Delta Dental of New Mexico

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Affordable Care Act Information

Essential Health Benefit Options:

Delta Dental of New Mexico offers the following pediatric dental Essential Health Benefit (EHB) options for new and renewing small employer groups. For questions regarding adding an EHB plan, please contact us.


EHB Certified High Plan EHB Certified Low Plan
Delta Dental PPO Delta Dental PPO
Delta Dental PPO Point of Service Delta Dental PPO Point of Service
Delta Dental Premier Delta Dental Premier
Advantage* Advantage*
Advantage Point of Service* Advantage Point of Service*

  * Available for renewing Advantage of Advantage Point of Service group plans only

PAGE LAST UPDATED 12/11/14


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 the Affordable Care Act?
  2. What is a Health Insurance Exchange (HIX)?
  3. Are dental benefits included in the ACA?
  4. What are "Essential Health Benefits" or EHBs?
  5. Will individuals or groups in New Mexico be required to purchase pediatric dental coverage since it is an Essential Health Benefit?
  6. Are dental insurers in New Mexico required to provide the Pediatric Dental Essential Health Benefits to groups or individuals purchasing their plans?
  7. Are medical insurers in New Mexico required to provide the Pediatric Dental Essential Health Benefits to groups or individuals purchasing their plans?
  8. Will adults and children have different benefits?
  9. Is orthodontia covered under the new Pediatric Dental Essential Health Benefits?
  10. What if a child covered by a plan containing the Pediatric Dental Essential Health Benefits has a procedure that is not part of the Essential Health Benefits, but is part of standard coverage available under the adult plan?
  11. How long is a patient covered in a plan containing the Pediatric Dental Essential Health Benefits?
  12. How does the out-of-pocket maximum work?
  13. What is included in the out-of-pocket maximum?
  14. Is the out-of-pocket maximum different for a policy covering one individual under 19 or two or more individuals under 19?
  15. What happens if a patient goes to an out-of-pocket provider?
  16. If a patient exceeds their limitations for EHB-covered services, does that count toward their out-of-pocket maximum?
  17. Will there be any impact on Delta Dental's maximum approved fee?
  18. Will there be any change regarding submission of claims?
  19. How can I verify a patient's eligibility?
  20. Do I need to take any additional action to change my participation status? 
  21. What should I do if there's any doubt about a patient's eligibility or coverage?
  22. Will dental coverage be offered on the New Mexico Health Insurance Exchange?
  23. Are group dental premiums covered by the tax incentives for health care coverage?
  24. How do subsidies work for individuals? Do they cover dental?
  25. When do ACA provisions go into effect?

1. What is the Affordable Care Act?

The Patient Protection and Affordable Care Act, commonly called the ACA, was signed into law by President Obama on March 23, 2010. The law seeks to reform health care in the United States through numerous provisions that go into effect over the course of eight years.
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2. What is a Health Insurance Exchange (HIX)?

A Health Insurance Exchange is an organized marketplace for the purchase of health insurance set up by a governmental or quasi-governmental entity specific to an individual state. In New Mexico there is the Individual Health Insurance Exchange and the Small Business Health Options Program or “SHOP” Exchange for small employers.
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3. Are dental benefits included in the ACA?

While dental benefits sold in stand-alone policies (not part of medical policies) are generally not subject to most ACA requirements, there are some exceptions. Pediatric dental benefits (for those under age 19) are part of the Essential Health Benefits Package (EHB), which must be offered by insurers and meet state-specific benefit standards beginning 2014. Some administrative contracts for larger employers are also impacted.
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4. What are "Essential Health Benefits" or EHBs?

10 benefit categories that must be covered by health insurers in order for those plans to be EHB or Exchange-certified:

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

For the most part, plans cannot impose annual or lifetime maximums (aka limits) on these services beginning in 2014.
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5. Will individuals or groups in New Mexico be required to purchase pediatric dental coverage since it is an Essential Health Benefit?

Individuals and groups in New Mexico are not required to purchase pediatric dental benefits. However, most individuals will be required to have “Minimum Essential Coverage,” or pay a penalty. The following are acceptable forms of Minimum Essential Coverage: individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE or certain other coverage.
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6. Are dental insurers in New Mexico required to provide the Pediatric Dental Essential Health Benefits to groups or individuals purchasing their plans?

As an excepted benefit, stand-alone dental insurers are exempt from the requirement to offer Essential Health Benefits along with their plans. However, Delta Dental of New Mexico has decided to make available Pediatric Dental Essential Health Benefits for all small employer groups. At renewal, a small employer group will make the decision whether or not to replace the plan’s current pediatric dental benefits with the new Pediatric Dental Essential Health Benefits. Delta Dental has gone through the approval process to make sure that all Pediatric Dental EHBs offered are “certified.”
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7. Are medical insurers in New Mexico required to provide the Pediatric Dental Essential Health Benefits to groups or individuals purchasing their plans?

Medical insurers are not required to include pediatric dental coverage in their plans, so long as they are reasonably assured a patient may obtain it elsewhere (such as from a stand-alone dental insurer like Delta Dental). New Mexico has expounded on that guidance by notifying the state’s health insurers that they need only to disclose whether or not their individual and small group plans contain pediatric dental coverage. In other words, small employer groups can continue their dental coverage (including pediatric coverage) through Delta Dental and are not required to purchase it through a medical insurer.
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8. Will adults and children have different benefits?

