BISMARCK, N.D. – The federal government has approved North Dakota’s application to change the essential health benefit (EHB) benchmark plan for Affordable Care Act (ACA) plans in the state.
The Centers for Medicare and Medicaid Services (CMS), the primary agency for ACA oversight, approved North Dakota’s application in late August. The changes to EHBs will only affect ACA-compliant plans offered in North Dakota on the individual market through licensed agents or the Healthcare.gov exchange and small-group plans offered by small employers, beginning in January of 2025.
“We have heard from consumers in every corner across the state about what is important for them when they go to a healthcare facility or pharmacy and utilize their health insurance policy,” said Insurance Commissioner Jon Godfread. “The healthcare needs of North Dakotans evolve, and we have done extensive research to determine how insurance policies can best support as many consumers as possible. This approval comes after studying our options, taking public comment, and with legislative approval. It was a long process, but in the end, will benefit North Dakota consumers who purchase their health care through the ACA marketplace.”
For qualifying plans that begin Jan. 1, 2025, the following benefits will be included:
- Insulin/Insulin supplies: Limits out-of-pocket costs for diabetes, providing limited cost sharing for a 30-day supply of covered insulin drugs and of covered medical supplies for insulin dosing and administration.
- Hearing aids: Coverage for one hearing aid per hearing-impaired ear every 36 months or more when deemed medically necessary by a licensed physician or audiologist.
- Nutritional benefits: Coverage for dietary or nutritional screening, counseling, and therapy for obesity, diabetes-related diagnosis or chronic illness or condition that could be managed through nutritional or weight loss programs (up to 12 sessions every policy year if deemed medically necessary by the insured’s physician).
- Weight loss drugs: Coverage for the use of glucagon-like peptide-1 (GLP1) and gastric inhibitory polypeptide (GIP) drugs as therapy for the prevention of diabetes and treatment of insulin resistance, metabolic syndrome, or morbid obesity.
- Periodontal disease: Coverage for diagnosis and treatment of periodontal disease in acute or chronic disease state if deemed medically necessary by a board-certified medical practitioner.
- PET scans: Coverage for positron emission tomography (PET) scans of an insured who has a prostate cancer diagnosis, including at least two different types of PET scans upon 2 initial diagnoses and one PET scan every 6 months for the life of the insured. Also provided without a cancer diagnosis.
- Opioids: Limit opioid prescriptions to 7 days, removing barriers such as prior authorization for drugs used in the treatment of opioid use disorder or opioid replacement drugs and requiring prescription drugs for an easy-to-use antidote when prescribing high-dose opioids.
The 68th Legislative Assembly adopted House Concurrent Resolution 3011, empowering the Insurance Commissioner to make changes to the state’s EHB. The changes are in response to consumer and market demands. The last change to the state’s EHB was in 2015.
Changes to North Dakota’s EHB benchmark plans do not apply to grandfathered plans or large-group plans, such as plans offered through employers.