By Madeline McBride, Elizabeth Bielic, Zeynep Celik, JoAnn Volk, and Kevin Lucia
The Affordable Care Act (ACA) recognized the importance of oral health for child development by including pediatric dental services as an essential health benefit (EHB), however, it did not significantly impact adult dental coverage. In the 2025 Notice of Benefit and Payment Parameters, the Centers for Medicare & Medicaid Services (CMS) finalized a change to federal rules, granting states the flexibility to update EHB benchmark plans to require coverage of routine adult dental services, effective for plan years beginning on or after January 1, 2027. This final rule streamlines the EHB benchmark plan selection process beginning in plan year 2026. CMS has also offered multiple rounds of grants and hosted a technical assistance webinar in November to explain the EHB update process and detail recent changes. This post summarizes recent state action on EHB updates and adult dental coverage and discusses some of the operational considerations states must contend with in order to make adult dental coverage feasible for their marketplaces.
Kentucky Invites Public Comment on Its Plan To Make Adult Dental Services An Essential Health Benefit
In February of this year, the Kentucky Department of Insurance (DOI) issued a memorandum announcing that it will be seeking to amend its EHB benchmark plan to include routine adult dental coverage along with a number of other benefits. The proposal expands dental coverage from the existing EHB benchmark, which now only covers adult dental treatment when required due to accidental injury, to include “class 1” routine dental services as shown below:
| Proposed Class 1 routine services to be covered | Visit limits |
| Oral exams | 1 Per 6 months |
| Prophylaxis (Ex: dental cleaning) | 1 Per 6 months |
| Fluoride treatment | 1 Per 6 months |
| X-Rays | 1 Bitewing series per 6 months |
| Space maintainers | No limit |
| Emergency treatment | No limit |
While state legislation required consideration of all other proposed additions, the DOI opted to include adult dental benefits in response to the new flexibility granted to states. The proposed updates were informed by an actuarial report which estimates the dollar value of adding each benefit compared to the dollar value of all covered services in a typical employer plan. Under federal rules, the overall value of the proposed benchmark plan, including additional benefits, must fall within the range between the most and least generous among a set of typical employer plans. The actuarial report concluded that the addition of adult dental benefits would increase the expected value of the benchmark plan by the equivalent of $20 per member per month, and that including adult dental coverage and the other proposed additions was within the generosity range allowed by federal rules. The Kentucky DOI is accepting public comments through April 5, 2025. Following the public comment period, the state has 30 days to review comments and make any changes to the proposed EHB benchmark update before submitting the state’s final version to CMS on May 7, the federal deadline for submitting proposed changes that would take effect in 2027.
As States Assess EHB Updates, A Few Consider Adult Dental Services
Other states are also considering leveraging the new flexibility to make adult dental an EHB. In California, Senate Bill 1290 mandates a review and update of the state’s EHB benchmark plan by 2027. California is moving forward with a proposed EHB benchmark update, ultimately deciding to add a less extensive set of benefits than they had originally considered. Adult dental care and other services were not adopted because they would have prompted the benchmark update to exceed the total value of the most generous employer plan. In addition, legislators expressed concern about the cost of adding adult dental care.
Virginia is also reviewing its EHB benchmark plan, as required by state statute, which mandates an EHB benchmark review every five years beginning in 2025. In preparation for the 2025 EHB benchmark review, Virginia’s Bureau of Insurance convened a workgroup in 2024 to explore potential changes for plan-year 2028. The Bureau of Insurance will submit a report to Virginia’s Health Insurance Reform Commission detailing the work group’s findings, recommendations, and any assessments of proposed mandates by March 31, 2025.
Finally, Maine’s Bureau of Insurance is considering EHB benchmark updates for the 2027 plan year. The Bureau has assembled a team, engaged with advocacy groups, and hired an actuary to perform an analysis of benefits. Although proposed changes have not been made public, stakeholders have suggested that Maine might include adult dental as an EHB, highlighting the growing momentum for expanding dental coverage across multiple states.
The Decision To Add Adult Dental As An EHB Is Only The First Step for States
The decision to add adult dental as an EHB is only the first step in the process of ensuring coverage of routine adult dental services. States have additional considerations regarding the availability of enhanced coverage and what that means for their markets and consumers. For example, adult dental as an EHB could potentially increase premiums. While premium increases may be offset by premium tax credits in the individual market, this would not be the case in the small group market. States must also weigh the potential tradeoffs in how such a change would affect cost-sharing. Currently, adult dental coverage is often purchased through stand-alone dental plans (SADPs) in which beneficiaries may have to meet a deductible, but services are subject to dollar limits on what the plan will pay. While pediatric dental services can either be embedded in qualified health plans (QHPs) or provided through SADPs to meet EHB requirements, the federal rule states that adult dental services must be embedded in QHPs. As such, adult dental care may be subject to the plan deductible, unless a state requires some services be covered without meeting the deductible. Requiring coverage of adult dental services as an EHB may mean that some beneficiaries could lose first dollar coverage in exchange for removing benefit limits. In addition, qualified health plans may have to build a network of dental providers to meet network adequacy standards and embedding adult dental coverage into QHPs would likely affect the SADP markets.
Looking Forward
There is growing recognition of the importance of oral health and its connection to overall health at both the state and federal levels. States expressed support for the flexibility to add routine adult dental coverage to EHB benchmark plans in comments submitted on the proposed rule, reflective of the increased attention to oral health. Some states have already indicated that they are considering utilizing this new flexibility as a part of broader EHB updates, though it is still early, and more work is needed to help states understand the possible impact of these changes and to make informed decisions. Finally, although the Trump Administration has yet to indicate its position on routine adult dental as an EHB, the Administration’s general threats to the ACA and rollback of many Biden-era regulations may give some states pause in moving forward with this flexibility that could have broader implications for their marketplaces.
