Confused about pediatric dental? Here's how it works

ACA gives kids better access to dental care, but coverage is still not universal

Pediatric dental is an essential health benefit under the ACA
Pediatric dental: It's an essential health benefit, but it doesn't work the same as the other EHBs. Andresr/E+/Getty Images

Pediatric dental is one of the Affordable Care Act's ten essential health benefits (EHBs). That means it's one of the categories of care that the ACA's creators felt were important enough to mandate their coverage on all ACA-compliant plans. The other essential health benefits include things like hospitalization, maternity, prescription drugs, and preventive care.

A different essential health benefit

But pediatric dental is different from the other nine EHBs.

The rest of them are non-negotiable; they've been included on every new individual and small group health insurance plan since January 2014. In-network treatment for those nine essential health benefits are aggregated towards the maximum out-of-pocket on the plan (which cannot exceed $6,850 for a single individual in 2016, or $13,700 for a family), and no new plans can be issued without including coverage for them - without annual or lifetime dollar limits on how much the plan will pay.

Pediatric dental, however, does not have to be included on new health plans. For people who purchase their coverage through the exchange, in most states, it's sufficient if the exchange just makes stand-alone pediatric dental plans available as an add-on purchase. But applicants aren't required to purchase it, and premium subsidies don't pay any portion of the cost to add a stand-alone pediatric dental plan.

States where pediatric dental is mandatory

In some states, pediatric dental is not optional in the exchange, but they're the exception rather than the rule: In Washington State, exchange enrollees are required to purchase pediatric dental coverage; Connecticut’s exchange has required embedded pediatric dental coverage on all plans since 2014, and California's exchange implemented a similar rule in 2015.

Pediatric dental not optional off-exchange

However, if you purchase coverage outside the exchange, all carriers - regardless of the state - are required to be "reasonably assured" that you've got pediatric dental from another source in order to let you purchase a plan without adding on pediatric dental. In other words, pediatric dental is required if you shop outside the exchange, but it only has to be made available to you if you shop in the exchange (unless you're in one of the states described above where coverage is mandatory or embedded on all plans).

What does embedded pediatric dental mean?

When pediatric dental is embedded (required in Connecticut and California's exchanges, and optional for carriers in other states), it means that pediatric dental coverage is part of the health plan, just like any other covered care. The coverage can have copays or it can just be counted towards the deductible, with benefits kicking in after the deductible is met and pediatric dental care covered in full once the out-of-pocket limit on the plan is met.

According to the American Dental Association, in 27 out of 40 states, pediatric dental was embedded in less than half of the health plans available in the exchange in 2015. In three states, no exchange plans had embedded dental benefits.

What about maximum out-of-pocket costs?

If you buy a stand-alone pediatric dental plan - through the exchange or off-exchange - the policy will have a maximum out-of-pocket of $350 for one child, or $700 for a family plan with more than one child. But premium subsidies don't apply to the cost of stand-alone pediatric dental.

If you buy a health plan that has embedded pediatric dental, the total maximum out-of-pocket on the plan - including pediatric dental costs - can be as high as $6,850 if the plan is for just one child, or $13,700 for a family plan (note that all family plans must have embedded individual out-of-pocket limits that don't exceed $6,850 starting in 2016). Other than that restriction, carriers have a lot of flexibility in terms of how they design their embedded pediatric dental benefits. 

So if your child ends up needing no medical care but lots of dental care during the year, a stand-alone dental plan will probably end up being the better option, as it will cap your dental costs at a much lower amount than a health plan with embedded pediatric dental coverage. But if your child ends up needing both medical and dental care during the year, a plan with embedded pediatric dental could result in a lower total out-of-pocket exposure, since both types of care would count towards the health plan's maximum out-of-pocket, with no separate out-of-pocket exposure for dental care.

What about adult dental?

The ACA does not require adult dental coverage to be included in health plans or offered in the exchanges. Many exchanges do offer adult dental plans as a stand-alone purchase option, although it's very rare to see adult dental benefits embedded in a health plan. Adult dental plans are also available as a stand-alone purchase outside the exchange.

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