North Dakota starts requiring ACA marketplace and small-group plans to cover GLP-1 drugs
North Dakota is the first state to build GLP-1 and GIP coverage into its ACA benchmark benefits, a change that reaches people who buy their own insurance or work for small employers.
North Dakota now requires individual-market ACA policies and small-group employer health plans sold in the state to cover GLP-1 and GIP medications, making it the first state to write the drugs into its essential health benefit package. Qualifying plans picked up the coverage on Jan. 1, 2025 [1][2].
The benefit is defined by drug class rather than by brand. It covers "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," the North Dakota Insurance Department said [1]. Those classes include semaglutide (sold as Ozempic, Wegovy and Rybelsus) and tirzepatide (sold as Mounjaro and Zepbound). Insurance Commissioner Jon Godfread told The Forum that North Dakota is the first state to cover GLP-1s through the ACA, and that he expects other states to follow [2].
The requirement reaches people who buy ACA-compliant coverage on their own through a licensed agent or on Healthcare.gov, and employees whose small employers buy small-group plans [1]. Large-group employer plans and grandfathered policies fall outside it [1]. Separately, Blue Cross Blue Shield of North Dakota began covering weight-loss medicines for its individual and small-group members on Jan. 1, a company spokesperson told The Forum [2].
GLP-1s were one piece of a broader rewrite of the state's benchmark benefits that took effect the same day. The package also caps cost sharing for a 30-day supply of insulin and of supplies used to dose and administer it; covers one hearing aid per hearing-impaired ear at least every 36 months when a physician or audiologist finds it medically necessary; allows as many as 12 sessions a year of nutrition screening, counseling and therapy; covers diagnosis and treatment of periodontal disease; adds PET scans for people with a prostate cancer diagnosis, including at least two types of scans at the first two diagnoses and one every six months for life; and limits opioid prescriptions to seven days while dropping prior authorization for drugs used to treat opioid use disorder and requiring an easy-to-use antidote when high-dose opioids are prescribed [1].
The state's application went through public comment and received legislative approval before CMS signed off in late August 2023 [1]. The 68th Legislative Assembly adopted House Concurrent Resolution 3011, which gave the insurance commissioner authority to change the state's essential health benefits [1]. The benchmark had not been revised since 2015 [1].
"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," Godfread said [1].
Cost pressure is part of the context. Spending on GLP-1s has weighed on insurers' finances in recent years, and some large-group plans and self-funded employers have stopped covering the drugs [2]. A 2024 Mercer survey of more than 2,000 employers found that 44% of those with 500 or more workers covered GLP-1s for obesity, a figure that rose to 64% among employers with 20,000 or more employees [2]. The Biden administration proposed widening Medicare and Medicaid coverage of weight-loss drugs, and some state Medicaid programs already pay for them [2].
Why it matters for patients
For North Dakotans who buy their own ACA policy or work for a small business, these medicines are now a named benefit instead of something a carrier can leave out. The benchmark ties coverage to preventing diabetes and to treating insulin resistance, metabolic syndrome or morbid obesity [1]. The practical details that decide what a patient actually pays, such as how a carrier defines obesity for eligibility, whether prior authorization or step therapy applies, and the size of a copay or coinsurance, have not been reported. People on large-group or grandfathered plans see no change from this decision [1]. Nationwide, access remains uneven, because self-funded employers and large plans set their own rules and some have pulled back [2].
What happens next
Godfread has said other states are expected to take a similar step, but none has been named and no timetable has been reported [2]. Federal proposals to extend Medicare and Medicaid coverage to weight-loss drugs have been put forward, with no decision date reported [2]. North Dakota has not announced any further changes to its benefit benchmark.
Sources
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