• Individuals can obtain dental coverage through the federal and state ACA Marketplaces as part of an ACA health plan or through a separate, stand-alone ACA dental plan.
• Because the ACA defines dental care as an EHB for children, both ACA health plans and stand-alone plans must make dental coverage “available,” but it does not have to be purchased.
• All plans in the Marketplace include vision coverage (eye exams and glasses) for children as an EHBs. Only some plans include vision coverage for adults.

Through the federal and state Affordable Care Act (ACA) Marketplaces, individuals can get dental coverage two ways: (1) as part of an ACA health plan or (2) through a separate, stand-alone ACA dental plan. If an ACA health plan includes dental, the premium covers both health and dental coverage. If a separate ACA dental plan is chosen, a separate, additional premium must be paid.

However, given the efforts to “repeal and replace” the ACA, the high cost of coverage in the federal and state healthcare Marketplace, and the lack of dental insurance coverage options for adults under the ACA, exploring traditional, non-ACA options for dental coverage makes sense.

ACA dental plan categories: High and low:

• The high coverage level has higher premiums but lower copayments and deductibles.
• The low coverage level has lower premiums but higher copayments and deductibles.

Adult & child dental insurance in the Marketplace

Under the ACA, dental insurance is treated differently for adults and children 18 and under:

• Dental coverage is an essential health benefit (EHB) for children: This means for ACA health coverage for someone 18 or younger, dental coverage must be “available” for the child either as part of a health plan or as a stand-alone plan. However, even though the coverage is “available,” it does not have to be purchased.
• Dental coverage isn’t an essential health benefit for adults: ACA plans don’t have to offer adult dental coverage.

Cancellation of ACA dental plans

Separate, stand-alone ACA dental plans can be cancelled any time. However, if enrolled in an ACA health plan with dental benefits, the plan can only be cancelled if the enrollee has a life event that qualifies for a Special Enrollment Period (SEP). If the enrollee qualifies for a SEP, a new health plan with or without dental coverage can be chosen, but a stand-alone dental plan cannot be obtained.

Traditional dental insurance

Most traditional, non-ACA dental insurance plans cover 100 percent of the cost of preventive care such as cleanings, checkups and x-rays, 80 percent of basic treatments such as fillings, and 50 percent of procedures such as root canals and crowns. Coverage begins after meeting an annual deductible. Traditional dental plans are usually issued by health maintenance organizations (HMOs) or preferred provider organizations (PPOs).

The premium paid tends to be higher on PPOs than on HMO plans. But regardless of plan, there will be an annual coverage cap between $1,200 and $1,500.

• Dental HMOs require in-network treatment. Referrals to dental specialists must be provided by the primary dentist. There is frequently no waiting period imposed before coverage kicks in, but the plan may limit the number of annual visits.
• Dental PPOs allow care from any dentist or dental specialist, but use of in-network providers will cost the member less. Typically, there are no annual limits on the number of visits, but a new plan member most likely will have to wait months before coverage is available for treatments such as bridges and crowns.

Vision coverage

All plans in the Marketplace include vision coverage (eye exams and glasses) for children as an EHBs. Only some plans include vision coverage for adults.

If a Marketplace plan doesn’t include adult vision coverage, a “stand-alone” vision plan can be obtained to reduce vision care expenses. The Marketplace doesn’t offer stand-alone vision plans. To shop for stand-alone vision plans, contact an insurance broker, search online for plans, or contact the state’s Department of Insurance.