Dental Insurance and the Affordable Care Act Explained

The Affordable Care Act (ACA) has made significant changes to the way healthcare works in the US, but what does it mean for your dental insurance? The ACA doesn't directly cover dental care, but it does provide some options for those who need it.

Many people are surprised to learn that dental insurance is not included in the ACA's essential health benefits package. This means that dental care is not considered a mandatory benefit for health insurance plans.

The ACA does, however, offer some alternatives for those who need dental care. For example, some states have expanded Medicaid to include dental coverage for low-income adults.

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Dental insurance is available through the Affordable Care Act, also known as Obamacare. This means you can explore options and compare prices through the Health Insurance Marketplace.

If you sign up for a stand-alone dental plan, you'll be billed separately for the coverage, so keep that in mind. You can cancel your plan anytime if you enrolled for separate coverage.

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Two categories of Health Insurance Marketplace dental plans exist: high and low. Review plan costs, coverage, and more to find the best dental insurance for you.

You can't opt out of dental coverage if your Marketplace health insurance plan comes with it, but you can make changes to your plan to adjust the coverage.

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Medical necessity is a crucial factor in determining what dental services are covered by insurance.

In the case of pediatric oral care services, the Essential Health Benefits (EHB) requirement may limit certain covered services to those that are medically necessary.

For children up to age 19, orthodontia is one such service that must meet this criterion.

Only orthodontic treatment that is assessed as being reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care, may be considered an EHB.

Medically necessary orthodontia was not specifically defined by federal law or regulation, which may lead to variation by state.

This means that insurance coverage for orthodontia may differ depending on where you live.

Dental insurance is available through the Affordable Care Act, also known as Obamacare. This means you can get dental coverage as part of your overall health insurance plan.

There are two main categories of Health Insurance Marketplace dental plans: high and low. These categories can help you compare plans and find the best fit for your needs.

Dental coverage is an essential health benefit for children ages 18 and younger. This means that dental care is a fundamental part of their overall health and well-being.

To find the best dental insurance for you, be sure to review plan costs, coverage, and more. This will help you make an informed decision and choose a plan that meets your needs and budget.

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The Affordable Care Act (ACA) has had a significant impact on dental insurance in the US. The law was signed into effect in 2010 by then-President Barack Obama, aiming to improve health outcomes and lower costs for Americans.

One of the key provisions of the ACA is the inclusion of pediatric dental coverage on the exchange. States are required to offer this coverage, either as a pediatric dental benefit embedded within a health plan or as a stand-alone dental benefit.

You can purchase dental insurance through the Health Insurance Marketplace, but you can't buy a stand-alone dental plan unless you're also buying a health plan. If you do purchase a stand-alone dental plan, you'll be billed separately for the coverage.

The ACA also introduced a new structure for children's dental benefits. Pediatric oral health services are now considered part of Essential Health Benefits (EHB), which means they can't have annual maximum limits and must limit consumer out-of-pocket expenses to $350 a year for one child or $700 a year for a family.

Here's a breakdown of the two tiers of Obamacare dental care:

If you need help with dental coverage offered through the Health Insurance Marketplace, you can call the U.S Department of Health and Human Services at 1-800-318-2596 (TTY: 1-855-889-4325). These lines are open 24 hours a day, seven days a week, except holidays.

To buy a dental plan through the Marketplace, you must enroll in a health plan at the same time. You can't purchase a stand-alone dental insurance plan without buying health insurance.

If you sign up for a stand-alone dental plan, you'll be billed separately for the coverage. You can cancel your plan anytime if you enrolled for separate coverage, but if your Marketplace health insurance plan comes with dental coverage, you cannot opt out of it.

You can check options and compare prices for dental insurance through the Health Insurance Marketplace. If you need help with dental coverage, you can call the U.S Department of Health and Human Services at 1-800-318-2596 (TTY: 1-855-889-4325) for assistance.

Here are some important dates to keep in mind:

Transparency in information is crucial when navigating the marketplace. You can contact Delta Dental's customer service for individual plans at 800-971-4108, or for group plans at 800-524-0149.

TTY users can reach out to these numbers by calling 711.

Balance billing is not allowed within the Delta Dental network.

Our network dentists agree to accept Delta Dental's contracted fees as full payment.

This means they won't bill you for any charges beyond what Delta Dental has already paid.

Balance billing occurs when a dentist bills you for charges other than copayments, coinsurance, or any amounts remaining on your deductible, following Delta Dental's payment on a claim.

This can be confusing, but rest assured that Delta Dental has your back and will handle the billing for you.

If you receive a bill from a dentist outside of the Delta Dental network, you may be subject to balance billing.

Additional reading: Dentist Who Accept Delta Dental Insurance

Retroactive denials can be a nightmare, especially if you're not prepared. A retroactive denial is the reversal of a previously paid claim, leaving you responsible for payment.

This can happen if you've terminated your policy before services are rendered. For instance, if you've paid your premium late, or if the information you provided is incorrect.

