Is pediatric dental coverage included in Marketplace health insurance plans?

Is pediatric dental coverage an essential health benefit?

Yes, pediatric dental is one of the ACA’s essential health benefits.¹ But pediatric dental is often not covered by health plans – unlike the rest of the EHBs, which must be covered by all individual and small-group plans effective in 2014 or later. This is because as long as there are stand-alone pediatric dental plans available for purchase in the Marketplace in a given area, federal rules do not require Marketplace health plans in that area to embed pediatric dental²

And CMS noted in 2023 that stand-alone pediatric dental plans have consistently been available in the Marketplaces nationwide.³ So unless a state requires health plans to embed pediatric dental coverage, it’s up to the insurers to include it or not.

Most states leave it up to the insurers to determine whether to embed pediatric dental coverage. But some state-run exchanges, including those in California,⁴ Connecticut,⁵ and Maryland,⁶ require all on-exchange medical plans to include embedded pediatric dental coverage.

If pediatric dental coverage is not embedded in health plans, Marketplace enrollees can generally decide whether to purchase a separate stand-alone pediatric dental plan. But Washington’s state-run exchange clarifies that enrollees are required to purchase pediatric dental coverage if anyone on their application is 18 or younger.⁷

How common is embedded pediatric dental insurance on Marketplace plans?

According to a Milliman analysis of 2024 coverage in the 32 states that used HealthCare.gov that year, 26 of those states had at least some Marketplace health plans that included embedded pediatric dental. Milliman noted that "from 2020 to 2024, the number of states utilizing [HealthCare.gov] with plans that embed both pediatric and adult dental benefits has increased from eight to 20, representing a material increase in consumer access to embedded dental coverage.” ⁸

And as noted above, a few states that run their own Marketplaces require all Marketplace plans to include embedded pediatric dental.

Do off-exchange plans include pediatric dental coverage?

For off-exchange coverage (plans purchased outside the Marketplace), federal rules require insurers to include pediatric dental unless they are “reasonably assured” that the enrollee has exchange-certified pediatric dental coverage from another source.⁹ However, because of the ambiguity around the concept of "reasonable assurance,” some states have taken a different approach to regulating this.

For example, several states allow carriers to simply notify off-exchange enrollees about whether or not the plan includes embedded pediatric dental coverage, and allow the consumer to make their own purchasing decision.¹⁰

What is the maximum out-of-pocket limit for pediatric dental coverage?

As of 2025, the maximum out-of-pocket cap for stand-alone pediatric dental plans that are certified by the exchange/Marketplace is $425 for a single child and $850 for multiple children on the same family policy.¹² For 2026, those limits increase to $450 and $900, respectively.¹³

But it's important to understand that if the pediatric dental coverage is embedded within a medical plan, the policy can be designed so that dental expenses are applied towards the overall deductible and only covered after the deductible is met (unless a state has more restrictive requirements).¹⁴ This is a common scenario on plans with embedded pediatric dental, although preventive pediatric dental care is sometimes covered before the deductible is met. Health plans can have maximum out-of-pocket costs as high as $10,600 for a single person in 2026. That can include pediatric dental costs if the coverage is embedded in the medical plan.

States can set stricter rules, and California is an example of one that does. As noted above, California requires Marketplace plans to embed pediatric dental coverage. But the state also requires insurers to limit out-of-pocket costs for pediatric dental at no more than $350 for one child, or $700 for multiple children on the same policy.¹⁵

A note about off-exchange dental coverage: If a stand-alone dental plan is not certified by the exchange, it does not have to comply with the ACA's rules for pediatric dental coverage. Outside of the exchange – or “off exchange” – carriers can sell both exchange-certified stand-alone dental plans and stand-alone dental plans that are not ACA-compliant.¹⁶ This is different from the individual and small-group major medical health insurance markets, where plans (effective in 2014 or later) must be ACA-compliant regardless of whether they're sold on-exchange or off-exchange.

Do pediatric dental plans have actuarial value rules?

No, pediatric dental plans do not have to conform to the sort of specific actuarial value requirements that apply to health plans. Through 2018, stand-alone pediatric dental plans certified by the Marketplace/exchange had to provide either provide “high” (85%) or “low” (70%) actuarial value. But HHS eliminated this requirement as of 2019, to give insurers more flexibility in designing plans.¹⁷

The maximum out-of-pocket limits described above still apply, and HHS continues to require stand-alone dental plans to receive certification of their actuarial value from a member of the American Academy of Actuaries, and report the certified AV to the exchange (HHS had proposed eliminating that requirement, but decided to keep it instead).

