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

Under rules finalized April 2 by the Centers for Medicare and Medicaid Services, dental benefits will be available to adults who buy insurance through the health insurance marketplaces, including Arkansans enrolled in the state's Medicaid expansion program.

The rules also aim to expand market coverage by establishing network adequacy standards and adjusting registration periods.

Expand coverage

The final rule allows states to include routine non-pediatric dental services among the essential health benefits (EHB) that Marketplace plans are required to cover. States can implement this change by updating their EHB baseline plans through an EHB baseline application process beginning in 2025, with coverage taking effect in the 2027 plan year.

If Arkansas elects to make non-children's dental services an essential health benefit, it would allow Arkansans enrolled in the Arkansas Health and Opportunity for Me (ARHOME) plan to receive coverage for these services under the plan for the first time. That's because Arkansas' unique approach to Medicaid expansion is to use federal Medicaid funds to purchase private plans on the health insurance marketplace for low-income Arkansans.

Medically frail Arkansans with incomes at or below 138% of the federal poverty level can choose a traditional Medicaid plan with full Medicaid benefits, including dental benefits capped at $500 per year, or an EHB, which currently does not offer Medicaid The equivalent replacement benefit plan does not include dental benefits. If Arkansas elects to make dental services an essential health benefit, people who choose an EHB equivalent plan will receive dental benefits.

network adequacy

Beginning with the 2026 plan year, the rule requires state health insurance marketplaces, including those that use the federal platform for enrollment like Arkansas does, to develop and implement quantified time and distance standards for qualified health plans (QHPs) , that is, a market certification program. These standards are consistent with those in federally facilitated marketplaces and are used to determine whether plan participants are geographically accessible to participating providers.

Insurers unable to meet the time and distance standards may submit reasons for exceptions based on circumstances, such as the availability of local providers or changes in local care needs.

Special enrollment period adjustment

Currently, the start date of coverage after enrolling in a QHP during a special enrollment period may vary by state. Beginning with plan year 2025, new federal rules require coverage start dates to be the first day of the following month, harmonizing start dates across all markets and improving transition for those transferring from other coverage.

The rule also extends a special enrollment period for individuals with incomes at or below 150 percent of the federal poverty level, ensuring 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 rules allow the market to continue the special enrollment period even after these subsidy enhancements expire. These changes can help those exiting Medicaid coverage in Arkansas, facilitate smooth transitions between health plans and ensure continued coverage.

A fact sheet from the U.S. Department of Health and Human Services summarizes more details about the rule.

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