Starting in 2014, the Affordable Care Act requires that individual and small-group health plans sold both on the state-based health insurance exchanges and outside them on the private market cover pediatric dental services. However, plans that have grandfathered status under the law are not required to offer this coverage.
The requirement also doesn’t apply to health plans offered by large companies, although they are much more likely to offer dental benefits than small firms. Eighty-nine percent of firms with 200 or more workers offered dental benefits in 2012, compared with 53 percent of smaller firms, according to the Kaiser Family Foundation’s annual survey of employer health plans. (Kaiser Health News is an independent project of KFF.)
The changes in the health law apply specifically to children who get coverage through private plans. Dental services are already part of the benefit package for children covered by Medicaid, the state-federal health program for low-income people. But many eligible kids aren’t enrolled, and even if they are, their parents often run into hurdles finding dentists who speak their language and are willing to accept Medicaid payments.
The health law encourages states to expand Medicaid coverage for adults, which advocates say will have the added benefit of probably bringing more children into the system.
Despite the challenges, advocates say they anticipate that many low-income children will gain dental coverage.
Dental health advocates say they’re pleased that pediatric dental services (along with other pediatric care) were included among the 10 “essential health benefits” that new health plans must cover in the exchanges and the small-group and individual markets under the law.
When it comes to health care, “oftentimes the mouth is separated from the body,” says David Jordan, dental access project director at Community Catalyst, a consumer health-care advocacy organization in Boston.
Experts say that poor oral health care can have a significant impact on overall health, causing pain and weight loss, missed school days and reduced self-esteem.
Still, some advocates are concerned that the new benefits may not be sufficiently comprehensive or affordable.
Specific coverage requirements will be determined by each state within guidelines set by the federal Department of Health and Human Services.
HHS guidance to date suggests that medically necessary orthodontia — to correct a problem with chewing, for example — may be required in addition to preventive and restorative care. Dental coverage may be embedded in a medical plan that’s sold on the exchanges or offered on a stand-alone basis.
In private dental plans, preventive care such as teeth cleanings, topical fluoride and sealants are typically covered at 100 percent, but such other services as fillings, crowns and root canals require patients to pay up to half the cost, and coverage maxes out at about $1,500 a year.