Are dental benefits included in ACA’s marketplace health plans?

Q. Are dental benefits included in the health insurance exchange plans?

A. Pediatric dental is one of the ACA’s essential health benefits. But there’s no requirement that dental care for adults be covered.

And even though pediatric dental is considered an essential health benefit, it works differently from the other nine essential health benefits. In some states, pediatric dental benefits are embedded in health insurance plans, either because the state requires this or because the insurers choose to take this approach. But in most states, as long as there are stand-alone dental plans available for sale in the exchange, the health insurance plans in the exchange do not have to include pediatric dental coverage. Instead, applicants can be directed to purchase pediatric dental as a separate, stand-alone plan.

And dental coverage for adults is rarely included in marketplace plans. Adults can choose to purchase stand-alone coverage, but since this is not an essential health benefit, the plans virtually always include fairly low annual benefit caps (for pediatric dental coverage, insurers cannot impose a dollar limit on the benefits, since pediatric dental is considered an essential health benefit and those cannot have annual or lifetime caps on how much the insurer will pay for treatment).

Stand-alone dental plans for adults can be purchased through the exchange. But in most states, including all of the states that use HealthCare.gov, stand-alone dental coverage can only be purchased if the person is also buying a medical plan (ie, you can’t just buy a dental plan on its own). Legislation is under consideration in Congress in 2023 that would change that rule, allowing a person to buy dental coverage through the exchange even if they don’t need to buy health insurance.

Because the Affordable Care Act didn’t address dental coverage for adults — and neither have any successful pieces of legislation in the ensuing years — the issue is an ongoing problem. Millions of Americans lack dental insurance, and end up delaying essential dental treatment because they can’t afford to pay for it.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.