Dental Coverage and the Affordable Care Act

Laird Harrison


December 05, 2012

In This Article

Dental Plans: Dropped Coverage?

Meanwhile, the NADP is concerned about a different aspect of the law. This provision bans dental plans from lifetime and annual caps on coverage. Currently many dental plans set caps averaging about $1500, and about 3% of beneficiaries exceed those limits each year, according to the NADP. Having to cover these folks will raise the cost of the plans, and the insurers expect to pass those costs onto the beneficiaries.

According to an analysis commissioned by the NADP, about 11 million adults would drop coverage if pediatric dental plan costs are "substantial," said Ireland, and from her reading of the new regulations, that is likely. Only 5.3 million would add coverage, the organization says, citing an estimate from the Pew Institute,[8] so there could be a net loss in the number of Americans with dental coverage..

So far, in giving guidance to states, the HHS has said that essential benefits should be based on:

  • One of the 3 largest small group plans in the state by enrollment;

  • One of the 3 largest state employee health plans by enrollment;

  • One of the 3 largest federal employee health plan options by enrollment; or

  • The largest HMO plan offered in the state's commercial market by enrollment.

If the plan chosen does not offer pediatric oral care, a state would supplement the plan with the benefits offered by either the Federal Employees Dental and Vision Insurance Program dental plan with the largest national enrollment (MetLife DPPO) or the state's CHIP program. The analysis commissioned by the NADP indicates that dental plans will charge about $27.90 per child per month, plus another 8% to 30% depending on what limits are set on out-of-pocket expenses. This is based on the understanding that medically necessary orthodontia must be covered at 50%. By contrast, a "typical" small employer dental plan now costs about $21 per child per month without orthodontia, and $23.80 with orthodontia covered at 50%.