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Health Care Reform...How Does it Affect My Dental Coverage?

The Affordable Care Act (ACA) continues to change the health and dental insurance landscape. To help you keep up with what has been going on, here are answers to some questions you may have.

Health Care Reform

Does Health Care Reform Apply to Me?

One key provision of the ACA is the Individual Mandate, which says that everyone must have insurance or pay a penalty. If you already have insurance, you probably don’t need to do anything. This can include coverage where you work, insurance you buy yourself, Medicare/Medicaid, CHIP, VA health coverage, retiree coverage and other sources.

Even if you don’t need to change your insurance, there are some new rules that may affect you. For example:

  • Children can now stay on their parents’ policy until age 26
  • New individual and small group plans must include a menu of Essential Health Benefits
  • Most preventive care will be covered at no cost to you
  • People can’t get turned down because of a preexisting condition or have their policy cancelled if they get sick

To make getting insurance easier, the federal government and individual states have set up exchanges called Health Insurance Marketplaces, where individuals and small groups can find health coverage and possibly qualify for financial help to buy it.

How is Dental Insurance Affected?

The ACA established a list of 10 Essential Health Benefits that individual and small group health insurance plans must now include. Pediatric dental coverage, for children up to age 19, is one of those. There is no requirement for adult coverage. But remember, good dental health is important to your overall health, so consider a plan for yourself, too. You can buy dental insurance for adults or entire families directly from a dental insurance company.

If you’re looking at dental insurance for your children, yourself, or the whole family – whether you get it from an employer or another source, there are two main ways that pediatric coverage is handled. Some small group or individual health insurance plans will include dental coverage as part of the policy. This is known as embedded dental. The other option is what’s called standalone dental. In other words, the policy covers just dental care and is separate from medical coverage. This is how most people traditionally have received their dental coverage.

What Do I Need to Consider in Choosing a Plan That Fits My Needs?

If the dental coverage is embedded in a medical plan, it will mostly likely cover only children up to age 19, since that’s all that’s required. If you also want coverage for adults you’ll need to buy a separate plan. Standalone dental plans can cover the whole family, both children and adults.

  • Embedded dental plans may use different dental networks, so your dentist might not be in the plan’s network. You'll want to check, because if your regular dentist is "out of network" it could make services more expensive.
  • Embedded dental coverage is sometimes combined with the deductible for medical. If you’re not likely to reach the deductible, you may end up paying for basic dental services. A standalone dental policy has its own, usually lower, deductible, and basic preventive services like exams and cleanings are often completely covered from the start.
  • Consider the maximum out-of-pocket. With an embedded plan, dental may be combined with medical, which for 2016 is as much as $6,850 for one person and $13,700 for a family. Certified standalone dental plans have a maximum of $350 for one child or $700 for two or more. 
  • Traditionally, dental policies have included orthodontic coverage for children. However, the ACA requires only medically-necessary orthodontics be covered in certified plans. The criteria are pretty strict, and cosmetic orthodontia, such as braces, will not qualify.

In general, you will want to read the fine print and find out exactly what the policy covers before you decide. The best plan for you or your family will depend upon how much you expect to use coverage and a comparison of premiums and amounts paid.

Five Important Terms to Know

Premium – this is the amount you pay each month for your insurance plan. Generally, policies with higher premiums pay a larger portion of claims. You pay the premium regardless of how much you actually use the coverage, and it doesn’t count towards your out-of-pocket maximum.

Deductible – this is the amount you pay before the insurance company starts paying for services. For example, if your dentist bills you $200 and you have a $50 deductible, you would pay $50 before the insurance company would cover any part of the rest. Some preventive services may be exempt from deductibles.

Coinsurance and Copay – the amount of the bill that you are required to pay. Coinsurance is usually given as a percentage, say, 20%, and the number can represent either the portion covered or the portion paid. Copay is usually a dollar figure you pay; example, $30 copay per office visit.

Maximum Out-of-Pocket – the most a customer will have to pay for services over the course of a year before the insurance policy covers the rest. This amount can vary widely, and on some dental plans there is no maximum payable for adults.

Network – most doctors and dentists are members of one or more networks. Participants in a network agree to accept lower negotiated fees for a variety of services. Most customers will save money by using a network provider. A non-network dentist may accept your insurance and you will still pay the same percentage of coinsurance, but it’s a percentage of what could be a higher price.


For more information about the Affordable Care Act, available plans, possible cost subsidies and more, visit:



Kaiser Family Foundation has answers to a long list of Health Care Reform questions.


Health Care Reform has increased the number of Americans who have health coverage, including dental coverage. Good oral health is important to good overall health, and United Concordia supports dental wellness in everything we do.