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American Association of Oral and Maxillofacial Surgeons

Practice Management & Allied Staff News & Materials

Affordable Care Act: Implementation Checklist

April 15th, 2014

Beginning January 1, 2014, health care coverage offered through the Accountable Care Act’s (ACA) health insurance exchanges, also referred to as marketplaces, took effect. The ACA exchanges/marketplaces allow patients who do not currently have employer-provided health care coverage to compare and purchase their health insurance coverage to fit their needs and budget.  Some states are operating their own marketplace, and other states are allowing the federal government to run theirs.  Regardless, oral and maxillofacial surgeons must know if the carriers they contract with are now a part of an ACA insurance marketplace and whether their patients are insured through one of these marketplace plans.  Knowing this will make all the difference in identifying your patients’ out of pocket expenses.   Below is a checklist that AAOMS has developed to help OMS offices adequately prepare for and accommodate this new patient population. For more information on the insurance marketplaces visit .
1.  Confirm if you are participating with ACA exchange/marketplace products and verify coverage.

  • Check with your state to verify which insurance carriers are involved within the insurance exchange/ marketplace. 
  • Review all your provider contracts with those carriers involved within the marketplace.
    • Were you automatically enrolled into the marketplace due to an all-products clause within your existing contract with the insurance carrier?
    • Check the fee-schedules of those carriers included within the marketplace that you are contracted with.  While you may be contracted with a plan, what the plan covers and what they reimburse in and out of the marketplace may differ.  Plans offered through the exchange/marketplace may reimburse according to a different fee schedule and offer only what is required under the ACA in order to keep premiums lower within the exchange. 
    • If you were not auto-enrolled, but are interested in becoming a participating provider with a plan offered through your state exchange/marketplace, keep in mind some exchange/marketplace plans are offering limited provider networks in attempts to keep premiums low.  In such states, providers and hospitals may find themselves being released of their provider contracts without cause. 

 2.  Verify the type of insurance each patient has as well as current eligibility status.

  • Ask each patient what type of medical/dental insurance they carry:
    • Are they insured by their state insurance exchange/marketplace?
    • Are they insured by their employer?  
    • Do they have indemnity insurance or have purchased benefits independently
  • If the patient is insured through the insurance exchange/marketplace, determine what type of dental plan the patient has from the following: 
    • Embedded Dental Coverage: the dental benefits are included within the medical policy;
      •  Medical plans with an embedded dental plan typically have one deductible and a combined maximum out-of-pocket, so the dental benefits may not kick in until the medical deductible has been met.
    • Bundled Dental Coverage: dental benefits are considered a separate plan with a separate deductible, but sold with a medical plan;
    • Stand-alone Dental Coverage: These are dental benefits which can be purchased separately from the patient’s medical insurance.
  • Have a formal office policy in place to discuss any or all expenses your patients may be responsible for per visit, including coinsurance, copayments, and deductibles. 
    • Many insurance plans included within the exchange/marketplace have high deductibles, which should be explained to each patient to prepare them for their financial obligations. 
  • Train office staff on how best to communicate with patients regarding your state’s insurance exchange/marketplace, their coverage, and their responsibility when they schedule their appointment. 

 3.  Be aware of the Essential Health Benefits (EHBs) in your state.

  • All health plans within the insurance exchange/marketplace must offer the core EHBs including physician visits, hospital and emergency services, maternity and newborn care, mental health and substance abuse treatment, prescription drugs, rehabilitative services and devices, laboratory services, preventive and wellness services, and pediatric services including vision and dental care. Note: there is no defined list of covered OMS procedures and coverage is handled on a state by state basis.
  • The scope of pediatric dental benefits that exchange/marketplace plans in any given state are required to cover is modeled after either benefits provided via the Federal Employee Dental and Vision Insurance Plan (FEDVIP) or the state’s Children’s Health Insurance Program (CHIP). You can find a full list of each state’s chosen EHB model at
  • Compare your state’s exchange/marketplace coverage and costs. This information can typically be found on your state’s marketplace Web site through specific comparison tools.

 4. Consider complying with the HIPAA operating rules which went into effect March 31, 2013. Doing so may provide you real-time access to patient eligibility and benefits.

  • The Committee on Operating Rules for Information Exchange (CORE) created the operating rules with the vision of giving providers access to eligibility and benefits information before or at the time of service for any patient or health plan.
  • By determining a patient’s eligibility and financial responsibility while the patient is still in the office so they may accept payment from the patient’s at the time of service.
  • For more information on the HIPAA CORE operating rules speak with your software vendors.

 5.  Have a policy in place relating to coordination of the patient’s benefits if they present with more than one insurance plan.

  • Do not assume that dental is always primary, or that medical is always primary. 
  • Always verify benefits with all insurance carriers presented to confirm which is considered the primary carrier and which is secondary.
    • The handling of your contractual obligations remains the same regardless if the patient is insured through the marketplace or employer plan.   
  • Check out AAOMS’s full summary on coordinating your patient’s benefits on the AAOMS website. 

 6.  Continue to stay abreast on Medicare and Medicaid program enhancements stemming from the ACA.

  • The Physician Quality Reporting System (PQRS) program:
    • A Medicare incentive program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals.  The ACA continues to apply penalties for not reporting quality performance measures on 2014 claims. A full summary along with a list of OMS related quality measures can be found on the AAOMS website.
    • The AAOMS partnered with CECity to offer the PQRSwizard, a fast, convenient, and cost-effective online tool to help collect and report quality measure data for the Centers for Medicare & Medicaid Services (CMS) PQRS incentive payment program.
  • The ACA now allows states the option to expand Medicaid to all individuals under 65 who have incomes up to 133% FPL based on a modified adjusted gross income.
    • If you are a Medicaid provider, you may begin to see an increase in Medicaid patients within your practice.   


Make sure you are aware of how your state exchange/marketplace effects you from an employer’s standpoint.  OMS’s can review the document found on the Governmental Affairs page of the AAOMS website, “A summary of the Health Insurance Marketplace and their impact on your practice.”