When you transition from an employer-sponsored healthcare plan that offers vision and dental benefits to a Marketplace plan, you might find it surprising that those benefits aren’t also offered with healthcare plans on the Marketplace. Under the Affordable Care Act, dental and vision coverage for adults is not mandated by the ACA. However, dental and vision coverage are considered essential benefits for children under 19. Pediatric dental coverage must be included in the plan or offered as a stand-alone option while pediatric vision coverage must be in included in the plan since there are no stand-alone plan options on the Marketplace.
Stand-alone dental and vision plans may be purchased any time of the year, meaning there is no required open enrollment period, however there may be a waiting period before full benefits can be accessed. However, if you or your dependents are getting dental or vision benefits through a medical plan, you will have to enroll during your state’s Open Enrollment period or a Special Enrollment period if you’re entitled to one.
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- Dental Plans: Stand-alone dental plans might be available on the ACA Marketplace in your area.If available, you can either buy a health plan with a dental plan included or buy a stand-alone dental plan on the Marketplace. You can also get coverage through stand-alone dental insurance carriers. Some popular stand-alone dental insurers include Delta Dental, Metlife, and plans through major health insurance plans such as Aetna or Blue Cross Blue Shield. On the Marketplace, dental plans are split into two categories:
- High Option Plan: higher premiums, lower out-of-pocket costs
- Low Option Plan: lower premiums, higher out-of-pocket costs
- Despite the name, quality and access to care do not vary between the two, however it’s important to review the coverage limits and copays.Dental benefits that are integrated into a Marketplace health plan will have a provider network that has to be utilized in order to have coverage. Below are a couple of questions to consider when comparing plans:
- Do I need a referral to see a dental specialist? This is most applicable when comparing PPO and HMO dental plans.
- What is the coverage? Many dental plans operate on a 100-80-50 ratio: 100% preventative services covered, 80% of basic services like fillings covered, and 50% of advanced services like root canals and crowns covered.
- How much is it to add dependents to the plan?
- As mentioned above, stand-alone vision plans are not available on the Marketplace. However, some vision benefits may be included in some plans. Vision benefits that are integrated into a Marketplace health plan will have a provider network that has to be utilized in order to have coverage.
- Like standalone dental coverage, standalone vision coverage can be purchased at any time. Some popular stand-alone vision insurers include VSP and Ameritas.
Below are some questions to consider when comparing plans:
- Will you need both contact lenses and glasses coverage? Many plans alternate the allowable reimbursement for contact lenses and glasses per year.
- What is the coverage for corrective surgery (like Lasik)?
- How much are annual eye exams or contact fitting exams? Be aware of the different exam costs that come with different types of eye exams as well as lens enhancements such as UV protection on your glasses.
If you’re switching to a health insurance plan on the Marketplace, it’s important to consider how you will get vision and dental insurance if this coverage is familiar or important to you. The information in this article will help you make this decision, but you can also reach out to Caribou for assistance in deciding the best option for your health and financial needs.
Last Revised February 14, 2023
