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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.

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 will start to be increased for inflation with plan years beginning after 2017. But based on the formula HHS is using, they have noted that there will be no change in the stand-alone dental out-of-pocket maximum in 2018; the first changes will come in 2019.

But when pediatric dental coverage is embedded in a medical plan, the maximum out-of-pocket can be as high as $6,850 for a single individual and $13,700 for a family in 2016, including both medical and dental services. These amounts are increasing to $7,150 for individuals and $14,300 for families in 2017.

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 this case, 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 small number of 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 benefit).

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.