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Dental coverage is a must for kids as it is necessary for them to visit dentists periodically since even a small cavity may lead to big health problems later. Though most children get coverage through their parents’ employer-based health insurance or the government-funded Children’s Health Insurance Program and Medicaid (CHIP), the American Dental Association says that around 10 million children aged 2 through 18 had no dental insurance in 2011. In order to help people not eligible for Medicaid and having no workplace coverage, health insurance marketplaces were opened last year. Marketplace plans offer ten essential health benefits which include children’s dental benefits under Affordable Care Act (ACA). However, a recent Kaiser Health News report shows that ACA is failing to provide dental coverage for children owing to the complexity and confusion involved in the purchase of dental insurance.

Major Reasons

There are two options available for parents who seek pediatric dental insurance at the health insurance marketplace such as purchasing the insurance as part of a family medical plan (embedded dental benefits) or as a separate, stand-alone policy. Though federal officials say nothing about the number of kids who got dental coverage through a family medical plan during the first enrollment period that ended on March 31, they reported that just 63,448 children received dental coverage from stand-alone dental plans sold through the federal website serving 36 states.

  • ACA and subsequent federal guidance consider pediatric dental benefits different from other essential health benefits. No separate subsidy is there for buying dental coverage and no federal penalty for not buying it. Only three states – Kentucky, Nevada and Washington require parents to purchase children’s dental plan. ACA provides income-based tax credits for purchasing medical plans. But that provision is not always given for buying a separate dental plan. This means that embedded dental benefits are included in calculations for financial assistance under ACA, but not standalone plans while subsidized cost-sharing reductions apply to embedded dental benefits, but not standalone plans.
  • As per a study by the American Dental Association (ADA), only 26 percent of medical plans sold at the insurance marketplace included embedded pediatric-only dental benefits. This left parents with difficult choices – either to buy an ideal medical plan for their family that might not have pediatric dental coverage or to buy a standalone plan at an additional cost.
  • Standalone plans are sold as either high-option plans (higher premiums, but smaller out-of-pocket costs) or low-option plans (premiums may be less costly, but may have more out-of-pocket costs) and both plans cover preventive care and services including fillings, sealants and medically necessary orthodontia (Utah and Michigan don’t offer orthodontia coverage). Though the national average price for a low-option policy was $21 and for a high option plan was $27, prices of plans vary according to where people live as insurance market places are regional. As per Kaiser Health News analysis, a low-option children’s dental plan costs $33 per month for a family in Cleveland County in southwestern North Carolina while the same level plan costs $8 for another family in Beaver County in southwest Utah.
  • Deductibles or the amount the enrollees need to pay before coverage starts vary by plan though ACA limits out-of-pocket costs (for standalone children’s dental plans, the limit is $700 if the plan covers one child and $1,400 if it covers two or more kids), which also complicates consumers’ choice. While buying a medical plan with embedded dental benefits, parents prefer one having a separate deductible for dental coverage or else the dental needs of their children may not be covered until the deductible is met.
  • The ADA study mentioned earlier says the lack of a Stand-Alone Dental Plan (SADP) purchase mandate within marketplaces is also causing a negative impact.


As the Open enrollment resumes on November 15, a group of state and federal marketplace officials, dental stakeholders and national experts suggest the following solutions for the better integration of dental benefits into the health coverage under ACA.

  • Increase the availability of embedded dental plans
  • Review federal guidelines to include standalone pediatric dental benefits while calculating financial assistance
  • Reinforce requirements that parents purchase dental coverage for their children
  • Provide training for healthcare exchange navigators to better understand the dental benefits available at the insurance marketplace

The Department of Health and Human Services lowered the out-of-pocket limits for stand-alone plans to $350 for one child and $700 for two or more children for 2015, which is a positive step.

The complexity with dental coverage under ACA is troubling not only for consumers, but also for dentists. Dentists must verify the insurance of each patient thoroughly for accurate billing and receiving the correct reimbursement in time. Seeking help from experts in dental billing and coding will make their job easier.