A reasonable, medically necessary whirlwind
There’s been a whirlwind of activity around implementation of the Affordable Care Act (ACA), so this seems like a good time to update what’s happening with the ACA and dental.
A lot has happened. Last time, we discussed the “outside-the-exchange” waiver issue (i.e., standalone dental plans providing pediatric dental coverage instead of having it embedded in the medical plan). On April 2, the Wisconsin Office of the Commissioner of Insurance (OCI) clarified how medical plans can be in compliance off-exchange when pediatric dental coverage is excluded from the medical plan.
The OCI bulletin deals with pediatric dental coverage provided through standalone dental plans, and stipulates that all comprehensive small-group and individual health plans sold in Wisconsin (on- and off-exchange) have to disclose prior to sale whether they cover pediatric dental. This means the 98 percent of the market that buys medical and dental separately retains the ability to buy the dental coverage that best meets their family’s oral-health needs.
At the federal level, the Centers for Medicare & Medicaid Services (CMS) clarified some outstanding issues related to standalone dental plans. In past blogs, we’ve discussed what a “reasonable” out-of-pocket (OOP) limit for standalone dental plans might be, and how medically necessary orthodontia will be defined. Now we have answers!
What is a reasonable OOP limit for standalone dental plans? Price and OOP limit move in opposite directions – the higher the limit the lower the price, and vice versa – so ultimately, “reasonable” needs to balance the two. For federally facilitated exchanges (FFE), CMS has stated that “reasonable” is an OOP limit of $700 or less per child, with a 2x family limit. Since premium is excluded from the OOP limit, the maximum a family will spend annually on dental services for children under 19 is $1,400.
The guidance on medically necessary orthodontia lets each carrier define “medically necessary” as part of the coverage, meaning there will not be a common definition of medically necessary orthodontia. Different plans offered by different carriers could have different definitions of medical necessity. The good news is consumers will have choice; a broader definition will cover more children, albeit at a higher price point, while a narrower definition will cover fewer children but at a lower price point.
Finally, we have clarity on timelines. Wisconsin has a public exchange administered by the federal government, more commonly known as an FFE or FFM (federally facilitated marketplace). The filing deadline is fast approaching for products offered on-exchange in FFE/FFM states. The medical-plan filing window is April 1-May 3, and the standalone-dental filing window is May 15-May 31. Products must be filed during these dates to be available to consumers on the exchange for open enrollment. As you can imagine, this is keeping everyone very busy!
There is a lot of work to do as implementation of the ACA continues. You can count on Delta Dental of Wisconsin to stay engaged and informed, and to be your go-to resource for information on the ACA and the future shape of dental benefits in Wisconsin.