1. essential health benefits (10 categories of services): (1) ambulatory patient services (2)...

Northeast Delta Dental’s Marketplace Plans

“What’s in it for my Nonprofit?”May 13, 2014

Brian StaplesSenior Sales Executive

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Essential Health Benefits (10 categories of services):

(1) ambulatory patient services(2) emergency services(3) hospitalization(4) maternity and newborn care(5) mental health and substance use disorder services,

including behavioral health treatment(6) prescription drugs(7) rehabilitative and habilitative services and devices(8) laboratory services(9) preventive and wellness services and chronic disease

management, and(10)pediatric services, including oral and vision care

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How the Pediatric Dental Benefit (PDB) is available:

PDB can be either embedded in a medical plan or covered in a stand-alone dental benefit plan.

Medical plans do not have to offer the PDB in its plan if a stand-alone dental plan is available on the state’s Marketplace and is offering a plan covering the PDB (“the dental carve out” or “9 out of 10 plan”). 3


What/who does Maine’s PDB cover?

The services covered are the same (minor differences possible) for all carriers offering PDB coverage and mirror the Federal Employee Dental and Vision Insurance Program (FEDVIP) plan.

Dental “pediatric” age on Federally Facilitated Marketplace is up to age 19.

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Plan design requirements for the PDB:

No annual plan maximum (New) Out-of-Pocket Maximum (OOPM) No deductible applied to preventive services Out-of-network expenses do not count to the

OOPM Actuarial Values of 70% or 85% Medically necessary orthodontics

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Adult coverage is not impacted by ACA. No requirement for adults to purchase dental

coverage. ACA plan requirements do not apply so adult

coverage will look similar to coverage in existing plans.

Because market reforms only apply to the Pediatric Dental Benefit (as an Essential Health Benefit), family dental plans can have different plan designs for kids and adults.

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Delta Dental’s 2014 ME Marketplace Plans:

Pediatric (only) Low Plan Pediatric (only) High Plan Family Low Plan Family High Plan

All four available to small groups or individuals at the same price.

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Marketplace Dental Benefit Plan Design

PEDIATRIC Coverage (ME)

Up to age 19 100/80/50/50 (85% actuarial value) or

100/60/50/50 (70% AV) Office visit co-pay $15 / $30 (high/low);

Deductible $50/ $150 No deductible on any preventive services OOPM $700, $1400 family maximum for 2+

children 100/100/100/100 after OOPM reached Only covered services apply to OOPM Medically necessary orthodontics

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Marketplace Dental Benefit Plan DesignADULT Coverage (ME)

100/80/50 (High) or 100/60/50 (Low)Office visit co-pay $15 / $30 (High/Low)Deductible $50/ $150 (High/Low)No deductible on any preventive servicesNo orthodontics coveredPlan annual maximum $1000Waiting periods: 3 months Basic, 6 months Major

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Delta Dental’s Maine Marketplace Plans’ Network:

Marketplace plans use the Delta Dental PPO network, a national network (think: kids on the family’s plan who are away at college).

Only costs for such services performed by Delta Dental PPO dentists accrue to the pediatric Out-of-Pocket Maximum.

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Factors to Consider When Looking at Dental Coverage Options:

Insurance carriers reputation for quality & service (ask your dentist!)

Provider Network

Value: Cost / Benefits

Confirm which deductible and OOPM applies to the pediatric dental benefit (the medical plan’s if the dental is embedded, or the stand-alone dental benefit plan’s if not).

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Questions?

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1. essential health benefits (10 categories of services): (1) ambulatory patient services (2)...

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