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15-Year-Old Wants Braces: Will Obamacare Cover Them?

Filed by KOSU News in US News.
December 18, 2013

It turns out that readers of all ages — from teenagers to seniors — have questions about the health law. We try to answer the latest batch.

I’m 15 years old, and I really want braces. If my mom signs me up for Obamacare, will it cover it?

It depends. Under the health law, pediatric dental coverage is one of 10 essential health benefits that must be offered to people who shop for plans on the health insurance marketplaces. Depending on the state, dental coverage may be offered on its own rather than as part of a regular health plan. If it is, you wouldn’t necessarily get dental insurance coverage unless your mom buys a standalone plan.

Under the law, plans are required to cover only medically necessary orthodontia, says Colin Reusch, a senior policy analyst at the Children’s Dental Health Project. States or insurers may define medical necessity differently. To determine whether you qualify, a dentist would generally refer you to an orthodontist to evaluate how misaligned your teeth are or whether you have difficulty chewing, for example.

“It’s probably worth contacting a couple of plans his mom is considering and asking how they define medically necessary orthodonia,” says Reusch.

Insurance typically pays 50 percent of the cost of braces; the total cost can exceed $5,000. For this kind of pricey care, your family might be better off with a standalone dental plan, says Reusch, because the deductible and out-of-pocket maximums will generally be lower than those of a standard insurance policy.

I’m on Medicare, but my wife is 63 and has no health insurance. Our income is $51,000, and we can’t afford the health plan premiums offered in Oklahoma. My wife’s income is $10,000 per year, and it’s all Social Security. To avoid the penalty for not having insurance, can we file separately?

If you file separate income tax returns, your wife’s income would be significantly lower and she might avoid owing a penalty for not having health insurance. But the financial ramifications of taking that step could be much more costly than the penalty itself, says Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities.

The penalty for not having insurance next year is $95 or 1 percent of income, whichever is greater. Your wife could avoid owing the penalty if her income is below the threshold for filing a tax return ($10,000 for an individual in 2013) or if buying a plan would cost more than 8 percent of her income.

Our tax system favors married couples who file their income taxes jointly, however. In general, joint filers pay a lower income tax rate overall. What’s more, if your wife files separately, her Social Security benefits will be taxed.

Some tax credits can’t be used at all if a married couple files separately, including premium tax credits to buy health insurance on the state marketplaces. These are available to people with incomes between 100 and 400 percent of the federal poverty level ($15,510 to $62,040 for a couple in 2013). While your wife’s income alone would be too low for a premium tax credit, under your combined income she should be eligible.

“This is a good example of why we can’t look at health care in isolation,” says Straw. “At the end of the day they would probably lose money [if they filed separately]. You may solve one problem only to create another for yourself.”

I will be able to keep the insurance available through my employer next year, but the deductibles and out-of-pocket limits in 2014 are frightening. Not only are some of my medications expensive, but my employer plan will be excluding coverage for 14 drugs. Is it acceptable under the ACA for me to purchase a prescription plan to stack with my employer plan?

There’s nothing in the health law that would prohibit you from beefing up your drug coverage with a drug discount card or buying supplemental insurance like a dental, vision, accident or single illness plan, for example, says Anne Waidmann, a director in human resource services at PwC, a consuting and accounting firm. None of those types of plans count as health insurance for the purpose of satisfying the requirement that people have what’s called minimum essential coverage starting in January. If you want to add to your existing coverage, you can.

If you have more questions, there’s a decent change we’ve already come up with the answers. Check the NPR Affordable Care Act app here. [Copyright 2013 Kaiser Health News]

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