When health reform was a mere twinkle in the eye of Washington supporters, the dental industry lobbied for admittance to the legislative club.
The results were a mixed bag.
- The Affordable Care Act (ACA) includes pediatric dental services as an essential health benefit
- No provisions were made for adults and dental coverage
And coverage for pediatric dental care has several twists and turns.
The following describes facts about dental services under health reform that you may not know.
Dental coverage is NOT required for ALL children.
With health reform, it is always a good idea to start with some definitions.
Essential health benefits are the minimum benefits required under the ACA that must be offered in the health insurance exchange (marketplace) in your state, and in the small group and individual markets.
Small group is defined by ACA as employers with 100 or fewer employees. However, the states can use their own definition (until 2016) and most states define small group as 50 or fewer employees.
The individual market is insurance that you would purchase yourself (not through an employer).
Pediatric dental services apply to children under the age of 19 (your state can extend that age).
Pediatric dental services are part of the essential health benefits; however, only plans offered in the insurance marketplace, and in the small group and individual markets must offer essential health benefits.
The large group market is not required to offer essential health benefits.
The good news is most large employers offer dental benefits to employees and their dependents.
I warned you about the twists and turns. The following are a couple of curves.
- Small groups that have self-funded coverage are not required to cover essential health benefits
- Grandfathered health plans are not required to offer essential health plans
Self-funded coverage is where an employer uses its own funds (instead of the insurance company) to pay claims. Ask the person who handles your company’s employee benefits if the plan is self-funded.
Grandfathered health plans are plans that have been in place before March 23, 2010, and have not been changed, except for certain acceptable changes. Ask your employer or your insurance company or broker (if you purchase insurance yourself) if your plan is grandfathered.
The table below is a visual summary of these points.
Most ACA provisions do NOT apply to stand-alone dental plans.
Stand-alone dental plans are policies that are separate from medical plans.
According to the National Association of Dental Plans (NADP), 98 percent of all dental benefits are provided through stand-alone dental plans.
Even though stand-alone dental plans are viewed as separate from medical, these dental plans are not subject to most of the ACA provisions.
For example, stand-alone dental plans are not required to cover dependent children to age 26.
Stand-alone dental plans must include pediatric dental services as part of essential health benefits for individuals and small group coverages (with the exception of grandfathered or self-funded plans).
ACA covers only medically necessary orthodontia.
In employer-sponsored dental plans, a huge motivator for employees purchasing dental coverage is the need for braces for their kids.
While ACA requires pediatric dental coverage as an essential health benefit, it covers only medically necessary orthodontia under the pediatric dental services requirement.
The definition of medically necessary could vary based on the plan.
Another potential problem is with orthodontia purchased through your state’s insurance exchange (marketplace).
Your child’s orthodontist may not be a part of the network offering coverage through the exchange. If your child is in the middle of treatment, that could be a problem.
States determine most of the dental benefits.
ACA defines dental benefits requirements in general terms. For the most part, states have a lot of flexibility in design.
ACA recommends states use one of the following as a guide for dental benefits.
- The state’s Children Health Insurance Program (CHIP) offered through Medicaid
- The Federal Employees Dental and Vision Program (FEDVIP)
Essential Health Benefits
- Each state establishes its own coverage package for essential health benefits
- As discussed, ACA restricts orthodontia to medically necessary services
Limits and Maximums
- ACA eliminates annual and lifetime limits on pediatric dental services coverage
- ACA requires a “reasonable” annual out-of-pocket maximum for stand-alone dental plans
- The states determine what’s reasonable
What You Need to Know
While ACA requires your state’s health insurance marketplace, and the small and individual markets to offer pediatric dental services, you are not required to purchase dental coverage.
If you are considering dental coverage, the following are areas for consideration.
- Review your dental options (employer? insurance marketplace?)
- Determine if there is an option for adult dental.
- Check to see if your dentist participates in the network offered.
- Review what dental services are covered.
- Check to see if there is a waiting period before services are covered.
- Review your out-of-pocket expenses – deductible, copays/percentage you pay.
- Review the out-of-pocket maximum – the most you pay annually.
- Review dental services that are excluded from the plan.
- Compare premiums and plan designs.
- Choose the plan that best meets your dental and financial needs.
Notice of Disclaimer –Cathy Miller is not an attorney or health care provider and cannot provide legal or health care advice. The information provided is for your general background only, and is not intended to constitute legal or health care advice as to your specific circumstances. We recommend you review legislation with legal counsel and visit your physician for health care issues.