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 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.
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.
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.