Biden Administration Proposes Rule to Include Adult Dental Coverage as an Essential Health Benefit on the ACA Exchanges

On Nov. 24, the Department of Health and Human Services (HHS) published in the Federal Register a proposed rule that would allow states to include adult dental services as an “essential health benefit” (EHB) that Affordable Care Act (ACA) health plans must cover without annual or lifetime limits. The rule governs issuers offering qualified health plans through federally facilitated exchanges and state-based exchanges on the federal platform, and it would allow adults who buy health insurance on the ACA exchanges to receive dental coverage as part of their medical care plan. Plan participants would still have to pay co-payments and/or co-insurance. The rule would become effective in the 2025 health insurance coverage year.

In the proposed rule, HHS intends to remove the regulatory prohibition at § 156.115(d) of its regulations governing the ACA. This section currently places a regulatory prohibition on health insurance companies from including routine non-pediatric dental services as an EHB. Removing the regulatory prohibition would allow states the option to add routine adult dental services as an EHB.

In most incidences, health insurance plans offered by private sector employers mirror those offered by the ACA exchanges.

HHS asserts that the purpose of this proposed change is to narrow a long-standing coverage gap in the 2010 health care law and to help advance health equity and mitigate health disparities as lower income populations and minority groups have limited access to dental care. Limited access impacts positive health outcomes.

Additionally, as part of its justification for the proposed rule change, HHS acknowledges the connection between oral health and systemic health, noting that, “oral health and overall health are inextricably linked; untreated oral health conditions can increase risk for and complicate the management of other chronic conditions. For example, studies have shown that periodontal disease and tooth loss are strongly associated with heart health, and oral health care can reduce the risk for cardiovascular disease, atrial fibrillation, and heart failure.”

Comments on the proposed rule are due on Jan. 8, 2024. The final rule will likely be released in the late spring or early summer of 2024, with implementation to follow in 2025. However, it is important to note that if HHS is able to include adult dental care as an EHB in the final rule, each individual state would still have to choose adult dental care as an option that they wanted to offer on their particular state’s ACA marketplace. If a respective state does not choose the adult dental care option, then that service will not be covered as an EHB on the state’s ACA exchanges.