Pediatric dental coverage is considered one of the ten essential health benefits to be included in a Qualified Health Plan (QHP). In Virginia, dental benefits will be offered two different ways in the Exchange: as an embedded benefit or as a stand-alone plan (separate from health insurance). Some qualified health plans will include a children’s dental benefit and also have an option to add coverage for an adult.
The questions below will help navigators and assisters as they work with consumers to identify the most appropriate dental plan for themselves or for their family.
- Do you have a child/children age 0-19 who will receive coverage through the marketplace? If so, your child/children are entitled to medical and dental benefits.
- Are you looking for a health plan that includes a dental benefit for your child, yourself or your family? In Virginia’s Exchange, dental plans for children and adults will be offered two ways, each with different copays:
> Embedded in a QHP (not all QHPs will have a dental plan)
> Purchased from a stand-alone dental insurer
Each plan will be different -- review the benefits each plan is offering and understand the deductible that you will have to pay before your coverage begins.
- Have you considered what dental care or procedures your children may need? In some cases, preventive services, like exams, cleanings, fluoride varnish and sealants, are free; in other cases, the deductible must be met first. Other services, like fillings, root canals, crowns and extractions, have different out-of-pocket costs depending on the plan you choose and your income. Each plan’s cost-sharing is different, and it is important to understand how a plan’s deductible will affect your out-of-pocket costs.
- Pediatric dental plans may have different costs and benefits. Given your children’s needs and your budget, what matters most to your family? Differences may include:
> Service limits (how frequently services can be received)
> Cost-sharing (how much you are expected to pay for certain services)
> Deductibles (what you have to pay out-of-pocket before certain services are covered)
> Out-of-pocket maximums (the most you may need to pay out-of-pocket each year)
Subsidies and deductibles are handled differently with embedded plans and stand-alone dental plans – this will affect out-of-pocket costs. Be sure to know what you have to pay out-of-pocket before coverage begins for both types of benefits.
- Do you know how to use your children’s dental benefits once you have them? For example, do you know how to find a dentist who takes your insurance, what dental services are covered in your plan, and what you can expect to pay out-of-pocket?
- Do you have a specific dentist you would like to see? Some dentists may not participate in the Exchange products, so be sure to check if your dentist is included in your plan’s network.
Download this fact sheet in English or Spanish.
For more information, contact the Virginia Oral Health Coalition 804.269.8720 or firstname.lastname@example.org.