Is pediatric dental coverage included in exchange plans?

  • By
  • healthinsurance.org contributor
  • March 30, 2016

Q: Can you explain the requirements for pediatric dental coverage? I’ve read that it’s an essential health benefit that has to be covered on all plans, but I’m also hearing that it’s optional?

A: It depends. There is no penalty for not having pediatric dental on your policy. And in most exchanges, you can purchase a plan without pediatric dental. But off-exchange, carriers are required to include pediatric dental unless they have determined that you have pediatric dental from another source.

Pediatric dental coverage is one of the ten essential health benefits (EHBs) that the ACA has required on all individual and small group plans since 2014. But section 1302 of the ACA (see page 61) explains that a policy sold in an exchange without embedded pediatric dental coverage can still be a qualified health plan (QHP) as long as there is also a stand-alone pediatric dental plan available in the exchange.

Exchanges must offer pediatric dental, either via coverage that is embedded with the medical plans, or in separate stand-alone plans. But in most states, enrollees are not required to have pediatric dental coverage if they buy a health plan through the exchange, even if there are children on the policy. They can simply purchase a QHP that does not have pediatric dental and will have satisfied the ACA’s individual mandate (There are some exceptions: Washington State exchange enrollees are required to purchase pediatric dental coverage; Covered California began requiring all health plans sold through the exchange to have embedded pediatric dental coverage starting in 2015; Connecticut’s exchange required embedded pediatric dental coverage on all plans starting in 2014.)

How common is embedded pediatric dental?

The American Dental Association conducted an analysis of embedded dental coverage in health insurance plans sold through the exchanges in 2015. They studied 40 states, although only three of them (California, Vermont, and Washington) had their own exchanges. The study found that in 27 of the states, dental benefits were embedded in less than half of the available health plans – and in three states, dental benefits weren’t embedded in any of the plans.  

Of the plans that did include embedded dental coverage, the vast majority (573 out of 597) only included pediatric dental, not coverage for adults. So in many cases, people who want pediatric dental coverage must purchase it in addition to their health insurance.  And virtually everyone who wants adult dental insurance must purchase it as additional coverage.

Coverage required off-exchange

If you shop off-exchange, pediatric dental is required. If you purchase an off-exchange plan, the carrier must be “reasonably assured” that you have exchange-certified pediatric dental coverage in place in order to sell you a policy without pediatric dental.

If you have no children under age 19 on your application and you’re shopping off-exchange, you may be able to purchase a zero-premium “adult pediatric” dental plan. (Talk with your broker or insurance carrier to see if this is available.) You wouldn’t pay anything for the policy, but since it only covers children, it wouldn’t provide any dental coverage for adults on the plan.

If you do have children under 19 on your application and you’re shopping off-exchange, you are not allowed to opt out of pediatric dental coverage. You must either purchase pediatric dental coverage (embedded with your plan or as a supplemental policy) or attest to the fact that you already have it from another carrier.

Coverage conforms to ACA regulations

Pediatric dental coverage has to conform to some ACA regulations, including a ban on lifetime and annual benefit limits. This is a big change from pre-2014 individual dental plans, which typically had low annual limits. But not all services are covered on the new plans – for example, orthodontia is generally not covered unless it’s “medically necessary” (which is different from cosmetically necessary).

Starting in 2015, the maximum out-of-pocket on stand-alone pediatric dental plans is $350 for a single child, and $700 per family if more than one child is covered on the plan (this is a decrease from 2014, when the maximum out of pocket was $700 per child or $1,400 for all the children in a family). Plans must either provide “high” (85 percent) or “low” (70 percent) actuarial value. But if the pediatric dental coverage is embedded with a medical plan, the policy can be designed so that dental expenses are applied towards the deductible and only covered after the deductible is met. This is a common scenario on plans with embedded pediatric dental, although preventive pediatric dental care is sometimes covered before the deductible is met.

It’s important to understand that services we typically think of as preventive dental treatment are mostly not included in the specific list of preventive services that the ACA requires plans to cover for free for all children. The only services related to dental care on that list are fluoride treatment for kids without access to fluoride in their water, and oral health risk assessments for young children. So things like dental cleaning and x-rays do not fall under the umbrella of free preventive care under the ACA. If you buy a stand-alone pediatric dental plan, there’s a good chance those benefits will be covered in full or with relatively low cost-sharing. But if you have embedded pediatric dental, it’s up to the carrier to design the benefits.

State-based exchanges can implement their own requirements though. Covered California is an example: All of their health plans include pediatric dental, and preventive dental care (x-rays, exams, cleanings, and sealants) are covered in full, even if the member has not met the deductible yet.

Although pediatric dental is one of the essential health benefits, premium subsidies are not available to help cover the cost of the plan if it’s purchased as separate stand-alone coverage. Subsidies are based on the cost of the second-lowest-cost Silver plan in the exchange, but not the cost of adding a stand-alone dental plan in addition to the health coverage. So even if a family receives a significant premium subsidy to offset the cost of their health plan, they’ll have to pay full price to buy a separate dental plan, either for the children or for the whole family. When plans embed pediatric dental, the dental coverage is simply part of the health plan, and there’s just one premium.

So embedded pediatric dental can be beneficial in terms of making sure all children have dental coverage, and in terms of having premium subsidies help cover the cost. But embedded pediatric dental can also mean that dental services aren’t covered until after the combined medical/dental deductible is met. There are pros and cons regardless of whether exchanges offer embedded or stand-alone pediatric dental coverage.

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