What dentists need to know about the Affordable Care Act (ACA) for their office and patients

ACA Dental TeamThe Affordable Care Act (ACA) defines small businesses as those employing under 50 full-time employees (“FTEs”) and, therefore, will likely affect your dental practice as a small business owner.  You can visit healthcare.gov for more information to determine if your practice falls into the small group category.  If so, then this summarizes some of the issues within the ACA impacting both health and dental coverage for you, your employees, and patients.

RELATED: ADA Series on the Affordable Care Act

Employers with fewer than 50 FTEs are not required to purchase or offer health coverage to their employees.  Employees may face a penalty if they do not purchase health coverage on their own, but there is no obligation upon small business to provide coverage.

The Exchange Option

Small businesses may purchase coverage through an insurance exchange in the Federally-facilitated Marketplace (FFM)-Small Business Health Options Program (SHOP).  If a small business has fewer than 25 employees and certain conditions are met, then the business may qualify for a tax credit which could make the FFM-SHOP beneficial.  In 2014, employers who participate on the FFM-Shop will select the medical and dental carrier for their employees similar to the process today.  Employers must select a stand-alone dental plan if they want their employees to receive coverage on the exchange because only stand-alone dental plans can offer adult dental coverage while medical carriers on the exchange can only offer pediatric dental coverage.  An employee may also select medical coverage without embedded pediatric dental on the FFM-SHOP and then continue to purchase stand-alone dental coverage.

The Off-Exchange Option (Traditional Market)

When shopping for plans in the traditional marketplace off of the exchange, small groups are not required to purchase pediatric dental benefits from a medical carrier. However, medical carriers offering plans to small groups off of exchanges are required to offer the pediatric dental benefit unless the medical carrier is “reasonably assured” that the group has an “exchange certified” stand-alone pediatric plan.  There is no need to embed pediatric dental benefits in a medical plan.

Some medical carriers may no longer allow small employers this choice and may mandate purchase of the pediatric dental benefits within their medical plans.  If that is the case, then small employers must review their medical plan to confirm the type of dental coverage being provided.  The basic essential health benefit for dental provides coverage for children under age 19 and then the coverage is subject to traditional medical deductibles of $1,000-$2,000 before benefits are provided.

Before you or your patients make changes to their dental benefits, consider the following:

  1. Employees and employers do not have to purchase pediatric dental coverage from a medical carrier or from an insurance exchange.
  2. There is no need for employees to switch to a different dental benefits carrier. You, your employees and patients have the right to keep their existing plan.
  3. Combining medical and pediatric dental benefits in one medical policy may lead to your employees and/or patients having to meet a large medical deductible before their dental benefits fully kick in.