What Parents Should Know About Dental Coverage for Their Children under the ACA and Other Sources

A child with good dental health has an easier time eating, speaking, sleeping, playing, going to school and paying attention in class. Unfortunately, tooth decay is the most common chronic early childhood disease in the United States, and dental problems cause America’s children to miss 51 million school hours a year. Part of the solution to protecting the dental health of your children is a solid dental insurance plan that is the right fit for your family.

What does the ACA mean for my child’s dental care?

The Affordable Care Act (ACA) requires the federal and state-run health insurance exchanges (health insurance markets) to offer coverage for dental care services for children. In other words, if you buy a medical plan for your child through one of these exchanges, the exchange must also offer the option of buying a pediatric dental plan or including it in the medical plan. On the federal exchange, these plans must cover children until they turn 19. State marketplaces have various age limitations.

Does that mean coverage is free?

The ACA does not mean that dental coverage for your child is automatic or free – or that all plans cost the same. Just as with medical care, parents have to make wise choices about the type of plan purchased and how much coverage the plan provides. The type of plan and level of coverage determine the cost. Aside from some exceptions, parents can choose to purchase or not purchase pediatric dental coverage.

Is the ACA the only way I can get coverage?

Not at all. ACA insurance exchanges are not the only way to obtain dental benefits for your children. Pediatric dental coverage is considered "essential" but not "mandatory" under the ACA. This means that plans inside health insurance marketplaces must offer pediatric dental coverage, but parents do not have to purchase it. Unlike medical coverage, parents generally will not have to pay a penalty for not enrolling a child into a dental plan. There are two exceptions to this rule.

  • The first exception is the state you lives in. For example, parents in Kentucky, Nevada and Washington are required to purchase separate stand-alone dental coverage for their children.
  • The second exception depends on where you buy your plan. If you buy a medical plan directly from an insurer, and not through one of the exchanges, you must offer "reasonable assurance" that you also will purchase a dental plan for your child. State insurance departments decide what counts as reasonable assurance. In some states, this may require parents to answer some questions when enrolling in a health plan. However, if a parent buys a plan with pediatric dental coverage "embedded" in the medical plan, as described below, then there is no need to purchase a separate pediatric dental plan.

What dental treatment is usually covered under these plans?

Each state chooses the services that children’s dental plans need to cover. Most dental plans cover preventive and diagnostic care and common restorative care, like composite restorations. Some dental plans will cover 100 percent of the cost of preventive care. Orthodontics (braces) may only be covered if they are "medically necessary" for the treatment of associated medical conditions such as cleft palate. Keep in mind that even though the plan covers what is called "medical necessary" orthodontics, the plan is not required to pay the full cost. If a parent thinks that their child may require braces, but will not meet the medical necessity criteria for orthodontic coverage, a parent may consider purchasing a dental plan that covers orthodontic services without such a requirement.

How can I get dental coverage for my children?

You have three possibilities.

  • Employers. If your family has a health plan through one or both parents with an employer, the plan may include options for enrolling children in dental coverage. Talk to your employer’s human resource representative for a description of the dental plan, or call the dental plan to ask about choices.
  • Health Insurance Exchange. The exchanges operating in each state, whether run by the federal or state government, are required to offer pediatric dental plans either as a stand-alone plan or embedded within a health plan.
  • Medicaid or the Children’s Health Insurance Program (CHIP). Medicaid and CHIP provides free or low-cost medical and dental coverage for children if parental income falls within a certain range. Parents can enroll children in these plans year-round, or may be directed to enroll children in these plans when applying for coverage through insurance exchanges, if family income qualifies their children for such coverage.

The different plans can be confusing. What should I know to make the right choice?

  • Embedded plans. These are health plans that include both medical and dental benefits in the same plan. Many employer and exchange plans offer children’s dental coverage through an embedded plan. ACA-embedded plans offer the option to cover your children’s dental care up to age 26, although age limitations vary from state to state.
  • Bundled plans. These are separate medical and dental plans that you buy through the same carrier. They are administered by the same carrier, although you may have different cost-sharing requirements for each plan. Some insurers may offer premium discounts for bundled plans.
  • Stand-alone plans. A stand-alone dental plan is one you buy in addition to your medical coverage, either through a medical carrier with a dental option or a stand-alone dental carrier. If you choose this option, your medical and dental benefits, as well as your premium costs, will be totally separate. It’s important to understand the difference between these types of plans, since it will affect the cost

How much will I have to pay out-of-pocket with these plans?

Dental plans have the same types of cost-sharing features as medical plans – premiums, deductibles, co-insurance and co-payments. Your cost will depend on the type of plan and how much cost-sharing is included. For example, if a plan includes both medical and dental coverage, parents only pay one premium each month. If a stand-alone plan is purchased, parents will pay two monthly premiums, one for medical and one for dental. Parents should investigate if the costs of separate medical and dental plans for their children exceed the cost of a combined medical and dental plan.

The same goes for deductibles, or the amount you have to pay before the plan starts to pay for any of a child’s care. (An out-of-pocket limit is the maximum amount parents will have to pay before the plan covers the full cost of any covered services received from the plan for the rest of the plan year.) With embedded health and dental plans, parents may only need to meet one combined deductible or out-of-pocket limit, but the limits can be very high before any dental benefits are available or the plan covers the full cost of dental services. With a bundled or stand-alone plan, you will need to meet two separate deductibles or out-of-pocket limits but your out-of-pocket costs for dental care may still be lower. For each type of plan, parents also may have co-payments or co-insurance for services. Typically under the ACA, parents do not have a co-pay or deductible for preventive services, but check to determine if dental services are included under the plan’s definition of preventive services.

Is there help if I can’t afford the plans through the ACA?

Under the ACA purchase of an embedded dental plan, you may be eligible for subsidies to help pay the health insurance premium. Subsidies are based on such factors as annual income and family size. Currently, subsidies are usually not available for stand-alone dental plans.

In addition, if parents cannot afford health care coverage, they can visit the website www.healthcare.gov to find out about their eligibility for Medicaid or CHIP.

Can we still go to the same dentist?

Each plan must offer an "adequate" dental provider network. However, there are no set guidelines on how many providers the networks must include, where they must be located or if the child may see a pediatric dentist as their primary dental care provider. Before enrolling in a plan, check to see if it includes your pediatric dentist or a dentist located nearby. Many dental plans limit coverage for out-of-network care, so there is no requirement for how much of the cost of an out-of-network provider is covered.

Adult dental benefits are never included in the medical plans sold in the state benefit exchanges. Some state exchanges offer the purchase of stand-alone family dental plans, which include dependents. This may be another purchase option if parents wish to enroll in a dental plan that gives them greater freedom in the selection of their dentist and that of their child.

Checklist for Parents

  • Check if the health plan already includes pediatric dental coverage. Parents can review plan documents, visit the plan website, or use the member service number on the insurance card to call the health plan. Inquire about specific coverage and costs.
  • Compare the costs. If both plans are available in your state, will it make more sense to purchase an embedded (medical and dental) plan or purchase them separately?
  • Ask the carrier about all costs incurred for each option including premiums, deductibles, co-insurance, co-payments and out-of- pocket limits. Take these costs and the coverage levels into account when determining how much medical and dental care your family uses each year. Before enrolling child in a dental plan, make sure that the dentist of choice is in the plan network or that there are several in-network dentists nearby.

For more information about children’s dental coverage under the ACA visit: http://www.aapd.org/advocacy/aca_basics/