Helping You Understand the Affordable Care Act and Your Dental Insurance Coverage
By Tammie P. MacMullen, BSB, MHA, office manager Oral Health Care Professionals, LLC
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By 2014, the Affordable Care Act will put millions of Americans in charge of their own health care. The Affordable Care Act addresses areas such as insurance subsidies for consumers; transparent exchanges to shop for insurance; new rules protecting consumer from insurance abuses; increased Medicare payment for physicians; and much more. All this new information can be confusing and difficult to navigate through and understand. This article is to help you understand the Affordable Care Act and how it applies to your dental insurance coverage in nonpartisan manner.
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The General Purpose/Definition of Insurance
To transfer the possibility of loss (risk) to an insurance company, this in turn spreads out the costs of unexpected losses to many individuals. Though the purchasing of insurance will not eliminate the risk of death, illness, injury or property damage, it relieves the insured of the financial losses these risks bring.
Health Insurance Marketplace
The Health Insurance Marketplaces are organizations set up to facilitate the purchase of health insurance in every state of the United States in accordance with Patient Protection and Affordable Care Act. Marketplaces provide a set of government-regulated and standardized health care plans from which individuals may purchase health insurance eligible for federal subsidies.
All exchanges must be fully certified and operational by January 1, 2014, under federal law. Enrollment in the marketplaces started on October 1, 2013 and will continue for six months.
Health insurance exchanges in the United States are intended to help insurers comply with consumer protection laws, complete in cost-efficient ways and expand insurance coverage to more people. Exchanges are not themselves insurers, so they do not bear risk themselves, but they do determine the insurance companies that are allowed to participate. An ideal exchange promotes insurance transparency and accountability, facilitates increased enrollment and delivery of subsidies, and helps spread risk to ensure that the costs associated with expensive medical treatments are shared more broadly across large groups of people rather than spread across just a few beneficiaries.
The new Health Insurance Marketplace helps uninsured people find health coverage. After filling out the Marketplace application the Health Insurance Marketplace will tell you if you quality for Private Insurance Plans, Medicaid and the Children’s Health Insurance Program (CHIP). Marketplaces are established by each state.
What does Marketplace health insurance cover?
All private health insurance plans offered in the Marketplace will offer the same set of Essential Health Benefits (EHB). These are services all plans must cover. Essential Health Benefits (EHB) are minimum requirements for all plans in the Marketplace. Plans may offer additional coverage. States expanding their Medicaid programs must provide these benefits to people newly eligible for Medicaid.
· Ambulatory patient services (outpatient care you get without being admitted to a hospital)
· Emergency services
· Hospitalization (such as surgery)
· Maternity and newborn care (care before and after your baby is born)
· Mental health and substance use disorder services, including behavioral health treatment (this included counseling and psychotherapy)
· Prescription drugs
· Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
· Laboratory services
· Preventive and wellness services and chronic disease management
· Pediatric services, including oral and vision care
Is Dental Coverage an Essential Health Benefit (EHB)?
Dental services for children under 18 are an Essential Health Benefit. You may be able to get these benefits from a Marketplace plan or a free-standing child or family dental plan you buy separately in the Marketplace.
Dental coverage is not an Essential Health Benefit (EHB) for adults. But dental policies for adults and families are available in the Marketplace.
Do I have to provide dental coverage for my children?
No. Dental coverage for children 18 and under is an Essential Health Benefit (EHB). This means child dental coverage must be available to you. This can happen through a health plan that includes child dental coverage or a free-standing, separate dental plan. But you can choose not to enroll in child dental coverage.
Can I get dental coverage in the Marketplace?
In the Health Insurance Marketplace, you generally can get dental coverage as part of a health plan or by itself through a separate, stand-alone dental plan.
Adult and child dental insurance in the Marketplace
Under the health care law, dental insurance is treated differently for adults and child 18 and under.
Dental coverage for children is an Essential Health Benefit (EHB). This means it must be available to you as part of a health plan or as a free-standing plan. This is not the case for adults. Insurers don’t have to offer adult dental coverage.
Starting in 2014, you must have health coverage or pay a fee. But this is not true for dental coverage. You do not need to have dental coverage to avoid penalty.
Dental coverage is available two ways
Health plans that include dental coverage. In the Marketplace, dental coverage will be included in some health plans. You’ll be able to see which plans include dental coverage when you compare them. You’ll also see what the dental benefits are. If a health plan includes dental coverage, you will pay one premium for everything. The premium shown for the plan includes both health and dental coverage.
Separate, stand-alone dental plans. In some cases separate, stand-alone plans will be offered. You may want to choose this option if the health coverage you plan to enroll in doesn’t include dental coverage, or if you want different dental coverage. If you choose a separate dental plan, you’ll pay a separate, additional premium for the dental plan.
Will I be able to cover all members of my family?
You can get dental coverage for all family members who are getting Marketplace insurance coverage, for some of them, or none of them. You cannot get dental-only coverage for someone who is not getting Marketplace insurance.
What is “guaranteed” and “estimate” prices for dental plans?
When you shop for separate, stand-alone dental plans in the Health Insurance Marketplace, look for one of two words next to the premium: “guaranteed” or “estimated.”
“Guaranteed” means that the dental plan will charge you the rate that you see on the website.
“Estimated” means that the dental plans could cost you more than the price shown. You could be charged more based on your dental history, gender, line of work, or other factors.
A lower estimated rate may look less expensive than a plan with a guaranteed rate. But it might end up being more expensive.
You’ll find out from the dental insurance company what that actual premium will be before you pay your first premium.
Where to find additional information regarding the Health Insurance Marketplace, the Affordable Care Act and dental coverage?
Federal Marketplace Website: https://www.healthcare.gov/
Federal Marketplace Phone Individual: 1-800-318-2596 TTY 1-855-889-4325
Federal Marketplace Phone Small Business Resources: 1-800-706-7893 TTY 1-800-706-7615
State of Illinois Marketplace Website: http://getcoveredillinois.gov/
State of Illinois Marketplace Phone: 866-311-1119
Please keep in mind that all this information is subject to change and the best place to get the most up to date information is from the contacts listed above.
Sources:
"Find Health Coverage That Works for You." HealthCare.gov. U.S. Centers for Medicare & Medicaid Services, n.d. Web. 23 Oct. 2013.
"Get Covered: A One-page Guide to the Health Insurance Marketplace." HealthCare.gov. U.S. Centers for Medicare & Medicaid Services, n.d. Web. 23 Oct. 2013.
"What Does Marketplace Health Insurance Cover?" HealthCare.gov. U.S. Centers for Medicare & Medicaid Services, n.d. Web. 23 Oct. 2013.
"Can I Get Dental Coverage in the Marketplace?" HealthCare.gov. U.S. Centers for Medicare & Medicaid Services, n.d. Web. 29 Oct. 2013.
"What Are My Preventive Care Benefits?" HealthCare.gov. U.S. Centers for Medicare & Medicaid Services, n.d. Web. 23 Oct. 2013.
If you would like to discuss this topic further, or have any suggestions for future topics, please feel free to contact me at my Downers Grove office.
Sincerely,
Tammie P. MacMullen, BSB, MHA
Oral Health Care Professionals, LLC
(630) 963-6750
