Wednesday, July 29, 2015

ACA and kids' dental benefits: What do I need to know?

Now considered an "essential benefit," children will either have pediatric dental benefits included in a medical plan package or there will be an option to purchase these benefits separately. Here's how to find a plan.

ACA and kids' dental benefits: What do I need to know?


Today's guest blogger is Paul Reggiardo, D.D.S., a pediatric dentist in Huntington Beach, California. He is a national spokesperson of the American Academy of Pediatric Dentistry and past president of the AAPD, as well as an advocate for the dental health and overall well-being of children.

Amidst open enrollment season, parents need to be aware of a significant change to health insurance under the Affordable Care Act. Pediatric dental benefits are now considered to be one of 10 “essential benefits” plans must provide. This means children will either have pediatric dental benefits included in a medical plan package or there will be an option to purchase these benefits separately.

On a national scale, this new provision could mean 8.7 million children currently lacking dental benefits could gain coverage through the ACA by 2018. This new accessibility to dental care has the opportunity to help curb the staggering statistics provided by The Centers for Disease Control and Prevention, which shows that tooth decay is the number one chronic infectious disease among children in the U.S., affecting 42 percent of children aged 2 to 11 years old.

But what exactly does it mean for you and your family?

When exploring health plan options available to you, below are some important questions that you should understand before enrolling in a plan.

Are there different levels of insurance available?

While all health insurance providers are required to provide for pediatric dental benefits, parents will want to be aware of a couple things. First, be sure to check a plan’s provider network since the number and locations of participating pediatric dentists will vary from plan to plan. Second, be cognizant of premium costs and benefit levels. For instance, if you select a lower level of insurance that may appear less expensive because of lower premiums, it may mean higher deductibles and out-of-pocket spending later at the dentist’s office.

Are pediatric dental benefits always included in the insurance exchanges?

While pediatric dental benefits for your child are always offered in the state insurance exchanges, they are not always included and may be marketed as a separate stand-alone dental plan. Be sure that dental coverage is part of your child’s health insurance package.

What are the differences between pediatric dental benefits embedded in my health insurance plan, a bundled plan that includes pediatric dental benefits and a stand-alone pediatric dental benefit plan?

With a dental plan embedded in a medical plan, the medical carrier assumes all risks and liabilities of covering the dental benefits and there is one premium. This coverage may have a combined medical and dental deductible. With these plans, it is important to understand that dental expenses may not be covered until the high common deductible is satisfied.

A bundled dental plan is sold with medical coverage, but there are two separate policies. The dental coverage could be administered by the medical insurance carrier or by a separate dental carrier. With bundled dental coverage, there is a common premium, but separate deductibles and out-of-pocket maximums are not affected by the medical coverage.

A stand-alone dental plan is one that is sold separately from medical coverage, and therefore always has separate premiums and deductibles that are specifically for the dental benefits. Stand-alone dental plans allow buyers to select independently of their children’s medical coverage the type of dental plan and the provider network which most closely matches their desires.  

What questions should I ask about pediatric dental benefits when comparing health insurance plans?

Health insurance options vary and not all plans are created equal. Parents should be sure to ask several key questions when selecting the health insurance plan and dental benefits that are right for their family.

  • How much will my deductibles, out-of-pocket maximums and co-pays cost?
  • Does the plan’s network include pediatric dentists near my home or children’s school?
  • Based on my benefit level, how much will my premium costs be?

The key to understanding a dental benefit plan’s design is recognizing that most oral disease, especially in children, is largely preventable. Unlike the traditional utilization of health insurance as a benefit to be used infrequently as a way of paying for the very high cost of unpredictable illness, accident or disease, a dental benefit plan is intended to be accessed regularly for preventive services to affect oral health positively.

The American Academy of Pediatric Dentistry recommends parents establish a “dental home” for their child by the age of one to ensure an ongoing relationship with a pediatric dentist for successful preventative care and treatment as part of optimal oral health and overall well-being. For more information and resources, visit

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The Healthy Kids blog is your window into the latest news, research and advice around children's health. Learn more about our growing list of contributors here.

If you have questions about your child's health, ask them here.

Anna Nguyen Healthy Kids blog Editor
Sarah Levin Allen, Ph.D., CBIS Assistant Professor of Psychology at Philadelphia College of Osteopathic Medicine
Stephen Aronoff, M.D., M.B.A. Chair of the Department of Pediatrics at Temple University Hospital
Peter Bidey, D.O. Medical Director of Family Medicine at Philadelphia College of Osteopathic Medicine
Christopher C. Chang, MD, PhD, MBA, FAAAAI, FACAAI Associate Professor of Medicine in division of Rheumatology, Allergy and Clinical Immunology at UC Davis
Katherine K. Dahlsgaard, Ph.D. Lead Psychologist of The Anxiety Behaviors Clinic at Children's Hospital of Philadelphia
Gary A. Emmett, M.D., F.A.A.P Director of Hospital Pediatrics at TJU Hospital & Pediatrics Professor at Thomas Jefferson Univ.
Magee DeFelice, M.D. Division Chief of Allergy and Immunology at Nemours/Alfred I. duPont Hospital for Children
Hazel Guinto-Ocampo, M.D. Chief of Pediatric Emergency Services at Nemours duPont Pediatrics/Bryn Mawr Hospital
Rima Himelstein, M.D. Adolescent Medicine Specialist at Crozer-Keystone Health System
Jessica Kendorski, PhD, NCSP, BCBA-D Associate Professor in School Psychology/Applied Behavior Analysis at Philadelphia College of Osteopathic Medicine
Anita Kulick President & CEO, Educating Communities for Parenting
Janet Rosenzweig, MS, PhD, MPA VP for Programs & Research for Prevent Child Abuse America
Beth Wallace Smith, R.D. Registered Dietitian at Children's Hospital of Philadelphia
Emiliano Tatar, M.D. Pediatrician at Einstein Healthcare Network Roxborough Plaza
Jeanette Trella, Pharm.D Managing Director at The Poison Control Center at CHOP
W. Douglas Tynan, Ph.D., ABPP Director of Integrated Health Care for American Psychological Association
Flaura Koplin Winston, M.D., Ph.D. Scientific Director of the Children’s Hospital of Philadelphia’s Center for Injury Research and Prevention
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