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How Does the Pediatric Dental Benefit Work?

With the passage of the Affordable Care Act, health insurance plans were required to cover 10 essential health benefits including pediatric dental. What a convenience, your children are automatically covered by a dental plan when you enroll them in health insurance! Unfortunately, this benefit is often misunderstood and because of that can disappoint, as today’s video discusses.

What people often don’t realize is that the pediatric dental deductible and the medical deductible are usually integrated. This means that there is essentially no coverage for dental procedures until the medical deductible has been met. With deductibles often being several thousand dollars or more per year, it may be difficult for a child who does not use many health services to meet that deductible. Therefore, they may never get any benefit from the pediatric dental “benefit.”

Orthodontia is usually not covered under the pediatric dental benefit either unless the misalignment of the teeth is so severe that it impedes the child’s ability to eat or speak. If braces are needed for cosmetic alignment of the teeth, it is doubtful that would be covered by the pediatric dental benefit embedded in health plans.

Since health insurance carriers have historically not included dental benefits in their health plans, when they were mandated to cover pediatric dental, most carriers did not opt to do the work to create their own network of dentists. Rather, carriers lease networks from established dental plans or dental network providers. It is sometimes not easy to ascertain what the network is for pediatric dental benefits and this information is not often included on the health plan ID cards. If you want to access the pediatric dental benefit, you may need to call the health plan to inquire as to what the network is and what information the dentist will need to confirm the child’s coverage.

If having dental coverage for your children is important to you, you will want to investigate how the plan you are considering covers this benefit. If the network or coverage doesn’t seem sufficient, you may want to see if there is a policy with “enhanced dental” available (for an additional cost) or perhaps you may be inclined to purchase a stand-alone dental plan. Just be aware that dental plans aren’t always worth the cost of the premium, but this is an analysis you will need to do yourself given your preference in dental providers, your child’s needs, and your budget.

Thank you for reading, and please share with whoever you think might benefit from this information.