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ACA FAQ

With the ongoing implementation of the Affordable Care Act (ACA), people still have questions about what it means for them. Renaissance appreciates your business and remains determined to make this process as smooth as possible.

Pediatric dental coverage is listed as one of the 10 Essential Health Benefits (EHB) under the ACA. Therefore, starting on January 1, 2014, Renaissance will have plan options that include pediatric dental coverage. Upon your renewal you will need to tell us if you require such a policy change.

Below is a list of frequently asked questions to help guide you through ACA related policy changes:

Frequently Asked Questions:

The ACA mandates that all policies issued in the small group and individual insurance markets provide coverage for certain benefits, which are commonly referred to as Essential Health Benefits (EHBs). Those benefits include the following:

  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
  10. Pediatric services, including oral and vision care

If you are 65 or older and have Medicare coverage, you are not required to purchase an EHB-compliant plan for yourself. The ACA will have no impact on your dental plan offering.

To the extent that you have one of the below scenarios or you have purchased medical coverage that meets minimum essential coverage requirements your policy may not need to be EHB compliant.

  • Employer-sponsored coverage (including COBRA coverage and retiree coverage);
  • Medicare Part A coverage and Medicare Advantage;
  • Most Medicaid coverage;
  • Children’s Health Insurance Program (CHIP) coverage; and
  • Certain types of veterans health coverage administered by the Veterans Administration

Generally, EHB-compliant pediatric dental benefits are provided up to age 19 unless a state selects a higher age. For example, the state of Kentucky mandates that EHB-compliant dental coverage must be provided up to age 21.

Orthodontia is covered as an EHB in most states. However, it may only be covered to the extent it is “medically necessary.”

Adults may have different benefits than their children/dependents who are under age 19 and enrolled in an EHB-compliant plan.

Dental benefits may be embedded in a medical plan. However, medical deductibles are often much higher than dental, and non-preventive dental expenses may not be covered until the medical deductible is reached. Even if benefits are embedded, you may want to check your options with a supplemental individual dental plan.

Individual who are at or below 400% of the poverty level will only receive subsidies (Premium Tax Credits) to help with insurance premiums when they purchase in the Individual Marketplace. They will not receive subsidies if they purchase through their employer. Also, these subsidies will apply to medical coverage first and may not be large enough to cover pediatric dental benefits. Subsidies cannot be used to purchase adult dental benefits. Note that if an employer covers part of the cost of an employee’s benefits, the employee is not eligible for a subsidy through the Individual Marketplace.

The policy will be active any time after January 1, 2014, based on new enrollment or renewal if you notify us that you require an EHB-compliant policy.

No, starting January 1, 2014, there will not be annual or lifetime limits on services described as EHB.

Typically, the out-of-pocket maximum is the maximum amount that the individual will pay in a given benefit year for in-network EHB covered services. Out-of-pocket expenses that count towards the out-of-pocket maximum include your deductible, co-pay, and co-insurance. This may vary slightly depending on your state.