There has been lots of news coverage and information about the Affordable Care Act (a.k.a. Obama Care). Although there is much debate about the merits of the new law between political groups we want to focus on one part of the ACA, dental coverage and specifically orthodontic coverage. The jist of it goes like this: Braces in most cases will be covered for kids (pediatric orthodontics); for adults though, braces are a medical need and not a cosmetic one. So if you are just looking to improve your smile then the Affordable Care Act will not cover you. That is where FSA and HSA spending accounts should be used.
This is what The Center for Consumer Information & Insurance Oversight says are excluded from the Affordable Care Act:
Pursuant to 45 CFR 156.115, the following benefits are excluded from EHB even though an EHB-benchmark plan may cover them: routine non-pediatric dental services, and/or non-medically necessary orthodontia.
Really each state is the last word on coverage and this list has links to each state. It varies so read up and look for loopholes.
Is dental coverage part of Obamacare?
The answer is “for some”. Affordable Care Act does not require all health insurance plans to offer affordable dental benefits. The ACA does have requirements some health insurance plans to include dental care for children but not adults. You may be wondering why this is the case. Currently, about 1.7 million children across the US are not receiving dental care. With the passage of the ACA, these children can have access to dental benefits. Why did the ACA include a requirement for dental coverage only for children?
In the US dental disease is the most common chronic childhood disease – almost five times more common than asthma. As a result, children miss about 52 million school hours per year due to dental problems. The ACA recognized this issue and deemed it an Essential Health Benefit so that all children would have access to dental care.
Although the Affordable Care Act set this as essential specifically for children there are some states that are allowing insurers to sell family plans and dental benefits together. Please note that the insurance marketplaces do not require the inclusion of dental insurance when you “check out”, you’ll need to be careful to include the benefit, either as a part of your medical plan or as a separate plan.
As always if you have questions seek out an Affordable Care Act Navigator to help you make the right choice for you and your family.
If you want a health plan that includes a pediatric dental benefit, look for an “EHB-compliant” plan sold on or off the state exchange.
Orthodontic treatments that are not a “medical necessity” will most likely not be covered by the dental plan. For instance, in California, an insurer stated that patients must score 26 or more points on the Handicapping Labio-Lingual Deviations (HLD) for in order for the Orthodontic treatment to be considered a “medical necessity”. You will want to research the plans in the private market where Orthodontic treatments may be covered.
reference article: https://www.aaoinfo.org/news/2013/12/orthodontists-seek-information-impact-affordable-care-act