A Hard Needle to Thread—Adding an Adult Dental Essential Health Benefit

By Mike Adelberg, NADP Executive Director

November 21, 2024

A year ago, when the Centers for Medicare and Medicaid Services (CMS) first proposed creating an adult dental Essential Health Benefit (EHB), I blogged that NADP supported the idea but warned of the “Jenga Tower” of unintended consequences that could accompany doing so. Now, I want to revisit this topic.

Per CMS’s regulation finalized earlier this year, states can add adult dental services to their EHB benchmark plan, shifting dental coverage from voluntary to mandatory. NADP wants to see Americans covered; dental insurance leads to better oral health and overall health.

But, in establishing this policy, CMS made two related decisions that, I fear, will harm consumers and likely make it impractical for states to adopt adult dental as an EHB. Specifically, CMS is 1.) treating adult dental services as a subset of ambulatory medical services, 2.) requiring that the adult dental benefit is embedded within the medical plan, despite most Americans having separate dental insurance.

I ask CMS and state policymakers to consider the risks to consumers of adopting adult dental EHB under this current construct.

A Largely Illusory Benefit: Dental insurance plans generally have low or no annual deductibles. Medical plans typically have large annual deductibles. If a dental benefit is embedded within a medical plan with a high annual deductible, consumers will find their dental coverage illusory until the latter part of the year when (and only if) the annual medical deductible is met. Consumers will go to their semi-annual teeth cleanings and discover they must pay out of pocket for services that are currently paid at 100%. This will suppress oral health.

Shifting to HMOs: Most consumers with dental insurance (more than 80%) are in PPOs that pay for services provided by out-of-network dentists. When a dental benefit is embedded into a larger medical plan, the medical plan will naturally select the lowest-cost product that satisfies the EHB requirement. This will shift consumers into lower-cost, closed-network dental HMOs. While DHMOs serve an important niche in the dental insurance world, I worry about the consumers who will lose the ability to see the dentists of their choice when this transition occurs. I also wonder whether DHMO networks will be ready for a surge of new patients.

Financing the Adult Dental Benefit: Adding adult dental to the benchmark plan must either raise the cost of the benchmark plan or be offset by reducing medical benefits. While dental services are a tiny fraction of the entire healthcare spend, the cost of adding adult dental must still be accommodated. I’ve asked how adult dental is added to the benchmark without tradeoffs in other benefits, and I have yet to see a way to do it. States may be tempted to minimize the tradeoffs by selecting a preventive-only dental benefit; this would be a step backward in providing real dental coverage to consumers and might not pass the “typicality” standard in the regulation as such benefits are atypical.

No Family Dental Home: Under the Affordable Care Act (ACA), standalone dental plans are an option for providing required pediatric dental EHB (that allows a family to maintain their current dentist). The requirement to embed adult dental services into medical benefits means there will be two structures for dental benefits: one for adults and one for children. Besides the inconsistency and consumer confusion this causes, it will make it much harder for consumers to maintain provider continuity and have all family members served by the same dentist.

There are other concerns with the current adult dental EHB policies from a legal and administrative perspective, but that is a subject for another time. Establishing an adult dental EHB is a hard needle to thread. NADP will work constructively with CMS, states, and other stakeholders until we thread the needle in the way that delivers the best dental benefits to the most consumers.