by Mark Roberts

When you think of dazzling smiles, those Hollywood starlets most often come to mind. But most people who live in California have a difficult time keeping up with the Kardashians when it comes to their dental care. If you have the cash, then you can buy the smile of your dreams, but if you are a regular Joe (or Josephine), the cost to have affordable dental care is beyond the reach of most families.

Developing a pricing structure for dental coverage requires extensive experience to design the plan and set a predictable premium that employers and employees can rely on for budgeting. Many carriers that offer dental don’t have the expertise to price coverage accurately. They may initially price plans low and then have to raise rates to cover unanticipated costs.

In a recent Sacramento Bee news article, information about dental care in California was provided as a high level overview of dental care and Affordable Care Act (ACA) health plans — two very distinct but connected health care products. Pediatric dental care is an essential health benefit as defined in the ACA. Adult dental care is not.

You’d expect that pediatric dental would be part of every plan because it’s an essential health benefit. But it didn’t quite work out that way this year. Due to a variety of factors that are too complicated to talk about in this article, pediatric dental wasn’t embedded in Covered California’s 2014 health plans. Next year, however, it will be included as well as the cost, and pediatric dental will account for about 1% of premiums, according to Covered California.

That’s nothing new for Californians who purchased their 2014 health insurance from the private market. With some exceptions, they already pay for pediatric dental coverage whether they like it or not, whether they have kids or not. The concept is similar to mandatory coverage for maternity and newborn care. Men don’t birth babies. However, the idea is that everyone pays into a big insurance pool to spread cost and risk.

The network of dentists available to your kids will depend on your health insurer. Insurers say they’re not limiting their dental networks the same way that some health plans limited their doctor and hospital networks this year. That doesn’t necessarily mean it will be easy to find a participating dentist. Several plans will offer dental HMOs, which means your child must stay in-network to obtain covered dental services. (With a PPO, your child can visit out-of-network dentists but you pay higher out-of-pocket costs.)

You cannot just select any dentist to receive covered services. Around the state, only about one in 10 dentists participate in an HMO. It’s higher in urban areas than rural ones. If the dentist you want isn’t in-network, there’s another option that affects adults as well. Covered California will be offering optional, stand-alone dental plans for adults and families next year, though they won’t be available when open enrollment begins on November 15. Look for them in early 2015, before open enrollment ends.

These plans — both HMOs and PPOs — cost extra and will be offered by six insurers, with choices varying by region.  For example, a stand-alone dental plan for an adult in Alameda County will run $12.99 to $64.25 per month, depending on the insurer and type of plan. You can add children to these stand-alone plans (as long as at least one adult is enrolled) for a cost. In San Diego County for instance, monthly rates range from $8 to about $34.  However, any tax credits you may be eligible for from Covered California cannot be used to defray the premiums for these stand-alone plans.

If employees are having trouble finding a dentist for their children in their embedded dental plan, they might find a participating denti st in a stand-alone plan. Plus there’s some positive news about cost. Although adults often face annual benefit limits on the amount their dental insurance covers, there are some new rules for kids. For both embedded dental coverage and the optional, stand-alone plans, there is no annual benefit limit on kids’ dental care. In the embedded coverage, anything you pay for it counts toward the plan’s annual out-of-pocket maximum, which will be capped at $12,500 for family policies in 2015.

In the stand-alone plans, the out-of-pocket maximum will be only $350 per child, with a maximum of $700 for two or more kids. Assuming you cover one child, plans will start paying for 100% of your kid’s covered dental treatment once you’ve spent $350. A final note on coverage: Even though children can stay on their parents’ health plans up to age 26, their embedded pediatric dental coverage will only last up to age 19.

Adults who purchase pediatric dental plans will need to purchase coverage separately for themselves and their dependents age 19 and older. Within a family, there could be different needs for dental care: Dependents age 19 and older may have special dental needs or may wish to purchase teeth whitening coverage in addition to routine dental exams. Adults may notice changes in their oral health as they age, which may require services beyond preventive care to help them enjoy good overall health in their senior years.

Children may need additional dental coverage for special needs, including cosmetic orthodontia.

Families need flexible dental coverage that can be customized. With dental insurance they are likely to schedule regular checkups and exams, so doctors can evaluate the health of their teeth and develop the right treatment plan.

Americans of all ages have dental needs. It is important to focus on children’s oral health since baby teeth lay a foundation for dental and medical health throughout life. Adults also should be reminded of the value of taking good care of their teeth and gums to avoid developing serious medical conditions. Having a mix of dental plan options is essential so employees can choose the plan that best meets their family members’ needs. Whether you offer fully insured, self-funded, indemnity, or discount plans, the real need is to make sure they can afford it. Brokers and employers can help employees understand the value of dental coverage, as well as the wisdom of paying a small monthly fee for dental care to protect their health and that of their family.


Mark Roberts’ professional sales background includes over 30 years of sales and marketing in the tax, insurance and investment markets. Mark is a licensed life, health and accident insurance agent in all 50 states and DC, for insurance products and discount health plans. Mark has also been writing a health care blog for the past 7 years, (, which is a topical weblog about various health care issues. You can reach Mark at