ADA urges Senate Finance Committee to include dental in insurance reforms

Association backs state waiver authority, calls for greater transparency and accountability in dental benefits 

The American Dental Association is urging the Senate Finance Committee to ensure dental benefits are included in potential health insurance reforms, including proposals addressing self-funded dental plans, greater oversight for third-party administrators, prior authorization and benefit transparency. 

The ADA submitted comments in response to a request for information from Senate Finance Committee Ranking Member Ron Wyden, D-Ore., seeking input on potential reforms across individual, employer and public insurance markets. The request for information, titled “Health Coverage That Works for Everyone,” focuses on opportunities to improve health coverage across these markets. 

The Association said dental benefits can be overlooked when broader insurance reforms are designed around medical coverage. 

“Oral health is integral to overall health, yet dental benefits are frequently omitted from broader insurance reform discussions,” reads the letter, which was signed by ADA President Richard Rosato, D.M.D., and Executive Director Nader Nadershahi, D.D.S., M.B.A., Ed.D. 

Drs. Rosato and Nadershahi urged the committee to expressly apply relevant reforms, when appropriate, to stand-alone, embedded and supplemental dental benefits, self-funded employer dental plans and the entities that administer those benefits. 

Among the Association’s priorities is addressing differences between protections available to people with fully insured dental plans and those with employer-sponsored self-funded plans. 

According to the letter, states have enacted 400 dental insurance reforms addressing issues including prompt payment, noncovered services, assignment of benefits, network leasing, prior authorization and retroactive denials. Carriers and administrators of self-funded plans frequently assert that the Employee Retirement Income Security Act preempts them from following these state laws, the ADA said. 

The request for information asks whether states should have waiver authority to regulate portions of the self-insured market and apply protections more consistently across private markets. 

“The ADA is highly supportive of the state waiver concept identified in the [request for information],” the Association wrote. “We believe the Committee should expressly permit states, through their insurance regulator, to seek federal approval, to apply specified state dental insurance protections to self-funded employer dental plans and the entities that administer them.” 

The ADA said eligible protections could include prompt-payment standards, restrictions on fees for noncovered services, prior authorization, limits on retroactive denials and recoupments, network-leasing transparency and provider-directory accuracy. The Association also reiterated its support for H.R. 7931, the Improving Dental Administration Act, which would exempt certain state laws related to dental benefits from ERISA preemption. 

Drs. Rosato and Nadershahi also called for greater oversight of third-party administrators and other entities involved in administering dental benefits, including entities that manage or lease dental networks, reprice claims or process dental payments. The ADA said federal requirements should follow the function an entity performs rather than its label and provide greater transparency into compensation and plan administration. 

They also recommended dental-specific standards for prior authorization, claims, denials, appeals and payment practices, saying federal reforms should account for dental coding, terminology and workflows. Clinical dental determinations should be made or reviewed by a U.S.-licensed dentist, with appropriate specialty expertise when necessary, the letter said. 

“A dental benefit should not be denied or reduced solely because preauthorization was not obtained when the patient otherwise qualifies for the benefit,” the ADA wrote. “Routine diagnostic and preventive services should not be subject to unnecessary preauthorization.” 

The ADA also called for standardized dental benefit information, accurate provider directories, meaningful network standards and dental loss-ratio accountability. According to the letter, stand-alone dental plans generally are exempt from the Affordable Care Act’s federal medical loss-ratio requirements. Drs. Rosato and Nadershahi called for public, standardized reporting on how dental premium dollars are spent and greater accountability for how those dollars support patient care. 

They also recommended greater oversight of supplemental dental benefits offered through Medicare Advantage plans, including reporting on dental spending, utilization, denials and network participation. According to the letter, dentists should be given the option of opting out of Medicare Advantage networks rather than automatically enrolled when they are part of the plan sponsor’s commercial insurance network. 

The ADA also addressed vertical integration, calling for disclosure when insurers or administrators own or control dental practices or related entities and safeguards addressing potential conflicts involving coverage, networks, claims payment and patient steering. 

On broader coverage policy, the ADA reiterated its support for treating pediatric and adult dental benefits as essential health benefits and preserving state authority to add or strengthen adult dental coverage.  

“The [request for information] presents a significant opportunity to improve the value, transparency and accountability of health coverage,” Drs. Rosato and Nadershahi concluded. “That work should not leave dental benefits behind.”