What to Know: Shopping for Dental Insurance on the Marketplace

Shopping for dental insurance can feel overwhelming, especially with the variety of plans and coverage options available through the Health Insurance Marketplace, or Obamacare. Understanding your options is crucial to ensure you and your family get the necessary care without breaking the bank.

In this blog, we’ll guide you through the process for selecting and enrolling in dental and vision insurance, highlighting key points to consider and steps to take.

Can you buy dental insurance with medical coverage from the Health Insurance Marketplace?

When it comes to shopping for dental insurance through the Health Insurance Marketplace, there are several factors to take into account.

Dental coverage with medical insurance

Some plans offered on the Marketplace include dental coverage. These are clearly labeled “health and dental” plans and allow you to bundle dental insurance with your medical insurance. This can be convenient, as it simplifies your coverage under one policy. But if none of the available plans meet your needs or budget, you still have the flexibility to purchase a standalone dental plan separately from a private insurance provider at any time.

Coverage for children

Under the Affordable Care Act (ACA), pediatric dental coverage is considered an essential health benefit. This means that all Marketplace health plans must offer dental coverage for children. This coverage often includes preventive services like exams and cleanings, as well as treatments like fillings and orthodontia. It’s important to review the details of each plan to understand what is covered and any associated costs.

Options beyond the Marketplace: Medicare and Medicaid

Medicare and Medicaid are two distinct government programs that also offer health and dental coverage, though they cater to different groups and have unique eligibility requirements.

• Medicare: This federal program primarily serves individuals aged 65 and older, as well as some younger individuals with disabilities. Traditional Medicare (Parts A and B) does not cover routine dental care, but you can purchase a Medicare Advantage plan (Part C) that often includes dental benefits. These are offered by approved private insurers and may cover routine services like cleanings, exams, and sometimes more comprehensive care. 
• Medicaid: This joint federal and state program provides health coverage to low-income individuals and families. Dental benefits under Medicaid vary by state. Some states offer comprehensive dental coverage for adults, while others provide only emergency dental services. For children under the age of 21, Medicare must cover dental services as part of its Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.

Switching plans

If your current health or dental plan no longer meets your needs, you have options. During the annual Open Enrollment period, you can switch to a different plan on the Marketplace. Additionally, certain life events such as getting married, having a baby or losing other health coverage may qualify you for a Special Enrollment Period, allowing you to make changes to your coverage outside of the usual enrollment window.

What types of dental plans are offered on the healthcare marketplace?

Dental coverage through the Marketplace can vary widely in terms of benefits, costs and the specific needs they address. First, you will need to determine whether you are more of a candidate for a standalone or bundled plan:

1. Standalone dental plans: These are separate policies specifically for dental coverage. They are ideal if your health insurance plan doesn’t include dental benefits or if you want to tailor your dental coverage independently from your medical insurance.
2. Bundled plans: Some health insurance plans offer the option to include dental coverage as part of a comprehensive package. These bundled plans combine health and dental insurance, providing the convenience of a single policy and‌ simplified billing.

Dental plans are also generally categorized into two levels of coverage: high and low. The level you choose will affect costs and the extent of services covered.

High coverage plans have higher monthly premiums but lower copayments and deductibles. They typically cover a broader range of services, including major procedures like crowns, root canals and orthodontia. As a result, you’ll have lower out-of-pocket costs for treatments — making high coverage plans more beneficial if you anticipate needing extensive dental care.

Low coverage plans have lower monthly premiums but higher copayments and deductibles. These generally cover essential services such as exams, cleanings, x-rays and basic procedures like fillings and extractions. This will lead to higher out-of-pocket costs, making these plans a more suitable option if you anticipate only needing routine care.

What dental procedures are covered by medical insurance?

Medical insurance may cover dental procedures that are deemed medically necessary. These often involve more complex conditions where dental health intersects with overall medical health, like:

Oral surgery

• Wisdom teeth removal: If the extraction of impacted wisdom teeth is necessary due to pain, infection or other medical issues.
• Jaw surgery: Procedures like corrective jaw surgery to address jaw misalignment, TMJ disorders or severe trauma. 

Injuries and trauma

• Accidents: Dental repairs resulting from accidents (such as broken teeth or jaw fractures), especially if the injury affects more than just the teeth.
• Facial injuries: Treatments needed due to facial injuries that involve dental elements, such as reconstructive surgery.

