Regular dental care is important for everyone, but it’s especially critical for growing children. That’s why the Affordable Care Act (ACA) requires the federal and state-run health insurance exchanges (health insurance marketplaces) to offer children’s (pediatric) dental coverage. If you buy a medical plan for a child through one of these marketplaces, they also must offer you the option of buying a pediatric dental plan. But, that doesn’t mean the coverage is automatic or free, or that all plans cost the same. Just like with your medical care, you will have to make choices about the type of plan you buy and how much coverage you’ll have—those choices will affect how much you’ll have to pay. Apart from some exceptions, you can choose whether or not to buy it. Learn more below in the section, Do I have to buy dental coverage for my child?
What does the law cover?
Children’s dental coverage is one of the 10 “Essential Health Benefits” required by the ACA. On the federal exchange, these plans must cover your children until they turn 19. Different state marketplaces may have different age limits.
Do I have to buy dental coverage for my child?
Pediatric dental coverage is considered “essential” but not “mandatory.” That means that health insurance marketplaces must offer pediatric dental coverage, but parents do not have to buy it. Unlike medical coverage, you generally will not have to pay a penalty if you do not enroll your child in a dental plan.
There are two exceptions:
1) The state you live in: Parents living in Kentucky, Nevada and Washington are required to have dental coverage for their children.
2) The type of plan you have: If you buy a medical plan directly from an insurer, and not through one of the health insurance marketplaces, you must offer “reasonable assurance” that you also will buy a dental plan for your child. State insurance departments decide what counts as “reasonable assurance.” In some cases, this may involve answering a few questions when you enroll in a health plan.
What dental care is included?
Each state can choose the services that children’s dental plans need to cover. Most dental plans cover preventive and diagnostic care, like check-ups, cleanings, and X-rays, and minor restorative care like fillings. Many dental plans will cover 100 percent of the cost of preventive care.
Braces (orthodontics) may not be covered by all exchange plans. And, if braces are covered by a plan, they may only be covered if they are “medically necessary.” For instance, a plan may cover braces if your child’s tooth alignment makes it difficult to eat or talk. But, even if your plan covers medically necessary orthodontics, it is not required to pay the full cost.
If you think your child will need braces but will not meet the medical necessity criteria that allow the orthodontics benefit to be covered under your ACA plan, you may want to consider buying a dental plan that covers orthodontics without a necessity requirement.
To learn about the coverage your state requires, visit www.naic.org to find the website for your state insurance department.
How can I get dental coverage for my children?
There are different ways to cover your child:
What are my plan choices?
There are three main types of plans that cover dental benefits:
What will I have to pay?
Dental plans have the same types of cost-sharing features as medical plans: premiums, deductibles, co-insurance and co-payments. Your costs will depend on the type of plan you choose and how much cost-sharing is included in the plan. For instance, if you have a single embedded plan that includes both medical and dental coverage, you only have to pay one premium each month. If you buy a stand-alone dental plan, you will pay two monthly premiums: one for medical coverage, and one for dental.
The same goes for your deductible—the amount you have to pay before your plan starts paying for any of your child’s care—and your out-of-pocket limit—the maximum amount that you will have to pay before your plan covers the full cost of any covered services received from the plan for the rest of the plan year. With an embedded health and dental plan, you may only need to meet one deductible or out-of-pocket limit, but those limits may be very high. With a bundled or stand-alone dental plan, you will need to meet two deductibles or out-of-pocket limits (one for medical and one for dental). These limits should relate to the costs for the medical and dental services and procedures.
For each type of plan, you also may have co-payments or co-insurance for services. Remember, under the ACA, you typically will not have a copay for certain preventive services like annual check-ups.
Make sure you understand what is covered and what you may have to pay before you choose a plan.
Can I get help paying for dental coverage?
Again, it depends on the type of plan. Under the ACA, if you buy a single plan that includes both medical and dental coverage, you may be eligible for subsidies to help you pay your health insurance premiums. These subsidies are based on factors like your income and family size. At this time, subsidies are not available for stand-alone dental plans.
What dentists can my child see?
Each plan has to offer an “adequate” dental provider network, but there are no set guidelines on how many providers these networks must include, or where they must be located. Before you enroll in a plan, check to see if it includes your current dentist, or a dentist located nearby. Many dental plans will limit their coverage (amount they pay) for out-of-network care, there is no requirement on how much of the cost they have to cover. If you take your child to a dentist outside the network, you’ll likely pay more out of your own pocket than if you go to an in-network dentist. You can use the FH Dental Cost Lookup to estimate costs for your child’s dental care if that care is received out-of-network.
Your Action Plan:
- The American Academy of Pediatric Dentistry offers information about caring for your children’s teeth at: http://www.mychildrensteeth.org/.
- The American Dental Association also offers information at www.mouthhealthykids.org.
Most importantly, don’t be afraid to speak up and ask questions. You are the best advocate for your child’s care. Understanding your options will help you make the right choice for your family.