Essential Benefits Update: AAPD and ADA Advocacy Efforts Continue

Federal Guidance Released on Dec. 16, 2011

Comments Due Jan. 31, 2012

On November 9, 2011, the AAPD and ADA met for a second time with staff of the Center for Consumer Information and Insurance Oversight (CCIIO), which is a new agency under CMS (the Center for Medicare and Medicaid Services) that was created under the Affordable Care Act (ACA).  CCIIO is responsible for writing the federal guidance to states concerning "essential benefits" that are required to be covered by all qualified health plans (QHPs).  Effective Jan. 1, 2014, QHPs are those plans in the small group and individual market offered inside or outside of state insurance exchanges.  Pediatric oral health is one of the essential benefits under the ACA, with the statutory guidance being that it should follow a "typical employer" plan.  The AAPD and ADA have provided extensive analysis and recommendations to CCIIO staff, based on the AAPD policy on model dental benefits.  A comprehensive analysis of the current dental insurance market-place was also provided, with both associations arguing for robust consumer choice among dental plans that have comprehensive coverage and adequate provider networks.


CCIIO subsequently released "essential benefits" guidance to states in the form of a bulletin, rather than a proposed regulation, on December 16, 2011.  The AAPD and ADA are preparing joint comments on this guidance, which are due January 31, 2012. Some preliminary analysis of the guidance is as follows:


¨      The guidance is clearly geared towards state flexibility, meaning there will be many specific decisions about implementing essential benefits made at the state level- along with overall implementation of state health insurance exchanges.  

¨      States are directed to look at benchmark plans.  For example, when considering adequate stand-alone pediatric oral health plans, states are pointed towards the Federal Employees Dental and Vision Insurance Program (FEDVIP) dental plan or state CHIP dental plan, which is consistent with recommendations from the AAPD and ADA.

¨      It is unclear what parameters for pediatric oral health must be followed when such coverage is offered under a medical plan.

¨      The treatment of state insurance mandates like general anesthesia appears to be favorable, for those states that already have such laws in place.


The federal CCIIO bulletin can be accessed at:

Along with these other background materials of note:


Additional information on this critical issue will be provided in upcoming issues of PDT and AAPD E-News.  For further information contact Chief Operating Officer and General Counsel C. Scott Litch at (312) 337-2169 or



Back to News