Coverage for additional health services in Virginia receive legislative recommendation


Nicole Pasia


Legislation to mandate additional coverage for amputees and postpartum people received a nearly unanimous recommendation from the Virginia Health Insurance Reform Commission on Monday. The bi-cameral Commission, chaired by Sen. George Barker (D – Alexandria), has spent the last few months analyzing a backlog of bills concerning health coverage and preparing legislative recommendations for the upcoming session.


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The Commission requested an analysis from both the Joint Legislative Audit and Review Commission (JLARC) and the Bureau of Insurance (BOI) for the following bills.

Coverage for prosthetic limbs

House Bill 2669 would change the existing code of Virginia to require private and employee-sponsored insurance plans to provide coverage for body-powered and electronic prosthetic limbs.

The Affordable Care Act already requires individual and small group plans to cover prosthetics as an essential health benefit (EBH), but language in the bill that defines prosthetics as “medically necessary” could include an expansion of coverage beyond EHB. 

As for large plans, Virginia code requires them to offer optional coverage for prosthetics, but according to Jamie Bitz, JLARC chief legislative analyst for ongoing oversight, coverage occurs on a case-by-case basis. If the bill passes, Virginia would join at least 20 other states that  would require all private and employee-sponsored plans to provide coverage for prosthetic limbs. 

Bitz estimated around 43,000 Virginians currently live with limb loss. Without coverage for prosthetic limbs, costs run from a few thousand per person for body-powered limbs to as much as $50,000 per person for an electronic limb. He said that number doesn’t account for additional replacements, sockets, and inserts the amputee may need.


Image: Virginia Joint Legislative Audit and Review Committee


The BOI analyzed how HB 2669 would impact plan premiums and the cost the state would cover. According to Bradley Marsh, BOI health insurance policy advisor, if the mandate passes, premium costs would increase depending on the plan type.

With the mandate, individual and small market premiums per member per month (PMPM) would increase by 12-16 cents. In large group markets, the new benefit would raise PMPM premiums by 12-15 cents. In total, mandating coverage would incur an additional annual cost of $1.1 million for large group insurers, $485,000 for individual plans, and $600,000 for small group plans. 

However, these amounts are not certain due to potential conflicts between federal and state law. Under federal law, states may require qualified health plans (QHPs) to offer additional benefits not listed as essential health benefits (EHB). As of Jan. 1, 2012, states must cover the cost of the additional non-EHB benefits QHPs provide. Should HB 2669 pass, some prosthetic coverage may be considered a non-EHB benefit.

Current Virginia state law, however, has prohibited QHPs from providing additional non-EHB benefits. The state law may be considered discriminatory, according to the BOI’s recent conversations with the Centers for Medicaid and Medicare Services (CMS).

A majority (93%) of Virginia’s individual market plans and some small group plans are QHPs. If state law changes and allows QHPs to provide non-EHB coverage for prosthetics, then the state would incur approximately $460,000 in costs, while premium increases would cover the rest. 

Senator Scott Surovell (D – Fairfax), said mandating additional coverage may be worth the rise in monthly premiums.  

“The cumulative effect of these [mandates] have a creeping effect on health insurance affordability and premium costs, but you’re talking nickels and dimes here, per month.” 

The committee voted 5-1 to recommend the approval of HB 2669. Del. R. Lee Ware (R – Chesterfield) was the only present member who voted against the bill. 

Coverage for Pasteurized Donated Human Breast Milk (PDHM)

Similarly, the Commission reviewed HB 2049, which would mandate coverage for postpartum people in need of PDHM. According to JLARC, PDHM “effectively reduces the rate of gastrointestinal disorders common in low birthweight infants and may reduce rates of other disorders for these infants.” At times, a fortifier may be added to PDHM as well. 

JLARC found that hospitals currently cover the cost of PHDM, although some patients may have to pay out-of-pocket costs after discharge. JLARC estimated PDHM can cost a nursing individual $144 per day. According to hospital staff’s estimates, the cost of PDHM with a fortifier for a single infant in the NICU over three months totaled $12,500.

There is virtually no current coverage for PDHM, according to JLARC. The only insurer that provides any coverage, TRICARE, limits benefits to service members and their families. 

The BOI’s cost analysis of HB 2049 used a rough estimate of the amount of PDHM needed in the state—about 352,000 ounces. Large group market plans would see a 6.6% increase in PMPM premiums, or $497,000 annually. Individual market plans would see an increase of $219,000 annually, and small group market plans would see an increase of $270,000 annually. 

Applying the same potential change in state law, the state may incur an additional $204,000 in costs for the mandated benefit.

Delegate Wendy Gooditis (D – Clarke) supported approval for the mandate with a statement that referenced the ongoing national debate on abortion restrictions. 

“If society wants these babies to be born, then it is society’s duty to care for them in this way.” 

Commission members voted unanimously to recommend the approval of HB 2049.

Despite their approval, some Commission members expressed concern over the possibility of the state-mandated benefit law being considered discriminatory under federal law—and consequently, how much the state defrayal cost would increase if the bills pass. BOI Deputy Commissioner Julie Blauvelt said the only guidance CMS has offered is a requirement for all states to submit a report on their EHBs by July 2022.