NEW YORK (MainStreet) You may have heard that you can buy a new dental insurance plan via healthcare.gov as part of the Affordable Care Act (ACA). For kids 18 and under, pediatric dental is now one of those new essential health benefits insurers must include under the ACA. For those under 18, dental coverage comes with out-of-pocket maximums that limit the amount you need to contribute toward kids' dental costs, without a benefits cap, same as the new health insurance policies offered on healthcare.gov work. And that is great for kids' dental health.
What you probably haven't heard is the new adult dental plans offered on Healthcare.gov are no better than any dental plan you may have considered before the enactment of the ACA, whether privately or via a past employer's health benefits package.
Benefit caps on adult dental plans not openly listed
The problem is that you wouldn't understand your total possible costs from simply looking at the dental plan benefits shown on healthcare.gov's anonymous shopping tool, or even when logged-in to enroll, says Jonathan Wu, C.E.O. of Valuepenguin.com, a consumer finance site that specializes in helping consumers make decisions about insurance. He recently analyzed the way the plans are displayed and found some very misleading language when it comes to the adult dental plans.
"You can see all the plans offered but be completely deceived as to the true dental plan costs and benefits for adults," he warns.
Understand the wording or pay the price
If you've shopped for ACA health insurance, then you're familiar with the term "out-of-pocket maximum" which limits the amount a consumer has to pay per year. With a $700 out-of-pocket maximum, once you have spent $700 in copays, deductibles and coinsurance, the insurer picks up all additional costs.
But when it comes to adult dental insurance, both before and after the ACA, another term, "annual maximum" (also called the "benefits cap"), comes into play which limits the maximum amount the insurer has to pay. Unlike the health plans, an adult dental plan with a $1,000 annual maximum means that once the insurer has paid out $1,000 in benefits, you are responsible for all additional costs.
"Because there is no such benefits cap on new health insurance policies due to the ACA, consumers shopping for both health and dental might not realize there is an adult dental benefits cap, especially when it is not openly listed," says Wu. "You can only find a plan's adult dental benefits cap, called "annual maximum," by clicking on the actual plan brochure and looking through the benefits chart."
The only other tip-off Wu found that an adult might be responsible for paying more than that maximum-out-of-pocket cost is some wording you find just underneath, only when logged-in to the actual enrollment and plan selection page on healthcare.gov.
You'll see the small print under maximum out-of-pocket cost that reads: "Applies to child essential health benefits only." That comes with no explanation. Wu says the maximum-out-of-pocket only applies to a child's dental care which has no benefit caps. He warns, "If you are an adult applying for adult dental insurance on the exchanges, do not enroll without clicking on the link to the plan brochure to find that 'annual maximum' benefit cap dollar amount, because if your dental needs go above it, you will be paying 100 percent out of pocket.
Do you need a new dental insurance plan?
Wu suggests prospective adult dental plan buyers do the math on any adult dental plan on the exchanges and contemplate their personal family budget. Below, is the math on an average adult dental insurance plan in the middle premium price range in Florida offered on healthcare.gov:
- 1. Plan premium is $50 per month for a total yearly cost of $600.
- 2. Plan has a $700 per year maximum out-of-pocket cost per person ($1,400 per family).
- 3. Plan brochure notes an annual maximum (benefit cap) of $1,000.
- 4. Plan allows for free cleanings and the copay for a one-surface filling is $20. Copays for major typical adult dental procedures such as a root canal and a crown, are approximately $300 each. These copays will be out-of-pocket until you reach your $700 maximum out-of-pocket cost.
- 5. If you need some fillings and a root canal and a crown, you will likely meet your out-of-pocket maximum of $700 per year for an individual plus pay $600 more in premiums for the year. Your plan will pay only $300 more before you reach the insurer's annual maximum, or benefit cap ($1,000), and you will again be responsible for any additional costs.
- 6. If you needed all that dental care, you will have paid, at the very least, $1,300 between premiums and copays toward your maximum out of pocket adult dental costs. If you didn't need any additional care beyond the free cleaning and checkup, you still would have spent the yearly $600 plan premium. Without insurance, a cleaning might cost $65, a dental visit and a filling around $150, a molar root canal around $800 and a crown around $1,000.
Is it worth it? Wu advises that if you are worried about your income or savings being able to cover your dental care, then buying one of these plans can help you pay monthly for any preventative cleanings and fillings you may need while budgeting for a dental emergency such as needing a root canal and a crown.
According to the Department for Health and Human Services press office, some of the health plans on the exchanges may include adult dental benefits, although they are not required. If you purchase one of those qualified health plans which include adult dental benefits and are eligible for a subsidy, you may realize dental savings that way.
Bottom line: Read the plan brochure before making any decisions on purchasing a dental insurance plan for an adult and be sure you know the difference between "out-of-pocket maximum" and "annual maximum" before clicking "enroll."
Written by Naomi Mannino for MainStreet