Alyssa Lane
Dental coverage is an essential health benefit for children, and insurance companies are required to provide this option for families with kids under 18. However, dental coverage is not considered an essential health benefit for adults, and health plans in the marketplace are not required to offer adult dental coverage. While some insurers may offer dental plans for adults, these are often separate from health plans and must be purchased at the time of enrollment. Additionally, states have the flexibility to determine what dental benefits are provided to adult Medicaid enrollees, and there are no minimum requirements for adult dental coverage.
| Characteristics | Values |
|---|---|
| Dental coverage for adults | Not an essential health benefit, rarely included in marketplace plans |
| Pediatric dental coverage | Essential health benefit, must be available as part of a health plan or separately |
| Marketplace dental plans | High and low categories, with varying costs, deductibles, copayments, and coinsurance |
| Medicaid dental coverage | Varies by state, some states provide coverage for adults while others do not |
| ACA dental plans | Not designed to cover all dental services, may require cost-sharing |
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What You'll Learn
Dental coverage is not an essential health benefit for adults
Dental coverage is treated differently for adults and children under the age of 18. While dental coverage is an essential health benefit for children, it is not considered one for adults. This means that health insurance plans are not required to offer dental coverage for adults. If you are seeking health coverage for someone under the age of 18, dental coverage must be available for the child, either as part of a health plan or as a separate dental plan. However, purchasing this dental coverage for children is not mandatory.
In the Marketplace, you have the option to select a health plan that includes dental benefits or one that does not. If you choose a health plan without dental benefits, you can still purchase a separate dental plan. However, it is important to note that you cannot buy a Marketplace dental plan unless you are also purchasing a health plan simultaneously. This means that stand-alone dental coverage cannot be purchased on its own in most states, including all the states that use HealthCare.gov.
The Marketplace offers two categories of dental plans: high and low. The cost of your health insurance will depend on the category you choose. In addition to your premium, you will likely incur other expenses, such as deductibles, copayments, and coinsurance. By comparing dental plans in the Marketplace, you can find detailed information about the costs, copayments, deductibles, and services covered by each plan. This information will enable you to make an informed decision when selecting a dental plan that best suits your needs and budget.
Legislation was under consideration in Congress in 2023 to allow individuals to purchase dental coverage through the exchange, even if they did not need to buy health insurance. This proposed change would provide more flexibility for adults seeking dental coverage. However, it is important to note that financial assistance is typically not available to reduce the monthly premium payments for dental insurance plans for adults.
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Pediatric dental is an essential health benefit
Pediatric dental coverage is considered an essential health benefit. This means that if you are seeking health coverage for someone aged 18 or younger, dental coverage must be made available to them. This can be either as part of a health plan or as a separate dental plan. However, purchasing dental coverage for children is not mandatory, even though it must be offered to you.
While pediatric dental is an essential health benefit, it functions differently from the other nine essential health benefits. In some states, pediatric dental benefits are included in health insurance plans, either because the state requires it or because the insurers choose to. For example, Washington State exchange enrollees are required to purchase pediatric dental coverage, and Covered California has required all health plans sold through the exchange to have embedded pediatric dental coverage since 2015. Similarly, the exchanges in Connecticut and Maryland also require all medical plans to include embedded pediatric dental coverage.
However, in other states, pediatric dental coverage is offered as a separate, stand-alone plan that supplements the enrollee's medical coverage. This is because dental coverage for adults is not considered an essential health benefit, and health plans are not required to offer it. As a result, most adults who want dental insurance must purchase it as additional coverage.
It is important to note that even though pediatric dental is an essential health benefit, premium subsidies are not always available to help cover the cost of the plan if it is purchased separately. Additionally, the specifics of pediatric dental coverage can vary depending on the state and the insurance provider. Therefore, it is recommended to check with your state division of insurance and the pediatric dental carriers in your state to understand what is required and offered, especially regarding orthodontia coverage.
