Access to Adult Dental Care Gets Renewed Focus in ACA Marketplace Proposal


The 2023 KFF Consumer Health Insurance Experience Survey found cost barriers to adult dental care across insurance types. The survey was conducted in February and March 2023 and included a nationally representative sample of 3,605 U.S. adults with health insurance. This Policy Watch discusses a new proposal in the 2025 Health and Human Services (HHS) Benefit and Payment Parameters to expand coverage of adult dental care in Affordable Care Act (ACA) Marketplace plans.

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Although dental coverage for children under 18 years of age is an essential health benefit (EHB) under ACA regulations, agency regulations currently prohibit adult dental care from being considered an EHB in individual and small group plans. Therefore, it is excluded from the ACA's major cost-sharing protections applicable to EHBs, such as prohibited annual and lifetime dollar limits and annual maximum limits on consumer out-of-pocket cost-sharing, and is not eligible for premium subsidies. For adults seeking dental care through the marketplace, there are still some coverage options available through stand-alone dental plans (SADP) or embedded plans (medical plans that include dental coverage). Dental care is often subject to a deductible, but the National Association of Dental Plans reports that many dental plans waive the deductible for preventive dental care like cleanings or cover 100% of preventive care. Dental coverage included in an embedded plan is typically subject to the plan's medical deductible, which averages $3,057 through 2024. cost. By comparison, the average deductible for standalone dental plans offered on the individual market will be $47 in 2023, which includes all qualified and nonqualified plans sold on of stand-alone dental plans: and over-the-counter.

The KFF Consumer Health Insurance Experience Survey found that consumers who reported having insurance at the time of the survey tended to avoid seeking dental care if out-of-pocket costs were high. Across insurance types, at least one-quarter of adults with health insurance report cost barriers to accessing dental care in the past year, including about four-in-ten with Medicaid (39%) and Marketplace insurance (37 % ) of adults and one in four covered by ESI (25%) and Medicare (26%) (figure 1).

Delaying needed dental care can lead to more serious health problems in the future. Poor dental health is linked to chronic conditions such as diabetes, heart disease and oral cancer, and can also place an additional burden on the health care system when patients seek care elsewhere.

The 2025 HHS Notice of Benefit and Payment Parameters proposes lifting the prohibition on classifying regular adult dental health insurance as an EHB. Under this proposed rule, states would have the option to classify adult dental care as an EHB. If a state elects to list adult dental health as an EHB, that state (or the federal government as a fallback) will be required to implement the same ACA protections for adult dental coverage that apply to other EHBs. They may also choose to impose additional protections on adult dental coverage offered as an EHB, above and beyond the federal requirements for an EHB.

What are the key issues to focus on?

Embedded deductibles may not provide consumers with financial protection for dental care. One issue raised in the comment letter for the 2025 Payment Notice is that consumers who receive dental care through embedded dental insurance may have to meet a medical deductible before they can begin receiving dental services. If a state elects to cover adult dental care as an EHB, a health plan is required to cover it, and a medical deductible may apply. Medical plan deductibles can run into the thousands of dollars, which can deter consumers, especially those with lower incomes, from seeking dental care.

Classifying adult dental care as EHB could increase costs for federal government and health issuers. CMS said in the proposed rule that it does not anticipate incurring any direct costs by giving states the option to include adult dental care in the EHB. However, implementing a prepaid premium tax credit for dental care could increase costs to the federal government. Additionally, cost-sharing provisions applicable to EHBs, such as prohibitions on annual and lifetime coverage limits and annual out-of-pocket maximums, may increase costs for health plan issuers because they can no longer apply these limits to dental care.

New rules may affect employer-sponsored plans. Small employer plans (such as those in the individual market) must cover EHBs. While large employer plans do not have to meet the EHB rules, federal regulations require these plans to select a state benchmark to comply with the ACA's prohibitions on annual and lifetime dollar limits. CMS noted in the proposed payment notice that if self-insured or fully insured large employer plans elect to include adult dental care as an EHB in a state's benchmark plan, they will be required to comply with that applicable to other EHBs. However, employer plans that offer dental plans separately as an “excepted benefit” (not subject to the ACA's comprehensive health insurance requirements) may not need to comply with these requirements.

Consumers may need to share the cost of preventive dental services. The ACA requires most private health plans to cover, without cost-sharing, preventive health services rated A or B in the U.S. Preventive Services Task Force recommendations; however, no adult dental services receive an A or B rating. Consumers may be required to share the cost of routine preventive dental services or be required to pay a deductible before coverage for preventive services begins, although as noted above, many private health plans already cover preventive health services, such as before the deductible begins. clean.

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The ACA's EHB requirements are designed to ensure that consumers in the individual and small group markets have comprehensive coverage that meets important health needs. The law requires the HHS Secretary to define an EHB that covers at least 10 general categories of benefits and has the same scope as benefits under a “typical employer plan.” According to the 2023 KFF Employer Health Benefits Survey, 90% of small companies and 94% of large companies offer dental insurance plans to their employees. If the proposed 2025 payment rules are finalized as proposed, it would allow states to elect to include adult dental care as a required benefit in state-regulated health plans. This could strengthen efforts to increase access to dental care, especially for low-income adults who are particularly vulnerable to unmet dental health needs. Additionally, KFF research shows that dental expenses are a component of medical debt. CMS and states may evaluate the most appropriate approach to establishing an adult dental benefit that provides financial protection against debt for common basic care, balanced by potential increases in federal costs.

This work was supported in part by a grant from the Robert Wood Johnson Foundation. The opinions and analysis contained here do not necessarily reflect the views of the Foundation. KFF maintains full editorial control over all of its policy analysis, polling, and news activities.



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