CMS finalizes network adequacy standards, expands dental benefits for ACA exchange

States now can add routine adult dental services as an essential health benefit, the Centers for Medicare & Medicaid Services announced in its 2025 Notice of Benefit and Payment Parameters final rule Tuesday.

Beginning Jan. 1, 2027, every state can update its essential health benefit benchmark plans to include cleanings, diagnostic x-rays, fillings and root canals. The benefits are approved through an application process that starts in 2025.

The rule also clarifies how long a consumer must travel to see different types of providers in state marketplaces on the federal platform. A plan's information must be certified as a qualified health plan. Time and distance standards would be calculated at the county level and applied to lists of provider specialties. This does not apply to many stand-alone dental plans.

Starting in 2026, marketplaces must require issuers seeking certification submit information on whether its network providers offer telehealth services.

“Access to affordable, quality health care options remain a concern across the country and a top priority for CMS,” said CMS Administrator Chiquita Brooks-LaSure in a statement.

For consumers with household income below 150% of the federal poverty level, or 38,730 for a family of three, the special enrollment period is extended. This means these families can enroll in Affordable Care Act plans during any month, not just during open enrollment.

"Previously, this special enrollment period was only available when enhanced subsidies under the Inflation Reduction Act were available," said CMS in a news release.

Additionally, federal and state marketplaces are required to have live call center representatives available during operating hours to help with customer questions. Members enrolled in a catastrophic plan will be automatically re-enrolled next year.

CMS is also revising prescription drug benefit requirements. First, Pharmacy & Therapeutic committees must have at least one patient representative.

"Second, CMS is codifying its current policy that prescription drugs that a plan covers in excess of those covered by a state’s essential health benefit benchmark plan are considered essential health benefits," CMS stated in a fact sheet.

These prescription drug benefits must meet the annual limit on cost sharing, however, the rule does not apply to large group market health plans and self-insured group health plans.

Notably absent from the rule is regulation that gives states more flexibility to adopt income and resource disregards when determining Medicaid eligibility, despite commenters' concerns. The agency intends to evaluate potential action at a later date.

Last year, the annual notice of benefit and payment parameters rule granted insurers the ability to provide four nonstandard plans per region on the federal exchange instead of two plans. It also finalized the ability for people who lose Medicaid or CHIP coverage to get access to the ACA through a special enrollment period.

CMS released the advanced notice for Tuesday's final rule in November.