“The Affordable Healthcare Act Doesn’t Cover Dental So I Don’t Have To Worry About It!”

aca“The ACA doesn’t include dental so it has nothing to do with me” is a common response after any mention of the ACA is made in my Facebook Marketing Group, The Dental Marketing Project.

That may be true if you run an insurance free practice but you accept assignment of dental benefits a ACA plan may soon show up at your door.

Children up to age 19 are now eligible for dental essential health benefits 86532348under their medical plan, as dental pediatric dental benefits are now included in the required essential health benefits package. Insurance companies also have a few stand-alone plans available for purchase by adults that have different frequencies and limitations than plans provided by employers.

Check out this information from the NADP ~


When I first heard of ACA, I thought the same as most offices do, “We are only in network for Delta Dental Premier and we don’t accept state aid so I don’t have to worry about that” and I continued to ignore all the articles and blogs that crossed the wall of my Facebook page, until this past December when the patients started making comments about 2014.

“Next year my kids will be covered under my medical plan, I’m thinking about dropping my dental coverage for them so you’ll have to file it under my medical plan.”  I heard a patient say to our patient coordinator. “We don’t submit claims to medical” my patient coordinator replied. “Well, you’re going to have to come 2014” Mrs. Patient said with all the confidence. At that point I interjected, “just bring me your benefit information, I’ll figure it out.” 

Since this first comment about the ACA was made, our office has heard a few other comments and questions but so far as of January 8, 2014, we have only had one parent come in with a medical ACA dental pedo benefits card.  It is effecting our office, not a whole lot, but enough that we realized we need to be in the know!

It was time to do some research about ACA so I dug in only to discover that the information available on the dental forums was sketchy at best. I found that  there is a lot of confusion and that some of the offices felt like they won’t be affected at all by ACA. Those who did seem to know a little bit about it were not comfortable sharing the sketchy details that they knew out of fear of being quoted and considered to be an expert on this confusing mess.

Even the insurance companies seemed confused. When I called Preferred One to verify a patient’s pedo medical coverage I found that the customer service rep didn’t seem to be very sure either,  she said she needed to ask someone and she put me on hold for a very long time. When she came back to the line, she told me that the coverage was preventive only and since we were out of network for their company, the benefit level was not at 100%. She told me that there was no maximum limit or a deductible for pedo dental/ medical plans.

When I hung up the phone, I told our patient what the Preferred One rep had said “preventive only and not at 100% since we are considered a non-restricted out of network provider.” Our patient, who is a savvy business woman, responded with “That gal does not know what she’s talking about that is not what they told me when I signed up for the plan.” I had to agree; as I told her that I had heard that it ACA includes all essential services not just cleanings. We decided to submit the claim and see what happens; this patient understood that this is new to us all.

After thinking about the information provided by the Preferred One Rep, I decided to do a little more research so I called our Local Delta Dental Corporate office (Delta Dental of MN) and started asking questions.

The lady named Lori who assisted me was fantastic! She led me to their website and showed me a graph that was made to explain the ACA plans that Delta Dental MN has to offer. She gave me her disclaimer that this chart is about DELTA MN plans but she also made the comment that the plans are set to meet the requirements from the ACA as written by our friends in Washington.

delta pedo aca
Contact your local Delta for information about your State, this chart only reflects information about Delta of MN plans.

I mentioned my call to Preferred One and what their rep had told me about the plans being preventive only and she suggested that I call and verify that plan again with another rep. She told me that the ACA contains the word Essential and since root canals are considered essential not preventive, “If I were you, I’d double check that information.”  she said. She did tell me that if the provider is out of network, the benefit will be paid on the out of network level, not at 100% but if the plan is administrated by Delta, and you are a Premier provider you are considered in network for the plans listed on the chart. I found that Claims are submitted for the ACA plans, are submitted just as they are for any stand alone dental plan, so there no need to run out and take a medical coding class!
ScreenHunter_410 Jan. 10 08.55

I also found via this chart from Delta Dental of MN, the guidelines  for ACA plans that Delta MN offers to adults. If you participate with Delta, these plans may be presented at your office (check with your state’s Delta for info about your state) They have different levels of coverage and frequencies so be sure to verify these benefits with the insurance company every time!

Interesting, this could be an opportunity or it could open the office back door.

Opportunity: Market to attract more pedo patients to your office. Wow them with fabulous customer service so their parents will become patients!

Back Door Concern: If these plans do end up paying reduced benefits to out of network providers, your office could lose patients who want to take advantage of 100% in-network coverage. Wow those patients with fabulous customer service so they will want to stay!

The ACA may not have a huge presence in your practice but if you look at it with the eyes of opportunity, you may just find a way to incorporate it into profits for your practice. 

With your success in mind,

nomi8 NOMI





Disclaimer:Nomi Waters is not a representative of Delta Dental or any other insurance company, or  an expert on the Affordable Healthcare Act so please don’t take any information contained in this blog as the gospel truth. The information contained in this blog entry is not official and while it may be helpful, it is intended for entertainment purposes only.  I STRONGLY recommend that you call and verify each ACA plan that is presented to your office and ask questions. NomiWaters.com or any representative of Nomi Waters cannot be held liable for any information obtained from this entry. Thank you.


  1. The Dental Warrior | | Reply

    I’m steering clear of it. I don’t see it as “opportunity.” I see it as a trap. Your mileage may vary.

  2. Mark lee | | Reply

    agree with @thedentalwarrior

Leave a Reply

Your email address will not be published. Required fields are marked *