New Federal Rule Allows States To Add Dental Services to Marketplace Health Plan Benefits

Dental benefits could become available for adults who purchase coverage through the health insurance marketplace, including Arkansans enrolled in the state’s Medicaid expansion program, under a rule finalized by the Centers for Medicare and Medicaid Services on April 2.

The rule also seeks to enhance marketplace coverage by establishing network adequacy standards and adjusting enrollment periods.

Expanded Coverage

The final rule allows states to include routine non-pediatric dental services in the essential health benefits (EHB) that marketplace plans are required to cover. States can make this change by updating their EHB-benchmark plans through the EHB-benchmark application process beginning in 2025, with coverage becoming effective in plan year 2027.

If Arkansas chooses to make non-pediatric dental services an essential health benefit, this would allow Arkansans enrolled in the Arkansas Health and Opportunity for Me (ARHOME) program to have insurance coverage for these services under the program for the first time. This is because Arkansas’s unique approach to Medicaid expansion uses federal Medicaid dollars to purchase private plans on the health insurance marketplace for low-income Arkansans.

Arkansans with incomes at or below 138% of the federal poverty level who are medically frail can choose either the traditional Medicaid program with full Medicaid benefits, including a dental benefit with a $500 annual cap, or an EHB-equivalent alternative benefit plan that currently does not include a dental benefit. If Arkansas chooses to make dental services an essential health benefit, those opting for the EHB-equivalent plan will receive dental benefits.

Network Adequacy

Beginning in plan year 2026, the rule requires state-based health insurance marketplaces, including those that, like Arkansas’s, use the federal platform, HealthCare.gov, for enrollment, to establish and impose quantitative time and distance standards for qualified health plans (QHPs), i.e., marketplace-certified plans. These standards, consistent with those for the federally facilitated marketplaces, are used to determine whether participating providers are geographically accessible to plan enrollees.

An insurer unable to meet time and distance standards may submit justifications for an exception based on circumstances, such as the local availability of providers or variables in local care needs.

Special Enrollment Period Adjustments

Currently, the start date of coverage following enrollment in a QHP during a special enrollment period can vary by state. Beginning in plan year 2025, the new federal rule requires the start date of coverage to be the first day of the following month, aligning the start date across all marketplaces and improving the transition for those shifting from other coverage.

The rule also extends the availability of a special enrollment period for individuals with incomes at or below 150% of the federal poverty level, ensuring access to zero-dollar premiums through enhanced subsidies originally provided under the American Rescue Plan and continued by the Inflation Reduction Act. The enhanced subsidies are set to expire at the end of 2025, but the new rule allows marketplaces to continue the special enrollment period even beyond the expiration of these subsidy enhancements. These changes could aid those transitioning out of Medicaid coverage in Arkansas, facilitating a smoother transition between health plans and ensuring continuous coverage.

More details on the rule are summarized in a U.S. Department of Health and Human Services fact sheet.