01/07/2015

Second year of ACA implementation underway


On Jan. 1, California and the nation began the second year of implementation of the Affordable Care Act (ACA). As of this writing, while the open enrollment period for people to purchase coverage through California's online marketplace — Covered California — is still ongoing, the reports are that it has been a much-improved application process and as a result, they are expecting more enrollments.

Last year, a total of 1.4 million people enrolled in medical coverage through Covered California, and they are hoping to enroll 1.7 million in 2015.

Despite the fact that we are entering into year two, there is still much uncertainty regarding the overall and long-term impacts of the ACA on both the medical and dental care insurance and delivery systems. What we do know, however, is that the ACA is ushering in access to dental benefits for many more children (under age 19) and creating more dental benefit options for adults.

Pediatric dental benefits are one of the 10 essential health benefits and all medical plans sold in the private individual and small group markets (whether sold inside Covered California or in the traditional individual and small group insurance markets) are required to provide all 10 essential health benefits.

This reflects a change in the requirements that Covered California is imposing on medical plans sold through the online system. In 2014, only medical plans sold in the traditional market outside of Covered California were required to offer pediatric dental benefits and Covered California exempted plans sold inside the online marketplace from that requirement. Despite being one of the listed essential health benefits in the law, Covered California made purchasing pediatric dental benefits optional, and very few families chose it as a result.

For 2015, all medical plans in the small and individual group market will offer policyholders pediatric dental benefits. In California, all of the medical plans are partnering with standalone dental plans to offer that coverage and California law states that the pediatric dental benefit offered must be comprehensive — equal to the benefit design offered by the former Healthy Families Program. It includes prevention services, restorative services and medically necessary orthodontic services.

While CDA supports pediatric dental benefits being one of the essential health benefits, the association has expressed concerns with medical plans offering the dental benefit, since most of the plans have never done so in the past and have limited relationships with dentists. This new, untested endeavor and relationship between California's health plans and dental plans will require state regulators to closely monitor these insurance companies to ensure they meet the needs of their policyholders and do what is necessary to ensure they maintain a robust network of dental providers who can provide timely access to care.

CDA's advocacy efforts have been successful in making sure that the plans sold through Covered California are structured in such a way that regulators must separately monitor the dental plans on these critical issues.

Additionally, Covered California will for the first time be offering adult dental benefits for purchase that will be paired with the pediatric essential health benefit as part of a family plan. Five standalone dental plans will be offering this new, optional benefit. In addition to providing a dental benefit option for adults, these family plans will give families with children the option of buying pediatric dental insurance from a standalone dental plan if they do not like the dental plan partnered with their medical plan. Due to IRS rules, federal subsidies will not be available to those who purchase this benefit through the Exchange.

Critical questions remain about the implementation of the ACA in California and the rollout of policies under Covered California. Major issues from last year's efforts include substantive problems with provider directories and the adequacy of provider networks. During the last open enrollment period, Covered California could not maintain an adequate list of the providers participating in each plan to inform potential health or dental plan purchasers. This left potential policyholders having to either attempt to contact each plan individually to figure out if their current doctor or dentist was a member of the network or buy an insurance product without knowing which providers would be available to them.

In addition, two of the medical plans that sold products through Covered California are currently under investigation by the Department of Managed Health Care (DMHC), the state agency tasked with regulating most of the insurance plans in the state and making sure they follow the laws on network adequacy. DMHC found that both Anthem Blue Cross and Blue Shield of California violated state law by misleading consumers about the size and specific makeup of their provider networks and whether their "narrow networks" made it too difficult for policyholders to get timely care.

The exact penalty for those violations, and whether all of the plans offering coverage will march into 2015 in compliance with the law, is still to be determined.

CDA remains actively engaged in all of the ACA implementation efforts, advocating on members' behalf with the state Legislature, administration — including the state agencies charged with regulating dental plans — Covered California and the federal government.

CDA is a resource for members interested in finding out more about the law and how it may impact dentists and the profession. For more information, contact CDA's director of public policy, Nicette Short, at nicette.short@cda.org or 916.554.4970.



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