Understanding Pediatric Dental Coverage Under the ACA — Healthshare

Understanding Pediatric Dental Coverage Under the ACA

Understanding Pediatric Dental Care Under ACA

Welcome to the new era of health care. As of October 1, Americans across the nation have had access to President Obama’s state exchanges—a much anticipated event for two reasons:

1) All the talk of “health care for all” is finally coming to a head, and 2) now that people can actually view the plans for themselves, hopefully all the confusing provisions and mandates will start to make a little bit more sense.

With the exchanges now open for business, I would love to say that some light has been shed on the situation, but the truth is that there are still many aspects of the law that remain unclear. One of those is pediatric dental health benefits.

One of the ACA’s mandates specifically states that all 10 of the services it lists as essential benefits must be included in both individual and small group insurance markets—on and off the state exchanges—beginning in January of 2014. One of those benefits is pediatric dental.

I put together a few FAQs to better explain some of the intricacies of the Affordable Care Act’s coverage of pediatric dental health benefits.

Who qualifies as an “individual” or a “small group?”

•    The ACA defines a small group as 100 people or fewer.

•    Most states define their small group markets as 50 people or fewer.

•    States can keep the definition of a small group at 50 until 2016, when all states must use the ACA definition.

How will pediatric dental be offered under the ACA?

As of right now, medical coverage offered on the exchange must include pediatric dental benefits. However, if the exchange offers a stand-alone dental plan with the required pediatric dental coverage, then you have the option to exclude the pediatric dental benefits from your chosen medical plan.

Whether or not you are required to purchase stand-alone pediatric dental coverage from the exchange (if it is offered) is all dependent upon the state in which you live. By federal law, you are not required to purchase it; however, some states, such as Washington and Kentucky, for example, are strongly considering making it a requirement.

Is pediatric dental included in all medical plans?

No. This varies state to state as well. Some states, such as Massachusetts, offer only stand-alone dental plans. However, other states, such as Rhode Island, offer both stand-alone plans and plans with embedded pediatric dental coverage.

Is pediatric dental coverage mandatory?

Again, that depends. According to a federal agency interpretation, pediatric dental need only be offered on the exchange, but purchase is not mandatory. However, if an individual or small group chooses to purchase health coverage outside of the exchange and from a private insurer, the dental coverage MUST be purchased along with it. Again though, that’s not to say that your state won’t make purchase of pediatric dental coverage obligatory both on and off the exchange.

Under the ACA, employers are not required to purchase new health coverage for their employees and dependents, so if their current benefits include pediatric dental, great! If not, they’re not required to switch to a plan that does. The ACA does require, however, that employers with 50 or more employees offer minimum essential coverage that is affordable and meaningful. If they don’t, they will have to pay a fine. But, minimum essential coverage does not include vision or dental.

If you or your spouse is already insured through your large employer, you are not required to go out and get dental coverage to meet the mandate.

What will be covered?

Again, this is determined state by state. The expectation is that pediatric dental coverage will cover procedures that are typically covered today—that is, cleanings, fillings, X-rays and any preventive treatments.

Several states have already defined what their children’s dental plans will cover. Others have not. States that do not define their benchmarks soon will have to go by the default dental benchmark set by the HHS (Health and Human Services), which is called the Federal Employees Dental and Vision Insurance Program (FEDVIP).

Some states will be required to include orthodontia, but only when medically necessary. As there is no concrete definition of “medically necessary,” this will be determined on a state by state basis as well. However, “medically necessary” orthodontia is typically a result of anything from a cleft palate (a split in the roof of the mouth) to varying stages of malocclusion (misaligned bite).

What will be cheaper, combined coverage or stand-alone plans?

If your state’s exchange offers medical plans combined with vision and dental coverage, then the premium will be combined into one—but that doesn’t necessarily mean it will be cheaper.

While it would make sense for it to be, the plans will more than likely have large combined deductibles, and non-preventive dental expenses may not be covered until the medical deductible is satisfied. This means that the high out-of-pocket maximum for medical coverage will have to be met before pediatric dental can be paid in full.

However, if you purchase a stand-alone dental plan in addition to a medical plan, you will be paying two premiums, and will have two deductibles to meet. In an attempt to keep coverage affordable, HHS proposed that regulations on essential health benefits must have separate, reasonable annual out-of-pocket cost-sharing limitations (defined as $1,000 in 2014). However, without careful research, you may find it difficult to get covered entirely—and to satisfy the ACA mandate—at an affordable price.

How many people will receive dental benefits under the ACA?

According to the American Dental Association, a projected 8.7 million new children will gain coverage under the ACA’s new mandate. Approximately 17.7 million adults are expected to gain coverage as well; about 800,000 of them will gain dental benefits through the state exchanges.

At HSA for America, we understand that making sense of just this one detail of the ACA can be frustrating; making sense of them all in time to find the plan that is right for you and your family can seem downright impossible.

But with our help, it won’t be frustrating or impossible. We make it our goal to make sense of your most challenging health care problems and concerns, and to ultimately help you find the coverage you need, at a price you can afford. When you work with us, you will learn that health care reform, though confusing in its nature, doesn’t have to be confusing to you. Visit our Health Care Reform page and let us make sense of all the details.


2 thoughts on “Understanding Pediatric Dental Coverage Under the ACA”

  1. C says:

    “By federal law, you are not required to purchase it; however, some states, such as Washington and Kentucky, for example, are strongly considering making it a requirement.”

    Washington state mandates pediatric dental insurance:


    states “All qualified health insurance policies must cover these standard basics […] Pediatric services, including oral and vision care — Dental check-ups, routine eye doctor visits, eyeglasses, immunizations, and more.”

  2. admin says:

    Hi C,

    This updated information you mention is correct; at our publish date in October, that decision was not yet made.

    We continue to see changes and rephrasing of many aspects of buying plans on the marketplace, and do not anticipate changes to end as long as the open enrollment period is active.

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