A direct voter referendum is slated for the November 2022 ballot in Massachusetts related to dental insurance reform. Voters will decide whether or not to establish the medical loss ratio (MLR) for dental plans at 83% and require the insurer to refund any excess premium to its individuals and covered groups.

Currently, Massachusetts has established an 88% MLR for medical insurance plans, but there is no MLR for dental insurance plans.

Numbers of public interest groups in a variety of states have attempted reforms to the dental insurance industry.

Most often, bills have been killed or tabled in legislative committee because of the powerful dental insurance lobby.

This particular effort initiated in Massachusetts, by the Committee on Dental Insurance Quality (CDIQ), seeks to expand patient benefits and lower costs, by going directly to voters.

A director for CDIQ, Mouhab Z. Rizkallah, DDS, MSD in an exclusive interview for Dentistry Today emphasized the importance of circumventing the legislative process, which is too often compromised by special interest groups. He espouses taking matters directly to citizens via a ballot initiative.

“We (CDIQ) expected Massachusetts Dental Society (MDS) and American Dental Association (ADA) support. In their endorsement, they wrote “we’re also realistic that November’s ballot measure is finally a chance to achieve the necessary change.”  Their use of the word ‘finally’ is correct, because legislative MLR bills always fail, in all states, because of the powerful dental insurance lobby. Our dental MLR ballot is the first of its kind, and it bypasses the insurance lobby. We expect to win with this novel approach.”

Rizkallah added, “To understand the tangible impact of our Ballot’s 83% MLR requirement, simply look at Delta Dental of Massachusetts most recent Form 990. In just the State of Massachusetts, Delta Dental’s reporting shows they gave $383 Million in payments to corporate officers, commissions, payments to affiliates, and gifts to their mother company in a single year. We have compiled this into a table for all to see.”

“It shows Delta Dental of Massachusetts only spent only 60% on patient care, while medical insurers in this state are required to have an 88% MLR.”

“Patients should not have to fight to be healthy, and so the corporate waste will stop with our dental ballot initiative.,” added Rizkallah.

Rizkallah opined the important of this referendum will not only impact citizens of the Commonwealth of Massachusetts, but dental patients nationally.

“This November, we will advocate for patients across the state, and we will install a dental insurance MLR for first time in the entire nation. And since our ballot also requires robust revenue/ expense reporting by insurance companies, our new law will feed the other 49 states with critical insurance data, so that each state can adopt a dental MLR, and can similarly shift 23% more funds into patient care, instead of funding greedy ‘not for profit’ companies. Our Ballot will impact hundreds of millions of patients.”

Robert E. Chavez, DDS (also a member of CDIQ) offered in support of the efforts of Rizkallah, “As a past president of the Massachusetts Association of Orthodontists, I feel I can speak for dentists and specialists across the state of Massachusetts. Dr. Mouhab Rizkallah is a leader like no other I have ever seen. Despite being brutally attacked by the insurance industry for the past decade, Dr. Rizkallah has been a tireless advocate and hero to tens of thousands of needy children.”

“His work with the dental ballot now makes him a bona-fide national hero in dental patient advocacy. No one is his match.,” concluded Chavez.


In long-term support of this dental insurance reform referendum, Jill A. Tanzi, DDS a director with the Massachusetts Dentists Alliance (MDA), has an extensive history of patient advocacy. The MDA confronted proposed fee decreases by Delta Dental of Massachusetts in meetings with the Commonwealth’s Division of Insurance.

The MDA championed patient rights for securing services of out-of-network insurance dental providers. The MDA also generated a framework to help alleviate a workplace shortage of dental assistants brought on by the COVID pandemic.

Tanzi stated related to the current voter initiative, “MDA is pleased that the MDS and the ADA will be supporting the dental ballot question in Massachusetts. We need all dentists and dental organizations to support this initiative that will mandate dental plans to do more for patients.”


The Massachusetts Dental Society (MDS) issued a strongly supportive statement for the November dental insurance reform referendum.

“As an advocate for both regular and affordable dental care for all Massachusetts residents, the MDS endorses the Massachusetts Medical Loss Ratios for Dental Insurance Plans Initiative and encourages Massachusetts residents to pass it in November,” said Dr. Meredith Bailey, President of the Massachusetts Dental Society. “Patient dollars should be required to be spent in support of their oral health, and patients deserve visibility into how much of their dental insurance premiums are paying for care as opposed to administrative costs.

The MDS also expressed frustration about past efforts with dental insurance reforms. “Several other states have already enacted laws to requiring dental insurers to file annual MLR reports. California is one such state. Using data from these reports, the California Dental Association found that the state’s dental plans average an MLR of 76%, significantly below medical plan rates.”

“For years, the MDS has worked to reform MLRs legislatively. While we continue to work with legislators and dental insurance providers to find common ground, we’re also realistic that November’s ballot measure is finally a chance to achieve the necessary change. Like medical patients, dental patients deserve to have their premium dollars spent on patient care.”

Kevin Monteiro, executive director of the MDS recently issued this statement (6/15/2022):

“We’re pleased that the Massachusetts Supreme Judicial Court has approved the November referendum to reform dental insurance Medical Loss Ratios (MLRs). The Massachusetts Dental Society endorses this measure to ensure that, just like medical patients, dental patients’ premium dollars are spent on their care, with critical components guaranteeing transparency and accountability. This ballot measure continues to gain momentum and support, and we’re confident voters will approve it in November.”


The American Dental Association (ADA) has also extended its endorsement for the Massachusetts dental insurance reform ballot initiative.

Michael A. Graham, ADA Senior Vice President for Government and Public Affairs was asked directly about the value in approaching voters directly through a referendum, versus the legislative process.

“Both avenues are viable. Regardless of which route this type of reform takes, more needs to be done to protect patients from dental insurance premium abuse and waste. This initiative is a step in the right direction to give more power to where it belongs, with patients.”

“It is very encouraging that we have seen increasing interest in applying a loss ratio to dental plans in legislatures around the country, with a new MLR reporting law enacted in Maine in 2022. We look forward to working with the Massachusetts Dental Society and other dental associations around the country on this patient-centered reform using whatever avenue works best in the state.”

Graham was also asked about the likelihood of federal legislation, if the voter referendum passes in Massachusetts and possibly becomes a national template.

“Absolutely. For too long, dental plans have avoided patient protections like medical loss ratio (MLR) that are consistently applied to major medical health coverage. Again, whether through the legislature or through a ballot measure, the ADA supports dental benefits that pay a high percentage of the premium collected to patient care.”

(Note: Delta Dental of Massachusetts was contacted for comment. No response has been received as of time of publication.)

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