As of October, 2015, the decision as to the definition of small business will be left up the states. They can choose to expand the definition to include employers with up to 100 employees, or maintain the current definition of small employer (companies with 50 or fewer employees). The majority of states have decided to stay at 50 lives. In 2014, the U.S. Department of Health and Human Services (HHS) mandated that individual out-of-pocket annual maximums will be $350 and family out-of-pocket annual maximums will be $700 (applies to two or more covered children) for all essential health benefits (EHB) dental plans beginning January 1, 2015.
The Affordable Care Act (ACA), or Health Care Reform, was passed in March 2010. Beginning in 2014, it requires that individuals and small employers must have access to affordable health coverage.
All employers are impacted by the ACA; however, the requirements differ depending upon the number of employees you have. Beginning in 2014, all employers must offer affordable medical coverage to their full-time employees and their children up to age 26. Employers with fewer than 50 full-time employees (or under 100 employees where required by the state) must offer health plans that cover the Essential Health Benefits (EHB) - which includes pediatric dental and vision coverage for children to age 19. For small employers, maintaining your existing dental benefits may minimize disruption and require less administrative work.
Starting in 2015, employers may be subject to penalties if they do not meet the ACA requirements. Please consult your Broker, Consultant or Tax Advisor for more information.
It depends on the type of coverage your business offers. Medical carriers are required to offer a medical plan containing Essential Health Benefits (EHBs) including pediatric dental and vision coverage for employers with fewer than 50 full-time employees (or fewer than 100 employees where required by state law). However, medical carriers may sell products that do not include pediatric dental coverage if medical carriers are "reasonably assured" that employers have obtained stand-alone dental coverage from a dental carrier.
The 10 EHBs include:
- ambulatory patient services,
- emergency services,
- laboratory services,
- maternity and newborn care,
- mental health and substance abuse services, including behavioral health treatment,
- prescription drugs,
- rehabilitative and habilitative services and devises,
- preventive and wellness services and chronic disease management,
- and pediatric services, including oral and vision care.
Yes. Most* businesses can meet the essential health benefits requirement for pediatric dental without going through health insurance marketplaces. To help the employees of our small-business customers comply with ACA, MetLife added pediatric dental benefits to many of MetLife's dental benefit plans for employers with fewer than 50 employees (or fewer than 100 employees in some states)**effective January 1, 2014. This means that you will be able to continue offering dental benefits like you do today. There is no need to bundle your dental benefits with your medical coverage. In fact, maintaining your dental benefit as a fully-insured stand-alone plan may eliminate many of the complicated ACA regulations.
**Not available in all states
The pediatric EHB cost varies by state. The cost for this benefit will be applied during standard renewal. Please contact your Broker, Consultant or MetLife Account Representative for more details.
Also known as Exchanges, these marketplaces will allow small businesses to compare costs and different types of features for products sold on the exchange. However, MetLife believes that it will be possible for your business to meet the essential health benefits requirement for pediatric dental without going through health insurance marketplaces. Starting in 2014, small businesses were provided access to health and dental benefits through public marketplaces.
On-exchange dental plans are purchased through public marketplaces, which are also referred to exchanges. Off exchange refers to dental plans that are purchased outside of public exchanges through traditional sales channels.
Affordable Care Act (ACA) legislation imposes an annual assessment on health insurers, including dental and vision insurers, beginning in 2014. The health insurance industry fee (ACA fee) and other fees contained in the ACA legislation are designed to help support cost-generating portions of the legislation like the individual insurance marketplace, state exchanges and health care research.
The ACA fee is allocated among insurers in proportion to their premiums for the preceding year and other factors. The ACA fee is not a tax deductible expense, which increases the cost of doing business from the perspective of health insurers.
Depending on qualifications, such as number of employees and average income, your business may qualify for a small business tax credit. Employers are encouraged to go through the steps in the IRS Small Business Healthcare Tax Credit Worksheet to see if they are eligible for a credit.
