This post comes from Beth Orenstein at partner site Insure.com.
If you thought that buying an Obamacare health insurance plan that meets your family’s needs was confusing, wait until you tackle dental coverage for your children.
The first question is: Under Obamacare, are you required to buy dental insurance for your children if they’re younger than 19? The answer is yes and no, says Colin Reusch, senior policy analyst at the Children’s Dental Health Project in Washington, D.C.
“It depends on where you live and how you’re buying your family’s health coverage,” he says.
Every state has a marketplace where families can buy health insurance. If you qualify for tax credits or subsidies to help pay the premiums, you must buy insurance on your state’s marketplace to get them. Every state’s marketplace is required to offer at least one pediatric dental plan. The dental coverage can be part of a health plan that covers medical care, or it can be a separate, stand-alone plan for dental only.
In some states you have both options, and in some states your only option is a separate dental plan, says Bill Chase, vice president of marketing for DentalPlans in Plantation, Florida, which offers dental savings plans.
No penalty for not having dental coverage
Here’s where it gets tricky: If you buy a health plan on the marketplace that does not include pediatric dental coverage, you must buy a separate plan to have it. However, if you don’t, you will not be penalized, Chase says. In essence, that means while the law requires state marketplaces to offer dental coverage for children, families don’t have to buy it. (Exceptions: Colorado, Kentucky, Nevada and Washington do require that you buy children’s dental coverage when buying through their marketplaces.)Also, if you buy a health plan outside your state’s marketplace, which is always an option, the health insurance company is required to ask whether you have dental coverage that meets the requirements of the law.
“If you aren’t able to provide reasonable assurance to the health plan that you have pediatric dental coverage, then the health plan will require you to purchase it (either as part of the health plan itself or through a separate dental plan) in order to enroll in their product,” says Reusch.
If you buy a health plan on the marketplace that includes pediatric dental coverage, you could be paying for something you don’t need or won’t use. What if you don’t have children? Or what if your children are too young to see a dentist?
“That’s the premise of insurance,” Reusch says. “We are required to buy benefits we won’t use. That’s how we spread the risk.”
Compare cost of premiums, deductibles, coverage
If you intend to buy dental coverage through the marketplace, don’t be surprised by lack of choice.
Reusch doesn’t see much variation among dental plans available on the marketplaces. “They’re all pretty comparable in terms of services covered,” he says.
Depending on your state’s offerings, the biggest decision you may need to make is whether you want a health plan that includes dental coverage or you want a stand-alone dental plan.
Here’s how to decide which is best: Look at your family’s likely medical needs and the plans’ out-of-pocket maximum. If your family uses a lot of medical care, you’ll likely want one health plan that includes both medical and dental. That way, all your spending counts toward the plan’s out-of-pocket maximum. Once you reach your out-of-pocket maximum, your plan starts paying the full cost of your care.
However, if your kids are otherwise healthy but need expensive dental care, you could make out better with a separate dental plan. This way, you reach the dental plan’s out-of-pocket maximum and have your plan kick in at a higher rate sooner.
How to read the medical and dental insurance fine print
Do some math. If you buy a health plan that covers dental care, you pay one premium for both types of coverage. If you buy a health insurance plan and a separate dental plan, you pay two separate premiums. Look at the deductible, which is the amount you must spend out of your own pocket before the plans provide any coverage, and estimate how much you could spend with the different options.
Also, Reusch says, check the fine print. Some health plans will pay for certain types of dental care before you’ve paid the full amount of your deductible. If you’re not sure or have questions, check with the representatives of the plans you are considering.
Depending on your household income, you may qualify for financial assistance to help you pay your monthly health insurance premiums. If you qualify and buy a health plan through the marketplace that includes dental coverage, you can use the subsidy to help pay for some or all of it. However, if you buy a separate dental plan, you can’t get financial assistance to offset its cost.
Plans may offer coverage for routine dental care such as cleanings, X-rays and fluoride treatments at little or no cost. But don’t expect the dental coverage you buy on the marketplace to cover orthodontia.
The Affordable Care Act “differs from traditional dental coverage in that it only covers orthodontia that is considered medically necessary,” Reusch says. Most orthodontia is usually to straighten teeth, which is considered cosmetic and not medically necessary.
Remember, too, under the Affordable Care Act there can be no limit to what the dental plan will pay for children’s coverage.
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