GOP Considers Trimming Health Law's 10 Essential Benefits

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As Republicans look at ways to replace or repair the Affordable Care Act, many suggest that shrinking the list of services that insurers are required to offer in individual and small group plans would reduce costs and increase flexibility.

That option came to the forefront last week when Seema Verma, who is slated to run the Centers for Medicare & Medicaid Services in the Trump administration, noted at her confirmation hearing that coverage for maternity services should be optional in those health plans.

Maternity coverage is a popular target and one often mentioned by health law critics. But other items also might be watered down or eliminated in the GOP revision.

There are some big hurdles, however. The Affordable Care Act requires that insurers who sell policies for individuals and small businesses cover at a minimum 10 "essential health benefits," including hospitalization, prescription drugs and emergency care, in addition to maternity services. The law also requires that the scope of the services offered be equal to those typically provided in the coverage that businesses offer their employees.

"It has to look like a typical employer plan, and those are still pretty generous," says Timothy Jost, an emeritus professor at Washington and Lee University Law School in Virginia who has studied and written about the health law.

Since the 10 required benefits are spelled out in the Affordable Care Act, the law would have to be changed to eliminate entire categories or to make them less generous than typical employer coverage. And since Republicans likely cannot garner 60 votes in the Senate to do that, they will be limited in changes that they can make to the ACA. Still, there's room to "skinny up" the requirements in some areas by changing the regulations that federal officials wrote to implement the law.

Habilitative services

The law requires that plans cover "rehabilitative and habilitative services and devices." Many employer plans don't include habilitative services, which help people with developmental disabilities such as cerebral palsy or autism maintain, learn or improve their functional skills, via speech or occupational therapy or other support services. Federal officials issued a regulation that defined habilitative services and directed plans to set separate limits for the number of covered visits for rehabilitative and habilitative services. Those rules could be changed.

"There is real room for weakening the requirements" for habilitative services, says Dania Palanker, an attorney and assistant research professor at Georgetown University's Center on Health Insurance Reforms, who has reviewed the essential health benefits coverage requirements.

Oral and vision care for kids

Pediatric oral and vision care requirements, another essential health benefit that's not particularly common in employer plans, could also be weakened, says Caroline Pearson, a senior vice president at the consulting firm Avalere Health.

Mental health and substance use disorder services

The health law requires all individual and small group plans to cover mental health services and treatments for substance use disorders. In the regulations, the Obama administration said that means those services have to be provided at "parity" with medical and surgical services, meaning plans can't be more restrictive with one type of coverage than the other regarding cost sharing, treatment and care management.

"They could back off of parity," Palanker says.

Prescription drugs

Prescription drug coverage could be tinkered with as well. The rules currently require that plans cover at least one drug in every drug class, a standard that isn't particularly robust to start with, says Katie Keith, a health policy consultant and adjunct professor at Georgetown Law School. That standard could be relaxed further, Keith says, and the list of required covered drugs could shrink.

Preventive and wellness services and chronic disease management

Republicans have discussed trimming or eliminating some of the preventive services that are required to be offered without cost sharing. Among those is covering birth control without charging women anything out of pocket. But, Palanker says, "if they just wanted to omit them, I expect that would end up in court."

Pregnancy, maternity and newborn care

Before the health law passed, just 12 percent of health policies available to a 30-year-old woman on the individual market offered maternity benefits, according to research by the National Women's Law Center. Those policies that did offer such benefits often charged extra for the coverage and required a waiting period of a year or more.

The essential health benefits package plugged that hole very cleanly, says Adam Sonfield, a senior policy manager at the Guttmacher Institute, a reproductive health research and advocacy organization.

"Having it in the law makes it more difficult to either exclude it entirely or charge an arm and a leg for it," Sonfield says.

Maternity coverage is often offered as an example of a benefit that should be optional, and that's what Verma has advocated. If you're a man or too old to get pregnant, critics of the requirement say, why should you have to pay for that coverage to be included in your policy?

But that a la carte approach is not the way insurance is designed to work, says Linda Blumberg, a senior fellow at the Health Policy Center at the Urban Institute. Women don't need prostate cancer screening, she points out, but they pay for the coverage anyway.

"We buy insurance for uncertainty and to spread the costs of care across a broad population so that when something comes up, that person has adequate coverage to meet their needs," Blumberg says.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Follow Michelle Andrews on Twitter: @mandrews110.