Understanding Pediatric Essential Health Benefits

One of the central provisions of the Affordable Care Act (ACA) is the requirement that medical plans offer 10 “Essential Health Benefits (EHB).” Pediatric dental coverage for children under age 19 is one of the 10 required benefits.

To help you better understand the pediatric dental benefit requirement, we’ve put together the following key facts:

Pediatric dental benefits focus on preventive care. Benefits cover the most commonly performed preventive procedures for children like exams, cleanings, fluoride, sealants, and x-rays at 100%.

No annual or lifetime maximums.

Annual out-of-pocket expenses for coinsurance are limited to $700 for one child and $1,400 for two or more children. Out-of-pocket expenses include coinsurance and deductibles for services provided by a network dentist.*

Choice and access to network dentists. Offering consumers a wide choice of dentists was another important provision of the ACA. Delta Dental provides access to the largest network of dentists across the country, more than 145,000 dentists participating in over 292,000 locations.

The Delta Dental network includes general dentists and specialists, including pedodontists (dentists who are specially trained to treat children). Most importantly, you don’t need a referral to visit any specialists in the network.

Coverage for Medically Necessary Orthodontic Services. This unique benefit provides orthodontic services for children with serious orthodontic impairment resulting from congenital abnormalities that affect their daily ability to function, e.g. eating, speaking, etc. Under the ACA provisions, there are no lifetime or annual maximum limitations for “medically necessary” orthodontia, which is covered at 50%*

*Please note: Coinsurance paid to out-of-network dentists does not count toward the out-of-pocket maximum. That’s why it’s best to seek treatment to dentists who belong to the Delta Dental network.

Finally, pediatric essential dental benefits are available for children up to age 19. If a child is covered under a parent’s plan, he or she may be eligible to continue coverage after age 19 as a young adult on the plan up to age 26.