The "Cadillac Tax" is an excise tax that employers may have to pay depending on the value of their insurance plan. Fully-insured stand-alone dental, vision, and supplemental health products are not subject to the Cadillac Tax. The tax was originally schedule to go into effect in 2018, but currently pending legislation may push back the date of the Cadillac Tax until 2020. Please consult your Broker, Consultant or tax advisor for more information.
Providers Common Questions
Our team of experts is providing MetLife participating dentists access to opportunities afforded by this new legislation. We are focused on:
- Offering dental plans that comply with applicable ACA requirements
- Providing a focused team of benefits experts to ensure the service you deserve:
- Quick and accurate claims payment
- An educated service center to answer your questions
- Easy access to benefits information
- Quick access to eligibility verification
The goal of the Affordable Care Act is to expand medical coverage to all Americans and to help control health care costs. Although the health care reform legislation is primarily directed at medical plans, there are direct and indirect impacts to MetLife's Dental and Vision products as well as certain aspects of our supplemental health products. The legislation will take several years to be fully implemented.
MetLife’s expertise, guidance and array of products enable us to confidently provide the right employee benefits solutions to meet customer needs as things change. The main requirement of Health Care Reform legislation applicable to MetLife's dental products is that, beginning in 2014, individuals and small employer groups (generally under 50 employees, but in some states, under 100 employees) must offer essential dental care to individuals up to age 19 ("Pediatric Dental Benefits").
For these businesses, medical carriers will be required to offer a medical plan consisting of defined essential health benefits. However, the law allows for the essential benefits for dental to be provided by a stand-alone dental carrier as well. Medical carriers may sell products that do not include pediatric dental coverage if medical carriers are "reasonably assured" that employers have obtained stand-alone dental coverage.
There are 10 categories of essential health benefits, including ambulatory patient services, hospitalization, maternity and newborn care and more. Pediatric dental benefits for children up to age 19 are part of the essential health benefits.
Insurance exchanges (or marketplaces) were created where medical and dental coverage can be purchased by employers and individuals. MetLife is permitted to provide Pediatric Dental Benefits within the insurance exchanges. However, it's important to note that these pediatric dental benefits do not have to be purchased on the exchanges - they can be purchased off the exchanges in the same manner in which dental benefits are purchased today.
The definition of pediatric dental benefits required by the ACA was left to the states to decide. Most states chose plans that resembled their state Medicaid dental plans, however, other states chose other plan designs. The coverage under the plans chosen is generally robust. The unique features of these pediatric dental plans require that they meet certain cost-share requirements and that there are no annual or lifetime limitations for children under the age of 19. When orthodontia is covered, it is only medically necessary orthodontia and not cosmetic orthodontia.
In states where we offer coverage that meets the essential health benefits requirements that apply to pediatric dental for small employers, we offer plans with no annual or lifetime limitations for children under the age of 19.
As of October, 2015, the decision as to the definition of small business will be left up the states. They can choose to expand the definition to include employers with up to 100 employees, or maintain the current definition of small employer (companies with 50 or fewer employees). The majority of states have decided to stay at 50 lives.
In 2014, the U.S. Department of Health and Human Services (HHS) mandated that individual out-of-pocket annual maximums will be $350 and family out-of-pocket annual maximums will be $700 (applies to two or more covered children) for all essential health benefits (EHB) dental plans beginning January 1, 2015. To account for the lower out-of-pocket maximums, all carrier plans were required to modify coinsurance/copay levels and deductibles of their 2015 plans.
The out-of-pocket annual maximum is the most participants pay during a plan year in cost-sharing for covered children under the age of 19 before the carrier begins to pay 100% of the maximum allowed charge for covered services. This limit does not include premiums, balance billing charges, the cost of health care services not covered by the plan or services provided by out-of-network dentists.
Plans are not exclusively assigned to individual offices; your practice will need to continue to accept all commercial plans.
Major restorative work may be needed on any new patient that is accepted, you really won't know what the condition of a patient's oral health is until you evaluate them. Covered services will be verified for you, just as it is now, when you verify eligibility and benefit coverage.