If I buy a dental insurance plan, what sort of out-of-pocket costs should I expect?

Q. If I buy a dental insurance plan, what sort of out-of-pocket costs should I expect?

A. For adults, it depends entirely on the amount of dental care you need during the year. But for children, the Affordable Care Act has imposed regulations that limit out-of-pocket costs for dental care.

On-exchange stand-alone dental plans

For families who purchase exchange-certified stand-alone pediatric dental coverage (a plan that’s obtained through the exchange but separate from the child’s health insurance), the plan cannot place a limit on how much it will pay for covered pediatric dental services and there are limits on maximum out-of-pocket costs for covered pediatric dental expenses:¹

• In 2025, the out-of-pocket limit cannot exceed $425 for one child, or $850 for two or more children on the same policy.²
• In 2026, the out-of-pocket limit cannot exceed $450 for one child, or $900 for two or more children on the same policy.³

Stand-alone dental plans that aren't certified by the exchange are not subject to the ACA's rules for pediatric dental coverage. So if a family purchases a stand-alone dental plan directly from an insurer (rather than through the exchange), the children's out-of-pocket limits described above will not apply, and the policy will likely have caps on how much it will pay in benefits for all family members, including children.

Pediatric coverage embedded in an ACA-compliant major medical plan

When pediatric dental coverage is embedded in a medical plan (purchased on-exchange or off-exchange), the maximum out-of-pocket can be as high as $9,200 for a single individual and $18,400 for a family in 2025, including both medical and dental services combined.⁴ For 2026, those limits increase to $10,600 and $21,200, respectively.⁵

In both cases, these limits are a result of the ACA; prior to 2014, there were no upper bounds on how high a health or dental plan could set their maximum out-of-pocket limits.

Carriers can also offer bundled coverage, with medical insurance and pediatric dental plans sold and billed together, but administered as separate policies with their own out-of-pocket limits. If the coverage is obtained through the exchange, the separate out-of-pocket limits described above apply to the pediatric dental coverage since the coverage is provided under two separate policies, even though they're sold and billed together.

Out-of-pocket not capped on adult plans

Out-of-pocket exposure is not capped on adult dental plans. Even if a person purchases a health insurance policy with embedded adult dental coverage (rare, but offered by some insurers), the policy's out-of-pocket cap would not apply to adult dental coverage.

This is because adult dental coverage is not considered an essential health benefit (EHB), and out-of-pocket limits only have to apply to services that are considered an EHB.⁶ So if an ACA-compliant health policy were to include embedded adult dental, the policy can impose limits on what services are covered and a cap on how much the plan will pay for those services.

Regardless of whether the policy is purchased through the exchange, stand-alone adult dental plans are not required to have any limits on out-of-pocket exposure. These plans were not required to make any changes as a result of the ACA.

Instead of out-of-pocket maximums, adult dental coverage typically comes with benefit maximums; they cap the amount the insurance company will pay, rather than capping the amount that the insured pays (note that dollar benefit maximums are no longer allowed to apply to pediatric dental coverage, since it's one of the essential health benefits).

In most cases, stand-alone dental coverage for adults comes with annual benefit caps that range from $1,000 to $2,500. For the most part, these benefit limits haven’t changed significantly in the decades since dental plans first became available, even though dental care is much more expensive now.

Typically, dental insurance plans provide significant benefits for diagnostic and preventive care, including exams, x-rays, and cleanings, often covering them completely. And for relatively minor restorative work, like fillings and extractions, a dental insurance policy typically covers a large portion of the charges.

But for procedures like root canals, crowns, and implants, it’s easy to exceed the benefit maximum, particularly if you need treatment for more than one tooth. In addition, many dental insurance plans have waiting periods before they cover dental work beyond preventive and basic care.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.