North Dakota becomes the first state to require ACA Marketplace and small-group plans to cover GLP-1s

North Dakota is the first state to require that Affordable Care Act Marketplace plans and small-group employer plans cover GLP-1 and GIP medications, a change that took effect for plans beginning Jan. 1 ^[2]. The coverage comes from an updated essential health benefit (EHB) benchmark plan that the Centers for Medicare & Medicaid Services approved in late August 2023 ^[1].

The benchmark language is specific about what the drugs are covered for. It requires "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" ^[1]. That phrasing — especially "morbid obesity" — is what insurers in the state use to build their medical criteria. The sources do not spell out a specific BMI cutoff or other eligibility rules that individual carriers apply, so exactly how each plan defines who qualifies is not addressed in the state's announcement ^[1][2].

The change is narrow in one important way: it applies only to ACA-compliant plans sold on North Dakota's individual market, either through licensed agents or Healthcare.gov, and to small-group plans offered by small employers ^[1]. Changes to the state's EHB benchmark "do not apply to grandfathered plans or large-group plans, such as plans offered through employers," the North Dakota Insurance Department said ^[1]. Self-funded employer plans, which cover many working Americans, are likewise outside the reach of a state benchmark plan.

Blue Cross Blue Shield of North Dakota, the state's largest insurer, also began offering coverage for weight-loss medications for individual and small-group plans on Jan. 1, a company spokesperson told The Forum ^[2]. Insurance Commissioner Jon Godfread told the same outlet that North Dakota is the first state to cover GLP-1s through the ACA and that others are expected to follow ^[2].

GLP-1 drugs were only one piece of a larger benchmark overhaul. The same update added limits on out-of-pocket costs for a 30-day supply of covered insulin and insulin supplies; coverage for one hearing aid per impaired ear every 36 months; dietary and nutritional screening, counseling and therapy for obesity, diabetes-related diagnoses or other chronic conditions, up to 12 sessions per policy year when a physician deems it medically necessary; coverage for periodontal disease; PET scans for people with a prostate cancer diagnosis; and a 7-day limit on opioid prescriptions along with fewer barriers to opioid use disorder treatment ^[1]. The 68th Legislative Assembly passed House Concurrent Resolution 3011, which empowered the insurance commissioner to change the state's EHB ^[1]. The previous change was in 2015 ^[1].

Why it matters for patients

For most Americans, whether a GLP-1 is covered depends entirely on which plan they happen to have. Employer coverage is uneven: a 2024 Mercer survey of more than 2,000 employers found that 44% of those with 500 or more employees offered GLP-1 coverage for obesity, rising to 64% among employers with 20,000 or more employees ^[2]. Some large-group plans and self-funded employers have dropped coverage as costs mounted, and the financial strain from these drugs has shown up in insurers' financial reports ^[2].

North Dakota's approach removes that coin flip for one slice of the market — people buying their own ACA plan or working for a small employer — by writing the drugs into the state's floor of required benefits ^[1][2]. It does not make the drugs free. Cost sharing, deductibles, prior authorization and each carrier's medical necessity rules still determine what a person pays and whether they qualify, and those details are not described in the state's announcement ^[1].

The benchmark route also matters beyond North Dakota, because every state sets its own EHB benchmark plan. If other states follow, the mechanism would likely look similar: a state application, CMS approval, and an effective date one or more years later ^[1][2].

What happens next

Key dates so far: CMS approved North Dakota's application in late August 2023 ^[1]; the new benefits, including GLP-1 and GIP coverage, applied to qualifying plans beginning Jan. 1, 2025 ^[1][2]. Godfread has said other states are expected to follow, but the sources do not name which states, or give timelines ^[2]. Federal action is separate: the Biden administration proposed expanding Medicare and Medicaid coverage for weight-loss drugs, and some state Medicaid programs already provide it ^[2]. The final outcome of that federal proposal is not covered in these sources.