E. Optional Coverages

1. Dental

Dental insurance typically distinguishes among several classes of dental expenses and treats each differently:

• Routine and preventive maintenance — covered up to an annual maximum with no deductible or copayment, usually including a routine exam and cleaning once a year and a full-mouth x-ray every 3 years. Waiving the deductible and copayment for this category is meant to encourage preventive care.
• Routine and major restorative care — covers cavities, oral surgery, bridges, and dentures, subject to an annual deductible per insured family member, a separate maximum, and coinsurance.
• Orthodontic care — if included, carries its own separate maximum and its own separate deductible, which may differ from the deductible applied to restorative care.

Pediatric dental coverage is an essential health benefit under the Affordable Care Act and must be made available, either as part of a health plan or as a stand-alone plan, for children age 18 or younger. Insurers are not required to offer adult dental coverage. Depending on the state, pediatric dental benefits may be delivered through a qualified health plan that includes dental coverage, a stand-alone dental plan purchased alongside a qualified health plan, or a contracted/bundled plan.

2. Vision

Some employers offer vision coverage as a form of group health insurance to pay for eye examinations, eyeglasses, or hearing aids on a limited basis. Under the Affordable Care Act, pediatric vision benefits are mandatory. Most vision expense plans commonly restrict adult benefits to one exam and one pair of glasses in any 12-month period.

3. Supplemental Accident

Accidental Death and Dismemberment (AD&D) coverage may be written as a rider to an existing policy or as a stand-alone policy, though it is most often included as part of group life and group health plans. AD&D pays a lump-sum benefit if the insured dies as the result of an accident (as defined in the policy) or suffers the loss of certain body parts or senses due to an accident.

Because AD&D pays only for accidental losses, it is considered a pure form of accident insurance. The principal sum — usually equal to the face amount of the policy — is paid for accidental death. For the loss of sight or an accidental dismemberment, a percentage of the principal sum, known as the capital sum, is paid, with the amount varying according to the severity of the injury.

A policy will typically pay the full principal sum for the loss of sight in both eyes or the loss of two or more limbs, but may pay only 50% of the principal sum for the loss of a single hand or foot. Some policies also include double or triple indemnity provisions, under which the policy pays twice or three times the face amount in the event of accidental death. Most policies pay the accidental death benefit only if death occurs within 90 days of the accident.