Do pediatric dental plans have to comply with the ACA's medical loss ratio rules?

No. Unless the pediatric dental coverage is embedded within a major medical health plan, the ACA's medical loss ratio rules do not apply. (States can establish their own loss ratio rules for dental plans.) ¹⁸ So stand-alone dental plans, even those that are exchange-certified and thus offering ACA-compliant pediatric dental coverage, do not have any federal restrictions on the percentage of premium revenue that must be used for claims.¹⁸

Is preventive pediatric dental care subject to out-of-pocket costs?

It depends on what preventive dental care is being provided. And 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 plans must cover for free for all children enrolled in ACA-compliant coverage.¹⁹

The only services related to dental care on that list are fluoride supplements for kids without access to fluoride in their water, fluoride varnish for infants and children, 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 an exchange-certified stand-alone pediatric dental plan, there's a good chance those benefits will be covered in full or with relatively low cost-sharing (and allowing for free or very low-cost preventive and routine dental care is part of the reason HHS eliminated the actuarial value categories for pediatric dental plans).¹⁷ If you have embedded pediatric dental, it's up to the carrier to design the benefits, but you may still find that you have access to routine cleanings for your kids at little or no cost. This will vary from one plan to another however, and you’ll need to check your plan’s details to know what out-of-pocket costs you’ll have.

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.¹⁵

Can premium subsidies be used to pay for pediatric dental insurance?

Although pediatric dental is one of the essential health benefits, premium subsidies are not necessarily available to help cover the cost of the plan if it's purchased as a separate stand-alone policy.

Premium subsidies are determined based on the cost of the benchmark (second-lowest-cost Silver) plan, the cost of the plan the applicant selects, and the applicant's income. And although the benchmark plan is normally just the second-lowest-cost Silver plan in a given area, it's a little bit more complicated if some of the available Silver plans include embedded pediatric dental and some do not.

In that case, under 26 CFR § 1.36B-3(f)(3), the benchmark determination is different.²⁰  The short story is that the total subsidy amount that's available to a household may or may not be based on adding a portion of the cost of a separate stand-alone dental plan – it depends on what Silver plans are available in the exchange to each applicant, and how the premiums stack up against each other when the cost of a stand-alone dental plan is added to the cost of the silver plans (if any) that don't include embedded pediatric dental coverage (more details in footnote).²¹

Which is better: Stand-alone pediatric dental coverage, or a health plan with embedded pediatric dental coverage?

In many states, consumers have the option to pick either a medical plan that includes embedded pediatric dental coverage, or a stand-along pediatric dental plan purchased in addition to the family's medical coverage. There’s no right or wrong answer, but here's a summary of the pros and cons of each option:

Embedded pediatric dental insurance:

Potential pros:

• Children are more likely to have dental coverage when health plans embed it in their policies, as the family doesn't have to purchase a separate dental plan.
• Premium subsidies can offset a portion (or all, in some cases) of the cost of the overall medical plan, including the cost of the pediatric dental coverage.

Potential cons:

• The plan's maximum out-of-pocket can be as high as $10,600 for a single individual in 2026. That can include any combination of medical and dental bills (unless a state has rules limiting out-of-pocket pediatric dental costs for embedded coverage).
• Unless a state prohibits it, the plan can require the child to meet a combined deductible for medical/dental care, which can mean that the family has to pay thousands of dollars in out-of-pocket costs before the plan starts to pay for dental care.

Stand-alone pediatric dental insurance:

Potential pros:

• Maximum out-of-pocket costs for the stand-alone pediatric dental plan in 2026 cannot exceed $450 for one child, or $900 for two or more children in the family (these amounts are indexed annually).¹³ For a child who needs extensive dental work, but not a lot of other medical care, a stand-alone policy can result in far lower out-of-pocket costs than a medical plan with embedded dental coverage.
• The deductible tends to be very low (it has to be low, given the low limits on maximum out-of-pocket), so benefits for dental work tend to kick in right away, even if the child only needs fairly minor dental work.

Potential cons:

• A separate plan has to be purchased, in addition to the family's medical coverage.
• Premium subsidies may or may not be available to cover part of the stand-alone dental plan premium (see explanation above).