Delta Dental of New Mexico

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Affordable Care Act Information

PAGE LAST UPDATED 9/16/15


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

 

Questions:

  1. What is the Affordable Care Act?
  2. Are dental benefits included in the ACA?
  3. What are “Essential Health Benefits” or EHBs?
  4. What is a Health Insurance Exchange?
  5. I work for a small business and my employer currently offers dental benefits. Will I be required to get my insurance on the Health Insurance Exchange?
  6. Is orthodontia covered under the new Exchange-Certified Pediatric Dental Benefit?
  7. What happens if I do not purchase health benefits?
  8. Am I required to purchase dental benefits?
  9. Will my health insurance cover dental?
  10. Do I have to see a specific dentist for care?
  11. Are the adult and pediatric benefits different?
  12. Is dental coverage offered on the New Mexico Health Insurance Exchange?
  13. If my employer or I purchase medical insurance through the Exchange, is it still possible to have dental insurance through Delta Dental?
  14. Are group dental premiums covered by the tax incentives for health care coverage?

  15. How do subsidies work for individuals? Do they cover dental?

1. What is the Affordable Care Act?

The Patient Protection and Affordable Care Act, commonly called the ACA or Obamacare, 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. Are dental benefits included in the ACA?

While dental benefits sold in Standalone 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. Some administrative contracts for larger employers are also impacted.
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3. What are “Essential Health Benefits” or EHBs?

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

  • Ambulatory patient services
  • Prescription drugs
  • Emergency services
  • Rehabilitative and habilitative services and devices
  • Hospitalization
  • Laboratory services
  • Maternity and newborn care
  • Preventive and wellness services and chronic disease management
  • Mental health and substance use disorder services, including behavioral health treatment
  • Pediatric services, including oral and vision care

For the most part, plans cannot impose annual or lifetime maximums (aka limits) on these services.
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4. What is a Health Insurance Exchange?

A Health Insurance Exchange (also called a “Marketplace”) is a resource available in each state for learning about and purchasing health insurance coverage. 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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5. I work for a small business and my employer currently offers dental benefits. Will I be required to get my insurance on the Health Insurance Exchange?

Employers are not required to purchase dental coverage through the Exchange. Employers can keep their current dental benefits with the same insurance carrier. Delta Dental of New Mexico offers Exchange-certified plans and products, which meet ACA requirements.
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6. Is orthodontia covered under the new Exchange-Certified Pediatric Dental Benefit?

Delta Dental plans that include an Exchange-certified pediatric dental benefit cover child-only “medically necessary” orthodontia. This is consistent with the Medicaid/CHIP Benchmark established by New Mexico. Medically necessary orthodontia is more restrictive than Delta Dental’s standard orthodontic coverage. 
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7. What happens if I do not purchase health benefits?

Most individuals are required to have “minimum essential coverage”. The following are acceptable forms of coverage: individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE or certain other coverage. Those who choose not to purchase health benefits may have to pay penalties. 
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8. Am I required to purchase dental benefits?

Individuals are not required by New Mexico or the Federal Government to purchase dental benefits in order to meet the test of minimum essential coverage. Likewise, small employers are not required to offer dental benefits. Medical insurers may choose to include dental benefits with their medical plans, but are not required to do so (NM OSI Bulletin 2014-017).
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9. Will my health insurance cover dental?

Some health insurance plans may include “embedded” or “bundled” dental plans. It is important to understand how those benefits work. Embedded or bundled dental plans may require you to meet a much larger medical deductible before your dental services will be eligible for coverage. Standalone dental plans like Delta Dental do not have the same restrictions. If your benefits are embedded in a medical plan, you may want to check your options for a supplemental individual dental plan. (Click here for more information on individual plans.)
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10. Do I have to see a specific dentist for care?

Individuals who purchase individual or small-group dental coverage will need to see a dentist that participates in that plan’s network to maximize their benefits. The limits on out-of-pocket costs may not apply to dentists not in the plan’s network.
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11. Are the adult and pediatric benefits different?

Adults purchasing dental benefits through the Exchange or a plan that includes an EHB/Exchange-certified pediatric dental benefit may have different benefits than their children/dependents under the age of 19. With Delta Dental benefits, you will be able to see the same network dentist for care if you prefer.
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12. Is dental coverage offered on the New Mexico Health Insurance Exchange?

The NM Health Insurance Exchange currently offers a limited number of dental insurance plans through its website.  Delta Dental does not currently participate on the NM Health Insurance Exchange.
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13. If my employer or I purchase medical insurance through the Exchange, is it still possible to have dental insurance through Delta Dental?

You and/or your employer are still able to purchase dental insurance through Delta Dental of New Mexico even if you buy your medical coverage on the Exchange. Please click here for more information on individual plans or have your employer contact us here.
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14. Are group dental premiums covered by the tax incentives for health care coverage?

Small employers (less than 25 employees) that cover at least 50% 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 the initial two years. It is important to note that the employer receives the tax credits, not the employee.
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15. 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. 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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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.