The Affordable Care Act (ACA) requires health insurance plans to cover ten essential health benefits (EHB).
One such EHB is pediatric dental care.
It sounds simple enough: “pediatric dental care” means providing oral health care for children.
But it turns out there are many questions — and few concrete answers — about exactly how the pediatric dental EHB will work in Virginia. Here is some of what we do know:
States Decide How to Handle Pediatric Dental Coverage
States were given latitude in designing their requirements for pediatric dental coverage under the Affordable Care Act. Therefore, each state is a little different, and some states are further along than others when it comes to laying out the details.
Pediatric Dental EHB in Virginia
What we know for Virginia is that the state’s pediatric dental benefit is required on all ACA-compliant individual and small group plans, regardless of whether or not you have children. Coverage is modeled after the state’s Children’s Hospital Insurance Plan (CHIP) and includes:
- Access to oral health care for children up to the age of 19.
- Orthodontia benefit, but based on a strict definition of medical necessity.
- There will be no annual or lifetime benefit maximums.
“Access to oral health care” has not been clearly defined by all health carriers, and even some dental carriers are sketchy on the details of the types of services that will be covered.
Embedded, Bundled, or Stand-Alone
There are three ways to get coverage for pediatric dental care. Coverage can be:
Embedded — pediatric dental coverage is included (embedded) in all ACA-compliant health plans, even if there are no children covered on your policy. But, be aware that your dental benefit will probably only kick in after your medical deductible has been met, and there may be co-insurance or co-payments.
Bundled — coverage is provided by a dental carrier (possibly separate from your health carrier), but your medical and dental premiums are bundled so you make a single payment for both coverages. You need to check carefully how deductibles work with bundled policies.
Stand-alone — a stand-alone dental insurance plan will have its own separate premium, separate deductibles, etc. You might want to consider purchasing a stand-alone plan if the pediatric dental coverage embedded in your-ACA compliant plan does not meet your needs.
Deductibles, Co-Payments, Co-Insurance
Another area states have been given wide latitude is in setting deductibles, co-payments, and co-insurance. And we don’t know yet what these will be in Virginia plans.
Please keep in mind that a low-cost pediatric dental EHB embedded in your medical coverage may not cover a lot and could end up costing more than you expect once you actually go for dental care for your child!
Individual/Family Policies
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When Buying Coverage Off Exchange |
When Buying Coverage On Exchange |
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If You Have Children Under age 19 |
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If You Do Not Have Children Under age 19 |
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Small Groups (fewer than 50 full time employees)
If you are a small business purchasing insurance for your employees, some health insurance carriers are including embedded pediatric dental benefits with their medical plans. Some will allow you to pull the embedded coverage out, and then purchase a stand-alone, exchange-certified dental policy for your employees that will satisfy the ACA requirement and better meet their needs.
Make sure you understand that with embedded pediatric dental EHB, your employees will probably have to first meet their medical deductible before dental benefits kick in.
Anthem BC/BS has released detailed information on the Pediatric Dental Benefits that will be embedded in small group plans at a cost of about $6 per person, per month. Click here.
Network of Dentists
ACA requires dental plans to offer an “adequate” selection of dentists, but things like how far a person should be expected to travel to see a dentist, or how long is reasonable to wait for an appointment, is up to each state to determine.
We do not have much information yet on how dentist networks are going to work in Virginia for the embedded pediatric dental benefit.
Questions Remain on Pediatric Dental Benefit
If you are confused, that is because this is quite confusing!
As of now the best we can see is that, for individuals, unless you are buying coverage on the federal exchange, you will have no choice but to purchase a plan with embedded pediatric dental coverage. We are seeing approximately $6 per person, per month being charged for this. It’s almost like a tax. But you can still purchase a stand-alone (or bundled) dental plan that will meet your family’s needs.
As we learn more information, we will of course pass it along. We do have a bit more information for how Maryland is handling the pediatric dental EHB, and will post that in an upcoming article.
In the meantime, give us a call if you have any questions.
Please be patient as we manage a high volume of calls and emails.
