Dental Coverage

Dental Coverage for Children

Summary

Regular dental care is important for all people, but especially for children. The Affordable Care Act (ACA) requires federal and state-run health insurance exchanges to offer children’s dental coverage. Suppose you buy a medical plan for your child through one of these public marketplaces. The exchanges must also offer you the option of buying a dental plan. 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.

Though plans in the exchanges have to offer children’s dental coverage as an option, parents do not have to buy it. (That is, unless they live in certain states that require it.) Are you buying a medical plan straight from an insurer and not through an exchange? Then, the plan must include pediatric dental coverage unless you offer “reasonable assurance” that you already have a dental plan for your child.Your costs for dental coverage will depend on the type of dental plan you choose. They will also depend on how much cost sharing the plan requires. Orthodontics (braces) may not be covered by all plans.

Before enrolling yourself and your family in a dental plan, make sure your dentist is in the plan’s network. Make sure there are plenty of in-network dentists near you. You may not be able to afford dental coverage for your child. If so, visit www.insurekidsnow.gov to learn about enrolling your child in Medicaid or the Children’s Health Insurance Program (CHIP).

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. (That is, unless they live in certain states that require it.) If you buy a medical plan directly from an insurer, and not through one of the health insurance marketplaces, the plan must include pediatric dental coverage unless you offer “reasonable assurance” that you already have a dental plan for your child.

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:

  • Your employer: If you have a health plan through your or your spouse’s employer, your plan may include options for enrolling your children in dental coverage. You can talk to your human resources representative, check your plan description or call your health plan to ask about your choices.
  • A health insurance exchange (marketplace): The federal and state exchanges are required to offer pediatric dental plans either as a stand-alone plan or embedded within a health plan. If your state does not have its own exchange, you can select and enroll in a plan from the federal exchange. Find out which exchange you can use here.
  • Medicaid or the Children’s Health Insurance Program (CHIP): Medicaid and CHIP provide free or low-cost medical and dental coverage for children if your income falls within a certain range. You can enroll your children in these plans year-round. To enroll or learn more, visit www.healthcare.gov or www.insurekidsnow.gov.
 

What are my plan choices?

There are three main types of plans that cover dental benefits:

  • 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. Embedded plans offer the option to cover your children’s dental care up to age 26. Note that age limits may differ by 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: This is a stand-alone dental plan that you buy in addition to your medical coverage, through either 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 for each, will be totally separate. It’s important to understand the difference between these plan types, since it will affect how much you have to pay.

What will I have to pay?

Dental plans have the same types of cost-sharing features as medical plans: premiums, deductibles, coinsurance and copayments. 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 copayments or coinsurance 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:


  • Check if your health plan already includes pediatric dental coverage. You can review your plan documents, use the member service number on your insurance card to call your health plan or visit the plan’s website. Ask specifically about what is covered and what your costs will be.
  • Compare the costs. If you are buying a dental plan, does it make more sense for you to buy an embedded medical and dental plan, or purchase them separately, if both types of plans are available in your state? Are there any differences between plans that make one plan better for you than others?
  • Ask the carrier about all the costs you’ll need to pay for each option, including premiums, deductibles, coinsurance and copayments. Make sure you know the out-of-pocket limit, too. Take these costs, and the coverage levels, into account when you think about how much medical and dental care your family uses over the year.
  • Before enrolling your child in a dental plan, make sure the dentist of your choice is in the plan network, or that there are plenty of in-network dentists near you.
  • If you cannot afford coverage for your child, visit healthcare.gov to see if your child is eligible for Medicaid or CHIP.
  • For more information about children’s dental coverage, visit www.insurekidsnow.gov or the Children’s Dental Health Project (CDHP). The CDHP also offers a guide to buying children’s dental coverage through the exchanges.
  • It sounds simple, but prevention is the most effective care. Making sure your children brush and floss regularly will keep their teeth healthy—and keep your dental costs down, too.
  • 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.mouthhealthy.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.

Dental Coverage for Children under the Afforable Care Act (ACA): FAQ's

Do I have to buy dental coverage for my child (pediatric dental coverage) under the Affordable Care Act (ACA)?
Pediatric dental coverage is considered “essential” but not “mandatory.” That means that health insurance marketplaces must offer pediatric dental coverage, but parents/guardians 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. But, there are exceptions to this rule based on the requirements of the state in which you live. Check with your state’s department of insurance to find out if there is a penalty if you do not buy dental coverage for your children.
What type of dental care is covered by plans offered through the ACA?
Each state can choose the services that a children’s dental plan must cover. Most dental plans cover preventive and diagnostic care, like check-ups, cleanings, and X-rays, and basic services, minor restorative care (like fillings) and oral surgery (like tooth removal). Many dental plans will cover 100 percent of the cost of preventive and diagnostic care if they have a network of dentists and you use a dentist from the network.

Braces (orthodontics) may not be covered by all plans bought through the exchange (marketplace). And, if braces are covered by a plan, they may only be covered if they are “medically necessary” according to the guidelines established by the plan. For instance, a plan may cover braces if your child’s tooth alignment compromises the child’s ability to chew or talk. But, even if your plan covers medically necessary braces, it may not be required to pay the full cost of the orthodontic care.
How can I get dental coverage for my children?
There are different ways to cover your child:
  • Through your employer: Your employer may offer dental coverage to employees and dependents.
  • Through a health insurance exchange (marketplace): The federal and state exchanges are required to offer pediatric dental plans. Find out your exchange so you can investigate purchasing dental coverage for your child, use www.healthcare.gov.
  • Through public programs such as, Medicaid or the Children’s Health Insurance Program (CHIP): These programs provide free or low-cost medical and dental coverage for children if your income falls within a certain income range. You can enroll your children in these plans year-round if you qualify by visiting www.healthcare.gov or www.insurekidsnow.gov.
How is dental coverage offered through the ACA?
When you look for dental benefits, the costs may vary based on the type of plan you choose. There are three main types of plans that cover dental benefits:
  • Embedded dental plans: These are healthcare plans that include both medical and dental benefits within the plan. These plans cover the same dental services as dental plans that are offered separately from medical plans, but costs may be different.
  • Stand-alone: These dental plans are offered separately, and are not related to any medical plan through a different insurance carrier. This is a dental plan that you buy in addition to your medical coverage. If you choose this option, your medical and dental benefits, as well as your premium costs for each, will be totally separate. You may not purchase them from the same carrier, and you may get them in different places – for example, you might get medical coverage through your employer, but buy a dental plan from an independent broker.
  • Bundled plans: These are separate medical and dental plans that you buy through the same insurance carrier. They are administered by the same carrier, but are considered separate plans for benefit and administrative purposes. You will make a separate election to include dental coverage for your child and you may have separate premiums for each plan. Some insurers may offer a premium discount if you purchase bundled plans from them.
If you are buying a dental plan, does it make more sense for you to buy an embedded medical and dental plan, or purchase them separately, if both types of plans are available in your state? You should look closely at the plans costs, networks and benefits to help make that decision.
Where can I go for more information about children’s dental coverage?
Visit www.insurekidsnow.gov or the Children’s Dental Health Project (CDHP). The CDHP also offers a guide to buying children’s dental coverage through the exchanges.

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