CMS proposes reversal of adult dental essential health benefit policy in payment notice
2024 policy allowed states to include adult dental in 2027 EHB benchmark plans
The Centers for Medicare & Medicaid Services is proposing to reverse course on a previous CMS policy released in 2024 pertaining to the Affordable Care Act that removed a prohibition on states to include routine adult dental services as an essential health benefit.
The proposal is part of the U.S. Department of Health and Human Services’ Notice of Benefit and Payment Parameters for 2027, released Feb. 9. The annual rule sets standards for qualified health plans and plan issuers on the ACA Marketplace exchanges.
Among numerous program integrity, eligibility and exchange policy provisions, CMS proposed to reinstate a prohibition that would prevent issuers from including routine non-pediatric, or adult, dental services as an essential health benefit.
The proposal would effectively undo a significant regulatory change finalized in the 2025 Payment Notice. In that rule, CMS removed a longstanding prohibition that prevented states from including routine adult dental services in their essential health benefit-benchmark plans. That action followed extensive stakeholder input, including comments from the ADA, and allowed states to add routine adult dental benefits as an essential health benefit beginning with plan year 2027.
A CMS fact sheet accompanying the new rule reads, “CMS believes this reversal of the policy finalized in the 2025 Payment Notice better aligns with statutory requirements, which directs that the scope of [essential health benefits] be equal to the scope of benefits provided under a typical employer plan.”
Under the 2025 policy, if a state elected to include adult dental services in its essential health benefit-benchmark plan, all qualified health plans in that state’s individual and small-group markets would be required to offer those benefits as part of comprehensive coverage with no monetary annual or lifetime limits. States were first permitted to submit benchmark updates by May 2025, for implementation in 2027.
The ADA supported CMS’ 2024 proposal to remove the prohibition on adult dental essential health benefits. In comments submitted in January 2024, the Association urged CMS to clearly define acceptable benefit design standards in line with ADA policy for adult dental coverage.
In the newly proposed 2027 rule, CMS does not revisit those design standards but instead proposed reinstating a categorical prohibition on including routine adult dental services as an essential health benefit.
Additionally, the proposed rule would lower the percentage of essential community providers that needed to be within a stand-alone dental plan's network from 35% to 20%. As defined by the ACA, essential community healthcare providers predominantly serve low-income and medically underserved individuals. This provision ensures access to dental services from individual providers or federally qualified health centers that serve low-income consumers.
CMS will accept public comments on the proposed rule through March 13 before issuing a final rule later this year. The ADA plans to submit formal comments. ADA News will provide additional updates when the Association submits comments and when CMS issues a final rule.
