Affordable Care Act (ACA): What It Means for You and Your Patients’ Oral Health NANCY GRAFF, MD, FAAP, AMERICAN ACADEMY OF PEDIATRICS
COLIN REUSCH, MPA, CHILDREN’S DENTAL HEALTH PROJECT
PAUL REGGIARDO, DDS, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
Affordable Care Act Overview
NANCY GRAFF, MD, FAAP AAP COMMITTEE ON STATE GOVERNMENT AFFAIRS (COSGA)
Affordable Care Act Enacted in 2010, implementation of various components of the
law ongoing Largest change to the health care system since the creation of Medicare and Medicaid
Affordable Care Act Goals Increase Access to Care Focus on Prevention and Primary Care Improve Quality of Care Lower Cost of Care
Affordable Care Act Larger Provisions Medicaid expansion Private plan consumer protections Oversight of insurance plan dollars Creation of federal/state marketplaces Essential
Health Benefits (EHB)
Essential Health Benefits (EHB) ACA established 10 categories of benefits that must
be included in qualified health plans (QHPs) 2011: HHS gave states authority to choose base-benchmark plan Those benefits not included in base benchmark must be supplemented
Essential Health Benefits (EHB) Base benchmark options: Largest plan by enrollment in any of the 3 largest small group insurance products Any of the largest 3 state employee health benefit plans by enrollment Any of the largest 3 national FEHBP plan options by enrollment Largest insured commercial non-Medicaid health maintenance organization operating in the state
Essential Health Benefits (EHB) Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance abuse disorder services 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision care 1.
For More Information Please contact the AAP Division of State Government
Affairs at
[email protected]. Thank you!
The Affordable Care Act (ACA): What It Means for You and Your Patients' Oral Health Colin Reusch Senior Policy Analyst Children’s Dental Health Project
About CDHP Children’s Dental Health Project Mission: Creating and advancing innovative solutions to achieve oral health for all children.
Our Approach: 1. Reduce dental disease burden 2. Improve access to high-quality dental care
Our Goals • • •
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Prevent childhood tooth decay, because cavities are the result of a disease that is overwhelmingly preventable. Promote solutions that are grounded in the best available research and support exploration when evidence is lacking Engage policymakers and other decision-makers in addressing ongoing inequities in oral health and to implement cost-effective solutions. the voice for children’s oral health | cdhp.org
PEDIATRIC DENTAL BENEFITS UNDER THE ACA
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the voice for children’s oral health | cdhp.org
Coverage: what Congress intended • Make oral health an integral part of kids’ coverage • Improve quality and affordability of care • Make prevention-focused, science-based practice a priority • Bridge the gaps between medical and dental care & providers • Systematically bolster & improve the entire oral health care system
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the voice for children’s oral health | cdhp.org
ACA Pediatric Dental Benefits ACA Reforms to Pediatric Dental Coverage: • Makes it part of essential health benefits (EHB) – Offered in Marketplaces (exchanges) and small group/individual insurance markets in each state
• Attempts to subsidize through premium tax credits • Limits cost-sharing (out-of-pocket maximums) • Removes annual and lifetime dollar limits on coverage (children only) • Requires offering of child-only plans (up to age 19) • Limits orthodontic coverage to medically necessary 14
the voice for children’s oral health | cdhp.org
EHB: Pediatric Dental Benefit • Category 10: “Pediatric services, including oral and vision care” • Stand-alone dental plans may provide Exchange coverage • If a stand-alone participates, Qualified Health Plans (QHPs) exempt from oral care requirement • Statute treats dental benefits differently when they are provided through a stand-alone dental plan vs. a QHP.
