Children’s Dental Benefits Types under ACA

The ACA covers children’s dental needs up to the age of 19 and there are three types of pediatric dental coverage arrangements that affect reimbursement levels.

Embedded pediatric dental benefits are included (embedded) in the medical policy.  Check the dental coverage provisions because they may be different than you are accustomed to.   For instance there may be a single higher deductibles that include medical and dental to meet but there also may be higher contractual out of pocket maximum that applies to both dental and medical. Once the deductible is paid the coverage would be 100% of in network covered expense.   Dental services for some plans may waive the deductible or there may be a smaller deductible for dental services alone.

Bundled dental and medical coverages are sold together but as two separate policies.  The dental coverage may be administered by the medical insurance carrier or by a separate stand-alone dental carrier.  Bundled dental coverage qualifies for separate deductibles and out of pocket maximums that are not affected by the medical coverage.  The deductibles are generally low like a typical dental benefit plan structure.   Out of pocket maximum for children is $350.00 and then pays 100% of covered in network services.

Stand –alone dental coverage includes most of the same advantages as bundled coverage and can be coupled with a medical policy that does not include dental coverage.  Out of pocket maximums of $350.00 Patient has cost sharing of coinsurance and deductibles.  ACA-compliant stand-alone (and bundled) dental coverage must offer a guaranteed “actuarial value” of either 70% or 85%. Actuarial value refers to the portion of covered services paid by the dental carrier, and with patient cost sharing (copayments and deductibles).

  1. ACA-compliant health plans include the required 10 essential health benefits (EHBs), one of which is pediatric oral care to age 19.
  2. An out-of-pocket maximum is the amount a patient pays for services (a total of annual deductibles and copayment/coinsurance amounts) before the plan begins to pay 100% for covered in-network services. A contractual out-of-pocket maximum with an embedded plan could be up to $6,650 per individual and $13,200 for families. An out-of-pocket maximum is different from an annual maximum because there is no time limit on how long it takes to reach the out-of-pocket maximum.
  3. Cost sharing refers to the enrollee’s annual out-of-pocket costs for health care. Federal rules set the maximum levels allowed, with stand-alone and bundled plans set at no higher than $350, and embedded plans that combined with medical can be as high as $6,600 per individual, up to $13,200 for a family.

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