Hospitalization and anesthesia

• Complex dental procedures: If a dental procedure requires hospitalization due to a patient’s health condition (e.g., heart problems, severe anxiety, or special needs).
• General anesthesia: In cases where general anesthesia is required for dental work due to a medical condition or the complexity of the procedure.

Infections

• Severe infections: Severe oral infections that pose a risk to overall health, such as abscesses that spread beyond the teeth and gums.

Treatment of diseases

• Oral cancer: Treatments related to oral cancer, including surgery, radiation and chemotherapy.
• Systemic conditions: Procedures related to systemic conditions that affect oral health (e.g., diabetes).

Is vision insurance covered?

The Marketplace offers vision plans for both adults and children, which differ in coverage.

Vision coverage for adults

Vision insurance is not considered an essential health benefit under the Affordable Care Act. This means that standard health plans offered through the Health Insurance Marketplace typically do not include vision care for adults — meaning you will have to purchase a standalone vision plan.

Standalone vision insurance plans usually cover:

• Routine eye exams
• Prescription glasses
• Contact lenses

Some plans may also provide discounts on corrective surgery like LASIK. These plans can be purchased directly from private insurance companies at any time, independent of the Marketplace’s open enrollment period.

Vision coverage for children

Under the ACA, vision care is categorized as an essential health benefit for children. This means that all health plans available through the Marketplace must include vision coverage for children under the age of 19. Pediatric vision coverage typically includes:

• Routine eye exams
• Corrective lenses
• Screenings and treatments

When can you enroll in dental and vision plans?

The primary time to enroll in dental and vision plans through the Health Insurance Marketplace is during the Open Enrollment Period (OEP). The OEP typically runs from November 19 to December 15 each year. During this time, you can:

• Sign up for new dental and vision plans, either as standalone policies or bundled with your health insurance.
• Switch to a different plan that better suits your needs.
• Add dental or vision benefits if your current health insurance plan doesn’t include this coverage.

Outside the OEP, you can enroll in or make changes to your dental and vision plans if you qualify for a Special Enrollment Period (SEP). SEPs are triggered by certain events, like:

• Loss of health coverage
• Getting married
• Having a baby or adopting a child
• Moving to a new area with different health plans

To take advantage of an SEP, you have 60 days from the date of the qualifying event to enroll in new plans or make changes to existing ones.

Medicaid, CHIP and Medicare

Those eligible for Medicaid or the Children’s Health Insurance Program (CHIP) can enroll in these programs at any time throughout the year. 

Those eligible for Medicare have the following enrollment periods:

• Initial Enrollment Period (IEP): When you first become eligible for Medicare, usually around your 65th birthday, you have a seven-month window to sign up for Medicare Advantage plans (Part C) that may include dental and vision coverage.
• Annual Enrollment Period (AEP): From October 15 to December 7 each year, you can enroll in or switch Medicare Advantage plans.
• Medicare Advantage Open Enrollment Period: From January 1 to March 31, those already enrolled in a Medicare Advantage plan can switch to a different Advantage plan or revert to Original Medicare and join a standalone dental and vision plan.

Employee-sponsored plans

If you get coverage through your employer, the enrollment periods are typically determined by your employer. This usually coincides with the company’s annual benefits enrollment period. In this instance, qualifying life events can again trigger special enrollment opportunities within employer-sponsored plans.

How to purchase dental and vision plans

Enrolling in dental and vision insurance seems daunting, but it’s important to take time to make sure you choose the best plan. Follow these steps:

1. Assess your needs: Determine what types of dental and vision care you and your family need. Consider services you may need now and in the future, like routine check-ups, eyewear, dental procedures and treatment for specific conditions. Establish how much you can afford to pay in monthly premiums and out-of-pocket costs. Balancing coverage with cost is key to finding the right plan.
2. Explore your options: Visit HealthCare.gov to explore available plans. Use the Marketplace’s comparison tools to evaluate plans based on coverage details, premiums and provider networks. If you’re employed, check with your HR department about benefits offered by the company. You can also research private insurance carriers directly on their websites to get detailed information and quotes.
3. Compare plans: Look at what each plan covers, including preventive care, major services and any exclusions or limitations. Compare monthly premiums, deductibles, copayments and coinsurance. Verify that your preferred dentists and vision care providers are included in the plan’s network. 
4. Complete the application: Once you’ve selected a plan, you can enroll online, in person or over the phone. You’ll likely need to provide certain details about your household income and any existing insurance coverage.