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Delta Dental Insurance - Health Care Exchange (Marketplace) for Dentists

Health Care Exchange (Marketplace) for dentists

Committed to keeping you informed about the Affordable Care Act¹ (ACA).

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Pediatric dental coverage under the ACA

An important step to helping your patients to choose a Delta Dental plan that meet their family's needs is understanding pediatric dental coverage arrangements. There are three types:

  • Embedded
  • Bundled
  • Stand-alone 

Understanding these coverage arrangements and how they might affect reimbursement for services will help you guide your patients to find the right plan. Coverage for each type might differ by state, depending on the rules and policies set by regulators and exchanges.

Please note: Children with dental coverage through a family member's employer are not required to have dental coverage through the ACA.

Embedded pediatric dental benefits are included (embedded) in the medical policy. The dental coverage provisions may be different from what you are used to seeing. For example:

A single high deductible may apply to both the dental and medical benefits together. For example, a deductible of $2,000 per individual ($4,000 per family) or greater may need to be met before a patient is eligible for coverage. Some medical plan carriers might waive this deductible for all dental services, only for diagnostic and preventive services or may establish a separate smaller deductible for dental services.

A contractual out-of-pocket maximum² could be up to $6,600 per individual ($6,250 in California) and $13,200 for families. As with the deductible, this is a combined maximum that includes both medical and dental out-of-pocket expenses. Once the out-of-pocket maximum is reached, the combined dental/medical policy provides 100% coverage for all additional covered services.

Unlike bundled and stand-alone dental plans, embedded dental plans are under no federal requirements to guarantee a pre-set actuarial value of 70% or 85% to members under age 19.

Bundled dental and medical coverages are sold together, but as two separate policies. The dental coverage could be administered by the medical insurance carrier or by a separate, stand-alone dental carrier. Delta Dental has partnered with a number of medical carriers to offer bundled coverage.

Federal rules governing the cost sharing³ of bundled dental coverage make it a good option for usable dental benefits:

Bundled dental coverage qualifies for separate deductibles and out-of-pocket maximums that are not affected by the medical coverage. The deductibles will generally be low, from around $35 to $130, after which a typical dental benefit plan structure applies.

There are no annual benefit maximums for children, but a separate out-of-pocket maximum that can never exceed $350 will determine when the policy begins to pay 100% of covered in-network services.

Stand-alone dental coverage includes most of the same advantages as bundled coverage described above, offering separate, limited deductibles and out-of-pocket maximums that never exceed $375. Stand-alone coverage can be coupled with a medical policy that does or does not include pediatric dental. Furthermore, 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 member'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 $375, and embedded plans that combined with medical can be as high as $6,600 per individual, up to $13,200 for a family.