Welcome back to Regulatory Joe! In today’s episode, we cover a timely and impactful topic: the consideration of routine adult dental as an Essential Health Benefit (EHB) starting in 2025. This policy change by CMS poses significant implications for health plans and their members—let’s explore what this means and how health plans can prepare.
Historically, pediatric dental has been covered under ACA marketplace plans. CMS is now considering whether to include routine adult dental as an EHB, as well. As of late, CMS has allowed states the option to add routine adult dental into their EHB benchmark plans, sparking much discussion and anticipation about the broader impact of this benefit.
This new CMS policy grants states the autonomy to decide whether to include routine adult dental in their EHB benchmark plans. This could mean significant changes for health plans by 2025, requiring them to offer routine adult dental coverage.
Implications for Health Plans
While this addition can enhance plan offerings and potentially provide a competitive edge, it also brings substantial challenges. The high costs associated with this benefit can be burdensome, particularly for smaller regional health plans. Plans need to consider the impact on their pricing strategies, cost positions and overall market presence. The addition of this benefit could also affect brand recognition and member retention, especially if other carriers offer this coverage while they do not.
Market Impact
The inclusion of routine adult dental as an EHB could lead to significant market changes. In addition to appreciating the added value, members will likely be able to reduce repeat visits and improve long-term health outcomes by having access to regular dental care.
As health plans adapt, it will be crucial to track population health data and member behavior to assess the full impact of this policy change.
Regulatory Joe’s Recommendations
- Evaluate state guidelines
Stay informed about your state’s stance on routine adult dental and engage with regulators to understand upcoming requirements. You can reach out to your state’s regulatory bodies to gain insights into their plans for enforcing routine adult dental as an EHB. - Adjust premium rates
Work with actuaries to anticipate and incorporate the costs of routine adult dental into your premium rates. If you anticipate or experience an influx of dental claims, consider how this will impact your total cost of care and adjust premiums accordingly. - Prepare documentation
Update plan documents and filings to include routine adult dental in your major medical portfolio. This includes ensuring your Plan and Benefits Templates (PBTs) and state-specific supporting documents are optimized for the inclusion of routine adult dental. - Conduct competitive analysis
Analyze market trends and competitor offerings to strategically position your plan. Perform a competitive analysis to understand how routine adult dental is being implemented by other carriers in your state and adjust your strategy to remain competitive. - Monitor data and develop ROI metrics
Develop processes to track the utilization of routine adult dental services among your members. Larger carriers may have more data at their disposal, but all carriers should start building a pipeline process to analyze ROI and understand the financial impact of this benefit.
Routine adult dental coverage as an EHB certainly presents its fair share of opportunities and challenges for health plans. But by staying proactive and informed, health plans can navigate these changes effectively and continue to provide valuable benefits to their members.
Be sure to watch the full episode for a more detailed run-down of changes and recommendations.
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Video Transcript
Hey, everybody, welcome to Regulatory Joe. I’m Joe Boyle, president of regulatory solutions at Penstock. Today’s topic we’ll be discussing is our favorite, routine adult dental.
We all know that pediatric dental has been historically covered to date with any ACA marketplace plan on or off the exchange. The question that CMS is posing for 2025 is whether to require routine adult dental as an essential health benefit. Recently, CMS has allowed the option for states to choose to include routine adult dental as part of their EHB benchmark plans. On paper, it’s a great thing: offering new benefits for plans to diversify their portfolios and perhaps even gain a competitive advantage by offering dental where other carriers do not.
However, this comes with many implications for how plans are designed and prepared, and it significantly impacts a plan’s presence and strategy in the marketplace. Routine adult dental is not cheap to implement. It is highly expensive and has a cost burden to many plans, especially smaller regional health plans. Since CMS has approved this policy change, allowing states to decide to cover adult dental as an EHB, it could be very interesting for the next few years as EHB benchmark plans are updated by state divisions of insurance.
Some states have made it easier for carriers by stating if there is a dental carrier or standalone dental plan offered on or off a federal exchange, a carrier would be precluded from having to offer routine adult dental anyway. Not all states are the same. If you have a strategy or a roadmap to expand your market presence, please closely examine how your regulators have established their guidelines. Even give them a call. Ask if it’s in their crosshairs or line of sight to require routine adult dental going forward if that’s not part of your core strategy.
