Q. If I buy a dental insurance plan, what kind of fees can I expect?
A. For adults, it depends entirely on how much dental care you need over the course of the year. But for children, the Affordable Care Act has imposed regulations that limit out-of-pocket costs for dental care.
For families who buy stand-alone pediatric dental coverage (a separate scheme from children’s health insurance), the maximum disbursement for pediatric dental expenses cannot exceed $ 350 for one child or $ 700 for two or more children on the same policy. These amounts started to adjust for inflation with plan years starting after 2017. But according to the formula used by HHS, there hasn’t been a change in the amount yet, and that’s still $ 350 and $ 700 from 2021 (This is because the amount of the inflation adjustment is always less than $ 25, and the rules require that the amount be rounded to the nearest multiple of $ 25.)
[note that as of 2019, HHS eliminated the requirement that stand-alone pediatric dental plans fall into one of two narrow actuarial value ranges; this rule change allows insurers more flexibility in terms of how they design pediatric dental plans, but the cap on out-of-pocket costs remains in place.]
But when pediatric dental coverage is integrated into a medical plan, the maximum amount payable can reach $ 8,550 for a single person and $ 17,200 for a family in 2021, including combined medical and dental services.
In both cases, these limits result from the ACA; prior to 2014, there were no upper limits on the level at which a health or dental plan could set its maximum limits.
Carriers may also offer bundled coverage, with pediatric medical and dental insurance plans sold and billed together, but administered as separate policies with their own limits. In this scenario, the limit of $ 350 per child / $ 700 per family applies to pediatric dental care.
Uncapped reimbursable fees on adult packages
However, direct exposure is not capped on adult dental plans, unless the insured has one of the very few health insurance plans that include adult dental coverage. And, as noted above, the only refundable limits that apply in this case are the refundable maximums for overall coverage, including medical expenses.
Independent adult dental plans are not required to have limits on direct exposure. These plans were not required to make any changes as a result of the ACA.
Instead of maximum payments, adult dental coverage typically includes advantage maximum; they cap the amount the insurance company will pay, rather than cap the amount the insured pays (note that dollar benefit caps are no longer allowed to apply to pediatric dental coverage, as it is is one of the essential health benefits).
In most cases, stand-alone adult dental coverage has annual benefit limits ranging from $ 1,000 to $ 2,000. For the most part, these benefit ceilings have not changed since the 1970s and 1980s, when dental plans first appeared – despite the fact that dental care is now much more expensive.
Generally, dental insurance plans offer significant benefits for diagnostic and preventive care, including exams, x-rays, and cleanings, often completely covering them. And for relatively minor restorative jobs, like fillings and extractions, a dental insurance policy usually covers a large portion of the costs.
But for procedures like root canals, crowns, and implants, it’s easy to exceed the maximum benefit, especially if you need treatment for more than one tooth. In addition, many dental insurance plans provide for waiting periods before covering dental care beyond preventive and basic care.
Louise Norris is an individual health insurance broker who has written on Medicare and health reform since 2006. She has written dozens of opinion pieces and educational articles on the Affordable Care Act for healthinsurance .org. His updates on the state health exchange are regularly cited by media outlets covering health reform and other health insurance experts.