Jul 11, 2024
New Potential ACA Rule – Adult Dental Coverage
A few months back, the Biden Administration proposed enhancing ACA insurance by adding adult dental coverage. This falls under the HHS Notice of Benefit and Payment Parameters 2025 Final Rule.
Currently, dental coverage for children under age 18 is an essential health benefit (EHB) under the ACA statute. Adult dental care is currently prohibited by agency regulations from being considered an EHB in individual and small group plans.
This new regulation, if passed and implemented, is of the first major changes made to the Affordable Care Act since first passed in 2010. This new regulation would allow individual states to require health insurers to include dental benefits through ACA marketplace plans in the individual and small group market.
The new rule provides states the ability to establish their own dental coverage elections and does not require them to do anything. If a state decides to label adult dental care as an EHB, the state must be sure that the same rules under the ACA are followed for adult dental coverage as they would be for other essential benefits.
States will be able to begin to require health insurers to include dental benefits/procedures as part of ACA plans beginning January 2027. But, if a state plans on participating in the expansion and update their benefits to include dental, they must indicate such by May 2025.
The dental benefits include the following services.
- Standard cleanings
- X-rays
- Fillings
- Root canals
Conservative states will likely take little or no action. More progressive states will embrace the decision to require insurers to implement and cover adult dental benefits.
Some Key Issues to Watch
Embedded deductibles might not provide consumers with financial protection for dental care.
- Consumers who receive dental care through embedded dental coverage may have to meet the medical deductible before coverage of dental benefits and services can begin.
Classifying adult dental care as an EHB could come at an increased cost to the federal government and health insurers.
- It is possible that application of advanced premium tax credits towards dental care could raise costs for the federal government. And, cost sharing provisions that apply to EHBs, such as the ban on annual and lifetime coverage limits and the maximum annual out-of-pocket limit, could possibly increase costs for health plan issuers since they could no longer apply these restrictions on dental care.
This new provision could affect employer-sponsored plans.
- Large employer plans do not have to meet EHB rules, however, if they chose to do so, ACA prohibits annual and lifetime dollar limits. The large employer plan is also required to choose a state benchmark in order to comply with this prohibition. So, if a self-insured or fully insured large employer plan choses a state benchmark plan that does include ‘adult dental care as an EHB’, the plan would be required to adhere to the cost-sharing requirements that apply to other EHBs under the ACA guidelines. Employer plans that offered dental plans separately as ‘excepted benefits’ would not be subject to the ACA requirements and probably would not be required to abide by the requirements.
Consumers could be subject to cost-sharing for preventive dental services.
- Currently under the ACA, preventive health services rated as an A or B in the USPSTF recommendations, are provided without cost sharing. The issue here is that no adult dental services have received this A or B rating. Consumers could be subject to cost sharing for routine preventive dental services or could be required to meet the deductible before coverage of preventive dental services begin.
- USPSTF = United States Preventive Service Task Force - USPSTF A and B Recommendations A and B Recommendations
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