Adult Dental EHB – A Good Idea, but Watch the Jenga Tower

By Mike Adelberg, NADP Executive Director

December 19, 2023

As most readers of this blog already well know, good oral health improves overall health, and oral health improves when people have dental coverage. In most states, the number of people lacking dental coverage is double those lacking medical coverage. Knowing this, the Centers for Medicare & Medicaid Services (CMS), which under the Affordable Care Act defines Essential Health Benefits (EHB) in health insurance, is proposing an important policy change. CMS proposes to allow states, for the first time, to include adult dental coverage in their Essential Health Benefits benchmark plans.

The National Association of Dental Plans supports policies that will result in more people being covered. The CMS proposal has the practical impact of bringing dental plans, medical plans, and state regulators to the proverbial Jenga Tower and asks each stakeholder to remove a block without upsetting the tower. As CMS fully considers this proposal, I ask CMS and other stakeholders to consider:

The Continuing Need for Stand-Alone Dental Coverage: While many medical plans embed a dental benefit, many others do not. Since it originated, dental insurance has usually been sold as a stand-alone product. The CMS proposal is silent on whether it will require adult dental to be “embedded” in the medical plan. If it does, this threatens to upend successful and common practices in both medical and dental insurance. It would also break with the successful precedent established for pediatric dental (already an essential health benefit). CMS does not force medical plans to embed pediatric dental when stand-alone dental plans already offer it. This flexibility has worked without a hitch for a decade and must be permitted in adult dental going forward.

Potential Cost Impacts: CMS’s rules for pediatric dental include a prohibition of annual maximums that limit the plan’s financial risk and require catastrophic protection for the few who require exceptional amounts of services. However, kids and adults use dental benefits very differently. For kids, the overwhelming majority of services are low-cost preventive care and cavity fillings. Adults require much more expensive restorative services such as crowns and implants. So, while preventing annual maximums and requiring catastrophic protection has a mild impact on plan premiums for pediatric benefits, the same rules for adult dental will require significant premium increases (whether the dental benefit is embedded or stand-alone). Waiting periods are also used in adult dental to prevent a consumer from purchasing coverage only when an expensive need arises. While some advocates dislike these practices, they hold down premiums, and lower premiums promote coverage. Higher premiums will have the opposite impact.

Selecting a Benchmark Plan: States that choose to add an adult dental EHB will then select a benchmark plan. When they do, there will be a temptation to select a plan with rich benefits. NADP supports providing the richest dental benefits possible, but a rich benchmark plan will negatively impact affordability. Millions of Americans and small businesses select dental plans with less generous benefits because they are inexpensive. If states are not prepared to subsidize the costs of richer dental benefits, they must carefully select a benchmark that keeps inexpensive plans in the market. CMS will not make this decision but is positioned to discuss this tension in its final regulation, and it can provide technical assistance to states without dental-focused actuaries.

I’m encouraged by CMS’s interest in promoting dental coverage and oral health. However, the proposed regulation, when finalized, needs to be more sensitive to the interdependencies and cost tensions in the dental benefits Jenga Tower. I offer myself and the considerable talents of NADP staff and dental plans to CMS so that we can strengthen, rather than weaken, the oral health of millions of Americans.