It depends on who needs the coverage. Under the Affordable Care Act (ACA), dental care for children is an essential health benefit, so kids can get dental coverage through the Marketplace. Dental coverage for adults is not required, so adults usually need to buy a separate dental plan or pay out of pocket. Here is how it works, what to check before you buy, and what to do if a plan does not fit your budget.
Children's dental coverage
Pediatric oral care is one of the ten essential health benefits under the ACA, and it applies to children up to age 19. Exact services, limits and costs vary by plan and state, but routine exams, cleanings and fillings are typical.
The benefit can come in two forms. In some cases it is built into a Marketplace health plan. In others it is offered as a stand-alone dental plan that you buy alongside your health plan. The plan details on HealthCare.gov or your state Marketplace will show which applies, so you know whether you need a separate plan to get your child's dental coverage.
Before you finish enrolling, check whether the health plan you picked already includes children's dental. If it does not, look for a stand-alone dental plan in the same shopping session. Some states have their own rules about this, so read the plan details closely.
Adult dental coverage
Adult dental is not an essential health benefit, so a Marketplace health plan for adults often has no routine dental coverage at all. Some medical plans cover limited dental treatment, such as care after an accident, but cleanings, fillings and dentures are usually not included.
Adults who want routine coverage generally buy a stand-alone dental plan. These plans are sold through HealthCare.gov and state Marketplaces, and each one has its own premium, deductible and benefits, separate from your health plan.
How stand-alone dental plans work
Marketplace dental plans work much like regular dental insurance. You pay a monthly premium, and the plan usually has a deductible, coinsurance, a network of dentists, an annual maximum, and sometimes waiting periods for major work such as crowns or dentures. On HealthCare.gov, dental plans are labeled with a low or high coverage level, which gives you a rough sense of how much of typical costs the plan covers.
You can usually enroll during open enrollment, or at other times if you have a qualifying life event, such as losing other coverage, moving or having a baby. Open enrollment dates can change from year to year, so check the current dates on HealthCare.gov or your state Marketplace.
Premiums can vary by the plan, where you live and the coverage level. Premium tax credits are designed mainly for health coverage and generally apply to stand-alone dental plans only in limited ways. Ask during enrollment what you would actually pay for the dental plan you are considering.
Where to shop and get help
Most states use HealthCare.gov, and some run their own state Marketplace websites. Either way, you can compare dental plans side by side, and you can call the Marketplace call center with questions. Free local help from trained Marketplace assisters is also available in many areas.
Be careful with dental plans you see advertised online or by phone. Some are Marketplace plans, but others are dental savings plans, which are not insurance. They charge a membership fee for discounts at participating dentists. Both can be useful, but they work differently, so find out which one you are looking at before you pay.
Medicaid, CHIP and Medicare
- Medicaid and CHIP. Children enrolled in Medicaid or CHIP get dental coverage. For adults, Medicaid dental benefits vary widely by state, from fairly comprehensive to emergency-only to none. Check your state Medicaid program for details.
- Medicare. Original Medicare generally does not cover routine dental care such as cleanings, fillings and dentures. Some Medicare Advantage plans include dental benefits, so check what your plan offers.
If you or your children might qualify for Medicaid or CHIP, it is worth finding out before you pay for a private dental plan.
What to check before you buy
- Is my dentist in the plan's network?
- What are the premium, deductible, coinsurance and annual maximum?
- Are there waiting periods, and for which services? Crowns, root canals and dentures are common ones.
- How does the plan treat preventive, basic and major care?
- Do the deductible and annual maximum apply to each person or to the whole family?
- Is my child's dental coverage already included in the health plan I chose? You do not want to pay for the same benefit twice.
- What is my total expected cost? Add 12 months of premiums, the deductible, and your share of the treatment you expect.
The Marketplace plan pages list these details. If anything is unclear, call the plan or the Marketplace call center before you enroll.
When a dental plan may not be the best fit
A plan is not always the cheapest route. If you need a lot of work right now, waiting periods can delay coverage for months while you pay premiums. Annual maximums also limit how much the plan pays in a year, which matters if you need major treatment. In those cases, a sliding-scale clinic, dental school or community health center may cost less.
If you mostly need checkups and cleanings, a plan may pay off sooner. Your own numbers decide it, so compare the yearly cost of the plan with what you would pay at a lower-cost clinic.
Find affordable care near you
Whether or not you buy a plan, you can look for affordable options close to home. Start with local dentists by state or compare low-cost dental service in top states. Ask each office about cash prices, payment plans and whether they accept your plan.
This article is general information, not legal or financial advice. Plan benefits, prices and enrollment rules change, so confirm details at HealthCare.gov, your state Marketplace, or with the plan directly.