Illinois Group Dental Insurance
Group Dental Insurance is a benefit that can be offered by an Employer to their Employees and their Dependents. The plan can either be Employer Sponsored Dental coverage (meaning the company pays a portion or all of the premium) or Voluntary Dental Benefits (meaning the Employee voluntarily enrolls and pays for coverage or declines coverage.) In either case, the Company can deduct the premiums paid for employees (non-owner employees), and Employees can pay their share of the premium on a pre-tax basis with a P.O.P. (Premium Only Plan.) The Group Dental benefits can be done with the same insurance carrier that provides the health insurance or with another insurance carrier, and the plan does not have to accompany any medical plan (otherwise known as a STAND-ALONE Dental plan.)
Similar to health insurance plans, Group Dental Plans can be offered with a PPO network, HMO network, or Traditional insurance (no network - you can go to ANY dentist.) Some dental carriers will allow an Employer to offer multiple plans to the Employees and let them pick and choose the Small Business Dental Insurance plan that best suits their needs. (There are some rules and restrictions on number of plans offered.) Most insurance plans cover three levels of services: 1) Preventative, 2) Basic, and 3) Major Services. Some, but not all, will offer coverage for Orthodontia (a 4th level of coverage.) Typically you will see plans covering Preventative at 100%, Basic at 80% and Major and Ortho at 50%. In addition, most plans have an annual maximum benefit that the insurance will pay out to providers or $1000, $1500, $2000 or $2500. This annual maximum is for each person covered on the plan. If the Employer decides to offer Group Dental Insurance for the first time, you will typically see a 1-year waiting period before Major and Ortho services are covered. The same rule applies to new hires getting on the group; they will have to wait 1-year to have these services covered.
Beginning January 1st 2014, the ACA (Affordable Care Act) requires all small group medical plans to cover Pediatric Dental coverage or add this benefit. While dental is not usually covered under a major medical insurance policies, some insurance companies did decide to "embed" this benefit into their health plans to make sure their members were compliant with the law. (UnitedHealthcare included Pediatric Dental in many of their medical plans.) Other medical carriers agreed to certify to the gov't that his was offered and if waived, the employees signed off that they have the adequately required Pediatric Dental coverage. (Blue Cross of IL has a pediatric dental that was automatically added to their small groups if the group did not offer their Group Dental Plans to employees. The Employer could sign a form if they had this coverage with another insurance carrier; the employees could also waive this individually if they had adequate coverage elsewhere i.e. spousal coverage or individual dental policy.)
Remember, companies with 50 or more F.T.E. EE's (Full Time Equivalent Employees) are required to offer HEALTH INSURANCE to full time Employees (beginning in 2016, and in 2015 for companies with 100 plus F.T.E. EE's.) They do NOT have to offer Small business Dental Insurance, but must certify that all employees have the adequate Pediatric Dental coverage.
CB Health Insurance is licensed with top carriers in Illinois, such as Delta Dental, Guardian, Humana, and others. Please contact our office for more information or a quote on either Employer Sponsored or Voluntary Dental Benefits.
P.O.P. - Premium Only Plan:
Under Section 125 of the Internal Revenue Code, Employers can set up a plan for the benefit of their employees in which certain items can be paid for with Pre-tax dollars. Some items include premiums for health and Group Dental Plans, unreimbursement medical expenses, and day care costs. Plans that only allow pre-tax deductions for premiums are referred to as Premium Only Plans. Plans that reimburse for certain medical expenses are called Flexible Spending Accounts. (NOTE: Under ACA, FSA contributions are limited to $2500/year and they no longer alloed to reimburse for Over the Counter medications.)
PPO - Preferred Provider Organization:
This is a list of medical providers including Doctors, outpatient facilities, urgent care and hospitals to name a few. They contract with an insurance company to be in the insurance company's PPO network, and agree to the payments the insurance company gives them for various services. They also agree not to bill a patient any EXTRA charges over and above what they receive from the insurance company. If a Doctor is not in the insurance company's PPO network, then they can bill the insured extra charges over and above what is received from the insurance carrier (referred to as Usual and Customary Charges.)
Insureds that are enrolled in a PPO plan have the freedom to choose to go to ANY doctor or provider they like; however, it is usually wise to check the network to make sure the provider is IN the PPO network. This way they do not have to worry about any extra fees, and typically have 'better benefits' such as a Dr. copayment for in-network Doctors.
HMO - Health Mainenance Organization
HMO's came about in the 70's, and typically offered richer benefits and no worries of being "balanced billed" vs Traditional Health insurance. However, most HMO network list of providers will be smaller than the list of providers in a PPO network. In addition, someone covered under an HMO must pick a Primary Dr. and get all of their coordinated health insurance benefits from their Primary Care Physician (PCP). If they need to see a specialist, the PCP will refer the insured to specialist within the HMO network. If the insured goes outside of the HMO network of providers, the insurance company won't pay any of these claims. By enrolling in HMO plan, the insured agrees to use the network of providers and get referrals from their PCP. In an emergency situation, the insured will always be covered, even if out of the HMO (or PPO) network.
Under the Affordable Care Act, individuals and small groups (2-50 employees) must have heatlh insurance coverage for all 10 essential health benefits, including Pediatric dental. 'Pediatric' under the law is defined as any child under the age of 19. The coverage cannot have any waiting periods for services and must have an out of pocket maximum per child no more than $700/year.
Please NOTE: Under the health care law, most people must have health coverage or pay a tax penalty. But this isn't true for dental coverage. You don't need to have dental coverage, even for children, to avoid the penalty. Pediatric Small Business Dental Insurance must be available to you, but you do not have to buy it. Also, employer groups under 50 full time employees do not face penalties for not offering insurance, health or dental.