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the voice for children’s oral health | cdhp.org
What Does Coverage Look Like? • Pediatric coverage up to age 19 • Covered services based on EHB dental benchmark:* – Federal Employees Dental and Vision Insurance Program (FEDVIP) – Dental coverage in state CHIP program
• Included in health plan (embedded) or sold as separate (stand-alone) plan • Cost-sharing, deductibles vary by plan • Separate out-of-pocket maximum for stand-alone dental • Orthodontic coverage must be medically necessary *Utah EHB dental based on state employee plan – very limited dental coverage
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the voice for children’s oral health | cdhp.org
Dental Benchmarks & Medically Necessary (MN) Ortho WA
As of 10.31.13
HI
MT
ND MN
OR ID WY
UT
WI IA
PA IL
KS
NM
NY MI
CO
AK
AZ
NH
SD
NE
NV CA
OK
MO
TX
Green = State CHIP program (24), MN Ortho covered except where pattern Blue = FEDVIP (25 plus DC), Carrier Defined MN Ortho Orange = Dental benefit in medical EHB (1), pattern indicates no MN Ortho
IN
WV
VA NC
TN AR
SC AL
GA
LA FL © National Association of Dental Plans
the voice for children’s oral health | cdhp.org
MA* RI CT NJ DE
OH
KY
MS
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ME
VT
MD DC
ACA: Dental Benefits How are dental benefits being offered in the marketplace? Pediatric Essential Health Benefits QHP Including Dental (or optional dental rider)
Qualified Health Plan (QHP)
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Stand-Alone Dental
the voice for children’s oral health | cdhp.org
ACA: Dental benefits Must pediatric dental benefits be purchased? • If pediatric dental benefits are offered through a stand-alone dental plan, QHPs are not required to but may provide such coverage. • Stand-alone dental plans are not required to be purchased unless state policy dictates otherwise. • Outside of the marketplaces, QHPs must have “reasonable assurance” that enrollees have purchased pediatric dental. 19
the voice for children’s oral health | cdhp.org
Comparing Plan Types Stand-alone • Optional to purchase (unless state requires) • Separate insurance policy & premium • Separate deductible • Separate out-of-pocket maximum • Adult coverage may be part of some plans • No cost-sharing reductions • Some consumer protections may not apply 20
QHP w/ Embedded Dental • Dental benefits part of health plan (QHP) • One premium for health and dental • May have unified deductible or separate deductible for dental • Individual or family plan includes dental for children; some plans may include adult dental • Cost-sharing reductions apply • All consumer protections apply
the voice for children’s oral health | cdhp.org
Out-of-Pocket Maximums • ACA sets limits on out-of-pocket expenses (OOP maximums) – OOP maximums vary by income up to 400% FPL
• ACA regulations allow for a separate OOP maximum for stand-alone dental plans – – – –
In addition to medical OOP maximum Does not vary by income Federal Standard: $700 per child/$1,400 multiple children State marketplaces can set their own standard
• If dental benefits are part of QHP, medical OOP maximum applies to all benefits
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the voice for children’s oral health | cdhp.org
Premium Tax Credits How is the tax credit calculated? • Based on the second-lowest cost silver health plan in the marketplace • If this plan does not cover pediatric dental, the tax credit will be based only on the cost of health services • The cost of stand-alone pediatric dental coverage is not included in this calculation • Families purchasing silver-level health coverage and stand-alone pediatric dental coverage will likely not have any tax credit available to support the purchase of dental coverage. 22
the voice for children’s oral health | cdhp.org
Premium Tax Credits • Example: Richmond, VA family of 4 w/ annual income of $70,650 – Expected annual premium contribution= $6,712 (9.5% of income) – 2nd lowest cost silver plan (no dental) = $8,959 – Tax credit: $9,636 – 6,712 = $2,247 – Dental premium (2 kids) = $552 – Total premium obligation = $7,264 (10.3% of income)
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the voice for children’s oral health | cdhp.org
Consumer Protections • The ACA includes numerous market reforms for all benefits provided through a QHP. • The ACA removes annual and lifetime dollar limits on coverage for stand-alone dental plans. • The following do not apply to benefits provided through a stand-alone dental plan: – – – –
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Protection against denials for pre-existing conditions Guaranteed issue/renewal Fair insurance premiums (based only on age and geography) Right to external appeals process
the voice for children’s oral health | cdhp.org
WHAT YOU CAN DO TO HELP FAMILIES
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the voice for children’s oral health | cdhp.org
ACA: The Pediatrician’s Role Primary Prevention & Care Coordination • Preventive services that must be covered at no cost by health plans: – USPSTF A & B Recommendations: • Fluoride supplement for children (6 mos & up) w/out fluoridated water • Draft Recommendation for fluoride varnish application from 1st tooth eruption through age 5 by PCPs.
