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ADA, AAPD comment on CMS proposed rule

November 28, 2017

By Jennifer Garvin

Baltimore — The American Dental Association and American Academy of Pediatric Dentistry on Nov. 27 filed comments on the Centers for Medicare and Medicaid's proposed changes to the benefits and payment parameters — including the definition of a "typical" employer plan and allowing states to limit their essential health benefits packages — that could adversely affect dental patients.

In a joint letter from ADA President Joseph P. Crowley and AAPD President James D. Nickman, the two organizations focused on five sections of the proposed rule, CMS-9930-P, the Notice of Benefit and Payment Parameters for 2019:

  • Navigator program standards.
  • Essential health benefits.
  • Standalone dental plans.
  • Network adequacy.
  • Essential community providers.

Navigator programs were established under the Affordable Care Act to help consumers understand their coverage options and find the most affordable coverage that meets their health care needs. The proposed rule seeks to change the existing requirement that each health care exchange have two navigator entities, with one being a community and consumer-focused nonprofit group. The new rule also eliminates the requirement that each navigator maintain a physical presence in the exchange service area.

"We believe this proposed change will limit consumers' abilities to take advantage of coverage that may be available, including pediatric dental services," wrote Drs. Crowley and Nickman. "We support maintaining the current navigator standards and funding, including the requirement for a physical presence to support in-person assistance to ensure consumers have access to necessary assistance as they select their medical and dental plan coverage."

Regarding essential health benefits, the new rule would allow states three new options to alter their essential health benefit benchmark by selecting:

  • Another state's 2017 benchmark.
  • One or more essential health benefit categories from another state's 2017 benchmark.
  • An essential health benefit benchmark plan equal in scope to a "typical employer plan" but no more generous than specified comparison plans.

Both the ADA and AAPD expressed concerns over the proposed rule's definition of a "typical employer plan."

"The rule proposes to define 'typical' as a small or large employer plan sold in one or more states with enrollment of at least 5,000 enrollees; or a self-insured group health plan sold in one or more states with enrollment of at least 5,000 enrollees. We are concerned that this proposed definition may lead to the selection of benchmark plans that have limited or less than comprehensive coverage for pediatric oral health services," Drs. Crowley and Nickman wrote.

Drs. Crowley and Nickman noted that previously both organizations have expressed concern over Utah's benchmark selection of a state employee health plan because it provides limited pediatric dental services and "does not provide coverage for restorative services such as fillings or root canals, which may be necessary to treat and manage dental disease." They also pointed out that currently Colorado, Michigan and Arkansas do not provide coverage for medically necessary orthodontia in their benchmark plans.

"Orthodontia may be part of a treatment plan for a child who has undergone surgery for a cleft lip and/or cleft palate, as an example," Drs. Crowley and Nickman said. "Our organizations support the offering and availability of comprehensive dental services as part of the [essential health benefits] as intended under the ACA.

The proposed rule allows states to limit their essential health benefits package, yet requires states to defray costs for any essential health benefits package that is "more comprehensive or provides for coverage of a new or necessary treatment" and proposes that for plan years following 2019, states may be limited to a "new, federal default [essential health benefits] definition and would be required to defray any additional costs."

In 2013, HHS finalized the requirements for the calculation of actuarial value for standalone dental plans, requiring them to adhere to a low actuarial value of 70 +/- 2 percentage points or a high actuarial value of 80 +/- 2 percentage points. The proposed rule is seeking to eliminate actuarial value requirements for standalone dental plans.

"Our organizations are concerned that this will negatively impact the benefit design and suggest that a minimum actuarial value of 70 percent remain in place for [standalone dental plans]," Drs. Crowley and Nickman wrote, adding that ADA and AAPD are "concerned that the proposed elimination of AV standards would impact the consumer experience when considering marketplace plans and inhibit the ability of consumers to understand the value of a plan."

Regarding network adequacy, Drs. Crowley and Nickman said that both the ADA and AAPD support network adequacy standard requirements for both standalone dental plans and medical plans with embedded pediatric dental coverage, specifically focused on adequacy of in- network pediatric and general dentists. The proposed rule would permit states that do not have the authority to conduct sufficient network adequacy reviews to rely on an issuer's accreditation "at least as consistent" as those included in the National Association of Insurance Commissioners Health Benefit Plan Network Access and Adequacy Model Act.

"The National Association of Insurance Commissioners model act does not address network adequacy standards for dental plans," Drs. Crowley and Nickman said.

"We request that CMS provide clarification in future rulemaking that every qualified health plan and standalone dental plan that offers pediatric dental coverage in the marketplaces include a range of dental providers, including pediatric dentists and other dental specialists," Drs. Crowley and Nickman said. "We also request that CMS clarify how the agency will determine that networks are sufficient and that networks contain sufficient numbers and types of providers to assure that all services will be accessible to enrollees without unreasonable delay."

Regarding essential community providers, the Affordable Care Act included requirements for issuers of qualified health plans and standalone dental plans to include a sufficient number and geographic distribution of essential community providers that include rural health clinics, safety-net and children's hospitals and community health centers. The proposed rule reduces the requirement for issuers to contract with available essential community providers from 30 percent in a service area to 20 percent.

"We urge CMS to reconsider the proposed 10 percent reduction to ensure that individuals have access to a wide range of ECPs to help ensure that timely and necessary oral health services are available without delay for all patients," Drs. Crowley and Nickman wrote.

Additionally, the ADA and AAPD encouraged CMS to following the Dental Quality Alliance's pediatric oral health measures from 2013 that "closely align" with CMS's oral health strategy and have been endorsed by the National Quality Forum.

"As the agency moves forward with incorporating additional quality improvement strategies, we urge the use of DQA-endorsed measures as well as encourage the agency to rely on the expertise of the DQA when implementing any QIS or additional quality requirements for oral health services and dental benefit plans," they concluded.