States Have New Flexibility to Add Adult Dental Care to Essential Health Benefits
JoAnn Volk, Georgetown University’s Center on Health Insurance Reforms; Tara Straw, Manatt Health
On April 2, 2024, the Centers for Medicare & Medicaid Services (CMS) offered a new option for states to update their essential health benefits (EHB) benchmark plan to require coverage of routine adult dental benefits. Research has highlighted significant disparities in oral health outcomes for adults depending on their insurance status, race and income. For example, Black adults are twice as likely to have untreated dental caries as White adults. While there are multiple drivers of inequities in oral health, including limited access to dental providers, a primary barrier to accessing dental services is the cost of care, a barrier that can be reduced with dental insurance. This expert perspective provides an overview of the newly available flexibility and discusses considerations for states weighing whether to add a requirement that plans subject to EHB cover routine adult dental care.
Adult Dental Care as an Essential Health Benefit
The Affordable Care Act (ACA) designates pediatric dental services as one of the ten essential health benefits that insurers offering plans in the individual and small group markets must cover, including plans sold through the ACA’s Marketplaces. As an EHB, any cost paid towards pediatric dental care must count towards the annual limit on out-of-pocket costs and insurers cannot place dollar limits on covered benefits.
Adult dental care may be among a plan’s covered services, whether through Marketplace plans or stand-alone dental plans (SADPs), but prior federal rules prohibited those services from being considered an EHB. Recognizing that improved access to dental care has been shown to improve overall health and health equity, CMS has removed the prior regulatory prohibition on EHB including routine adult dental services, thereby allowing states to require coverage of these services. States must use the federally prescribed process to update their benchmark plans to enact this coverage change, even if their benchmark plan currently includes routine adult dental care. The earliest date a coverage requirement can take effect is January 1, 2027 (with benchmark plan updates submitted for CMS approval by May 7, 2025). Under the ACA, pediatric dental requirements allow Marketplace insurers to omit pediatric dental benefits from their plans as long as those benefits are available through a SADP. However, that allowance does not apply to routine adult dental services; they must be embedded in the underlying Marketplace plan.
Considerations for States
In finalizing the proposal to give states the option to require coverage of routine adult dental services as an EHB, CMS notes that states will need to “weigh the advantages of expanded dental services against the challenges of providing such services.” Indeed, a state’s decision of whether to include adult dental care in its EHB benchmark raises many novel questions. Among those:
Defining “Routine” Dental Services
The regulations do not define what services should be considered “routine” dental care, giving states license to make that as narrow or broad as they wish. Currently, several states cover non-routine dental benefits for adults in their EHB, generally related to emergency dental services that require hospitalization, but states occasionally go further. For example, beginning in 2025, North Dakota’s EHB benchmark will cover “diagnosis and treatment of periodontal disease in acute or chronic disease state if recommended by a board-certified medical practitioner based on health-related impacts or on further deterioration in disease state due to gum disease,” but the benchmark otherwise excludes coverage for routine adult dental or orthodontia. CMS has given states broad flexibility to define routine adult dental services to meet the needs of their market and enrollees. In determining the scope of covered routine benefits, states need to balance any potential impact of a richer benefit on premiums and actuarial value, with enrollees’ needs and the potential for dental care to lower non-dental costs, among other factors.
Satisfying the Typicality Standard
Separately, CMS requires states to demonstrate that their proposed EHB benchmark has benefits equal in scope to a “typical” employer plan (a requirement of the ACA) by providing an actuarial analysis showing that it falls within the limits of the least and most generous of exemplar employer plans. Given the flexibility to define routine adult dental services, states can design their coverage requirement to fall within the upper limits of the “typical” employer plan. Even with this flexibility, as noted by CMS, a state seeking to add routine adult dental benefits “may need to consider removing and/or adjusting other benefits to make room for the non-pediatric dental services to fit into the scope of benefits within the state, to ensure the scope of benefits falls within the typicality standard.”
Premiums and Cost-Sharing
Adding routine adult dental benefits to EHB may, depending on the generosity of the benefit and other factors, raise premiums to some extent. However, any potential premium increases will be offset by some improvements in affordability for Marketplace enrollees. As an EHB, routine adult dental services can be offset by premium tax credits. It will also improve affordability for families that may obtain coverage of pediatric benefits through their Marketplace plan but, absent a requirement to cover routine adult dental services, need to purchase a SADP to obtain coverage for those services. However, any premium increase will not be offset by tax credits for those purchasing coverage in the small group market.
States may also want to consider tradeoffs in affordability of out-of-pocket costs. As an EHB, insurers may not impose annual or lifetime dollar limits on routine adult dental services, although insurers can impose visit limits. Many SADPs cover adult dental services as non-EHB benefits without having to meet a deductible, but impose dollar limits on covered services. Embedding adult dental care in the underlying Marketplace plan would make that coverage subject to the plan deductible, unless a state requires pre-deductible coverage.
Networks
Insurers required to cover EHB may need to establish a new network of dental providers to deliver the range of “routine” dental services as defined by the state. CMS notes that this can be done by contracting directly with providers or with a SADP to deliver services—a model used by some Medicare Advantage plans—as long as the enrollment, service delivery and payment of premiums and cost-sharing is seamless to the enrollee. In addition, insurers offering plans in Federally Facilitated Marketplaces and, beginning in 2025, in State-Based Marketplaces, must meet network adequacy time and distance standards for dental providers, as well.
CMS also recognizes operational concerns regarding insurers’ lack of expertise and infrastructure to incorporate the dental coverage procedure codes necessary for appropriate payment. For example, they may have little experience with dental service codes (Current Dental Treatment, or CDT, codes).
Effect on the Stand-Alone Dental Plan Market
SADPs can be useful to people with a range of dental needs, including routine services. Coverage of routine adult dental services in EHB could affect SADPs in a few ways. First, if insurers integrate routine dental coverage into qualified health plans, typical SADPs might be more likely to only cover non-routine care; this could lead to risk selection if only people who need more costly non-routine dental care purchase that coverage. Furthermore, some states allow individuals to purchase a SADP without having to purchase a Marketplace plan. This option can be attractive to Medicare enrollees and to individuals with employer coverage that doesn’t include dental care. States may want to consider how adding routine adult dental to their EHB benchmark plan may alter the scope, affordability and availability of SADPs.
Effect on Self-Insured and Fully-Insured Large Group Plans
Self-insured and large group plans are not directly subject to EHB requirements and would not need to add adult dental services if the state expanded EHB. However, in general, plans must use a permissible definition of EHB (which could include any of the EHB benchmark plans selected in any state) to determine whether they comply with the annual limitation on cost-sharing and restrictions on annual and lifetime dollar limits. If the large group or self-insured plan selects an EHB benchmark plan that includes routine adult dental services, and if the plan opts to cover routine adult dental services, the cost-sharing limitations and prohibition on dollar limits that are common in today’s employer-sponsored dental coverage would apply to those services.
Looking Ahead
The new option for states to require coverage of routine adult dental benefits gives states the opportunity to mitigate longstanding inequities in oral health and help improve overall health outcomes. To do so, states will need to consider the affordability and access tradeoffs of requiring this coverage and the operational challenges of making it available in the plans sold on- and off-Marketplace.