ADA and AAPD respond to CMS request for information on essential health benefits

Dental groups support making pediatric oral health coverage mandatory in ACA exchange plans

“Coverage for pediatric dental services can provide necessary preventive and oral health education services that may prevent and manage disease,” the American Dental Association and American Academy of Pediatric Dentistry told the Centers for Medicare and Medicaid Services in response to the agency’s request for information on essential health benefits.

In a Jan. 31 letter , ADA President George R. Shepley, D.D.S., and AAPD President Amr M. Moursi, D.D.S., Ph.D., said their organizations support making pediatric oral health coverage mandatory within the Affordable Care Act exchange plans for families with children.

“Oral health is an essential part of overall health and tooth decay remains one of the most common, chronic pediatric diseases,” they wrote. “Coverage for pediatric dental services can provide necessary preventive and oral health education services that may prevent and manage disease.”

In the request for information, the two organizations shared ways the consumer experience of purchasing pediatric dental benefits could be improved as well as ways the coverage provided supports adequate access to care.

Additional benefits as essential health benefit

The ADA and AAPD urged CMS to include benefits for maternal oral health as an essential health benefit for one-year postpartum within the ACA Marketplaces, which would align with CMS’s recent expanded dental coverage for pregnancy in Medicaid and also address disparities in maternal health outcomes.

Issues with benchmark plans

The dental groups urged CMS to undertake a study to compare benchmark plans and assure that benchmark plans cover services to adequately meet the dental needs of the beneficiaries across all states with first dollar coverage for evidence-based preventive services.

Dental benefits as optional

Regarding pediatric oral health coverage, ADA and AAPD “strongly urged” CMS to close regulatory loopholes that allow pediatric dental benefits to be regarded as optional benefits for families with children.

Qualified health plans versus standalone dental plans

The organizations asked CMS to take steps to evaluate dental benefits offered as bundled or embedded products within qualified health plans with regards to application of deductibles and out of pocket maximums. They noted that qualified health plans continue to result in cost barriers for consumers, especially when cost sharing reductions are not made available to all consumers resulting in higher deductibles for those consumers choosing silver or bronze plans.

Dependent coverage

ADA and AAPD asked CMS to ensure that dependent coverage up to age 26 applies to the dental plans regardless of whether benefits are purchased as part of a QHP or a SADP.

Coverage criteria

Both the ADA and AAPD said they support coverage for comprehensive pediatric dental services as part of the essential health benefit as intended under the ACA, including routine exams, X-rays, cleanings and sealants, and restorative services such as fillings or root canals, as well as medically necessary orthodontia. Regarding medically necessary orthodontia, the organizations urged CMS to adopt standardized coverage criteria across all dental plans.

Emerging evidence-based services

The dental groups said they support modifying/updating essential health benefits for changes in medical evidence and scientific advancement, including, as mentioned in the request for information, the use of silver diamine fluoride for arresting progression of dental caries.

Follow all of the ADA’s advocacy efforts at ADA.org/advocacy .