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Dental Health Care Reform Basics for Producers

Health Care Reform

The Affordable Care Act (ACA) has reshaped the health and dental insurance landscape. As a result, your role has become even more important in helping your clients and consumers understand the options available to them and make the choices that are best for them. 

One of the ways in which the ACA has changed things is the new Marketplace structure. The individual exchanges help individuals shop, compare and buy health, as well as standalone dental coverage, for themselves and their families. Many of these consumers may also be eligible for financial assistance through premium tax credits and cost sharing reductions, if they buy coverage on the individual Marketplace. 

What Is the SHOP Marketplace Option for Small Businesses?

For small businesses, there’s the Small Business Health Options Program (SHOP), which also provides a Small Business Health Care Tax Credit for eligible employers.

  • You and your clients can browse, compare and purchase available SHOP health and dental plans through www.healthcare.gov or your state's SHOP Exchange.  
  • An employer must have 50 or fewer eligible full time-equivalent (FTE) employees to be able to buy coverage through the SHOP. In 2016, in some states employers with 100 or fewer FTEs will be able to use the SHOP.
  • In 2016, employers can choose to offer a health care plan, a standalone dental plan or both.  You no longer have to offer health to offer dental through the SHOP.
  • 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).

You can visit www.healthcare.gov to learn more about SHOP coverage and use the helpful tools to help calculate FTEs, estimate the premium tax credit, and more.

To serve FF-SHOP clients and their employees, you should register with the FF-SHOP. You should also take the training, although that is not required. State-based SHOPs may have different requirements.

Additional resources for producers can be found here.

What Are Off-SHOP Plans?

United Concordia Dental also offers small group products off-SHOP to meet most employers’ needs.  Our certified pediatric dental rider has EHB coverage for children under the age of 19.  This rider can provide reasonable assurance to health plans that don’t embed pediatric dental.  Reasonable assurance is subject to state requirements and a health plan’s willingness to accept it

Call United Concordia Dental’s Small Business Unit at 1-888-483-9930 for more information on SHOP products and off-Exchange small group options.

*United Concordia offers FF-SHOP products in New Jersey, Pennsylvania and Virginia.  These plans would potentially qualify for the Small Business Tax Credit. United Concordia offers certified plans off-exchange in AZ, FL, GA, MD, NJ, TX and VA.

Purchases must be made through the marketplace to qualify for the tax credit.

What Is the Impact of ACA on Dental Insurance?

The ACA’s 10 Essential Health Benefits include pediatric dental coverage up to age 19. The pediatric dental requirement can be satisfied through purchase of a health plan with embedded pediatric dental or with a standalone dental plan. There is no requirement for adult coverage.  

  • By law, standalone dental plans can satisfy the pediatric mandate on the Individual and SHOP Marketplaces. If there is a standalone Qualified Dental Plan (QDP) on the exchange, Qualified Health Plans (QHP) do not have to include pediatric oral services.
  • Health insurance issuers must include the pediatric dental EHB in their plans offered in the off-exchange market. However, they don’t have to include it if they are willing to be “reasonably assured.” This means that they are reasonably sure that the customer bought a separate, exchange-certified dental plan. The dental plan has to have exchange certification. To be certified, the dental plan must meet the same requirements as a plan offered on the exchange. Certain states have specific definitions of what it means to be reasonably assured.
  • EHB coverage includes medically necessary orthodontia only. Guidelines vary by state but are fairly strict. Traditional cosmetic orthodontia is not included as part of the EHB.
For More Information

Center for Consumer Information and Insurance Oversight – For Agents and Brokers on the Health Insurance Marketplaces
Learn more

PDF about the role of agents, brokers, and web-brokers in Health Insurance Marketplaces
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Official website for the Affordable Care Act
Learn more