WEDNESDAY, NOVEMBER 18, 2015
Optional Dental Coverage for Adults. Covered California, the health insurance marketplace set up by the State of California to enable the Patient Protection and Affordable Care Act (ACA), also known as ObamaCare, will offer dental coverage for adults for the first time in 2016.
Under the ACA, dental coverage for children (persons under 19 years old) is considered to be an "essential health benefit," and therefore all health insurance plans under the ACA must include dental coverage for children. This has been the case for Covered California sponsored plans from the beginning of the Covered California program. However, dental coverage for adults is not treated as an essential health benefit under the ACA, and has not been included in Covered California sponsored policies until now.
But beginning in 2016, adults who purchase health insurance through Covered California may also purchase dental coverage for themselves and for other members of their household. If an adult purchases dental coverage, it is not required that all other adults in the same household be included in such coverage. However, if a family dental policy includes one child in a household, it must include all children in the household.
Adult Dental Coverage Not Subsidized and Not Mandatory. Because dental coverage for adults is not an essential health benefit, federal financial assistance in the form of tax credits are not available to help meet coverage premiums. In addition, adults are not required or mandated to obtain dental coverage, and there is no tax penalty for failure to obtain such coverage.
Participating Insurers. There are five participating dental insurance carriers in the Covered California program: Access Dental Plan, Anthem Blue Cross, Delta Dental of California, Dental Health Services, and Premier Access. However, not all of these carriers offer dental policies in all parts of California. A dental policy can only be purchased in connection with a Covered California sponsored health insurance policy.
DHMOs and DPPOs. There are two basic types policies: Dental Health Maintenance Organization (DHMO) plans, and Dental Preferred Provider Organization (DPPO) plans.
As with health insurance policies offered through Covered California, the basic terms and coverages of dental plans have been standardized to a large extent to make it easier to shop for and compare plans.
In the case of a DHMO there is no charge for adults or children for diagnostic and preventative services such as X-rays, exams, cleanings and sealants. The co-payments for children and adults is $25 for a filing, $300 for a root canal, $65 for a tooth extraction, and $300 for a crown. A family of two or more children will benefit from an annual maximum out-of-pocket cost of $700, although this does not apply to adults. Generally you may see only a dentist within the HMO and will need a reference to see a specialist. Premiums are significantly lower than for DPPOs.
In the case of a DPPO there is no charge for adults or children for diagnostic and preventative services. Co-payments for children and adults for filings is 20 percent of the charge, and 50 percent of the charge for root canal, tooth extraction and crowns. There is a $65 per year deductible for children and a $50 deductible for adults. The deductible is waived for diagnostic and preventative care. Children have an annual out-of-pocket maximum of $700 per year, and adults have a maximum of $1500 per year. You may see any dentist on the participating PPO list and typically do not need a reference to see a specialist within the PPO group. Monthly premiums are generally significantly higher than for DHMOs.
While the above coverages and costs are standardized under all Covered California sponsored dental plans, there are specific differences among the various plans that are available, including: participating dentists and specialists, maximum out-of-pocket limits for adults, and waiting periods for certain treatments for some recently enrolled adults. Consumers should review the individual plans to determine what program works best for them.
Monthly Premiums. There are also price/premium differences. Premiums vary by plan and by region. To give you an idea of the costs, here are the plans and monthly premiums available in Santa Clara County, Pricing Region 7, as indicated in the Covered California booklet: "Family Dental Plans and Rates for 2016" (available on the Covered California website):
Plan Adult Child
Access Dental DHMO 13.00 16.00
Anthem DPPO 51.90 29.80
Delta Dental DHMO 12.99 14.49
Delta Dental DPPO 60.99 34.99
Dental Health Services DHMO 13.75 12.95
Premier Access DPPO 64.46 48.00
Premiums vary slightly in some other Pricing Regions. And keep in mind that not all plans are available in all regions.
Embedded Coverage for Children. You should also keep in mind that children (under 19) already have dental coverage under family health plans obtained through Covered California. You will want to purchase a separate dental plan only if you want the additional benefits available to your children under that plan or if you want dental coverage for one or more of the adults in your household.
Enrollment Period. Dental plans, like health plans offered through Covered California, must be purchased during the open enrollment period, which began on November 1, 2015 and will end on January 31, 2016. There are enrollment exceptions for special life events such as marriage, birth, and certain relocations.
Pfeifer Insurance Brokers. If you have questions about dental or health insurance coverage, please contact Pfeifer Insurance Brokers. We are familiar with Covered California programs and can help you choose coverage that works for you and your family. Keep smiling!
Pfeifer Insurance Brokers
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