Most California health plans include children’s dental and vision coverage at no extra cost. The pediatric dental and vision coverage will tend to mirror the health plan type like HMO or PPO. Parents should leverage the children’s coverage first before enrolling in other dental and vision plans.
The California health plans will offer a variety of children’s or pediatric dental and vision services at no cost.
Children’s Dental and Vision Coverage Embedded in Health Plans
The Evidence of Coverage or Member Agreement of your health plan will outline any pediatric dental and vision coverage. This document will also explain the type of coverage and network of providers the health plan is using for children’s coverage.
Usually, the pediatric dental and vision coverage will mirror the type of health plan. If your health plan is an HMO, the children’s dental and vision will have an HMO copayment cost structure. PPO plans will have coinsurance for some services and offer out of network coverage.
Some health plans maintain their own network of dentists and optometrists. Other health plans will contract with a third party or other insurance company to manage the benefits. For example, an HMO health plan may contract with the HMO DeltaCare dental plan to manage the children’s dental benefits.
Children’s Dental Coverage
Regardless of whether the children’s dental coverage is HMO or PPO, there will be long list of dental services that are no charge for children with in-network dentists.
HMO dental plans will have a fee or copayment schedule for specific dental services. For example, Amalgam – one surface (filling for a cavity) is $25 under this HMO plan. The set copayment helps budget for dental services.
A PPO children’s dental coverage will have many preventive services at no cost. Other restorative services like fillings, extractions, or crowns will be subject to coinsurance. For example, to have your child’s cavity filled, you pay 20 percent and the plan pays 80 percent. If you receive the services from an out of network (non-participating dentist) you will pay a higher coinsurance percentage.
Orthodontics will only be covered if they are medically necessary, regardless of whether it is an HMO or PPO coverage.
Children’s Vision Coverage
HMO vision coverage will have many routine diagnostic services at no cost. The frame allowance is $150. You pay all costs over $150 for the frames. Certain extra items like polarized lenses will be an extra set cost.
The PPO vision coverage is very similar to the HMO coverage for your costs. The big difference is you can use an out of network optometrist and still get some coverage for services, lenses, and frames. However, you will pay more if you use an out of network optometrist.
HMO dental and vision coverage embedded in the health plans may not work very well for families who live in rural areas. There tend to be fewer – or no – HMO dentists and optometrists in rural areas. You may have to drive a distance to visit a dentist who accepts the HMO dental plan. In these situations, it may be more cost effective to purchase your children a separate dental or vision plan.
YouTube video of the children’s dental and vision coverage.
