Oral Health Kansas, in partnership with the Children’s Dental Health Project, developed this webinar to provide an overview of Kansas marketplace dental coverage options under the Affordable Care Act. Watch the webinar for an in-depth discussion of the issues most important for Navigators to be aware of when helping consumers select dental plans, such as learning how dental coverage is available in the Kansas marketplace, the differences between stand-alone dental plans and dental coverage as part of a qualified health plan, and an explanation of factors that families should understand before purchasing a plan.
1. How is dental coverage offered on the marketplace? The Affordable Care Act (ACA) requires that pediatric dental coverage must be offered on the marketplace either as part of a qualified health plan (QHP) or as a stand-alone dental plan sold separately. This means that any child or adolescent (ages 0-18) enrolling in health coverage on the marketplace is also eligible to enroll in dental coverage.
In nearly all counties in Kansas there is at least one QHP that includes pediatric dental coverage. For the 2017 plan year, BlueCross BlueShield Kansas Solutions, Inc. is the only insurer offering QHPs with pediatric dental included. However, this insurer does not offer plans in Johnson or Wyandotte Counties.
In addition to QHPs that include pediatric dental coverage, families have the option to purchase their children’s health and dental coverage through separate plans. These stand-alone dental plans may also allow adults to purchase dental coverage for themselves at an additional cost.
2. Are families required to buy dental coverage for their children? Under current law, children enrolling in a QHP that does not include pediatric dental coverage are not required to enroll in a stand-alone dental plan.
3. What services are covered?
The specific dental services that must be covered are based on the benefits outlined in the state’s Children’s Health Insurance Program, Healthwave. Any plan offering pediatric dental coverage must cover preventive and restorative services like cleanings, fluoride treatments, dental sealants, x-rays, and fillings. Orthodontic services like braces are typically only covered when medically necessary (e.g., if a child has trouble chewing or speaking). The full list of services is available at:
Each plan may have different rules for how frequently a patient can receive certain services, which providers a patient may see, and how much patients are required to pay out of pocket for specific services. These details should be available through the plan brochures and summaries of benefits.
4. How does dental coverage differ between QHPs and stand-alone dental plans? When purchasing a dental plan separately from a QHP, families will be required to pay an additional monthly premium for that dental coverage. Furthermore, stand-alone dental plans have a separate out-of-pocket maximum of $350 for one child or $700 for two or more children. This means that out-of-pocket costs for dental services do not contribute to the patient’s out-of-pocket limit on the medical side. As such, a family in this scenario would have a higher total out-of-pocket obligation. However, QHPs in the Kansas marketplace do not have a separate deductible for dental coverage, meaning that, for most pediatric dental services, families would have to pay out-of-pocket for the full cost of care until they met their health plan deductible. Stand-alone dental plans have much lower deductibles.
5. Are subsidies available to help purchase dental coverage? Currently, premium tax credits are not calculated based on the cost of stand-alone dental coverage so most families will not receive a tax credit large enough to cover the cost of both a QHP and a dental plan but this is expected to change after 2018. In addition, cost-sharing reductions for individuals and families at or below 250% of the federal poverty level (about $30,000 per year for an individual and about $61,000 for a family of 4) do not apply to stand-alone dental plans.
Additional resources: https://www.cdhp.org/topics/affordable-care-act
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