Sixty-seven percent of consumers believe that the top health care priority should be to lower out-of-pocket costs, instead of cutting benefits and consumer protections. Yet the Trump administration continues to undermine the progress made by the Affordable Care Act (ACA) in ensuring that people have access to basic health care services. The latest regulation issued by the Department of Health and Human Services, the Notice of Benefit and Payment Parameters for 2019 (Final Rule), continues that downward spiral.
In its most recent effort to sabotage the Affordable Care Act, the Trump administration is seeking to weaken coverage of the federal law’s essential health benefits (EHBs), which ensure that people enrolling in Marketplace plans can get comprehensive, affordable, quality insurance. The EHBs require individual market health plans to cover services in ten categories. These categories are: ambulatory patient services, hospitalization, laboratory services, preventive services, prescription drugs, rehabilitative and habilitative services, pediatric services, emergency services, maternity and newborn care, and mental health and substance use disorder (SUD) services. States must define the coverage for these ten categories by selecting one benchmark plan as reference for other plans to follow.
Before the Affordable Care Act, many plans in the individual market did not cover comprehensive health care benefits. For example, many did not provide mental health and SUD coverage. A 2012 study, moreover, found that plans often imposed a separate deductible for maternity coverage, as high as $10,000. Because of this, many individuals and families were unable to afford coverage that provided the services they needed or paid out of pocket for care because of threadbare benefits packages. Without the EHBs, individuals living with pre-existing conditions would pay astronomical costs for the treatment they need.
Trump’s new rule will undermine core health care protections and limit states’ ability to provide the best coverage possible. Some of the detrimental changes that we could see beginning in 2020 include:
● States could define their EHB categories using benchmark-plans selected by other states. States could choose out-of-state plans that provide few health care benefits and increase out of pocket costs for individuals.
● States could select a new benchmark plan altogether as long as the scope of benefits is actuarially equivalent to the scope of benefits in a typical employer plan within the state. This opens the door to benchmark plans that are less comprehensive than the current options.
● Plans could substitute benefits between EHB categories as long as the substituted benefit is actuarially equivalent to the benefit that is being replaced. Previously, issuers could only substitute benefits within categories. Under the new rule, for example, states may allow Marketplace plans to substitute particular hospitalizations services for particular mental health or SUD services as long as the substitution does not change the actuarial value of the plan.
● States will not be able to add more benefits than what’s covered in their 2017 benchmark plan without having to pay the cost, hamstringing their ability to require coverage of additional necessary services in the future.
While individuals enrolled in Marketplace plans technically must still receive all ten categories of EHBs, the new rule may lead individuals and families to lose coverage for certain services if states decide to change their benchmark plan for plans with skimpier benefits. Individuals with pre-existing conditions in need of particular costly services may end up in the same situation as before the ACA: with no suitable coverage options and paying high out-of-pocket costs for services that are no longer covered. In addition, changes to the EHB framework may lead to shoddy coverage of maternal and newborn care, putting black women who experience high rates of maternal mortality at heightened risk. Because of the new rule, issuers may try to pare down benefits in this category within legal limits.
The National Health Law Program and FamiliesUSA sent a letter to HHS urging the agency “to protect the coverage gains made under the ACA that have made it possible for consumers to access a wide range of benefits and secure the health care they need in 2019 and beyond.” States now have until July 2, 2018 to submit their benchmark plan proposals for 2020 using the new rule. In the next weeks and months, it is imperative that advocates stay engaged at the state level to ensure that individuals enrolled in Marketplace continue receiving comprehensive coverage that meets their needs. For more information, access National Health Law Program’s new issue brief, “Overview of Changes to the Essential Health Benefits Standards in NBPP 2019.”