Health Care Reform and Dental

Understanding Pediatric Essential Health Benefits

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

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

  • Pediatric dental benefits focus on preventive care. This benefit covers the most commonly preventive procedures for children such as exams, cleanings, fluoride, sealants and x-rays at 100%.
  • There are no annual maximums or lifetime maximums.
  • Annual out-of-pocket expenses for co-insurance are capped at $1,000 for one child and $2,000 for two or more children. Out-of-pocket expenses include co-insurance and deductibles for services provided by a network dentist.*
  • Offering consumers a wide choice of dentists was another important provision of the ACA. Altus Dental offers the state’s largest Preferred Provider (PPO) network of dentists, with more than 3,000 dentists, and more than 6,000 dental office locations in Massachusetts, Rhode Island and southern New Hampshire. The Altus Dental network includes general dentists and specialists, including pedodontists (dentists who are trained to treat children). Most importantly, you don’t need a referral to visit specialists in the network.
  • Coverage for Medically Necessary Orthodontic Services 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 ACA provisions, there are no lifetime or annual maximum limitations for medically necessary orthodontia, which is covered at 50%*

*Please note: Co-insurance paid to out-of-network dentists does not count toward the out-of-pocket maximum. That’s why it’s best to seek treatment from dentists who belong to the Altus Dental network. Click here to find a dentist in your area.

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 as a young adult on the parent’s plan up to age 26.