Affordable Care Act

Should Small Employers and Individuals Go to a Public Exchange for Dental and Vision Coverage?


Many Americans report that the ACA regulations for medical insurance are confusing. Thankfully, dental and vision are easier to understand.

Under the Affordable Care Act (ACA), starting on Jan. 1, 2014, all Americans without insurance or those working for a small employer are required to have minimal essential medical coverage through an employer, public exchange or private exchange. But this requirement does not include dental or vision insurance.

Stand-alone Dental and Vision Plans

According to the National Association of Dental Plans, 98 percent of dental benefits are provided through stand-alone dental policies for individuals or families, independent of a medical plan. Under the ACA, dental and vision benefits sold in stand-alone policies are not subject to most provisions. Only pediatric dental and vision benefits are part of Essential Health Benefit Packages (EHBPs), which are required to be offered to most individuals and small employers, unless their medical plans are grandfathered.

Many Employers Can Keep Same Benefits

In the ACA, employers are not required to purchase any health coverage for employees and their dependents through a health insurance exchange, which means they may keep their current medical, dental and vision benefits with the same insurance carriers.

Small employers planning not to offer employees access to insurance plans should still assist employees in finding the coverage that will best meet their needs and those of their family members.

As a note of caution, individual consumers choosing not to purchase health benefits may be assessed a small penalty, but it is not clear whether that extends to the purchase of pediatric dental or vision benefits in the small-group market.

Public Exchange Plans

Medical coverage offered within an exchange must include a pediatric vision and dental benefit. If the same exchange offers a stand-alone dental plan providing the required pediatric dental benefit, the medical plan has the option to exclude that benefit.

In an exchange marketplace, medical plans with dental or vision coverage likely will cover only children. This means that adults who purchase pediatric dental and vision coverage for dependents will need to purchase these benefits separately to maintain their own health. Adults and dependents purchasing dental or vision through an exchange or EHBP could then have different benefit plans than their children.

Combined Plans May Not Provide Expected Benefits

Exchange marketplaces may offer medical plans combined with dental and or vision coverage. While a medical plan offering dental coverage may seem cheaper (one premium), it may have a large combined deductible, and nonpreventive dental expenses may not be covered until the medical deductible is satisfied. The high out-of-pocket maximum for medical likely will have to be met before covered pediatric dental or vision would be paid in full by the plan.

Learn more about dental and vision coverage under the ACA by visiting our Affordable Care Act section.