State Flexibility To Add Grownup Dental Care to Important Well being Advantages: An Replace on State Motion 

By Madeline McBride, Elizabeth Bielic, Zeynep Celik, JoAnn Volk, and Kevin Lucia

The Reasonably priced Care Act (ACA) acknowledged the significance of oral well being for little one improvement by together with pediatric dental providers as an important well being profit (EHB), nonetheless, it didn’t considerably impression grownup dental protection. Within the 2025 Discover of Profit and Fee Parameters, the Facilities for Medicare & Medicaid Providers (CMS) finalized a change to federal guidelines, granting states the pliability to replace EHB benchmark plans to require protection of routine grownup dental providers, efficient for plan years starting on or after January 1, 2027. This closing rule streamlines the EHB benchmark plan choice course of starting in plan yr 2026. CMS has additionally provided a number of rounds of grants and hosted a technical help webinar in November to elucidate the EHB replace course of and element current modifications. This put up summarizes current state motion on EHB updates and grownup dental protection and discusses a few of the operational issues states should deal with in an effort to make grownup dental protection possible for his or her marketplaces. 

Kentucky Invitations Public Touch upon Its Plan To Make Grownup Dental Providers An Important Well being Profit 

In February of this yr, the Kentucky Division of Insurance coverage (DOI) issued a memorandum saying that it is going to be searching for to amend its EHB benchmark plan to incorporate routine grownup dental protection together with plenty of different advantages. The proposal expands dental protection from the prevailing EHB benchmark, which now solely covers grownup dental therapy when required because of unintentional damage, to incorporate “class 1” routine dental providers as proven under:  

Whereas state laws required consideration of all different proposed additions, the DOI opted to incorporate grownup dental advantages in response to the brand new flexibility granted to states. The proposed updates had been knowledgeable by an actuarial report which estimates the greenback worth of including every profit in comparison with the greenback worth of all lined providers in a typical employer plan. Beneath federal guidelines, the general worth of the proposed benchmark plan, together with extra advantages, should fall inside the vary between essentially the most and least beneficiant amongst a set of typical employer plans. The actuarial report concluded that the addition of grownup dental advantages would improve the anticipated worth of the benchmark plan by the equal of $20 per member per thirty days, and that together with grownup dental protection and the opposite proposed additions was inside the generosity vary allowed by federal guidelines. The Kentucky DOI is accepting public feedback by way of April 5, 2025. Following the general public remark interval, the state has 30 days to overview feedback and make any modifications to the proposed EHB benchmark replace earlier than submitting the state’s closing model to CMS on Might 7, the federal deadline for submitting proposed modifications that will take impact in 2027. 

As States Assess EHB Updates, A Few Take into account Grownup Dental Providers

Different states are additionally contemplating leveraging the brand new flexibility to make grownup dental an EHB. In California, Senate Invoice 1290 mandates a overview and replace of the state’s EHB benchmark plan by 2027. California is transferring ahead with a proposed EHB benchmark replace, in the end deciding so as to add a much less intensive set of advantages than that they had initially thought of. Grownup dental care and different providers weren’t adopted as a result of they might have prompted the benchmark replace to exceed the full worth of essentially the most beneficiant employer plan. As well as, legislators expressed concern about the price of including grownup dental care. 

Virginia can be reviewing its EHB benchmark plan, as required by state statute, which mandates an EHB benchmark overview each 5 years starting in 2025. In preparation for the 2025 EHB benchmark overview, Virginia’s Bureau of Insurance coverage convened a workgroup in 2024 to discover potential modifications for plan-year 2028. The Bureau of Insurance coverage will submit a report back to Virginia’s Well being Insurance coverage Reform Fee detailing the work group’s findings, suggestions, and any assessments of proposed mandates by March 31, 2025. 

Lastly, Maine’s Bureau of Insurance coverage is contemplating EHB benchmark updates for the 2027 plan yr. The Bureau has assembled a workforce, engaged with advocacy teams, and employed an actuary to carry out an evaluation of advantages. Though proposed modifications haven’t been made public, stakeholders have instructed that Maine may embody grownup dental as an EHB, highlighting the rising momentum for increasing dental protection throughout a number of states.   

The Resolution To Add Grownup Dental As An EHB Is Solely The First Step for States

The choice so as to add grownup dental as an EHB is simply step one within the means of guaranteeing protection of routine grownup dental providers. States have extra issues concerning the provision of enhanced protection and what meaning for his or her markets and shoppers. For instance, grownup dental as an EHB might probably improve premiums. Whereas premium will increase could also be offset by premium tax credit within the particular person market, this may not be the case within the small group market. States should additionally weigh the potential tradeoffs in how such a change would have an effect on cost-sharing. At present, grownup dental protection is usually bought by way of stand-alone dental plans (SADPs) through which beneficiaries could have to fulfill a deductible, however providers are topic to greenback limits on what the plan can pay. Whereas pediatric dental providers can both be embedded in certified well being plans (QHPs) or supplied by way of SADPs to fulfill EHB necessities, the federal rule states that grownup dental providers should be embedded in QHPs. As such, grownup dental care could also be topic to the plan deductible, until a state requires some providers be lined with out assembly the deductible. Requiring protection of grownup dental providers as an EHB could imply that some beneficiaries might lose first greenback protection in trade for eradicating profit limits. As well as, certified well being plans could must construct a community of dental suppliers to fulfill community adequacy requirements and embedding grownup dental protection into QHPs would possible have an effect on the SADP markets. 

Trying Ahead 

There’s rising recognition of the significance of oral well being and its connection to total well being at each the state and federal ranges. States expressed assist for the pliability so as to add routine grownup dental protection to EHB benchmark plans in feedback submitted on the proposed rule, reflective of the elevated consideration to oral well being. Some states have already indicated that they’re contemplating using this new flexibility as part of broader EHB updates, although it’s nonetheless early, and extra work is required to assist states perceive the potential impression of those modifications and to make knowledgeable choices. Lastly, though the Trump Administration has but to point its place on routine grownup dental as an EHB, the Administration’s basic threats to the ACA and rollback of many Biden-era laws could give some states pause in transferring ahead with this flexibility that might have broader implications for his or her marketplaces.