California has a state-run exchange named Covered California for the sale of certified individual/family medical and dental plans.
Unlike most states, California requires all health insurers that offer plans in the Marketplace to embed pediatric dental coverage in the medical plans. So any child enrolled in a health insurance plan through Covered California has pediatric dental coverage integrated with their health coverage.
In addition, stand-alone dental plans are available for purchase that cover both adults and children. Covered California clarifies that if a family chooses to purchase stand-alone dental coverage in addition to a health plan, coordination of benefits will apply to the pediatric dental coverage on the two plans.
For adults who purchase their own stand-alone dental coverage through the exchange in California, premiums in May 2024 ranged from about $9 to $54 per month. 1
If a family is purchasing coverage through the health insurance exchange, the premiums associated with embedded pediatric dental coverage can be offset by premium tax credits (premium subsidies). But since all of the health plans sold through Covered California include embedded pediatric dental benefits, premium subsidies cannot be used to offset the cost of a separate stand-alone dental plan. (Here’s more about how subsidies work for pediatric dental coverage, depending on whether the health plan has integrated pediatric dental benefits.)
In California, the stand-alone pediatric dental plans available through the Marketplace (Covered California) will comply with the ACA’s pediatric dental coverage rules. This means out-of-pocket costs for pediatric dental care will not exceed $400 per child in 2024 (or $800 for all the children on a family’s plan), 2 and there is no cap on medically necessary pediatric dental benefits.
When a family is relying on pediatric dental benefits that are embedded into a health plan, the out-of-pocket costs can be higher. But there is still no limit on how much the health plan will pay, as pediatric dental is an essential health benefit and thus cannot be subject to annual or lifetime benefit caps.
For all essential health benefits, the specific coverage requirements for pediatric dental care are guided by the state’s essential health benefits benchmark plan.
You can see details here for California’s benchmark plan, which does include coverage for both basic and major dental services for children. All major medical plans sold through Covered California include embedded pediatric dental coverage, but it’s also possible to purchase additional stand-alone pediatric dental coverage and the plans will coordinate benefits. 3
In 2024, there are five insurers that offer stand-alone individual/family dental coverage through the health insurance marketplace in California. These are dental plans that are not included with a medical plan and must be purchased separately.
These plans can be purchased through Covered California during open enrollment (November 1 to January 31) or during a special enrollment period triggered by a qualifying life event. Exchange-certified stand-alone dental plans are compliant with the ACA’s rules for pediatric dental coverage. And benefits will coordinate with the pediatric dental coverage that’s integrated with all medical plans sold through Covered California.
There are also a variety of dental insurers that sell stand-alone dental plans directly to consumers in the Golden State. These plans are not subject to the ACA’s essential health benefit rules for pediatric dental coverage, but they are regulated by the California Department of Insurance. If you would like to purchase a non-ACA qualified dental plan, ask a dentist for recommendations or search online.
In California, there are also various dental discount plans available. Dental discount plans are not insurance, but they can offer discounted rates at participating dentists. Here’s what you need to know about the differences between dental insurance and dental discount plans.
To find off-exchange discount plans in your area, search online for dental discount plans and California.
The Medi-Cal Dental Program, which is part of Medi-Cal (California’s Medicaid program) provides free or low-cost dental services to children and adults.
Adults enrolled in Medicaid in California are eligible to receive full dental benefits up to $1,800 a year (with the possibility to exceed the annual limit if deemed medically necessary).
California Healthy Families (which is California’s CHIP) provides coverage to children and pregnant women with income above the eligibility limits for Medicaid.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.
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