By Zeynep Çelik, JoAnn Volk, Lindsay Cox, and Kevin Lucia
Dental care is an important element of comprehensive health care. Oral health impacts job opportunities and children’s success in school, and dental complications, if left untreated, can lead to negative health outcomes and even death. Inability to pay is a major obstacle to dental care, making insurance a key factor in access to dental services. Adults are more likely to face challenges accessing dental care compared to children. These discrepancies are exacerbated by racial disparities that are getting worse over time, with Black and Hispanic Americans continuing to face the highest level of unmet dental care needs.
The Affordable Care Act (ACA) recognized the importance of oral health to children’s development and learning outcomes, requiring coverage of pediatric dental services in many commercial plans, but the law had less of an impact on adult dental coverage. The Biden administration, recognizing that improved access to dental care supports oral health, overall health, and health equity for adults, recently proposed a change to federal rules that could expand adult dental coverage.
In this blog, the first in a series for CHIRblog on dental coverage in the Marketplaces, we summarize the legal framework of dental coverage and discuss potentially forthcoming changes under the proposed Notice of Benefit and Payment Parameters for 2025.
The ACA’s Limited Dental Coverage Requirement
Pediatric Dental Coverage
Pediatric dental services are one of the ten essential health benefits (EHBs) that qualified health plans (QHPs) offered in the individual and small group markets must cover, including plans sold through the ACA’s Marketplaces. However, the ACA does not require QHPs to embed pediatric dental benefits in the underlying health plan. Instead, these plans may forgo all dental benefits so long as there is a stand-alone dental plan (SADP) available on the Marketplace, unless state policy otherwise compels QHPs to include pediatric dental services.
SADPs come at an additional premium cost and carry a separate maximum out-of-pocket limit. Subsidies that reduce an enrollee’s premium can be applied to pediatric dental benefits covered by SADPs only if the enrollee has financial assistance left after it is applied to the QHP. Given this cost burden, and because families are not required to purchase an SADP for their child (even if the family’s QHP doesn’t include embedded pediatric dental benefits), a child enrolled in a QHP may not have dental coverage.
Marketplace dental benefits have to meet certain standards and cost-sharing limits. When offered either as an embedded benefit in a QHP or as an SADP, pediatric dental coverage must be equivalent to the covered services required under the state’s CHIP plan or the plan available to federal employees. As an EHB, any cost paid towards pediatric dental care in a QHP plan must count towards the maximum out-of-pocket limit of the plan. And when offered through an SADP, out-of-pocket costs for dental services are capped at $350 for one child and $700 for two or more children.
Adult Dental Coverage
In contrast to pediatric dental coverage, under current regulations, adult dental care cannot be considered an EHB. This means that QHPs generally do not include adult dental benefits, leaving most people to purchase a separate SADP whose cost-sharing structure is determined by the insurers and typically imposes dollar limits on covered services. Most SADP purchasers on the Marketplaces are working-age adults who pay entirely out-of-pocket for dental coverage that does not count toward their annual out-of-pocket limit.
Because insurers have flexibility in whether and how they cover adult dental services, coverage varies widely across plans. As a result, a family may purchase a QHP that includes pediatric dental benefits, but they may also need to pay for an SADP for adult family members in the same household as many states do not have QHPs with embedded adult dental benefits. An additional plan could be prohibitively expensive, even for Marketplace enrollees eligible for substantial subsidies, which currently only apply to pediatric dental services.
A Recent Proposal Could Expand Dental Coverage for Adults
The proposed Notice of Benefit and Payment Parameters (NBPP) for 2025 could help fill in current gaps in adult dental coverage. Under the proposed change to federal regulations, states would be permitted to require coverage of adult dental services as part of the EHB. This would mean that plans in the individual and small-group markets would be required to cover adult dental services. Those services would also be subject to the ACA’s prohibition on annual dollar limits on benefits and caps on enrollees’ annual out-of-pocket costs, removing current barriers to dental care for adults that require high-cost dental procedures.
Enrollees in plans offered in the large-group market and by self-funded employers could be indirectly impacted by the proposed rule. While these plans are not required to cover EHBs, the ACA requires them to limit annual out-of-pocket costs and refrain from annual or lifetime dollar limits on EHBs. If a state updates its EHB benchmark plan to include adult dental services, and a large employer or self-funded plan selects the state’s EHB benchmark plan to determine the scope of services subject to the ACA protections, then adult dental services will be subject to the cap on annual out-of-pocket spending and restrictions on dollar limits.
However, even where Marketplace plans now include adult dental services, states would still have to go through the process of updating their EHB benchmark plan to require adult dental services as EHB. States that opt to include adult dental services could improve oral health outcomes in communities that face unmet dental needs, including people of color and low-income groups.
Next Steps
The ACA’s dental coverage requirements set a floor across all states for pediatric dental coverage. If finalized, the proposal in the 2025 NBPP would allow states to build on this progress and require coverage of adult dental benefits as an EHB. But whether and how states would update their EHB offerings to include adult dental services remains a question.
The preamble to the proposed NBPP includes considerations for states that might take advantage of this new policy, including the need to build a network of providers and how to offer that network to enrollees. States would also need to establish rules for how adult dental services are embedded; the federal policy allowing Marketplace plans to omit pediatric dental benefits based on SADP availability does not extend to adult dental benefits. Additionally, states would need to define the scope of adult dental coverage as an EHB. If the proposed change is made final, states that seek to update their EHB benchmark plans to include adult dental services will have to resolve these questions.
Even after a historic expansion of health insurance coverage under the ACA, dental coverage remains out of reach for many Americans. States that choose to expand EHB under the 2025 NBPP proposal could remove current barriers to adult dental services, improving health outcomes for all Marketplace enrollees, and particularly for populations disproportionately impacted by these barriers.
