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 was primarily directed at medical plans, there have been direct and indirect impacts to MetLife's dental and vision products as well as certain aspects of our supplemental health products.
The main requirement of Health Care Reform legislation applicable to MetLife's dental products is individuals and small employer groups (generally under 50 employees, but in some states, under 100 employees) must offer essential dental care to individuals to age 19 ("Pediatric Dental Benefits").
For these businesses, medical carriers have been 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 attained 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.
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.
The out-of-pocket annual maximum is the most participants are required to 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 providers.
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 dental plans containing the pediatric dental essential health benefit. To account for the lower out-of-pocket maximums, all carrier plans were required to modify coinsurance/copay levels and deductibles.
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 they are now, when you verify eligibility and benefit coverage.