Quote and enroll in an ACA health plan during annual open enrollment or a special enrollment period if you qualify.
How Does Dental Insurance Work?
Dental plans typically cover four categories of services: preventive, diagnostic, basic and major care.
The list below includes examples and is not a complete list of coverages, exclusions and limitations.
Individual plans vary, so you’ll want to read the plan details closely to validate the coverage and benefits you’ve selected and limitations and exclusions that apply.
Cleanings + checkups
Crowns, bridges + root canals
Anything after the plan’s annual maximum benefit amount has been reached
Elective cosmetic procedures (e.g., tooth-whitening)
Orthodontics (e.g., braces)
Prosthodontics (dental prostheses)
Oral care related to a medical condition (e.g., TMJ)
Prescription drugs + analgesia pre-medication
Pediatric services, including oral and vision care, are part of the 10 essential health benefits for children 18 years of age and under. Adults, however, must obtain dental insurance if they want coverage and don’t have it through an employer.
This type of supplemental insurance is designed to cover dental care expenses. Dental insurance can be offered as part of a medical insurance policy, or as a stand-alone plan.
Dental insurance can help you pay for costs related to maintaining good oral health, which studies indicate can positively impact your overall health.
No, dental plans are not qualified health plans under the terms of the ACA.
However, the Affordable Care Act (ACA) lists dental coverage as an essential health benefit for children under age 18. This means if you purchase an ACA-compliant health insurance plan, dental coverage must be available for your child as either part of that plan or as a separate dental plan.
The ACA does not consider dental coverage to be an essential health benefit for adults 18 and over, nor require insurers to offer adult dental coverage.
Anyone who is interested in having good oral health, and wants to receive covered dental procedures at no-cost or at a reduced cost should consider purchasing a dental insurance policy.
Dental insurance is guaranteed issue, which means that all applicants between the ages of 18 – 99 are accepted regardless of health history.
Your dental insurance premiums are calculated based on factors such as:
Typically, dental insurance has low deductibles and can be an affordable way to help pay for costs related to your oral health. Premiums for individual plans cost around $25 per month (or $300 annually), however, premiums can range from $150 to $600 annually.
Dental insurance typically covers four types of care with a 100/80/50 plan payment structure:
|Preventive – cleanings and check-ups; fluoride treatments for children||100%|
|Diagnostic* – bitewing x-rays (every 6 months) full-mouth x-rays (every 3 years)||100%*|
|Basic – fillings, extractions||80%|
|Major – root canals, crowns and bridges||50%|
* Under some plans, diagnostic services are paid at 80% and subject to a waiting period
Services not typically covered by dental plans include, but are not limited to, cosmetic procedures, orthodontics, implants, dentures, oral care related to a medical condition, prescription medication and analgesia pre-medication. Your plan also will not cover expenses in excess of the plan’s annual maximum benefit.
Remember, you must read any policy you’re considering carefully to understand what is covered and what is excluded. And often, waiting periods apply for procedures that aren’t considered preventive care. The above lists are only examples.
Dental insurance provides a benefit payment for a designated set of covered procedures related to teeth and gums, as outlined in your plan’s Schedule of Benefits. Reviewing your Schedule of Benefits enables you to plan how and when to receive care by showing:
Depending on the plan you select, your policy may include:
Note that routine preventive services, such as exams and cleanings, may not be subject to your plan’s deductible. Learn more about how dental insurance works.
Generally, if you need major services, you can ask your dentist to submit a proposed treatment plan to your insurance company. That can help you determine what your out-of-pocket costs for services will be. If you have additional questions, be sure to contact your insurance company for specific details about your plan benefits.
A PPO dental plan offers a network of dental providers. If you visit an in-network provider, your out-of-pocket costs are typically lower. That’s because dentists within the network have agreed to a negotiated dollar amount for each covered charge with your insurance company.
Out-of-network dentists may charge fees either higher or lower than the insurance plan allows; excess fees are usually your responsibility to pay.
Typically under an HMO dental plan, you must receive covered services from a contracted network provider for the plan to pay benefits.
Yes. There is an annual maximum benefit amount, which varies based on the plan you select. However, most dental plans’ annual limit does not exceed $2,000 per person, per calendar year.
There is also a lifetime maximum amount for prosthodontics and major dental care services; be sure to check your policy for specific details, which vary depending on the plan you choose.
If you select an indemnity plan, you typically may choose to receive your benefit payments directly, or you may ask your insurer to pay the benefit amount to your dental provider.
There is no official enrollment period for dental insurance away from the ACA Exchange, so you may apply for coverage at any time. Coverage typically begins the next day after online enrollment. You may only enroll in a dental plan from the ACA Exchange during the annual open enrollment period (or a special enrollment period, if you qualify) when you enroll in your medical policy.