By Madeline McBride, Liz Bielic, Zeynep Celik, JoAnn Volk and Kevin Lucia
As discussed in a recent CHIRblog, coverage of adult dental services as an essential health benefit (EHB) was initially prohibited by the Affordable Care Act. The 2025 Notice of Benefit and Payment Parameters changed federal rules and gave states the flexibility to require adult dental coverage beginning in plan year 2027. The deadline for states to submit proposed EHB benchmark updates to the Centers for Medicare & Medicaid Services (CMS) to take effect at the start of 2027 passed last month. This was the first update deadline since states were granted the adult dental coverage flexibility.
Kentucky’s EHB Benchmark Update
In February, Kentucky’s Department of Insurance (DOI) announced its proposed EHB benchmark update and invited public comment. Kentucky’s initial proposal would have expanded coverage for five benefits, including coverage of Class I routine adult dental services. Routine services would have included oral exams, preventative care such as dental cleanings, fluoride treatments, x-rays, space maintainers, and emergency treatment.
Ahead of the May 7 CMS submission deadline, the state published its finalized proposal. The final actuarial report and supporting documents indicate that the state moved forward with four of the expanded benefits in the EBH benchmark update but excluded routine adult dental coverage. If approved, Kentucky’s final proposal would eliminate the existing visit limit for speech therapy service, require coverage of biomarker testing and medically necessary infertility treatment, and expand coverage of recommended cancer screenings. Recently enacted state law required coverage of biomarker testing and infertility treatment and directed the DOI to consider removing visit limits for speech therapy and expanding coverage of cancer screenings as part of the state’s EHB benchmark plan. However, in releasing the proposed EHB benchmark plan changes for public comment, the DOI said coverage of adult dental services was included because of new flexibility given states to require such coverage as an EHB.
Why KY Did Not Move Forward With Adult Dental Services As An EHB
Public comments regarding Kentucky’s proposed EHB benchmark update have not been published, and the DOI has not publicly shared an explanation for the decision to remove adult dental coverage in the final EHB benchmark submission, but cost may have been a consideration. The initial actuarial report conducted by Lewis & Ellis found that the addition of routine adult dental benefits would increase the expected value of the benchmark plan by the equivalent of $20 per member per month. The expected value was lower in the final report, equivalent to $15.38 per member per month. This additional cost of coverage fell within the state’s EHB benchmark plan generosity range allowed by federal rules, but would likely translate to higher premiums. Increased premiums resulting from the inclusion of adult dental services as an EHB would have been offset by premium tax credits in the individual market, but this would not be the case for small group plans.
Increased premiums may have been a primary driver of Kentucky’s decision not to take up the new flexibility to include adult dental services as an EHB, but costs are not the only challenge that KY and other states might face. Federal rules require that, if adopted, adult dental coverage be embedded into qualified health plans. This will have implications for the companies that offer stand-alone dental plans. It also requires QHP insurers to develop networks of dental providers, which they may not currently have.
Looking Forward
To date, no state has opted to require coverage of routine adult dental services as an EHB for 2027, and recent and pending federal law changes that will raise premiums for most Marketplace enrollees may dampen state interest in expanding coverage for the foreseeable future. But oral health is increasingly recognized for its connection to overall health outcomes, and states may one day return to considering ways to improve access to and affordability of adult dental care.
