Pediatric dental is one of 10 essential health benefits required by the Affordable Care Act. All ACA-compliant individual and small-group medical plans issued after Jan. 1, 2014 include this coverage, which includes preventive care, fillings and other dental services. Pediatric dental benefits are available for children up to age 19 who are covered on a parent’s medical plan.
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Following are five things to know about pediatric dental coverage. This is important for anyone who has children under age 19 and is considering coverage under individual or group medical and dental plans. It’s particularly important for participants at companies with 51 to 100 employees who were affected by the ACA small-group expansion and were shifted from large group plans (without pediatric dental) to small group plans (with pediatric dental). It's likely those participants didn't realize that they received pediatric dental coverage when they moved to small group, and they may no longer benefit from having their children covered on their dental plans.
- Pediatric dental benefits may be subject to the medical plan deductible. Preventive and diagnostic services are provided at no cost and are not subject to the deductible. Other services may be subject to the annual deductible. This varies by plan.
- It can be challenging to find a list of pediatric dental benefits included in a medical plan. Because pediatric dental benefits are included in medical coverage, the medical plan’s summary of benefits includes some information, which varies by insurance carrier. Be sure to read the fine print, as you may be directed to a separate document with more information. The medical plan’s evidence of coverage will also include detailed information.
- The medical carrier determines the dental provider network. Some medical carriers use their own network of dental providers, and some contract out to use a third party’s network. Also, the medical plan design determines the extent of the network and benefits. Under an HMO, benefits are only payable for services from in-network providers. Under a PPO, the highest benefits are payable for services from in-network providers, and there are reduced benefits for services from out-of-network providers.
- Participants should be providing their medical plan information at the time of dental care. If they have separate dental coverage, they should show both their medical insurance and dental insurance information, and their provider’s office should be inquiring with both carriers about any coordination of benefits. Note that some medical carriers issue a separate ID card for pediatric dental coverage.
- There may not be a benefit to purchasing separate dental insurance for children under age 19. If the medical plan has a coordination of benefits provision (found in the plan’s evidence of coverage document), it may treat the pediatric dental benefits as primary, and any other dental coverage as secondary. If there is no coordination of benefits provision, then there may not be any benefit to having a separate dental plan, unless a child needs orthodontic benefits that are considered cosmetic and not medically necessary.
Pediatric dental is one of many complicated issues created by the Affordable Care Act. Since many of the details are carrier and plan specific, it’s important to understand which questions to ask and where to find information so coverage can be used most effectively.
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