The American Dental Association is warning Congress that dental coverage risks getting overlooked as lawmakers consider broader health insurance reforms, calling for state oversight of self-funded dental plans, reforms to prior authorization practices and benefit transparency, according to a Sept. 30 news release from the ADA.
Here are seven notes:
- The ADA’s central goal is state waiver authority, which would allow states, through their insurance regulators, to seek federal approval to apply state dental insurance protections to self-funded employer dental plans and the companies that administer them. Carriers and administrators of those self-funded plans frequently argue that ERISA preempts them from following state dental insurance laws.
- States have already enacted 400 dental insurance reforms covering issues like prompt payment, noncovered services, assignment of benefits, network leasing, prior authorization and retroactive denials — protections the ADA wants extended to self-funded plans, which currently fall outside their reach.
- The ADA reiterated its support for H.R. 7931, the Improving Dental Administration Act, which would exempt certain state dental benefit laws from ERISA preemption.
- The organization called for dental-specific standards on prior authorization, claims, denials and appeals, arguing federal reforms need to account for dental-specific coding, terminology and workflows rather than being modeled solely on medical insurance. It also wants clinical dental determinations made or reviewed only by a U.S.-licensed dentist with relevant specialty expertise.
- On preauthorization specifically, the ADA wrote that “a dental benefit should not be denied or reduced solely because preauthorization was not obtained when the patient otherwise qualifies for the benefit,” and that routine diagnostic and preventive services shouldn’t require it at all.
- The letter calls for dental loss-ratio accountability, noting that standalone dental plans are generally exempt from the Affordable Care Act’s medical loss-ratio requirements. The ADA wants public, standardized reporting on how dental premium dollars are spent, plus greater oversight of Medicare Advantage dental benefits, including reporting on spending, utilization, denials and network participation.
- The ADA also raised vertical integration as a concern, calling for disclosure when insurers or administrators own or control dental practices or related entities, along with safeguards against conflicts involving coverage, networks, claims payment and patient steering. More broadly, the organization reiterated its support for treating pediatric and adult dental benefits as essential health benefits while preserving states’ authority to add or strengthen adult dental coverage on their own.
Read the ADA’s full comment letter here.
