Understanding Your ACA Coverage

As part of the Affordable Care Act (ACA), Delta Dental has outlined the following transparency in coverage information for members enrolled in dental plans purchased through healthcare.gov.

Balance billing

Balance billing occurs when a dentist bills a member for charges—other than copayments, coinsurance or any amounts that may remain on a deductible—following Delta Dental's payment on a claim. Our network dentists agree to accept Delta Dental’s contracted fees as full payment and not to bill the member above that amount. Balance billing is not allowed within the Delta Dental network.

Out-of-network liability

If the submitted amount for an out-of-network dentist is more than the allowed amount, the member is not only responsible for paying the dentist that percentage listed in the policy, but is also responsible for paying the dentist the difference between the submitted amount and the allowed amount. Nonparticipating dentists are under no obligation to limit the amount of their fees and the member will be responsible for paying the amount that is charged.

If an in-network dentist is not readily available within a reasonable period of time or driving distance, it may be possible for a member to receive covered services from an out-of-network dentist and be reimbursed at the same benefit level as if the covered services were provided by an in-network dentist. If this situation occurs, the member should call customer service at 800-971-4108 (TTY users call 711) to discuss options prior to visiting the out-of-network dentist.

If a member requires emergency treatment and receives covered services from an out-of-network dentist, covered services for the emergency care rendered during the course of the emergency will be treated as if they had been provided by an in-network dentist.

Claim submission

One benefit of staying in the Delta Dental network is that our participating dentists will submit claims on your behalf. If you choose to visit a nonparticipating dentist, you will need to submit your own claims within 12 months of the date of service to:

Delta Dental
PO Box 9085
Farmington Hills, MI 48333-9085

You can download a claim form here.

Prior authorization

Prior authorization is the process through which an issuer approves a request to access a covered benefit before the member accesses the benefit. Delta Dental does not require prior authorization for any covered services. If you are concerned about your coverage or the cost of a covered service, you can request a pre-treatment estimate.

Claims pending

A claim is pending when it has been submitted to Delta Dental and is still being processed by the claims department.

Grace periods

If the member fails to pay the full amount of the premium by the date it is due, a grace period will apply. The grace period allows the member additional time to pay the premium without losing coverage. The grace period refers to either a 3-month grace period for members receiving advance payments of premium tax credit, or a general grace period for members not receiving advance payments of premium tax credit.

  • The general grace period is a 31-day grace period. This means that if a premium, other than the initial premium, is not paid by the date it is due, it may be paid during the following 31 days. Your policy will remain in force during this grace period. The grace period will not apply if, at least 30 days before the due date, Delta Dental has delivered or mailed to your last known address a written notice of our intent not to renew your policy.
  • The 3-month grace period applies to members receiving advance payments of the premium tax credit who have previously paid at least one full month's premium during the benefit year. Your policy will remain in force during this grace period. If premium payment is not received within the 3-month grace period, your coverage will terminate on the last day of the first month of the grace period.

During the 3-month grace period, Delta Dental will pay all appropriate claims for services rendered to the member during the first month of the grace period and may pend claims for services rendered to the member in the second and third months of the grace period.

Retroactive denials

A retroactive denial is the reversal of a previously paid claim, as a result of which the member then becomes responsible for payment. A claim can be denied retroactively, for example, if Delta Dental pays a claim during the grace period and it is discovered that the member has terminated the policy prior to covered services being rendered.

The best ways to prevent retroactive denials are to:

  • pay your premium on time online or by phone
  • ensure you have provided us with the correct information
  • ensure you are covered when services are performed.

Premium overpayments

If an overpayment occurs, it will automatically be given as a credit toward the next month's premium unless the member contacts customer service to request a refund. The refund will be issued in the way the premium was paid, or a refund by check can be requested.

Medical necessity

The Essential Health Benefits requirement for pediatric oral care services (for children up to age 19) may limit certain covered services, including orthodontia, to those that are medically necessary. In the case of orthodontia, this means that only orthodontic treatment that is assessed as being reasonable, necessary and/or appropriate, based on evidence-based clinical standards of care may be considered an essential health benefit. Medically necessary orthodontia was not specifically defined by federal law or regulation and may vary by state.

For the most up-to-date information about ACA, please explore the following resources:

For consumers:


For brokers/agents/benefit administrators:


Disclaimer: This information is not intended to serve as legal advice and only constitutes Delta Dental of Tennessee’s opinion on this subject. Please consult your attorney and/or accountant for more information about how the ACA may impact you or your business.