To avoid retroactive denials, make sure to pay your premium on time, either online or by phone. This helps ensure you're covered when services are performed.

Ensure you've provided us with the correct information, so we can process your claims smoothly. This includes keeping your policy details up to date.

Here are some ways to prevent retroactive denials:

You can buy dental insurance from the Marketplace, but you'll need to enroll in a health plan first. If not, you can choose to add a stand-alone dental insurance plan and pay a separate premium for it.

To get started, you'll need to enroll in a health plan through the Marketplace, which will give you access to a stand-alone dental plan.

There are two types of dental plans available: high-option and low-option. High-option plans have higher premiums but lower co-payments and deductibles, while low-option plans have lower premiums but higher co-payments and deductibles.

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You can compare dental plans in the Marketplace to find the one that best fits your needs. Look for details about each plan's costs, co-payments, deductibles, and services covered.

Some dental plans may have an annual maximum limit, which means that you'll be responsible for any costs above that amount. However, some plans may not have an annual maximum limit.

If you're buying health insurance for your child or teen through the Marketplace, insurers must offer dental benefits for your child, either as part of a health plan or through a separate dental plan.

You can cancel your dental insurance plan at any time if you enrolled for separate coverage, but if your Marketplace health insurance plan comes with dental coverage, you cannot opt out of it.

To make the most of your dental coverage, be sure to understand what's covered and what's not. Most plans cover 100% of preventive care and apply copayments to other levels of care.

Here's a breakdown of what's typically covered in a dental plan:

Keep in mind that some plans may have different coverage levels or annual maximum limits. Be sure to review your plan details carefully to understand what's covered and what's not.

Approximately 261 million Americans, or nearly 80% of the population, had dental benefits at the end of 2020. This significant increase is largely due to Medicaid expansion as authorized by the Affordable Care Act (ACA) and improved data reported by the Centers for Medicare and Medicaid Services (CMS).

About 63% of dental PPOs have a maximum annual benefit of $1,500 or more, while deductibles for these products are usually between $50 and $100. Some carriers now offer policies that roll some portion of unused annual maximum.

Most plans cover 100% of preventive care, and apply copayments to other levels of care. Preventive care usually includes periodic oral evaluations, X-rays, and sealants. Basic procedures such as office visits, extractions, fillings, root canals, and periodontal treatment for gum disease are typically covered at a lower percentage amount, for instance, 80% when in-network.

Here's a breakdown of the seven basic areas of dental care that policies cover:

Dental benefits are essential for children because cavities (dental caries) are the most common childhood disease, and for adults because over 70% of adults aged 65 and older have some level of gum disease.

Out-of-network liability can be a concern for those who need dental care outside of their network. You'll be responsible for paying a percentage of the submitted amount, as well as the difference between the submitted amount and the allowed amount.

If an in-network dentist isn't available within a reasonable time or distance, you may be able to see an out-of-network dentist and get reimbursed at the same benefit level as if you saw an in-network dentist. However, it's essential to call customer service before visiting the out-of-network dentist to discuss your options.

In emergency situations, covered services from an out-of-network dentist will be treated as if they were provided by an in-network dentist, which can be a relief during a stressful time.

For your interest: How Does Out of Network Dental Insurance Work

There are four fundamental types of dental benefits products with significant market shares today.

Today, 86% of all commercial dental policies are dental Preferred Provider Organizations (DPPOs).

Dental HMOs provide comprehensive dental benefits to a defined population of enrollees in exchange for a fixed monthly premium.

Enrollees must use network dentists to obtain coverage except where a point of service provision allows them to opt-out of the network but at reduced coverage.

Dental PPOs have contracts with dentists to obtain a discount on overall fees.

Enrollees receive value from these discounts when using contracted dentists but may go outside the network of discounted dentists with a reduction in coverage.

Dental Indemnity Plans transfer the risk for claims incurred from the employer to a third-party insurer for a specified premium.

Dentists are reimbursed on a fee-for-service basis, and there are no discounted provider contract arrangements.

Discount Dental or Dental Savings Plans are non-insured programs where a panel of dentists agrees to perform services at a specified discounted price or discount off their usual charge.

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Dental plans typically cover a range of services, but the specifics can vary depending on the type of plan and provider. Most plans cover 100% of preventive care, which usually includes periodic oral evaluations, X-rays, and sealants.

Preventive care is often the only service that's fully covered by most plans, while other services may have copayments or deductibles. For example, basic procedures like office visits, extractions, and fillings may be covered at a lower percentage, such as 80% when in-network.

The seven basic areas of dental care that policies cover include preventive care, restorative care, endodontics, oral surgery, orthodontics, periodontics, and prosthodontics. Here's a breakdown of these services:

Most plans cover these services at different levels, with preventive care typically being the most comprehensive. Basic procedures like office visits and extractions may have lower copayments or deductibles, while major procedures like crowns and dentures may have higher copayments or deductibles.

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