ACA Dental Plans - Dental Benefits | MouthHealthy - Oral Health Information from the ADA

Choosing A Dental Plan Under The Affordable Care Act (ACA)

A paper cutout family under an Affordable Care Act umbrella.

The Affordable Care Act requires that health insurance marketplaces offer dental plans for children. Although the law does not require dental coverage for adults, some state marketplaces may.

Enhancements to Coverage

The ACA prohibits dental plans from placing annual or lifetime dollar maximums on children’s dental coverage. In the past, many plans had an annual or a lifetime maximum which capped the amount of money the plan would pay, leaving you to cover the rest. That’s no longer the case for pediatric dental benefits.

The ACA also eliminated exclusions for pre-existing conditions. This means that plans cannot deny coverage because of a condition you already had when you enrolled in the plan.

Securing Dental Coverage

In the Health Insurance Marketplace, you can get dental coverage as part of a medical plan (and pay one premium) or by itself through a separate, stand-alone dental plan (and pay an additional premium). In some states, such as California, all medical plans include pediatric dental benefits. In these states, you will always get dental coverage through a medical plan and have the option of purchasing additional coverage through a stand-alone plan. In other states, such as Washington, you can only get pediatric dental benefits coverage through a stand-alone dental plan.

High and Low Categories of Dental Plans

Dental plans on the ACA fall into two categories:

  • A high option dental plan has a higher premium but lower copayments and deductibles. You will pay more on a monthly basis and less when you actually use dental services.
  • A low option plan has a lower premium but higher copayments and deductibles. You will pay less on a monthly basis and more when you actually use dental services.

Out-of-Pocket Limit for Children

Remember, dental plans are not designed to cover all dental procedures. Many covered procedures are not covered at 100%, meaning that you will have to pay part of the costs for those procedures through out-of-pocket costs like deductibles and coinsurance.

If you purchase a dental plan separately from your medical plan, you will have a separate out-of-pocket maximum for your children’s stand-alone dental plan. The out-of-pocket limit is the largest amount of money you can be made to pay for your dental care including deductibles, coinsurance and copayments. The out-of-pocket maximum is $350 for one child and $700 for two or more children. After you reach this amount, the dental plan must pay for all additional covered expenses for the rest of the plan year.

Links to Help You Choose Marketplace Insurance has a number of resources available to help you choose the plan that best fits you. Here are a few resources to get you started:

If you have questions or need more help, call the Department of Health and Human Services’ Hotline at 800-318-2596.