CMS dental rule a step forward, but more work still needed: Exec

CMS' final rule adding routine adult dental services as an essential health benefit under the Affordable Care Act is a step in the right direction for improving accessibility, according to Kaz Rafia, DDS.

The new rule allows states to add routine non-pediatric dental services as an essential health benefit to benchmark plans beginning in 2025. CMS said the new rule expands access to care by removing regulatory barriers, and also gives states the opportunity to improve oral health outcomes for adult patients.

Dr. Rafia, the chief health equity officer and executive vice president at the CareQuest Institute for Oral Health, recently spoke with Becker's to discuss the rule and what it means for dental care accessibility going forward. 

Editor's note: Responses were lightly edited for clarity and length.

Question: What was your initial reaction to the final rule from CMS?

Dr. Kaz Rafia: It's incredibly exciting. This is an incredible step forward building on the momentum that's been generated recently in the policy landscape when it comes to dental benefits. Of course, I have to hold myself back from focusing on the glass half empty and just really lean into the glass half full and how much of a victory this is moving forward.

Q: How many people could this potentially affect?

KR: There's a couple of ways we can look at this. Firstly, when we're talking about folks who have been to the exchange — [maybe] around 21 million people just in 2024 — if that number were to carry over into 2027 with zero change, which we know won't be the case, we're talking about provisions of access to that many individuals. We can also talk about the number of folks who our own research has shown end up being disenrolled through the Medicaid disenrollment plan. When you talk about redetermination, our own assessment was 14 million people, but I like to think of it as, if 20 million or 21 million people have signed up for the ACA this past year, it stands to reason that this is the number of folks who at the bare minimum will be impacted when this rule goes into effect.

Q: Do you have predictions for how many states could potentially add these services to their marketplace?

KR: We can sit and prognosticate as to who is going to show up and do the right thing and who may hold back, but to me this is a space where the advocates on the ground, those network leaders who are doing the hard work to build on this momentum, [have] to have those meaningful conversation with their legislature, knock on doors and spread the message that HHS gave their guidance and now it's up to us to go ahead and deliver. If I were to throw a dart at the board, I would say the states that have expanded Medicaid, so that would be all states minus 10, are going to be the ones that are probably going to step up. 

Q: What might keep a state from making this move?

KR: What immediately comes to mind [is] perhaps some push back from organized arms of the dental professions. It could cause concerns around network adequacy and workforce shortages and what that would mean. In a tactical sense, it would be everything from resourcing to budgeting, to the workforce, to counter-advocacy against this. 

What doesn't change is the impact of lack of access and what that lack of access means to the bottom line of a state. When folks don't have access to oral healthcare, what that means is that they're not going to be able to be employed, they're going to be having visits to the [emergency department], they are going to be suffering from physical and behavioral conditions that are as a result of their oral health conditions. So what I encourage everyone to do is to look across the horizon to see, if not now, then when? And if we don't want to talk about the impact of oral health and equities and disparities on a state's bottom line, I don't know what other imperative we can lean into to actually do this.

Q: Is there anything missing from this rule?

KR: Well, it's not a mandate and there's a lot of flexibility around the states. It is not forcing the states to do this. In an absolute ideal world, we'd love for this to have been defined at the federal level, a little bit more of a firmer stance on this. Having said that, when it comes to that level of coordination of policy and interface of state and federal, there's a lot of navigation that needs to be done. There's a lot of delicacies that need to be maneuvered around, so we're appreciative of the fact that this victory is on our column, but there's still work that needs to be done.

Q: What trends are you following right now regarding dental care accessibility?

KR: There's building momentum and generated force behind the fact that oral health is no longer peripheral to overall health. Adult dental benefits are now referred to as essential health benefits. If nothing else, just zeroing in on that by itself is powerful. On one hand, I think states are realizing investment in Medicaid adult dental benefits and creating access for everyone across the board and resourcing them adequately has benefits that are wide-ranging beyond the provisions of oral health. Federal government realizes it. Our research and the research a lot of our partners are doing connect the pieces of oral health and physical and behavioral health and how the systems and diseases are interconnected. I think that conversation is going to continue. I do see health systems leaning into it when we're talking about medical-dental integration and what that play looks like....that sector leaning into this is really exciting for me and I think it's going to be incredibly transformative in these next few years.

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