While any addition of essential health benefits is great for the member and favorable for the members we serve, it’s important to understand that this would impact any carrier’s cost position, price position, brand recognition, and other attributes to the health plan in the marketplace. Whether you’re looking to gain new membership or retain and renew your existing membership, if other carriers are starting to offer routine adult dental and your carrier is not, regardless of state requirement, you could see attrition with your membership, leading members to churn for dental care they need more than medical benefits.
We see routine adult dental becoming more common not just for 2025, but also for 2026 and 2027 when EHB benchmark plans are updated towards 2027 and beyond. I would not be surprised if further rigor is added around dental in general, both pediatric and adult. Adding routine adult dental as an EHB in some states will improve healthcare for members, with hopes to reduce repeat visits to any provider and improve overall longevity and health outcomes for years to come. It will be very interesting to see after 2025, as members receive routine adult dental benefits and it becomes more common within the marketplace, to track how this impacts population health data.
This means monitoring changes in member behavior, repeat visits back to the provider if more care is needed, the cost of overall visits for each dental visit, and the evaluation of total cost of care for the actual member. Based on the data available to each carrier, which will vary in shapes and sizes, larger carriers may have more access to data than smaller carriers. We recommend developing a pipeline process for the members receiving routine adult dental to establish all necessary ROIs to understand the members you’re serving today.
These changes will have significant pricing implications for how you set your premium rates year over year. If you see an influx of routine adult dental claims and expenses to your total cost of care per member, it’s a good time to look at how you’re setting your premium rates for next year. Talk to your actuaries, set up a workgroup, and understand how to incorporate premium rates and pricing to overcome the expense of routine adult dental. This could impact the entire plan design or product shelf you plan to offer in 2026, 2027, or 2028. This simple change in state decision-making could impact an entire plan strategy year over year.
For all the filers out there, it’s important to call out how these routine adult dental benefits would be filed. Traditionally, as it becomes more required by states across the country, filers should include this benefit within your major medical portfolio, regardless of segment, whether individual or small group, on or off the exchange. Historically, standalone dental plans have been filed separately outside of major medical portfolios to satisfy member needs with a complete dental solution. Going forward, we may see potential displacement of standalone dental plan filings. As we know, SADPs come with their own set of CMS requirements and state-specific requirements.
We will be curious to learn which states are early adopters of this benefit and deployment for carriers within their state. If you are an SADP issuer, think about the new federal rule and track carriers adding this to their major medical offerings. If you are a health plan, understand if there are SADP filings within the state you participate in. If you have a core SADP filing already available in your state, you may either be precluded from having to offer routine adult dental altogether. If you do offer routine adult dental, it could be a challenge for your plan.
We’ve discussed the federal rule and CMS policy language. Now, let’s talk about how this benefit would be filed on or off the federal exchange, regardless of segment, individual or small group. Routine adult dental would be included in a major medical portfolio. This would be inclusive in your traditional plan and benefit template and subsequent state-specific supporting documents. Every filer should know this upfront and optimize your documents in anticipation for the states you play in already.
As states adopt and deploy this benefit, and health issuers are required to offer it within their geographies, routine adult dental will be included in your traditional major medical, individual or small group filing. For filers completing the work, be mindful of how your plan and benefit templates and state-specific supporting documents are completed today with your current dental benefits. I recommend anyone in a state where routine adult dental will be enforced in 2025 and beyond to review your current plan documents to understand how you’ve detailed and set up your dental benefits on your PBT and subsequent state-specific supporting documents.
Doing this work a year ahead of time will set you up well to understand next year what changes need to be made if you’re participating in those states. As we wind down with certifications and approvals prior to AEP on November 1, it’s important for your teams, probably the product strategy and operations team, to do competitive analysis in the markets you serve to understand how routine adult dental will be enforced, if at all, for 2026, 2027, and beyond. Evaluate any new market entrants, whether SADP or major medical only, entering states you currently participate in or plan to enter, to understand who currently offers this specific benefit.
Why is it so important to do that? Based on your business plan or expansion strategy, routine adult dental is expensive. We know it’s in favor of the member, but please incorporate it into your overall strategy for competitive analytics or it could be detrimental to your roadmap as you proceed through 2026 and 2027. Overall, we’re seeing an ongoing theme from CMS with their policy guidelines and new guidance and rules. The common theme is increasing access to healthcare and health equity for all members across the country participating in an ACA or marketplace plan.
Since routine adult dental has been introduced as an EHB and enforced by states, we’re now wondering what CMS will introduce next. Thanks, everybody, for tuning in today for another Regulatory Joe topic. Give us a like, give us a share. We’d love to hear your feedback on what you want to see next. See you next time.
