What health benefits insurers would most likely eliminate under AHCA

Maternity care services may the first thing insurers on the individual market drop from plans if the American Health Care Act (AHCA) becomes law and states seek waivers on what benefits have to be covered.

The Affordable Care Act (ACA) replacement bill narrowly passed in the House in May would allow states to try and waive the law’s 10 required health benefits: outpatient care, emergency services, hospitalization, maternity care, mental health, prescription drugs, rehabilitation, laboratory services, preventive care and pediatric services. These waivers, when combined with the possibility of waiving the ACA’s “community rating” provision, could destabilize the individual market in certain states, according to both the Congressional Budget Office and the chief actuary of CMS.

The Kaiser Family Foundation (KFF) tried to ascertain what benefits would be the first on the chopping block in waiver states by examining what nongroup plans covered before the ACA was passed. In that era, benefits requirements were largely left up to states, with plenty of variation over the package of services and minimum level of coverage.

“For example, some plans did not cover prescriptions, others covered only generic medications or covered a broader range of medications subject to an annual cap, while still others covered a more complete range of medications,” with KFF vice president Gary Claxton and his coauthors. “This diversity was possible because insurers generally were able to decline applicants with pre-existing conditions, and could require their existing customers to pass screening if they wanted to upgrade to more comprehensive benefits.”

The study examined data submitted by insurers in the individual market for 8,343 unique plans in 2013. The most commonly excluded category of services was delivery and inpatient care for maternity care, with 75 percent of nongroup plans not providing that coverage. No other category wasn’t offered by most plans. Inpatient and outpatient substance abuse (45 percent) and mental/behavioral health services (38 percent) were next on the list in categories commonly excluded.

“The AHCA presents state policymakers with a dilemma: they can reduce the essential health benefits to allow less expensive insurance options for their residents, but doing so may eliminate access to certain benefits for people who want and need them,” Claxton and his coauthors wrote.

If services are waived, individual market customers would likely to have cover close to the full cost of that care because insurers would expect most purchasers to use those benefits. For example, the CBO report on the AHCA said maternity care may cost more than $1,000 per month for nongroup plans waiver states, which drew opposition from the American Congress of Obstetricians and Gynecologists (ACOG).

Other specialty groups, however, may find some relief in the KFF analysis. All of the more than 8,000 plans examined covered inpatient hospital services, inpatient physician and surgical services, imaging services, as well as emergency care, which had been a major concern of the American College of Emergency Physicians (ACEP).

Furthermore, 99 percent of plans covered outpatient physician/surgical services, primary care visits, home healthcare services and inpatient and outpatient rehabilitation services.