How is Dental Care Covered under the Affordable Care Act?
Dental care for adults is not considered an essential health benefit under the Affordable Care Act and is not required to be included in all health insurance plans sold on the Marketplace. However, the ACA does mandate dental coverage for children as one of the essential health benefits. If you have a child 19 years of age (or 21 in Kentucky) or younger enrolled in a Marketplace health plan, pediatric dental benefits are included.1
Although dental coverage for adults is not required to be included in Marketplace health insurance plans, some include dental coverage, also called a bundled plan. Also, many insurers offer dental insurance as an optional add-on. These standalone Affordable Care Act dental insurance plans can typically be purchased separately through the Marketplace or directly through the insurer.
How is Vision Care Covered under the Affordable Care Act?
Vision care, like dental care, is not considered an essential health benefit for adults under the Affordable Care Act (ACA). Similarly, the ACA mandates vision coverage for children as an essential health benefit, so children 19 years of age (or 21 in Kentucky) or younger will have Marketplace vision insurance included in their ACA plan.1
While vision coverage for adults is not required to be included in Marketplace plans, having optional add-on vision insurance can be valuable, especially if you anticipate needing regular eye care. These plans may be purchased directly from the health insurer.
How to Purchase Dental and Vision Plans
Learn more about where you can purchase dental and vision insurance plans.
On-Exchange Plans: Dental plans are available for purchase through the Health Insurance Marketplace. These plans adhere to ACA regulations, offering standardized coverage options and benefits. Vision plans, however, are not available on the Marketplace.
Off-Exchange Plans: On the other hand, both dental and vision plans are available for purchase directly from health insurers. These plans may offer greater flexibility in terms of coverage options, benefit structures, and pricing.
In summary, you have the option of purchasing dental plans on- or off-exchange, while vision plans are only available off-exchange. Since neither vision nor dental plans are eligible for subsidies, you’ll want to look at the details of each of the plans offered, including the services covered and the monthly cost, to decide which is the best fit for you.
When Can You Enroll in a Dental or Vision Plan?
On-exchange dental plans are typically available for enrollment during the Open Enrollment Period season. Open Enrollment usually takes place from November 1 to January 15 of each year, but exact dates may vary by state. Since you may already be reviewing medical plan options during this period, it may be a great time to consider adding on-exchange dental coverage.
If you experience a qualifying life event outside of Open Enrollment, you may be eligible for a Special Enrollment Period (SEP). Examples of a qualifying life event (QLE) include getting married, having a child, moving to a new area or state, losing health coverage, or other significant life changes. If you qualify for an SEP, you typically have 60 days from the date of the QLE to enroll in or make changes to your plan, including adding dental or vision coverage.
However, off-exchange dental and vision plans can typically be purchased year-round directly from an insurer, without the need for an SEP.
Coverage and Out-of-Pocket Limits in ACA Dental and Vision Plans
In ACA dental and vision plans, coverage and out-of-pocket limits play crucial roles in determining the scope of care services you're eligible for and the maximum amount you'll have to pay for covered expenses.
Coverage in ACA Dental and Vision Plans
Coverage refers to the specific services and benefits that a dental or vision plan provides. ACA-compliant dental and vision plans are required to cover certain essential health benefits, especially for children, but the specific benefits can vary between plans. Coverage typically includes preventive services like regular check-ups, cleanings, and screenings. Dental coverage may also include basic procedures such as fillings and simple extractions. Vision plans might cover eye exams, prescription eyewear (glasses and contact lenses), and other vision-related care.
Some dental plans require a waiting period before you can get certain procedures, such as fillings and crowns. Look at the details of each plan to understand what services are covered, any limitations, and the percentage of costs the plan will pay for different care services.
Out-of-Pocket Limits in ACA Dental and Vision Plans
Out-of-pocket limits, also known as maximum out-of-pocket costs, are the most you would have to pay for covered services during a plan year. These limits include your deductible, copays, and coinsurance. Once you reach the plan’s out-of-pocket limit, the insurer pays 100% of the costs for any remaining covered services during the plan year.
Out-of-pocket limits can vary between different plans, and they might also differ for individual coverage and family coverage. Plans with a lower monthly premium might have a higher out-of-pocket limit, and vice versa. When comparing plans, consider both the monthly premium and the potential out-of-pocket costs to determine which coverage offers the best overall value based on your anticipated care needs and budget.
Other Ways to Pay for Dental and Vision Care ACA Coverage
If you're looking for additional ways to pay for dental and vision care, there are a couple of options and resources you can consider to help manage the costs:
- Health Savings Accounts (HSAs): If you have a high-deductible health plan (HDHP), you may be eligible for an HSA. HSAs allow you to set aside pre-tax money to cover qualified medical expenses, including dental and vision care. These accounts can provide significant tax advantages and help you budget for healthcare costs.
- Saving and Budgeting: While vision and dental plans aren’t eligible for subsidies themselves, if you're enrolled in an ACA medical plan and qualify for subsidies, that may give you more room in your budget for dental and vision coverage.
Explore these options to find the most suitable and affordable solutions based on your specific needs and financial situation.