The ADA is urging the Centers for Medicare & Medicaid Services to revise how it defines essential health benefits, saying both pediatric and adult dental coverage should be considered essential health benefits. 

In a comment letter responding to a CMS request for information on the Essential Health Benefits framework the ADA said oral health benefits should be treated as a core component of comprehensive health coverage rather than an optional add-on. The Association also requested that CMS reconsider and rescind its current prohibition on states adding adult dental services as an essential health benefit. 

“The American Dental Association believes that, both pediatric and adult dental benefits should be considered ‘Essential Health Benefits’ (EHB), which is a policy long espoused by the association,” the letter states. “Coverage inside and outside of the Marketplace Exchanges must include pediatric and adult dental benefits and should not include dollar-value annual and lifetime maximums.” 

Much of the ADA’s comments focused on how CMS defines a “typical employer plan.” when used as a benchmark to define a plan that meets the essential health benefits criteria. CMS has suggested defining such plans based primarily on major medical coverage, but the ADA said the definition should encompass the full range of health-related benefits employers commonly offer. 

“The American Dental Association maintains that the term should encompass the comprehensive portfolio of healthcare-related benefits routinely offered by employers, including dental coverage,” the letter states. 

According to the ADA, many employers already offer dental benefits alongside medical coverage, making dental insurance a routine component of employer-sponsored benefits. The letter also said using self-funded plans as the primary benchmark for defining essential health benefits would be inappropriate because those plans are not subject to the same benefit requirements as fully insured plans. 

“Inclusion of adult dental services aligns with the statutory standard that [essential health benefits] reflects the scope of benefits provided under a ‘typical employer plan,’ while also advancing clinical effectiveness and long-term affordability,” the letter added.  

The ADA said adult dental benefits should be evaluated as part of preventive care and chronic disease management. According to the letter, preventive dental services “play a foundational role in pediatric and adult good oral and systemic health,” and expanding adult dental coverage would align with CMS’ emphasis on prevention.