Press Release

March 19, 2013
Cardin, Senators Urge CMS to Protect Affordable Dental Coverage for Children

Washington, DC – U.S. Senator Ben Cardin (D-MD) has called on the Obama Administration to ensure that the pediatric dental benefits guaranteed by the Affordable Care Act (ACA) are affordable and accessible for American families.  He was joined by eight other Senators, including Finance Health Subcommittee Chairman John D. Rockefeller (D-WV), Appropriations Committee Chairwoman Barbara A. Mikulski (D-MD) and Senators Ron Wyden (D-OR), Michael Bennet (D-CO), Sherrod Brown (D-OH, Robert P. Casey, Jr. (D-PA), Bernard Sanders (I-VT), Martin Heinrich (D-NM), in a letter to the Acting Administrator of the Centers for Medicare and Medicaid Services Marilyn Tavenner that urges CMS to “establish a framework in its federally facilitated exchanges that encourages the purchase of pediatric dental benefits and holds families harmless regardless of how those benefits are offered.” The letter follows the release of a final rule on the Essential Health Benefits by the U.S. Department of Health and Human Services (HHS) that contradicts the intent of Congress that dental coverage for children be integrated into coverage offered by health insurance exchanges and not constitute an extra expense for families.  

“The whole point of adding pediatric dental benefits to the essential health benefit package was to make certain that oral health not be considered separate from overall health. Dental decay is the most common chronic childhood disease in the United States, but the affordability of guaranteed dental coverage for children is at great risk unless CMS and HHS act in a responsible way,” said Senator Cardin

“After the tragic and untimely death of Deamonte Driver, Senator Cardin and I worked together to improve dental coverage for children as part of the CHIP reauthorization law. Children’s dental health is too important to be sidelined as a non-essential health benefit, which is why Congress took additional steps in health reform to further integrate dental care for children into overall health coverage,” Senator Rockefeller said. “The unaffordable out-of-pocket costs that will result from CMS’s recent decision will burden struggling families and consumers—the very people we fought to protect when we passed the law. I urge CMS to carry out the law as Congress intended. The consequences are simply too great.”

“Access to dental care is essential to overall health – especially for children,” Senator Wyden said. “The exchanges must be structured in a way that encourages, rather than hinders, access to pediatric dental coverage for all families.”

“In the United States of America, we shouldn’t lose kids because they don’t have access to a dentist,” Senator Mikulski said. “In the Affordable Care Act, we made sure that American children would have access to affordable, quality dental care. The Centers for Medicare and Medicaid Services must protect what we accomplished for kids dental care in health care reform, and make sure its promise is fulfilled. Deamonte Driver died because he didn’t have access to dental care. This did not happen in some foreign country, it happened in Maryland. The way we honor his memory is to ensure that no child ever dies of a curable tooth infection ever again.”

“Dental care is a critical part of overall health care,” Senator Bennet said. “The Affordable Care Act is designed to ensure that kids in Colorado and across the country have access to this vital service. We’re urging HHS to follow through on the law’s intent.” 


“Dental health is critical to the overall health of young people,” said Senator Brown. “We must ensure that pediatric dental benefits are both affordable and accessible so that American children grow up strong and healthy.”


“Children need access to comprehensive health care so that they can grow into healthy adults,” said Senator Casey “This should include affordable pediatric dental care which is critical to overall health.”

“All too often, children suffer from preventable dental problems which can lead to missed school, pain and infection, and in some cases, serious medical problems and even death. As children with untreated conditions grow older, they can become adults who have trouble eating or finding a job because of the condition of their teeth. We must ensure that dental care is accessible and affordable for the health of our children and our country,” said Senator Sanders.

“Access to affordable dental care is vital to a child’s overall health. Including comprehensive pediatric oral health services in the Essential Health Benefits was a key component of the Affordable Care Act and a major step toward ensuring that New Mexico children don’t suffer unnecessarily from preventable health risks.  To truly be meaningful, this benefit must be affordable,” Senator Heinrich said.

