More Americans could get dental coverage under Biden proposal
01/14/2024

Dental care could soon become more widely available to adults who buy health insurance on the Affordable Care Act marketplaces under a new federal proposal that aims to narrow a long-standing coverage gap in the 2010 health care law.

Why it matters: Healthy teeth and gums are tied to a person's overall health — for instance, gum disease is linked to cardiovascular issues and diabetes — but dental services are often treated differently than medical care.

The Biden administration proposal may especially benefit people of color and those with lower incomes, who are more likely to have poor oral health.

Driving the news: The Centers for Medicare and Medicaid Services last week proposed allowing states to include adult dental services as an "essential health benefit" (EHB) that ACA health plans must cover without imposing annual or lifetime limits on customers.

While states wouldn't have to require the coverage, the proposal would reverse a ban on states from including adult dental services as an essential benefit. However, insurers are already required to offer the benefit for kids covered through the ACA marketplaces.

When federal health officials over a decade ago first crafted EHB standards, they looked to employer health plans as a guide for what insurers would have to cover in the new ACA marketplaces. Since employers generally offer dental care separately from medical benefits, adult dental care was left out.

The administration is now walking back that decision. "Given that oral health has a significant impact on overall health and quality of life" and the high percentage of employers offering dental coverage, it makes sense to revisit the government's previous thinking, CMS wrote.

All states already offer at least one adult dental coverage option on the marketplace, but designating the benefit as "essential" would make coverage more accessible and generous.

Under the CMS proposal, the dental coverage could be wrapped into medical coverage or offered as a standalone plan.

What they're saying: "It's a really important moment in advancing the entire conversation" around oral health, Melissa Burroughs, director of strategic partnerships at Families USA, told Axios.

Families USA and other consumer advocacy organizations have been calling on CMS to make this change.

"[Health and Human Services] is to be applauded for recognizing the link between oral health and overall health and for making a proposal that is designed to allow for extended dental coverage," said National Association of Dental Plans executive director Mike Adelberg.

 

Yes, but: It's not clear how many states would add the coverage as an essential benefit. They'll have to consider how it would affect insurance costs.

If the proposal is finalized, states can add the benefit starting in 2025.

Zoom out: Dental coverage can be out of reach for adults with other types of government coverage. States do not have to cover adult dental benefits in Medicaid, and more than half provide limited or no coverage through their programs.

Traditional Medicare also doesn't cover dental benefits, though enrollees can get oral health coverage through private Medicare Advantage plans.

But earlier this month, the Biden administration expanded all Medicare beneficiaries' access to dental services when they're necessary for other medical care, like cancer treatment.

Improving coverage and access to oral health care is part of a strategic plan CMS laid out last year.

Separately, a bipartisan bill from Sens. Maggie Hassan (D-N.H.) and Roger Marshall (R-Kansas) would allow shoppers on HealthCare.gov, the federal-run ACA marketplace serving over 30 states, to purchase standalone dental plans without also having to enroll in a medical plan.