CMS approves additional Essential Health Benefits to be included in North Dakota & Virginia

via the Centers for Medicare & Medicaid Services (CMS):

CMS Approves Added Benefits to Essential Health Benefits (EHB) Benchmark Plans in North Dakota and Virginia

September 6: CMS approved added benefits to the Essential Health Benefits (EHB) benchmark plans for North Dakota and Virginia for the 2025 plan year. The Affordable Care Act requires non-grandfathered health plans in the individual and small group markets to cover essential health benefits (EHB), which include items and services in ten benefit categories. For plan year 2020 and after, the Final 2019 HHS Notice of Benefits and Payment Parameters provides states with greater flexibility by establishing new standards for states to update their EHB-benchmark plans, and for tailoring them to fit the health care needs of their states.

Here's the best summaries I could find of the additional benefits for each state:

North Dakota:

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. 

Virginia:

Among the potential benefits studied for inclusion in Virginia’s 2025 EHB benchmark plan were medically necessary prosthetic devices and components as well as formula and enteral nutrition products as medicine. The recently-passed 2023 legislation directs the Bureau to add these benefits to the EHB benchmark plan in addition to the current benefits. Following public comment, the proposed 2025 EHB benchmark plan application must be approved by CMS in advance. A CMS determination on Virginia’s proposed 2025 EHB benchmark plan is expected by late summer 2023.

In addition to the legislation regarding the 2025 EHB benchmark plan, the 2023 General Assembly passed legislation that would establish a formalized process for future review and updates to Virginia’s EHB benchmark plan.