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FAQ: Oral Health in the ACA

FAQ: Oral Health in the ACA

How does health reform affect oral health coverage?

The Affordable Care Act spurred states to create health insurance exchanges where consumers can shop for health care coverage beyond what their employers offer. Health insurance is required for everyone; dental insurance, by law, is required only for children. Evidence demonstrates that adults with dental benefits are more likely to receive dental care, making dental insurance coverage a critical piece of maintaining good oral health.

What is a health insurance exchange?

A health insurance exchange is an online marketplace that sells a variety of insurance products. States had three options: run their own exchange, operate and exchange as a partner with the federal government, or rely on an exchange run entirely by the federal government.  Virginia chose the latter.  

Who can participate?

Individuals and families purchasing insurance on their own.  In 2015, small businesses can also purchase insurance for their employees. An individual does not have to be uninsured to purchase insurance on the exchange.

How do subsidies work?

The exchanges offer a subsidy to buyers who make less than 400 percent of the Federal Poverty Level (or roughly $94,000 per year for a family of four). The subsidies vary based on income, but the ACA dictates that individuals and families will not pay more than  9.5 percent of their total income on health insurance.

Is oral health care included? 

States must include pediatric dental coverage on the exchange, either as a pediatric dental benefit embedded within a health plan or as a stand-alone dental benefit, however the guidelines do not require individuals to purchase the pediatric dental benefit. 

Virginians who wish to purchase dental insurance have two options:

  • Buy a health plan that includes dental coverage
  • Buy a stand-alone dental plan in addition to their health insurance (similar to what most consumers have today)

Who are Navigators and Assisters?

Virginia-based “navigators” and outreach and enrollment "assisters" will educate consumers and enroll them in the exchange. In Virginia, two organizations – the Virginia Poverty Law Center (VPLC) and Advanced Patient Advocacy, LLC (APA) - were awarded funding to train navigators throughout the Commonwealth.  The VPLC will place navigators in legal aid centers throughout the state.  APA will house navigators in select hospitals throughout Virginia. In addition, community health centers will have community outreach assisters onsite.  

Check out our Dental Coverage Fact Sheet for Exchange Enrollment, available in English and Spanish.  And, view this webinar for those helping consumers choose dental coverage in the exchange.

What insurance plans will be certified by the exchange?

Virginia's exchange will offer health plans that come with an embedded dental benefit as well as stand-alone dental plans.  Some of the plans will provider dental coverage for adults and children; others are just for children. Many of the medical plans will have a dental plan included.  Check out Enroll Virginia for specific, up-to-date coverage information.

You cannot be denied coverage due to pre-existing conditions.

In order to be certified by the exchange as a qualified health plan, plans must:

  • Meet marketing requirements to assure that they will not discourage people with major health problems from enrolling
  • Ensure a sufficient choice of providers, including essential community providers that serve low-income individuals
  • Be accredited on clinical quality measures, including consumer assessment surveys
  • Use a standard format for presenting health benefits plan options.

Resources

Download a PDF copy of the Dental Coverage Fact Sheet in English or Spanish.

View a webinar on dental coverage options, geared toward those helping with exchange enrollment.

View a presentation on ACA dental coverage for the uninsured from our 2014 Virginia Oral Health Summit, presented by Colin Reusch from Children's Dental Health Project.

Contact Us

4200 Innslake Drive, Suite 103, Glen Allen, VA 23060  |  804.269.8720  | info@vaoralhealth.org
 
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