- Exchange-certified stand-alone pediatric dental plans cap out-of-pocket at $375 for one child and $750 for multiple children in 2022.
- 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 exchange-certified 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 in 2022 cannot exceed $375 for one child, or $750 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 uses, the first inflation adjustment was implemented for 2022.
Prior to that, the caps had initially been $700 per child and $1,400 per family in 2014, although those limits had dropped to $350 and $700, respectively, as of 2015, and had remained at that level through 2021. The unchanged out-of-pocket limits were due to the fact that the inflation adjustment amount had been less than $25 prior to 2022, and the rules call for the amount to be rounded down to the nearest multiple of $25.
(Note that as of 2019, HHS eliminated the requirement that stand-alone pediatric dental plans fall into one of two narrow actuarial value ranges; this rule change allows insurers more flexibility in terms of how they design pediatric dental plans, but the cap on out-of-pocket costs remains in place.)
But when pediatric dental coverage is embedded in a medical plan, the maximum out-of-pocket can be as high as $8,700 for a single individual and $17,400 for a family in 2022, including both medical and dental services combined.
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. (Stand-alone dental plans that aren’t certified by the exchange are not subject to the ACA’s rules for pediatric dental coverage.)
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 $375-per-child / $750-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 (health plans can have out-of-pocket limits that are lower than the caps set by HHS).
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 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.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.