The question of whether the Affordable Care Act (ACA) covers dental care does not have a simple answer. The ACA established Health Insurance Marketplaces and consumer protections, but dental benefits depend heavily on the individual’s age and the specific plan chosen. The law treats dental coverage differently for children and adults, creating a complex system of requirements and options for consumers. Understanding these distinctions is necessary to determine what dental benefits are available through Marketplace plans.
Pediatric Essential Health Benefit
The ACA mandates that pediatric dental care is one of the ten Essential Health Benefits (EHBs) that qualified health plans must cover in the individual and small group markets. Federal law lists “Pediatric services, including oral and vision care” as a required category of coverage. This means that for individuals up to age 19, dental coverage must be either included in the health plan or available to purchase separately. Insurers offering plans through the Marketplace must ensure that pediatric dental benefits are available to families with children.
Because children’s dental benefits are classified as an EHB, they meet specific consumer protections. Plans cannot impose annual or lifetime dollar limits on the amount they will pay for covered services, and costs must count toward the annual limit on out-of-pocket expenses. The coverage extends until the end of the month the enrollee turns 19, though some states may set a higher age limit. While the coverage must be offered, purchasing it is not mandatory for the consumer.
This pediatric coverage is delivered in one of two ways: either “embedded” within a major medical plan or offered as a separate “stand-alone dental plan” (SADP). If the coverage is embedded, the medical plan’s deductible and out-of-pocket maximum apply to the dental services. When purchased as an SADP, it operates with its own separate premium, deductible, and out-of-pocket maximum, which is capped for pediatric services. The scope of services covered is determined by the state’s EHB benchmark plan, which sets the standard for the specific treatments and limitations.
Adult Coverage Under the ACA
The coverage situation changes significantly for adults, as dental care for individuals aged 19 and older is not considered an Essential Health Benefit under the ACA. This means Marketplace medical plans are not required to include routine dental coverage for adults. The absence of this mandate results in a coverage gap, requiring adults to purchase a separate plan if they desire dental benefits.
While some medical plans voluntarily choose to embed adult dental benefits, most Marketplace health plans do not include embedded adult dental coverage. Since adult dental coverage is not an EHB, the consumer protections that apply to pediatric coverage do not automatically extend to adult plans. This allows adult dental plans to include annual dollar limits on benefits and may involve waiting periods for certain procedures.
The availability of publicly funded adult dental coverage is primarily managed through state Medicaid programs, which is separate from the ACA’s Marketplace structure. States are not federally required to provide comprehensive dental benefits for adult Medicaid beneficiaries, leading to wide variation in coverage across the country. Some states offer extensive benefits, while others limit coverage to emergency services or offer no dental benefits at all. Recent federal changes allow states to update their EHB benchmark plans to include routine adult dental services, but this implementation remains optional.
Purchasing Dental Plans Through the Marketplace
When shopping for coverage on the Health Insurance Marketplace, consumers encounter two primary options for dental benefits: integrated plans and stand-alone dental plans (SADPs). Integrated plans bundle medical and dental coverage, typically for children to meet the EHB requirement, under a single monthly premium. The cost-sharing and deductibles for the dental portion are subject to the medical plan’s structure.
Stand-alone dental plans are purchased separately and require a distinct premium payment. These plans are the most common way for adults to obtain coverage through the Marketplace, and they also serve as an option for meeting the pediatric EHB requirement. SADPs are generally offered in two tiers: a high-option plan with a higher premium but lower cost-sharing, and a low-option plan with a lower premium but higher deductibles and copayments.
A crucial point regarding affordability is the application of premium tax credits, or subsidies, to dental plans. Subsidies are typically only applied to the medical portion of coverage, or to the pediatric dental portion if it is part of an integrated plan. If a consumer purchases an SADP, the federal subsidy generally does not cover the cost of the dental premium, meaning the enrollee pays the full cost. Consumers should compare the plan’s details carefully, noting whether the coverage is comprehensive or if it is primarily focused on preventive services such as cleanings and exams.