Ask Emily: Look Ma, no option! My teeth are covered

Five of Miriam Martinez's molars have had to be extracted because of decay.
Five of Miriam Martinez's molars have had to be extracted because of decay. "If I'd had dental insurance, I'd still have my teeth," the 52-year-old said.
Adrian Florido

Covering California series icon 2013

Another in a series of Q&A columns answering consumers’ questions about the Affordable Care Act.

Like many things in Obamacare, dental insurance is more complicated than it should be. In today’s column, I’ll try to bring some clarity to the issue and preview coming changes that may affect how often you see a dentist – and at what cost.

There’s some good news amid the complexity, especially for kids.

Q: Can you tell me where the monthly payment for the children’s dental goes that I pay with my Obamacare insurance?

A: First, some context for Ruth’s question.

Under the Affordable Care Act, all health plans sold to individuals and small businesses must cover 10 categories of services known as “essential health benefits.”  They include emergency care, hospitalization, prescription drugs, and maternity and newborn care. (Please note that last category.)

Pediatric dental care is also an essential health benefit. Adult dental care is not.

You’d expect that pediatric dental would be part of every plan because it’s an essential health benefit. But it didn’t quite work out that way this year.

Due to a variety of factors that are too complicated to get into here, pediatric dental wasn’t embedded in Covered California’s 2014 health plans.

Next year, however, it will be included, as will the cost. It will account for about 1 percent of premiums, says Covered California spokesman Larry Hicks.

That’s nothing new for Californians who purchased their 2014 health insurance from the private market. With some exceptions, they already pay for pediatric dental coverage whether they like it or not, whether they have kids or not.

Thus Ruth’s question. The answer is that her premium helps defray the cost of children’s dental care across the state. 

The concept is similar to mandatory coverage for maternity and newborn care that I referenced above. Though men don’t give birth, the idea is that everyone pays into a big insurance pool to spread cost and risk.

The network of dentists available to your kids will depend on your health insurer. Kaiser Permanente, for instance, contracts with Delta Dental.

Insurers say they’re not limiting their dental networks the same way that some health plans limited their doctor and hospital networks this year.

“It’s the same network we’ve been offering for at least 10 years,” says Steve Temme, who handles dental contracts for Kaiser.

That doesn’t necessarily mean it will be easy to find a participating dentist. Several plans will offer dental HMOs, which means your child must stay in network to obtain covered dental services, Hicks says. (With a PPO, your child can visit out-of-network dentists but you pay higher out-of-pocket costs.)

“You cannot just select any dentist to receive covered services,” says Jeff Album, a vice president for Delta Dental of California. “Around the state, only about one in 10 dentists participates in an HMO. It’s higher in urban areas than rural ones.”

If the dentist you want isn’t in network, there’s another option that affects adults as well.

Covered California will be offering optional, stand-alone dental plans for adults and families next year, though they won’t be available when open enrollment begins on Nov. 15. Look for them in early 2015, before open enrollment ends, Hicks says.

These plans – both HMOs and PPOs – cost extra and will be offered by six insurers, with choices varying by region. (You can find specifics on the Covered California website.) 

For example, a stand-alone dental plan for an adult in Alameda County will run between $12.99 and $64.25 per month, depending on the insurer and type of plan.

You can add children to these stand-alone plans (as long as at least one adult is enrolled) for a cost. In San Diego, for instance, monthly rates range from $8 to $33.60. 

(Any tax credits you may be eligible for from Covered California cannot be used to defray the premiums for these stand-alone plans.)

If you’re having trouble finding a dentist for your child in his or her embedded dental plan, you might find a participating dentist in a stand-alone plan.

Plus there’s some positive news about cost.

Although adults often face annual benefit limits on the amount their dental insurance covers (for me, it’s $1,500), there are some new rules for kids.

For both embedded dental coverage and the optional, stand-alone plans, there is no annual benefit limit on kids’ dental care.

In the embedded coverage, anything you pay for it counts toward the plan’s annual out-of-pocket maximum, which will be capped at $12,500 for family policies in 2015.

In the stand-alone plans, the out-of-pocket maximum will be only $350 per child, with a maximum of $700 for two or more kids.

Assuming you cover one child, plans will start paying for 100 percent of your kid’s covered dental treatment once you’ve spent $350.

“This has never existed in dental plans before the ACA,” says Jeff Album, a vice president for Delta Dental of California. “It’s the complete opposite of what we had in typical commercial dental plans.”

A final note: Even though children can stay on their parents’ health plans up to age 26, their embedded pediatric dental coverage will only last up to age 19, Hicks says.

Questions for Emily:

Learn more about Emily here.

The CHCF Center for Health Reporting partners with news organizations to cover California health policy.  Located at the USC Annenberg School for Communication and Journalism, it is funded by the nonpartisan California HealthCare Foundation.

An earlier version of this story incorrectly stated the number of dentists taking new patients through Kaiser. KPCC regrets the error.