Stakeholders Weigh in on a Proposal that Could Expand Adult Dental Coverage

By Lindsay Cox, Zeynep Çelik, JoAnn Volk, and Kevin Lucia

In November, the Biden administration released the proposed Notice of Benefits and Payment Parameters (NBPP) for plan year 2025, an annual rule setting standards for the Affordable Care Act (ACA) Marketplaces and health insurers. A detailed two-part summary of the proposed 2025 NBPP can be found on Health Affairs Forefront here and here. The final rule is expected soon.

One of the proposed changes to federal regulations would permit states to require coverage of adult dental services as part of the Essential Health Benefits (EHB). If finalized as proposed, states opting to update their EHB “benchmark plan” to include adult dental coverage would prompt plans in the state’s individual and small-group markets to cover adult dental services. Those services would also become subject to the ACA’s prohibition on annual and lifetime dollar limits on benefits as well as caps on enrollees’ annual out-of-pocket costs. This would alleviate current financial barriers in adult dental plans and help reduce income-related disparities in dental care access. 

As part of a CHIRblog series on Marketplace dental benefits, CHIR examined how this provision of the proposed 2025 NBPP would impact access to dental coverage and care. The first blog post in this series summarized the legal framework of Marketplace dental coverage and detailed the potentially forthcoming changes under the proposed 2025 NBPP. For this second blog in the series, CHIR reviewed comments submitted in response to the proposed rule by select stakeholder groups, including consumer advocates, dental providers, state-based Marketplaces (SBMs) and state insurance departments, health insurance plans, and dental insurance plans.

SBMs and State Insurance Departments

Consumer Advocates

Dental Providers

Health and Dental Plans

While the proposed rule covered many issue areas,* this blog post focuses on comments in response to the proposal that would permit states to designate routine adult dental services as an EHB.

Proposal that Would Allow States to Designate Adult Dental Services as an EHB Receives Mixed Reviews

Consumer Advocates, Dental Providers, SBMs and Insurance Regulators Supported Proposal to Facilitate Adult Dental as an EHB 

Consumer advocates, SBMs, and state insurance regulators in our sample unanimously endorsed the proposal to permit states to require coverage of adult dental services as part of the EHB. Nearly all dental providers in our sample also supported the proposed policy, with the exception of AGD. Some stakeholders urged HHS to go a step further and mandate adult dental coverage as an EHB, emphasizing the importance of comprehensive coverage for improving access to care and addressing disparities. For example, Families USA and Community Catalyst asserted that a mandatory coverage policy would provide better protection than a piecemeal approach where states opt in to update their benchmark plans.

Payers Voiced Concerns Regarding the Proposed Rule Change, Citing Costs

Many health plans and health plan associations in our sample were either against the proposed change to the EHB or otherwise voiced strong concerns.  The plans voicing opposition cited the impact expanded coverage would have on the affordability of coverage options as a result of EHB expansion. Among dental plans, NADP supported the proposed change, while Delta, noting it “does not oppose” the option to add adult dental benefits to EHB, raised concerns, including cost increases due to adverse selection if adults wait to enroll in a plan with dental benefits until they need care. Delta said these costs can be mitigated with waiting periods, dollar limits on benefits, and preexisting condition exclusions that can apply if adult dental benefits are not considered EHB. Health and dental plans also pointed to potential operational challenges, including the incorporation of dental conditions into risk adjustment, the impact of dental benefits on plans’ actuarial value, and integration of cost-sharing accumulators.

Some stakeholders opposing this provision offered alternative approaches should HHS finalize the proposal. United requested delaying the effective date to no earlier than 2027. Several health plan comments suggested mimicking the approach that allows insurers flexibility to exclude pediatric dental coverage from qualified health plans (QHP) if there are stand-alone dental plans (SADPs) available in the Marketplace, arguing that this would better reflect how adult dental services are covered in a “typical” employer plan and suggesting the SADP market would otherwise collapse and enrollment would decline significantly. However, HHS has stated that, unlike pediatric dental benefits, there is no statutory basis to provide this exception for routine adult dental services.

Even Among Supporters, Calls for Clarity in Benefit Design for EHB Dental Plans

Some comments approving of the proposed change asked for more clearly defined benefits to ensure consistency and equitable access to dental care. The New York Marketplace recommended that federal regulators define “routine” dental services. Many dental groups, like the ADA and the CDA, went further, advocating for a detailed definition of benefits. For example, the ADA urged HHS to require an expansive set of benefits that includes “all the necessary services that are reasonable and appropriate for diagnosis, treatment, and follow-up care (including supplies, appliances and devices).” Both the ADA and the CDA also recommended a required dental loss ratio (often referred to as a DLR), similar to a medical loss ratio (MLR), to ensure dental plans spend a minimum share of premium dollars on dental care rather than administrative costs and profits.

Other comments, however, asked that HHS instead provide flexibility for states to define adult dental as an EHB, emphasizing the importance of state choices in this realm. The NAIC, for example, asserted that “determining exactly which dental benefits should come with EHB protections should . . . be based on state needs and preferences.”

Looking Forward

The proposal facilitating the addition of adult dental to the EHB definition has ardent supporters and dissenters. It remains to be seen if the proposal will be finalized, and if so, whether and how the benefit will be defined. If finalized, expanding EHB to include adult dental services would remove cost barriers to adults in communities that have disproportionately lacked access to dental care.

In our next blog in the series, we will look further into how states and stakeholders may opt to implement adult dental as an EHB to improve access and affordability of dental insurance, should the final NBPP include this provision.

*Previous blogs looked at stakeholder comments on other provisions of the proposed 2025 NBPP, including comments from insurers and brokers, consumer advocates, and state insurance departments and Marketplaces.

A Note on Our Methodology

This blog is intended to provide a summary of comments submitted by including consumer advocates, dental providers, SBMs and state insurance departments, health insurance plans, and dental insurance plans. This is not intended to be a comprehensive review of all comments on every provision in the proposed 2025 NBPP, nor does it capture every component of the reviewed comments. To view more stakeholder comments, please visit https://www.regulations.gov/.