Beginning in January of 2014, most Americans will be required to provide dental insurance plans for their children under the implementation of the Affordable Care Plan (ACA). The ACA requires all insurance plans to cover 10 categories of care, known as the Essential Health Benefits (EHB), and pediatric dental insurance is one of these benefits. The ACA does not provide a definition for specific oral health services to be provided by insurance plans.
According to the American Dental Association, approximately 8.7 million children could gain extensive dental coverage through the ACA by 2018. For children, the expansion will be almost evenly split among Medicaid (3.2 million), health insurance exchanges or marketplaces (3 million) and employer sponsored insurance (2.5 million).
Currently 99% of Americans with dental coverage receive that coverage through a separate dental plan as opposed to receiving coverage that is packaged with their primary health insurance plan. Nationally, the most recent statistics on dental insurance rates were compiled in 2009, when average prices for individual plans ranged from $19 to $35 monthly or $231 to $415 on an annual basis.
Individual states will define requirements for pediatric insurance plans offered in the state exchanges, including age limits and mandatory services offered. It is expected that these definitions will be based on existing requirements for other insurance programs, usually the state’s Medicaid program.
For example, in California it is assumed that the tests, treatments, and services that must be covered under the pediatric dental section of the EHB will be based on the current requirements of the Healthy Families Program. Healthy Families offers low-cost health insurance to children whose families do not qualify for Medicaid but cannot afford to pay for private insurance plans.
The Healthy Families definition of dental benefits includes:
The minimum dental services required by the Medicaid & CHIP programs include relief of pain and infections, restoration of teeth, and maintenance of dental health. Dental services may not be limited to emergency services.
It is likely that most states will develop basic dental service requirements similar to those listed above. Additionally, pediatric dental coverage must be made available to age 19, but individual states can choose to extend this age limit.
Pricing of dental plans will also vary between individual state exchanges. Using California as an example again, rates for pediatric dental coverage depend on factors such as geographical region, the insurance company that provides the plan, and the type of plan purchased.
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