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 if you cover a dependent(s) under the age of 19 on your Blue Cross and Blue Shield of Texas (BCBSTX) health plan, you may also have a separate dental plan for kids.
All BCBSTX dental plans sold in the individual market are separate plans with their own deductible and out-of-pocket maximums (OOPMs). You can find details about dental plans in your Dental Benefit Book. Covered dental services have copays or coinsurance as listed. Dental coverage starts to pay dental claims when the dental deductible is met. You will need to pay dental service copays and coinsurance until the dental OOPM is reached.
Your health plan deductible and OOPM do not affect your dental coverage.
How Are Dental Benefits Paid?
All dental benefits are based on a 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 above that maximum allowance.
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