CMS finalizes rule prohibiting adult dental benefits as an essential health benefit

ODC opposes rule change, citing access concerns, lack of MLR for commercial dental benefits

The Centers for Medicare & Medicaid Services finalized several Marketplace Exchange policies affecting dental coverage in the 2027 Notice of Benefit and Payment Parameters Final Rule. The final rule includes a decision to reinstate the prohibition on routine nonpediatric dental services as an essential health benefit, while declining to finalize proposed reductions to essential community provider participation thresholds. 

The final rule contains both setbacks and partial victories for organized dentistry. The Organized Dentistry Coalition, which includes the ADA, urged CMS in a March comment letter to preserve state flexibility for adult dental benefits and maintain safeguards protecting access to safety-net providers. 

CMS finalized its proposal to prohibit routine adult dental services from being treated as an essential health benefit in qualified health plans, reversing flexibility that had allowed states to include adult dental benefits in Exchange benchmark plans. 

In the rule, CMS said because the statute only mentions pediatric oral care, the best reading indicates that nonpediatric oral care was not meant to be included as an essential health benefit.  

The agency also stated that reinstating the prohibition “better aligns with the statutory structure and the typicality standard, as routine non-pediatric dental services are not typically included in employer-sponsored major medical plans.” 

The Organized Dentistry Coalition opposed the proposal, writing that “these concerns outlined in the proposed rule do not reflect the original legislative intent, current market adaptations, or current plan infrastructure since adoption of the Affordable Care Act.” 

The presence of stand-alone dental plans should not be interpreted as evidence that Congress intended to exclude adult oral health services from comprehensive essential coverage, according to the letter.  

The letter also said the marketplace has evolved significantly since the Affordable Care Act’s enactment, noting that qualified health plans in 36 states already embed adult dental benefits. The coalition pointed to Medicare Advantage plans offered by major insurers as evidence that carriers already possess the infrastructure necessary to administer dental benefits. 

“Continued prohibition of non-pediatric dental services as an [essential health benefit] no longer serves its original purpose and would go against evolving markets and adult dental coverage in states,” the coalition wrote. 

CMS acknowledged comments from both supporters and opponents of the proposal, including concerns about access to dental benefits, provider network adequacy, and potential market disruption. In the final rule, the agency emphasized that embedding routine nonpediatric dental services as an essential health benefit “could have impacted [stand-alone dental plans]” and created “an ‘illusory benefit’” due to combined deductible structures and differences in how dental coverage is typically delivered. 

CMS also stated that embedding adult dental services as an essential health benefit in qualified health plans could have undermined the stand-alone dental plan market by reducing enrollee demand for stand-alone dental plans, and said reinstating the prohibition “preserves the stable dental insurance market structure that currently serves millions of enrollees.” 

CMS declined to finalize lowering essential community provider participation thresholds from 35% to 20%, which was a proposal that drew widespread opposition from provider organizations. The proposal would have reduced the minimum percentage of essential community providers, including federally qualified health centers and safety-net dental providers, that qualified health plans and stand-alone dental plans must include in their provider networks. 

In its March letter, the Organized Dentistry Coalition said the requirement ensures that lower-income consumers who purchased qualifying health plans or stand-alone dental plans in the Marketplace Exchanges will have access to providers who can treat them at lower costs. 

CMS also highlighted comments from dental organizations and health centers warning that federally qualified health centers serve as critical dental safety-net providers. The agency said it “take[s] note of the concerns raised by commenters that a reduction in the [federally qualified health center] threshold, considered alongside broader proposals affecting dental benefits, could have a disproportionate and compounding disadvantage for dental providers and the populations they serve.” 

The final rule also left current federal medical loss ratio standards unchanged. 

“Preserving [medical loss ratio] reporting remains essential in maintaining meaningful incentives for plans to increase access to care for their policyholders,” the Organized Dentistry Coalition said.  

CMS said it would continue considering stakeholder feedback regarding possible future adjustments to medical loss ratio standards in the individual insurance market.