– Bright Futures periodicity schedule: • Oral health risk assessment • Referral to a dental home • Fluoride prophylaxis (supplements and consider varnish) 26
the voice for children’s oral health | cdhp.org
What Families Need to Know • Children (0-19) are entitled to dental coverage in the small group & individual insurance markets • May be separate or part of health plan • How their coverage works (cost-sharing, deductibles, etc.) when part of a health plan • Which oral health services they get at no cost • How to find a dental home • Pediatricians can help provide preventive oral health services to families 27
the voice for children’s oral health | cdhp.org
Advocacy Opportunities State Level • Consumer protections for dental plans • Dental network adequacy standards • Adult/family coverage options • Offering of dental as part of health plan, protected from medical deductible
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Federal Level • IRS tax credit fix • Coverage for all Bright Futures oral health services • Dental quality standards
the voice for children’s oral health | cdhp.org
Contact Information
Colin Reusch, MPA
[email protected] 202.417.3595 http://www.cdhp.org
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the voice for children’s oral health | cdhp.org
The Affordable Care Act’s Pediatric Oral Health Benefit: What it Means to the Busy Pediatrician on Monday Morning
PAUL REGGIARDO, DDS CHAIR, COUNCIL ON DENTAL BENEFIT PROGRAMS AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
What is the Impact of ACA Coverage? It is estimated that about 3.0 million children will
gain dental benefits through the state health benefits exchanges by 2018 (about a 5% increase in commercial coverage). An additional 3.2 million children will gain coverage under Medicaid expansion. And 2.5 million will gain dental coverage through employer-sponsored plans.
Pediatric Dental Purchase Options Stand-Alone Dental Plan
Traditional “Dental Insurance” High Option (85%) and Low Option (70%)
Bundled / Embedded Dental Plan
One Premium One Actuarial Value One Network Common Deductible? Common Maximum Out-Of-Pocket ? Common Federal Subsidy
Key Purchasing Decisions 1. 2. 3. 4. 5.
Did I purchase a dental plan for my child? What services are covered by the dental plan? What are the benefit levels and co-pays for covered services? What is the delivery system? What does the dental provider network look like (Network Adequacy and Quality)?
Key Purchasing Decisions 6. What is the (combined) monthly premium? After any eligible subsidy or premium reduction 7. What is the annual dental deductible which must
be met before benefits begin and is it a combined medical/dental deductible? 8. What is the annual maximum out-of-pocket cost for dental expenses and is it combined with medical expenses?
Where Can A Parent Find Help? State Health Benefits Exchanges Can be confusing Limited information Facilitators, Navigators and Brokers Limited training and knowledge Misinformation Their Pediatrician Their Dentist or Their Children’s Dentist
For More Information For oral health questions, contact the AAP at
[email protected]. For questions related to the ACA contact the AAP Division of State Government Affairs at
[email protected]. To contact Dr Reggiardo, email him at
[email protected]. To contact Colin Reusch at CDHP email him at
[email protected]. Archived ACA Webinar will be available 1 week following this call at www.aap.org/oralhealth.
Resources AAP State Government Affairs Resources:
http://www.aap.org/en-us/advocacy-and-policy/state-advocacy/Pages/State-Advocacy.aspx http://www.aap.org/en-us/advocacy-and-policy/Pages/State-Health-Insurance.aspx
Children’s Dental Health Project Resources:
CDHP FAQs on ACA Pediatric Dental - https://www.cdhp.org/resources/165-faqs-pediatricoral-health-services-in-the-affordable-care-act CDHP Checklist for In-person Assistance - https://www.cdhp.org/resources/299-checklistfor-in-person-assistance CDHP/Families USA Consumer Information Document https://www.cdhp.org/resources/301-buying-children-s-dental-coverage-through-themarketplace Other resources at www.cdhp.org
American Academy of Pediatric Dentistry Resources:
ADA and AAPD Comments on Federal Regulations for Pediatric Dental Benefits in ACA http://www.aapd.org/aapd_and_ada_comment_on_federal_regulations_for_pediatric_de ntal_benefits_in_2015/ Consumer Guidance http://www.mychildrensteeth.org/aapd_expert_helps_consumers_understand_aca_pediat ric_oral_health_care_coverage/
The Impact of Affordable Care Act on the Pediatric Dental Practice – Audio and Slides will be available for purchase soon on the on the AAPD website’s new
Education Portal.
Join the Section on Oral Health Membership in the AAP Section on Oral Health is
free for pediatricians. Simply email
[email protected] for more information.
Receive our quarterly newsletters, participate in the listserv, get help with oral health implementation in practice with tools and technical assistance, and more!!!
Visit www.aap.org/oralhealth for more information.
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