Will Essential Benefits be Covered in Post-AHCA Legislation?

Individuals may lose coverage for prescription drugs and mental health services.

Although the American Health Care Act (AHCA) was not able to garner enough votes to pass Congress and was subsequently pulled, lawmakers may choose to re-introduce the bill with alterations that would satisfy the desires of various House constituencies.

If passed, the latest version of the bill would have allowed individual states to determine the minimum package of health benefits offered by insurance companies selling plans in individual marketplaces, rather than being standardized on a federal level.

While the language in the bill is ambiguous, it could have a potentially devastating effect on individuals covered by these plans, according to an article published by the Commonwealth Fund. The law would give insurers flexibility to remove benefits provided under the Affordable Care Act (ACA), and could leave enrollees without adequate coverage.

The ACA sought to make individual insurance marketplaces more comparable to large employee-sponsored plans by implementing the requirement that plans cover 10 essential health benefits, including: 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; and pediatric services, according to the law.

Prior to the ACA, a majority of individual plans did not cover the essential benefits because they were not required to. If plans did cover certain services, there was likely a dollar limit per person, the Commonwealth Fund reported.

Going forward, if GOP lawmakers choose to repeal this hallmark provision of the ACA, some Americans may lose coverage for services they have become accustomed to.

Before the ACA, 1 in 5 individuals purchasing plans through the marketplace had no prescription drug coverage, while only 5% of those with employer-sponsored plans did not have this coverage, according to the article. Only 12 states required maternity services to be included in plans, and 6 out of 10 enrollees had no maternity benefits whatsoever. Since pregnancy and birth is so expensive in the United States, providing coverage for these services is important for families.

Mental health services were only required to be covered by plans sold in 17 states and the District of Columbia, but some states charged extra for the services. Under the ACA, the coverage of mental health services was required to be similar to other services, which got rid of rules restricting access to care and out-of-pocket costs.

Even though it is uncertain if lawmakers will revise and re-introduce the AHCA, eliminating federal standards for essential benefits may leave individuals with pre-ACA coverage, which was largely unstandardized and contained gaps, according to the article.

Insurers will be able to choose which benefits they will provide, with more expansive plans coming at a much higher price. Patients with chronic illnesses or injuries may be at risk of bearing significant financial burden if essential benefits are not standardized at the federal level, according to the article.

Lawmakers should be aware of the potential consequences of repealing federal standards for health benefits, and take multiple options into consideration prior to introducing new healthcare legislation, the article concluded.