required to offer the pediatric dental benefit, either embedded in a medical plan or through a stand-alone dental plan. Additionally, Connecticut, the District of Columbia, Vermont and West Virginia have medical plans which all embedded pediatric dental benefits, so your child will automatically be enrolled in a pediatric dental benefit plan in these states.

If I choose to treat my children, will I be reimbursed for the services I provide to my own children?

The ADA believes that coverage should not be denied due to the familial relationship. The ADA has been active in contacting insurance companies and advocating on behalf of our member dentists to eliminate these exclusions as we are made aware of them. Most recently, the ADA has contacted the National Association of Dental Plans for further assistance in addressing companies that still have this exclusion and these efforts will continue.

I have less than 50 employees and currently purchase medical insurance for my staff and am thinking about giving them cash to purchase medical insurance on their own instead of buying it for them. How will this impact me?

If you decide to give your employees cash to purchase medical insurance on their own, it will be treated as taxable income to them by the IRS and will also increase your payroll taxes. If you continue to purchase medical benefits for your staff, you may want to consider the tax advantages of a Section 125 plan, which will allow you to pay for the benefits on a pre-tax basis.

For further assistance, please contact the ADA at 1-800-621-8099 or

Quick tips

Always contact the plan on the patient's ID card—both medical plans and standalone dental plans—prior to the scheduled visit.

Questions to ask the carrier:

• Does the patient have coverage?

• Any changes to billing/claim submission procedures?

• Summary of benefits for the plan that the patient has purchased. Remember these are individual plans and can be very different from patients to patients

• Whether you are an in-network dentist in that plan?

• Will the dentist be paid directly?

• Which plan is primary/secondary if there are multiple plans?

• How will explanation of benefits be sent?

• How will checks be sent?