U.S. proposal would make adult dental coverage available under the ACA

The U.S. Department of Health and Human Services (HHS) published a proposal on November 24 in the Federal Register that would allow states to make dental coverage available to adults who buy health insurance from Affordable Care Act (ACA) marketplaces.

The agency is seeking comment on the proposal, which calls for ACA plans to cover dental care for adults without annual or lifetime limits, until January 8, 2024. If the proposal, which calls for dental coverage to be included with medical insurance or offered as a standalone plan, is finalized, states may add the benefit in 2025.

“We propose to remove the regulatory prohibition on issuers from including routine non-pediatric dental services as an EHB (essential health benefit),” according to the proposal.

In 2020, about 110 million people in the U.S. had private dental coverage. About 91% of those with private coverage get their benefits through an employer or an entity such as the AARP. Also, about 2 out of every 3 employers offer at least one dental plan, with 46% offering one plan, 18% offering two plans, and 3% offering three or more plans, according to National Financial Partners (NFP)'s "US Benefits Trend Report 2023."

Therefore, it appears that routine dental care for adults is “commonly covered as an employer-sponsored or other job-based benefit to a degree that warrants removing the prohibition on their provision as an EHB,” according to the proposal.

About a decade ago, when U.S. health officials first created the EHB standards, they used employer-sponsored health plans as a guide for what insurers would need to cover for the ACA marketplaces. At that time, dental coverage was not included because employers offer dental benefits separately from health insurance.

Since the beginning of his administration, President Joe Biden has made improving coverage and access to oral healthcare a priority. In 2021, the administration attempted to have Medicare pay for dental benefits for adults. Budget constraints eventually led the proposal to fail. Though many saw adding a dental benefit as making oral healthcare accessible to more patients, the addition to Medicare Part B has been a controversial topic in organized dentistry. The ADA and other associations opposed adding a dental benefit to part B.

In 2022, the U.S. Centers for Medicare and Medicaid Services expanded access to dental care by finalizing payment for services considered “integral to covered medical services.” The details were included in Calendar Year 2023 Physician Fee Schedule final rule released on November 1, 2022. Coverage began in 2023.