Dental care is an important part of a person’s overall health, and with over 25 percent of adults age 20 to 64 having untreated tooth decay, it’s an issue that affects millions of people. While the majority of people have dental insurance through their employer and receive care for their teeth, the 11 million Americans that get their health insurance through the Affordable Care Act are in a unique situation.
If you’re enrolled in the Affordable Care Act, here’s everything you need to know about dental insurance.
The Affordable Care Act does not require adults to carry dental insurance and insurers through the ACA aren’t required to offer dental coverage to adults, but it is a requirement for kids. Dental care is considered to be an “essential health benefit” for children under 18 (which means that insurers must offer dental insurance for kids, either as part of a medical plan or as a stand-alone plan), but adults don’t have that same requirement. In some cases, adults find that dental insurance isn’t even available.
Just because adult dental insurance isn’t offered or mandated through the ACA doesn’t mean you don’t have options.
If you’re getting your medical insurance through the ACA, there are two ways you can get dental insurance as well:
Purchase an ACA Marketplace health plan that has pediatric dental insurance and purchase a traditional dental insurance plan for the adults in your family: The easiest way to get dental insurance for your children when you’re using the ACA is to choose a health plan on the ACA Marketplace that includes it. If you choose a plan with dental coverage, your premium will include both health and dental insurance.
Since the ACA is only required to provide dental coverage for those under age 18, adults will need to purchase traditional dental insurance or a dental savings plan in addition to their ACA health plan. Some insurers work with the ACA to offer dental coverage.
Purchase a stand-alone Marketplace dental plan: There are some insurance plans available in the ACA Marketplace that are for dental coverage only. These plans are offered by insurance companies that work with the ACA to provide dental insurance for kids (required) and adults (optional). If you go this route, you will pay a separate premium on top of your medical premium. There’s one very important thing to know though: You can not buy a stand-alone dental plan through the ACA Marketplace unless you also buy a traditional health plan at the same time.
It’s important to note, not all dental services are covered by stand-alone plans. For example, orthodontia (braces) is not covered. The maximum out-of-pocket expense for stand-alone ACA dental plans for children is $350 for a single child and $700 per family if you have more than one child needing coverage.
Keep in mind, if you purchase an ACA Marketplace health plan with dental coverage embedded in it as mentioned in the first bullet point, dental expenses are usually only covered after your deductible is met. The average deductible is $5,731 for individuals and $11,601 for families.
While the actual plans vary depending on several factors, there are two categories of dental plans customers can get with their ACA Marketplace plan:
High-coverage dental plans: These are insurance plans that have higher premiums (the amount you pay each month), but lower co-pays (what you pay each visit) and deductibles (the amount you’ll pay after you receive care). With a high-coverage plan, you will pay more every month, but you will pay less when you receive care. If you visit the dentist regularly or expect that you’ll need a lot of dental care, you want to go with a high coverage plan.
Low-coverage dental plans: These are plans that have a lower premium every month, but higher co-pays and higher deductibles. With these plans, you pay less for your dental insurance every month, but you will pay more when you actually have work done. If you tend to only visit the dentist when you have a problem and just want insurance to be there should a problem arise, or you take exceptional care of your teeth and rarely have problems, you’ll probably want to go with a lower coverage plan.
To give you an estimate, it costs about $150 for a filling without insurance. That’s a figure a lot of people can afford if the need arises, but keep in mind that some dental procedures can cost much more. And even for people that take immaculate care of their teeth, emergencies like broken teeth can happen to anyone. Even if you don’t think you’ll need it, it’s smart to carry at least a little dental insurance.
There is a penalty for people who choose not to buy health insurance through the ACA (currently $695 for adults and $347.50 for children), but this penalty does not extend to dental coverage. Dental coverage is entirely optional, even for children.
For people that switch from traditional insurance to a plan purchased through the ACA Marketplace, it can be a surprise for people to find out that dental insurance isn’t required for adults. In fact, some insurers in the ACA don’t offer it. But if you take the time to shop through plans, you’ll find that dental coverage is available for most people.
It’s important to note, you don’t have to get dental coverage through the ACA. If you find a better deal through other dental insurance providers or dental savings plans, you can use those policies alongside your ACA health coverage.