Lawmakers, advocates press to add hearing aids, DME, wigs and adult dental to California’s EHB; actuarial room limited

Lawmakers pressed state officials on whether hearing aids, home and mobility durable medical equipment (DME), cranial prostheses (medical wigs) and adult dental can be added to California’s essential health benefits (EHBs) for the 2027 plan year.

At the Feb. 11 informational hearing, Wakely actuary Matt Slaughter and Department of Managed Health Care Director Mary Watanabe summarized the options and the fiscal constraints facing the committee. Wakely priced a set of benefits and estimated that the combined marginal allowed-cost impact of the priced items ranged from about 1.6% to 3.5% of total allowed costs, while the CMS typicality ceiling gives the state approximately 1.06% to 2.23% of room to add benefit richness. "So we do have, just with the benefits priced here, it's gonna be more rich than the room we have available," Slaughter said, adding the state will have to select a subset of the options Wakely priced.

Hearing aids

Advocates and multiple lawmakers urged including hearing aids. Wakely said the state’s current benchmark contains no hearing-aid coverage; the firm priced hearing-aid options for all ages rather than children only because CMS has told states that coverage limited by age may be discriminatory. An attendee with a child who uses hearing devices and multiple advocacy organizations urged coverage to reduce developmental delays and special-education costs. Assemblymember Celeste Rodriguez and other legislators noted that pediatric hearing coverage has featured in prior bills and stakeholder meetings.

Durable medical equipment and mobility devices

Wakely presented a DME breakout that showed a wide range of costs driven by high-cost items such as CPAP machines and powered wheelchairs. CHBRP presented a separate PMPM (per-member-per-month) estimate for DME and said it assumed utilization-management steps for very high-cost devices. "We estimated that coverage at a dollar point, 64 per member per month," CHBRP’s director said in the committee session for a broad DME category.

Cranial prosthesis (wigs/hairpieces)

Stakeholders with alopecia and cancer survivors advocated including cranial prostheses. Wakely said it had priced wigs across a range of unit types (synthetic to authentic hair) and that the price range reflects that variation; Slaughter noted the need for consistent benefit definitions and enforcement to narrow cost ranges. "We priced hairpieces — there's a wide range of the unit cost of wigs as you go from synthetic to mid range to, fully authentic hair," he said. Several public witnesses described the mental-health and social impacts of medical hair loss.

Adult dental

Wakely and CHBRP presented two adult-dental pricing scenarios (preventive-only and comprehensive). Wakely’s estimates for comprehensive adult dental exceeded the state’s available actuarial room. Officials explained that federal rules and the requirement to price on an allowed-cost basis limit how states can account for standalone dental plan costs, and those constraints contributed to adult dental’s high actuarial impact.

What officials and advocates asked next

Committee members pressed officials on whether the state could fine-tune coverage definitions (for example, limiting wig frequency or DME types) to bring options within the ceiling and on the practical enforcement approach. DMHC said more precise definitions would narrow Wakely’s ranges but warned that changes would have to be made quickly to meet the May submission timeline. Advocates asked that any final package avoid cutting current benefits; DMHC staff said the current benchmark remains the baseline and would continue unless CMS approves a new benchmark.

Ending

The committee did not vote; members directed staff to continue refining definitions, gather additional letters and stakeholder materials, and return with recommendations in the coming weeks. If the state moves forward this year it must select a constrained set of benefits that fit within the actuarial ceiling or defer changes to a later filing cycle.