ACA Provider Information

Reshaping Health Care

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The Affordable Care Act (ACA)—aka “ObamaCare” —has the potential to reshape health care in the United States. Are you
interested in learning more about the ACA and its impact on dentistry? Learn More
 

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Blue Cross Blue Shield of Massachusetts News Alert

  

Blue Cross Blue Shield of Massachusetts (BCBSMA) sent out a news alert on December 2, 2013, to participating dentists explaining how the ACA will impact how they will administer pediatric dental benefits under the ACA for small groups and individual plans effective January 1, 2014, as groups renew.

 

Blue Cross Blue Shield explained in this December Alert that it will be administrating the ACA's pediatric dental benefits under the member's medical plan.

 

Here are some questions and answers to help explain the Blue Cross Blue Shield Alert:

 

What does this mean?

Under the ACA, certain plans must cover 10 essential health benefits (EHBs) which include pediatric dental benefits. In Massachusetts, the group plans that are impacted are the small group plans and the self-pay plans. All  Massachusetts children (under the age of 19) who have Blue Cross Blue Shield insurance through a small group or through a self-pay plan will now have essential dental benefits bundled into their Blue Cross Blue Shield medical plan.


What are the essential health benefits (EHBs)?
Under the ACA, each state was required to select an existing health plan as a benchmark of what benefits must be included. Massachusetts selected the Health Insurance Plan (CHIP) as the benchmark plan; therefore, the pediatric dental benefits that were in that plan are considered EHBs in Massachusetts.  

 

What are the pediatric dental benefits for children?

EHBs include pediatric dental benefits for children up to age 19, and will be covered at 100 percent after the member has met his or her maximum out of pocket cost share ($1,000 for families with one child, $2,000 for families with 2 or more children). Effective January 1, 2014, on account anniversary, the plans will include coverage for pediatric dental benefits (Dental Blue® Pediatric Essential Benefits) for children under the age of 19 with BCBSMA small-group and self-pay plans. There are no impacts to the adult coverage under any of the Dental Blue plans.

 

This type of service

Including these services

Will be covered at 

1

Preventive and diagnostic services, including oral exams,
x-rays, and routine dental care

100%

2

Basic restorative services, including fillings, root canals, stainless steel crowns, periodontal care, oral surgery, and dental prosthetic maintenance

75%

3

Major restorative services, including tooth replacement, resin crowns, and occlusal guards

50%

Medically necessary orthodontia

Services for severe and handicapping malocclusion as defined by HLD index score of 28 and/or one or more auto qualifiers

50%

 

Will these patients have a different benefit card?
Yes, patients will have a Blue Cross Blue Shield of Massachusetts medical card. In some cases, patients may have both a medical card and a dental card. The cards will have the same identification number.

BCBSMA members who have a pediatric dental benefits will have a BCBSMA medical ID card because these benefits are covered under the member’s medical plan. In some situations, a member may have both a BCBSMA medical and a Dental Blue ID card. Both cards will have the same identification number with a different prefix.

 

To check eligibility and benefits:

 

  • Call the Dental Information Center at (800) 882-1178.
  • Call BCBSMA’s InfoDial system (available 24 hours a day, seven days a week) at (800) 882-1178 and follow the prompts for Benefits and Eligibility.

 

Does this mean children who didn't have dental benefits in the past now will have benefits?
Yes, more children will now have essential dental benefits. The ADA estimates that 135,000 additional children in Massachusetts will have dental benefits by 2018, which could mean more patients in your practice. 

 

Is there a yearly benefit maximum for children in these plans?
No, there is no plan or calendar year maximum.

 

Is there a waiting period on pediatric benefits?

No, benefits start immediately.

 

When do these benefits for children begin?
Benefits will phase in over 2014 based on a company's renewal date. The earliest renewal date will be January 1, 2014. You will need to verify eligibility and benefits before delivering care.

 

How do I bill for services?
You must submit all claims for these services either electronically or by paper submission using the most current ADA dental clam form and the member's medical ID number to Dental Blue.

Submit claims to:

Blue Cross Blue Shield of Massachusetts

P.O. Box 986005

Boston MA 02298

  

Will I be paid differently?
You will collect the same fee but a component of it may be coming from the patient in the form of copayment or deductible. This is referred to as "cost share."

 

In the individual market, is dental part of the EHB for children?
Yes. While this Blue Cross Blue Shield Alert was focused on group implications, people who get their insurance through the individual market outside of the Massachusetts Connector (Exchange) are required to have dental as part of their EHB. Therefore, it is recommended that you check eligibility and cost sharing information on all patients. 

 

How will I know what the cost share responsibility is for the patient?
You need to call to verify benefits and eligibility by contacting (800) 882-1178 and you asking about the related out of pocket responsibility of patient. It may be in the form of a copayment (a fixed dollar amount), co-insurance (a percentage of the cost), or deductible (a first-dollar amount).

  • Call the Dental Information Center at (800) 882-1178.
  • Call our InfoDial system (available 24 hours a day, seven days a week) at (800) 882-1178 and follow the prompts for Benefits and Eligibility

 

Is there a maximum a cost share amount for the patient?
Yes, there is a maximum out-of-pocket cost share of $1,000 for a family with one child and $2,000 for families with two or more children which applies only to dental care.

 

What happens when the cost share maximum is reached?
Once a member reaches his or her maximum cost share amount, all covered dental benefits for the remainder of the policy year are paid by Blue Cross Blue Shield at 100 percent. Since there is no maximum benefit, children will be eligible for more dental benefits than they have had in the past.

 

Are there any impacts to the adult coverage?
No, essential dental benefits only apply to children.

 

How does the orthodontia benefit work?
Prior authorization is required for medically necessary orthodontia services, and these services must be furnished by an orthodontist.

 

Do I need to participate with Dental Blue to be reimbursed?
Yes, you must be a participating dentist with Blue Cross Blue Shield of Massachusetts through the Dental Blue indemnity network to provide dental EHBs under the member's medical plan.

 

Do I need to do anything different?
Yes, you need to check patient eligibility and cost sharing amounts for all Blue Cross Blue Shield patients for every appointment (since the cost sharing may change over the course of the year).

 

Why does the Dental EHB not apply to all group plans?
The way the law was interpreted limited the requirement for group dental EHBs to small groups and self-insured plans. There is a requirement for the other group plans to offer the pediatric dental benefits, but they are not required to purchase them.  (Doesn't make sense but this is the way it has been interpreted!)


Questions on the Blue Cross Blue Shield News Alert
If you have any additional questions, please call Blue Cross Blue Shield at (800) 882-1178.

 

Other resources
Review the information on the MDS website, which includes a series of ACA Prezis to educate members on the dental impact of the ACA.

 

Other questions?
Contact Ellen Factor, MDS director of dental benefits, at (800) 342-8747, ext. 228.