Health Care Bill House Just Passed Loosens Rules for Insurers Regarding Obamacare’s 10 Essential Categories

The ACA mandated coverage in 10 essential categories, meaning that insurers selling on the exchanges cannot put any lifetime limits on coverage in those categories. Employer-sponsored health plans also had to cover these essential benefits, although they did have the leverage to apply those benefits under the rules of a state where the insurers didn’t actually do business. That really didn’t matter because the 10 essential categories were the same nationwide.

The GOP health care bill, which passed in the House this afternoon, allows states to obtain waivers from covering some of the 10 essential categories, reports the Wall Street Journal. That means that an employer-sponsored health insurance plan can choose the rules from a state that mandates the least.

“By choosing a waiver state, employers looking to lower their costs could impose lifetime limits and eliminate the out-of-pocket cost cap from their plans under the GOP legislation,” the Wall Street Journal reports. “A company wouldn’t have to do business in a state to choose that state’s benefits level, analysts said. The company could just choose a state to match no matter where it is based.”

Larry Levitt, a senior vice president at the Kaiser Family Foundation, tells the newspaper: “The real question is, would employers do this? Many wouldn’t. Many employers offer quality benefits to attract employees. But employers are always looking for ways to lower costs.”

Andy Slavitt, former acting administrator of CMS under President Obama, is more alarmed: “It’s huge. They’re creating a backdoor way to gut employer plans, too.”

According to CMS, the 10 mandated coverage categories are:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity, and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)

Source: Wall Street Journal