Pediatric Dental Benefits under Medical policies

By Martine G. Brousse (not AI!)

"The Medical Bill Whisperer"™

Patient Advocate, Certified Mediator

AdvimedPro

January 7, 2025

Watch the video: https://youtu.be/jM3ClIL1q9I

Thanks to Obamacare or the Affordable Care Act, has been in effect, insurance companies must offer pediatric dental benefits if they sell their policy on open market, through a Marketplace, or if they cover companies with 50 or less employees, either as a separate policy or under the medical coverage of their parents.

Let’s explore children’s dental care and services when covered under the medical policy.

A. “Medical” vs “Dental”

1.     “Medical” benefits usually means services preventive, diagnostic or therapeutic when rendered by medical professionals (surgeons, PCPs, specialists, therapists), or facilities (hospitals, surgery centers, infusion centers, imaging centers) but also drugs, devices and ambulance rides.

2.     “Dental” care is considered a completely separate portion of your body, and therefore usually excluded under the medical portion of a policy.

B. What do ”dental benefits” cover while under a “medical” policy?

It covers three types of services: preventive, diagnostic and therapeutic.

1.     “Preventive” services usually come at no cost to you, the parent.

·      Two cleanings a year,

·      some X rays,

·      sealant in the back molars,

·      fluoride applications,

·      yearly check-up/evaluation.

2.     Should the dentist find any kind of issue, services are no longer free but likely (partially) payable by your plan:

·      Detailed X-rays or CT scan to determine the extent of the issue

·      Evaluations or consultations with specialists

3.     Treatments

·      Fillings

·      Periodontal maintenance or intervention

·      Root canals

·      Oral surgery

·      Cleft palate reconstruction

·      Preparation for radiation or cancer treatment

·      General anesthesia if the child’s age, physical or mental condition or medical necessity require it

·      Emergency services due to an injury to the jaw or for an injury from chewing or biting (usually not just from biting on a nut) but resulting from a specific medical or mental condition)

·      Orthodontics (braces) may possibly be covered

·      TMJ is often a condition that brings up confusion. While both surgical and non-surgical treatments are usually covered, the extent of coverage for the associated services may vary per policy.

C. Common exclusions

·      Cosmetic treatments (whitening, excessive spacing between teeth..)

·      Treatment for crowded dentitions (unless affecting ability to eat)

·      Extractions required for orthodontic purposes (before braces)

·      Replacement or repair for appliances or braces, that are lost, stolen or broken 

·      Dental implants

·      Speech or language assistance, 

·      devices including for sleep

·      General anesthesia or IV sedation (unless medically necessary, see above)

·      Cost of any precious metal used to any kind of dental service

·      The extend of exclusions vary per plan

D. Tips

1.     Make sure your plan is covered under the mandates of the ACA. 

If not, you may have what is called a self-funded plan: your employer decides what benefits 

are available, under what circumstances, and whether dental coverage for your children is even available.

2.    Go through the Evidence of Coverage or policy to confirm that those braces are covered,

 or whether deep cleanings are allowed.

3.    Call your insurance company before any scheduled treatment to confirm coverage and share of cost.

4.    Call your insurance to report any dental emergency to ensure highest rate of pay, and avoid a denial

5.    While emergency care should be covered at the higher In Network rate, be aware that any follow up or subsequent services rendered by the same out of network provider can be  excluded, reduced or paid at the lowest Out Of Network rate.

6.    Time is important. Your child can get two cleanings per year, but do they need to be 

six months apart? How often are sealants, X-rays or check-up visits allowed or payable?  Is there a waiting period for a procedure?

7.    Always request a written cost estimate or even a pre authorization before any non-emergency service is rendered, especially for treatments or expensive procedures. This will establish which of the medical or dental part of your policy accepts responsibility, will help determine your final share of cost and how much to expect your insurance to cover.

Conclusion: Even if that provider is In Network with Your plan, both the office and your wallet can avoid bad surprises down the line by doing a little bit advanced work. 

Better contact your insurance and ask them if a specific provider or a specific procedure 

will be covered and at what cost before the facts.

Better yet to get the information in writing. As for the dental provider or office, they should do their due diligence and inform you ahead of time – whenever possible – of what to expect, from a clinical as well as a financial point of view.

Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.

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