This article is intended for members enrolled in an individual health insurance plan.

Dental coverage for children is an Essential Health Benefit (EHB) under the Affordable Care Act (ACA). That means that for subscribers with members who are under the age of 19, dental coverage for kids is included in ACA metallic health plans.

The cost of the included dental coverage is built into the health plan premiums for your main medical coverage. If you do not have a dependent under the age of 19, that cost is not factored into your monthly payment.

Benefits for covered dental services for children are treated like any other benefit under the health plan — coinsurance, copay and other cost-sharing rules apply. The child’s dental claims count toward the health plan deductible and out-of-pocket maximum (OOPM). Dental benefits may not be payable until the medical deductible is met.

Your member ID card will show that pediatric dental services coverage (under age 19) is available.

What If You Need Additional Coverage?

The dental coverage for kids that comes with your main medical health plan is considered the primary plan for the covered dental services for kids. In some cases, the dental coverage for kids that comes with your medical plan may not cover all the dental services your child needs.

Stand-alone dental plans may offer additional cost savings for members with children who are under the age of 19. A stand-alone dental plan can have benefits paid under its own deductible and may include increased benefits for children and adult dental coverage not provided in the medical plan.

If you also signed up with Blue Cross and Blue Shield of Texas (BCBSTX) for the additional coverage of a stand-alone, full family dental plan, those plans usually start covering services where your included coverage with your medical plan leaves off. If you have full family dental coverage from BCBSTX, the benefits are processed by BCBSTX, which means your benefits and claims for both plans are automatically coordinated.

How Are Benefits Paid?

All benefits are based on the maximum allowance. That is the amount that BCBSTX sets as the maximum amount for payment of benefits. A dentist that participates in your plan’s network cannot bill you directly for charges that BCBSTX does not cover.

Benefits for services provided by a non-participating dentist will be based on the same maximum allowance. Non-participating dentists may bill you for the difference between BCBSTX’s maximum allowance and whatever they usually charge. This means you pay more out of pocket.

The percent of the maximum allowed charge that is covered depends on whether you see a dentist that participates or doesn’t participate in the plan’s network.

What Services Are Covered?

Services typically covered by stand-alone dental plans include:

  • Check-ups (deductible waived)
  • Cleanings (deductible waived)
  • Diagnostic X-rays (deductible waived)
  • Basic repairs
  • Non-surgical extractions
  • Non-surgical root work
  • Endodontic services
  • Oral surgery services

Some services require that members wait 12 months (until you renew your policy) for coverage (check your policy or call customer service to confirm):

  • Deep tissue surgical procedures like root canals
  • Major restorative services like crowns, implants, inlays/onlays, bridgework, wisdom teeth removal
  • Artificial tooth replacements

What About Orthodontic Services?

It’s important to note that orthodontic services covered under your main medical health plan are only for medical necessary treatment. Family dental plans can be purchased that include orthodontia treatment coverage for cosmetic appearance.