The text of the letter to the Acting Director of CMS follows:

Ms. Marilyn Tavenner

Acting Administrator 

Centers for Medicare and Medicaid Services

200 Independence Avenue, S.W.

Washington, DC  20201

Dear Acting Administrator Tavenner:

Ensuring that health care is accessible and affordable is the primary goal of the Patient Protection and Affordable Care Act (ACA). The health of every child depends on access to affordable care for all of his or her health needs, including dental services.  We are concerned by the failure of CMS to carry out the intentions of the Affordable Care Act and ensure that pediatric dental services, a specified essential health benefit, are affordable and available to families. 

 The death of Deamonte Driver, the 12-year old Marylander who died of a tooth infection six years ago, was a result of his family’s inability to access dental care. It is appalling that oral health care largely remains separate from other health care services as if the mouth were not an essential part of the body. That is why we specifically included oral health care as part of the pediatric services in ACA’s essential health benefits. However, in recent weeks CMS has made decisions that are likely to make those benefits unattainable for families. 

Last month, HHS released the final rule for the Essential Health Benefit which allows for a separate out-of-pocket (OOP) limit for pediatric dental benefits provided through stand-alone dental plans, in addition to the OOP limit already established by the law for essential health benefits. On March 1, in the draft “Letter to Issuers on Federally-facilitated and State Partnership Exchanges,” CMS went further to propose that any separate OOP limit up to a $1,000 per child OOP for pediatric dental services would be considered reasonable in the federally-facilitated exchanges (FFEs). Such policy is in conflict with the intent of Congress to provide affordable benefits for families to access routine and necessary care, including pediatric oral health care. We find it deeply concerning that CMS would allow stand-alone dental insurers to OOP limits as high as $1,000 per child beyond what the law intends families to pay for services considered essential health benefits.  

While not all families are likely to incur high out-of-pocket expenses as a result of pediatric dental care, the children most likely to experience severe dental disease live in families who are least able to afford the cost of major restorative care. The ACA clearly establishes that out-of-pocket limits for all essential health benefits, including pediatric dental, reflect a family’s ability to pay.[1] Therefore, we urge CMS to establish a framework in its federally facilitated exchanges that encourages the purchase of pediatric dental benefits and holds families harmless regardless of how those benefits are offered.

Such an approach would require that any separate out-of-pocket limits be tiered according to income. Additionally, separate out-of-pocket limits for stand-alone dental benefits would be built into the overall out-of-pocket limit established by the law. Under this scenario, families can anticipate the same out-of-pocket costs regardless of how their children get dental coverage and insurers face no additional administrative burden assuming that out-of-pocket limits are disclosed into the standard plan designs. This framework respects the existing stand-alone dental marketplace while aligning OOP costs.

For example: A family of four living at 300% FPL would have an overall OOP limit of $5,950. If an exchange decides that a reasonable OOP limit for stand-alone dental is $800, the OOP limit for that family’s medical plan would be $5,150. This approach would promote affordability and holds families harmless regardless of how they get their children’s dental coverage (stand-alone or embedded in a QHP).

We believe this is of even greater importance because the final rule on Essential Health Benefits clarified that families are not required to purchase stand-alone dental coverage in the exchanges. If pediatric dental benefits are unaffordable, many families may choose to forgo the purchase of dental benefits for their children. Such an outcome would put the health of children at risk and negate the work of Congress to clearly establish dental care as an essential component of pediatric health care.

When Congress included pediatric oral health care as part of a comprehensive set of pediatric services under the Essential Health Benefits, we took a major step towards ensuring that no child would suffer needlessly from preventable tooth decay. Allowing stand-alone dental insurers to offer benefits in the marketplace should not be in conflict with this commitment or the clear intent of the law. It is the responsibility of CMS to ensure that both the law and the underlying intent of that law are upheld. 

We thank you for your immediate attention to this matter.


Senator Benjamin L. Cardin

Senator John D. Rockefeller IV

Senator Ron Wyden

Senator Barbara A. Mikulski

Senator Michael Bennet

Senator Sherrod Brown

Senator Robert P. Casey, Jr.

Senator Bernard Sanders

Senator Martin Heinrich


[1] Patient Protection and Affordable Care Act §1402(b)