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States choose whether to provide dental benefits for adults with Medicaid
While dental coverage is an essential health benefit for children with Medicaid, the same cannot be said for adults. States are required to cover dental services for people with Medicaid under the age of 21 as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. This is a mandatory service required under a state's Medicaid program. However, states have the flexibility to decide whether or not to provide dental benefits for adults with Medicaid. There are no minimum requirements for adult dental coverage.
In 2010, the Centers for Medicare & Medicaid Services (CMS) established an Oral Health Initiative (OHI) to improve children's access to appropriate preventive dental care. Since then, there has been an increase in Medicaid and CHIP enrollment among children and adults, as well as state expansion of dental benefits for adults enrolled in Medicaid. In 2023, CMS convened an expert workgroup to provide input on strategic priorities for the next phase of the OHI, with a focus on increasing access to preventive, minimally invasive, and timely oral healthcare.
While dental coverage for adults is not typically included in marketplace plans, adults can choose to purchase stand-alone coverage. However, in most states, stand-alone dental coverage can only be purchased if the person is also buying a medical plan. Legislation is currently under consideration to change this rule, allowing individuals to buy dental coverage through the exchange even if they do not need to purchase health insurance.
When comparing dental plans in the marketplace, individuals can consider factors such as costs, copayments, deductibles, and services covered. It is worth noting that dental insurance is treated differently for adults and children under the age of 18. While dental coverage must be available for children, it is not a requirement for adults, and health plans are not obligated to offer it.
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Dental plans vary in cost and coverage
The cost of dental insurance varies depending on the plan and coverage level. Monthly premiums for dental insurance typically range from $20 to $50 per person, but can go up to $64 per month for more comprehensive coverage. Some factors that can affect the premium amount include the type of plan, the dental insurance company, and the coverage level. For example, Dental Preferred Provider Organization (DPPO) plans tend to be on the lower end of the cost range, while indemnity plans can be twice as expensive as DPPO plans.
In addition to monthly premiums, there are usually other out-of-pocket costs associated with dental care, such as copayments, deductibles, and coinsurance. Copayments are flat fees that you pay for covered health care services, while coinsurance is a percentage of the dentist's charge that you are responsible for. Deductibles refer to the amount you pay for covered health care services before your insurance plan starts to pay. For example, with a $2,000 deductible, you would pay the first $2,000 of covered services yourself.
The level of coverage provided by dental insurance plans can also vary significantly. Some plans may only cover preventive services, while others may also cover a percentage of the cost of basic or major services. Basic services typically include fillings and extractions, while major services can include dentures, implants, crowns, bridges, and root canals. It is important to carefully review the details of each plan to understand what is covered and what percentage of the cost is covered by the insurance.
Overall, when choosing a dental insurance plan, it is important to consider both the cost of the plan and the coverage it provides. By comparing the monthly premiums, out-of-pocket costs, and the specific services covered, individuals can select a plan that best meets their needs and provides the most value.
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Stand-alone dental plans for adults can be purchased through the exchange
Dental coverage is treated differently for adults and children under the age of 18. While dental coverage is an essential health benefit for children, it is not considered one for adults. This means that health plans are not required to offer dental coverage for adults.
There are two categories of Marketplace dental plans: high and low. When comparing dental plans in the Marketplace, you can find details about each plan's costs, copayments, deductibles, and services covered. In addition to the premium, you usually have to pay other costs for your healthcare, including deductibles, copayments, and coinsurance.
Legislation is under consideration in Congress in 2023 that would change the rule and allow people to buy dental coverage through the exchange even if they do not need to buy health insurance.
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Frequently asked questions
No, dental coverage is not an essential health benefit for adults. However, dental health is an important part of overall health.
No, health plans don't have to offer adult dental coverage. However, some insurers may offer dental plans in your state.
States have the flexibility to determine what dental benefits are provided to adult Medicaid enrollees. There are no minimum requirements for adult dental coverage under Medicaid.