Adults purchasing dental benefits through the Exchange or a plan that includes an Exchange-certified pediatric dental benefit may have different benefits than their children/dependents under the age of 19. With Delta Dental benefits, children and parents enrolled on the same plan will have access to the same provider network.
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9. Is orthodontia covered under the new Pediatric Dental Essential Health Benefits?

Delta Dental plans that include Pediatric Dental Essential Health Benefits will cover child-only “medically necessary” orthodontia. Medically necessary orthodontia is more restrictive than Delta Dental’s standard orthodontic coverage.
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10. What if a child covered by a plan containing the Pediatric Dental Essential Health Benefits has a procedure that is not part of the Essential Health Benefits, but is part of standard coverage available under the adult plan?

The procedure will be denied and the patient will be responsible for payment.
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11. How long is a patient covered in a plan containing the Pediatric Dental Essential Health Benefits?

Coverage for EHB services, except medically necessary orthodontia, shall continue for an enrolled individual through the end of the benefit period in which they turn age 19. At the end of that benefit period, coverage for EHB services shall cease, and the individual will have access to the standard non-EHB covered services provided by the group for their enrollees (at the onset of the new benefit period). Maximum benefit amount and all other standard provisions will apply. This shift in coverage has no bearing on dependent status when applicable. Coverage for EHB medically necessary orthodontia shall cease at the end of the month in which the covered individual turns age 19.
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12. How does the out-of-pocket maximum work?

Certain costs paid by the patient for in-network EHB-covered services apply to the out-of-pocket maximum. All in-network, EHB services covered in a plan containing the Pediatric Dental Essential Health Benefits are paid at 100 percent after the out-of-pocket maximum has been reached.
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13. 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 a plan containing the Pediatric Dental Essential Health Benefits.
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14. 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 $700 for families with one covered member under the pediatric age limit and $1,400 for families with two or more covered members under the pediatric age limit.
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15. What happens if a patient goes to an out-of-network provider?

If the patient is under the age limit for a plan containing the Pediatric Essential Health Benefits, the services are still paid according to the EHB coinsurance levels, but the patient’s payment does not apply to the out-of-pocket maximum. 
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16. If a patient exceeds their limitations for EHB-covered services, does that count toward their out-of-pocket maximum?

No. 

Why?

Only those services actually covered under the plan containing the Pediatric Dental Essential Health Benefits will count toward the out-of-pocket maximum. 
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17. Will there be any impact on Delta Dental’s maximum approved fee?

No.
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18. Will there be any change regarding submission of claims?

No.  
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19. How can I verify a patient’s eligibility? 

Patient eligibility verification has not changed. Verification can still be accomplished through the IVR, Dental Office Toolkit and/or customer service.
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20. Do I need to take any additional action to change my participation status?

No. As a participating provider you are considered in-network for EHB.
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21. What should I do if there’s any doubt about a patient’s eligibility or coverage?

Submit a pre-treatment estimate.
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22. Will dental coverage be offered on the New Mexico Health Insurance Exchange?

At the outset, the NM Health Insurance Exchange will only offer voluntary child dental plans (with no adult coverage). Delta Dental believes it is important that children and adults can receive coverage together under the same plans and therefore will not be participating on the Exchange in 2014. Delta Dental will consider participation on the NMHIX in subsequent years.
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23. Are group dental premiums covered by the tax incentives for health care coverage?

Small employers (less than 25 employees) that cover at least 50 percent of the cost of single (not family) health care coverage for each of their employees and whose employees have average wages of less than $50,000 a year may be eligible for tax credits when they purchase medical coverage for their employees. This does not apply to dental coverage, and the tax credits are only available when purchasing in the Exchange during 2014 and 2015. It is important to note that the employer receives the tax credits, not the employee.
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24. How do subsidies work for individuals? Do they cover dental?

Individuals who are at or below 400 percent of the Federal Poverty Level (FPL) are eligible to receive subsidies to help with insurance premiums when they purchase coverage through the Individual Exchange. They will not receive subsidies if they purchase coverage through their employer. Also, these subsidies will apply to medical coverage first and may not be large enough to cover pediatric dental benefits. Subsidies cannot be used to purchase adult dental benefits. Note that if an employer covers part of the cost of an employee’s benefits, the employee is not eligible for subsidies through the Individual Exchange.
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25. When do ACA provisions go into effect?

Close to 90 ACA provisions were set to be implemented between 2010 and 2018 by the law. Over half of these provisions are already in effect. However, some of the most notable changes will be occurring in 2014.

2014 provisions include:

  • Expanded Medicaid Coverage to 138 percent of FPL
  • Individual Requirement for Minimum Essential Coverage or Shared Responsibility Payment (also known as the individual mandate)
  • Health Insurance Exchanges
  • Guaranteed Availability of Coverage—to require medical insurers to cover patients regardless of pre-existing conditions and limit rating variation
  • Essential Health Benefits
  • Employer Wellness Programs and Incentives
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Disclaimer: This information is not intended to serve as legal advice and only constitutes Delta Dental of New Mexico’s understanding of the subject. Please consult your attorney and/or accountant for more information about how the ACA may impact you or your business.