- Stand-alone pediatric dental plans cap out-of-pocket at $350 for one child and $700 for multiple children in 2018.
- When pediatric dental is embedded in a medical plan, the plan’s overall out-of-pocket limit applies to the combined medical/dental services.
- There is no mandated cap on out-of-pocket costs for adult dental coverage.
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.
For families who purchase stand-alone pediatric dental coverage (a plan that’s separate from the children’s health insurance), the maximum out-of-pocket for pediatric dental expenses cannot exceed $350 for one child, or $700 for two or more children on the same policy. These amounts started to be subject to inflation adjustments with plan years beginning after 2017. But based on the formula HHS is using, there was no change in the stand-alone dental out-of-pocket maximum in 2018, and they have not proposed a change for 2019 either.
[note that HHS has proposed removing the requirement that stand-alone pediatric dental plans fall into one of two narrow actuarial value ranges; if finalized as proposed, the rule change will allow insurers more flexibility in terms of how they design pediatric dental plans, but the cap on out-of-pocket costs will remain in place.]
But when pediatric dental coverage is embedded in a medical plan, the maximum out-of-pocket can be as high as $7,350 for a single individual and $14,700 for a family in 2018, including both medical and dental services combined. HHS has proposed increasing these amounts to $7,900 for individuals and $15,800 for families in 2019.
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. In that scenario, the $350-per-child / $700-per-family out-of-pocket limit applies for pediatric dental.
Out-of-pocket not capped on adult plans
However, out-of-pocket exposure is not capped on adult dental plans, unless the insured happens to have one of the very few health insurance plans that embed adult dental coverage. And, as noted above, the only out-of-pocket limits that apply in that case are the out-of-pocket maximums for the overall coverage, including medical costs.
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).
In most cases, stand-alone dental coverage for adults comes with annual benefit caps that range from $1,000 to $2,000. For the most part, these benefit limits haven’t changed since the 1970s and 1980s when dental plans first came on the scene – despite the fact that 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.