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Health Care Reform Basics for Employers

Health Care Reform

The Affordable Care Act

Also known as the ACA, the law provides small businesses and individuals access to affordable health care coverage through Health Insurance Exchanges, or Marketplaces. The Marketplaces, established by or for each state, offer health insurance coverage, as well as standalone dental coverage.

The ACA also helps employers provide insurance for their full-time employees (FTE) through the Small Business Health Options Program, or SHOP.

Why Do You Need to Provide Pediatric Dental Coverage?

The law requires that small business employers offer employees health insurance plans that cover a set of 10 Essential Health Benefits (EHB). These EHBs include:

  • Outpatient care—the kind you get without being admitted to a hospital
  • Trips to the emergency room
  • Treatment in the hospital for inpatient care
  • Care before and after your baby is born
  • Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy
  • Your prescription drugs
  • Services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
  • Your lab tests
  • Preventive services including counseling, screenings, and vaccines to keep you healthy and care for managing a chronic disease.
  • Pediatric services: This includes dental care and vision care for children under age 19.

The ACA does not mandate adult dental coverage.

Do United Concordia’s Dental Plans Comply With the Pediatric Dental Requirement?

Your business or non-profit organization must have 50 or fewer full-time equivalent employees (FTEs). (Some states may use different employee maximums for 2016.) We have Exchange-certified pediatric riders to complement your traditional standalone dental coverage. Plans are available in 25 states. These plans fully comply with the required pediatric oral services essential health benefit, including adherence to the state’s chosen benchmark plan, removal of annual and lifetime limits and addition of an annual maximum out-of-pocket for in-network covered services for dependent children under the age of 19.

We also offer small group qualified dental plans (QDPs) on the NJ, PA and VA FF-SHOP Marketplaces.

Contact your broker or United Concordia's Small Business Unit at 1-800-972-4191 Option 4 for more information.

SHOP Fast Facts

To use SHOP, you must offer coverage to all FTE employees.

  • Some small employers may be eligible for a Small Business Healthcare Tax Credit.
    • Per guidance issued by the IRS, an employer is eligible to claim the Small Business Healthcare Tax Credit if the employer:
      • Covers at least 50% of the cost of employee-only health care coverage for each of their employees;
      • Has fewer than 25 full-time equivalent employees whose average wages are less than $50,000; and
      • Purchases insurance through the SHOP Marketplace.
    • The tax credit is worth up to 50% of an employer’s contribution toward their employees’ premium costs (up to 35% for tax-exempt employers)..
  • In 2015, employers that have 50 or fewer FTE employees can purchase coverage on the SHOP.
  • In 2016, employers that have 50 or fewer full-time equivalent employees (some states may use different employee maximums for 2016) can purchase coverage on the SHOP.
  • Employers can determine how much contribution to premiums they wish to make.
  • Open enrollment for the 2016 coverage year begins November 1, 2015.
  • In 2016, employers no longer have to offer health care in order to offer dental coverage. An employer can now use the SHOP just to provide dental.

Eligible employers can visit www.healthcare.gov to learn more about small business coverage options available through the SHOP.

How Do I Know If I Qualify?

Qualifications vary by state; please contact your broker for details or questions. You can also use the following sources:

  • The official website for the Affordable Care Act - www.healthcare.gov
  • SHOP Customer Service: 1-800-706-7893 Monday through Friday, 9 a.m. to 5 p.m. EST. (Agents and brokers may also use this number.)

My Employees’ Health Plan Includes the Pediatric Dental EHB. Should I Consider a Traditional Standalone Dental Plan?

There are a number of reasons why standalone dental coverage makes sense, even if the required pediatric coverage is embedded in the group’s health plan.

  • Coverage for everyone in the family through the same dentist(s)
  • The option to add additional premium benefits like ortho for both pediatric and adults
  • Pediatric benefits that pay sooner, especially if the health plan deductible has to be met before the dental benefits will pay
  • Network with general dentist and dental specialists

What is Reasonable Assurance and Why am Being Requested to Provide it From My Health Insurer?

Reasonable assurance is a way your medical plan can be assured your pediatric dental coverage meets the required EHB for pediatric dental benefits. However, there is no standard definition for reasonable assurance. United Concordia can work with the health plan to find out what it needs for you to meet the requirement. We offer certified dental riders (to traditional plans) that normally fulfill the reasonable assurance requirement. Contact our Small Business professionals at 1-800-972-4191 Option 4, to learn more about the process for your state.

What’s the Difference Between Traditional and Certified Products?

Traditional - A traditional plan covers adults and children but does not necessarily include some or all of 10 essential health benefits. It can be purchased only off-exchange by groups of any size, and is not certified by the Exchange.

Certified - A certified plan is a standalone dental plan offered off-Exchange that includes the pediatric dental essential health benefit for children up to age 19.

The state’s Exchange must approve a certified plan, even though it may not be offered on the Exchange. The certified plan has to meet the same requirements and go through the same approval process as a plan sold on the SHOP. Only certified plans can provide reasonable assurance to a health plan that the pediatric EHB has been purchased.

What Is Medically-Necessary Orthodontic (Ortho) Coverage and Why Does the Plan Need It?

Medically-necessary ortho means that a child must have a qualifying medical/dental condition in order to have coverage for orthodontics, which is part of the ACA pediatric dental requirements.  

United Concordia requires pre-authorization for orthodontic coverage in its certified small group plans. The orthodontist must submit the appropriate materials for advisor review and a medical necessity determination. If you need the specific guidelines for a given state, please contact us at 1-800-972-4191 Option 4.