Virginia Essential Health Benefits Benchmark Plan Receives Federal Approval

RICHMOND – The federal government has approved Virginia’s application to change the essential health benefits (EHB) benchmark plan for Affordable Care Act (ACA) health plans offered in the Commonwealth in the individual and small-group markets beginning January 1, 2025. The EHB benchmark plan sets the required benefits that must be provided by comprehensive fully insured individual and small-group health insurance coverage issued in Virginia. This is the first time changes have been made to Virginia’s EHB benchmark plan since 2017.

The Centers for Medicare and Medicaid Services (CMS), the federal agency primarily responsible for ACA oversight, approved Virginia’s application in late August.

The State Corporation Commission’s (SCC) Bureau of Insurance (Bureau) submitted the application pursuant to legislation passed by the 2023 Virginia General Assembly directing the Bureau to select a new EHB benchmark plan for plan year 2025.

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

“We are pleased to announce CMS’s approval of these benefits for the 2025 EHB benchmark plan as specified by the Virginia General Assembly,” said Virginia Insurance Commissioner Scott A. White. “We look forward to our continuing future review of potential health benefit options to present to legislators for possible inclusion in the EHB benchmark plan for individuals and small groups who purchase fully insured health coverage in Virginia.”

Among the changes that have been made to Virginia’s EHB benchmark plan for qualifying health plans that begin January 1, 2025, are the following:

• Coverage for enhanced prosthetic devices and components – the new EHB benchmark plan redefines medically necessary prosthetics to include myoelectric, biomechanical or microprocessor-controlled prosthetic devices; and
• Formula and enteral nutrition products for inherited metabolic disorders as medicine – the new EHB benchmark plan requires coverage of orally administered, medically necessary formula and removes the requirement that medically necessary medical formula provide more than 51% of caloric needs.

Benefit changes to Virginia’s EHB benchmark plans do not apply to grandfathered plans or large-group plans, such as plans offered through large employers (51 or more employees).

A state’s EHB benchmark plan must include coverage for the following:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

For questions or to learn more about Virginia’s 2025 EHB benchmark plan, contact the Bureau of Insurance by telephone at 804-371-9741 in Richmond or toll-free at 1-877-310-6560, by email at BureauofInsurance@scc.virginia.gov, or visit its website at Virginia SCC - Essential Health Benefits Benchmark Plan.

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Contact: Katha Treanor, 804-371-9141