The Future Of Adult And Group Dental Coverage

Essential health benefits are offerings that must be covered by insurance plans under the Affordable Care Act (ACA), as defined by each state. These benefits include emergency care, prescription drugs, laboratory services, preventive care, and wellness services. While pediatric dental benefits have long been included as an essential health benefit, adult dental benefits have not. In November 2023, however, CMS proposed changing this because “oral health has a significant impact on overall health and quality of life.”

Pushing For Change

The American Dental Association (ADA) supported the CMS proposal allowing states to include adult dental insurance as an essential health benefit and submitted comments on behalf of its members to CMS and the Department of Health and Human Services (HHS). Additionally, the ADA suggested CMS and HHS institute a dental loss ratio and advocate for CMS to set a benchmark for adult dental plans. This would include “all the necessary services that are reasonable and appropriate for diagnosis, treatment, and follow-up care.”

The ADA's proposed adult dental plan design includes:

• Diagnostic and preventive services.
• Emergency care and restorative care.
• Oral and maxillofacial surgery.
• Endodontics and periodontics.
• Prosthodontics and orthodontics.

Efforts by the CMS and ADA paid off in April 2024 when the HHS Notice of Benefit and Payment Parameters for 2025 final rule cleared the way for states to add routine non-pediatric dental services as an essential health benefit. In another win, the revisions incentivized states to include adult dental care in their essential health benefits plans by clarifying that states will not have to cover the costs, as is typically required. 

The final rule, however, failed to define an adult dental plan benchmark or establish a dental loss ratio, as requested by the ADA.

Moving Decisions To The States — And Collateral Effects

Before the essential health benefits benchmark application period, which runs January 1, 2025, to May 7, 2025, states that choose to add routine adult dental coverage as an essential health benefit will need to draft their benchmark plan, determine their dental coverage limits, and solicit public comments. The changes will then become effective January 1, 2027.

While adding adult dental insurance as an essential health benefit will make routine dental care more accessible, the change will impact employers, individuals, and brokers. Brokers might experience a disruption in both broker support and the sales experience. Employers will need to amend their plan documents to include adult dental coverage, and both employers and individuals likely will face increased costs. 

Despite these challenges, insurers like Anthem applaud the possibility of greater equity in dental care and will work with both employers and members to help control costs and increase the value of their health coverage.