As Republicans in Washington sought to replace the Affordable Care Act, they considered excising a key piece of the existing law — a move that would have had an outsized effect on Idahoans.
The law requires insurers to cover a broad slate of services. Unlike some other states, Idaho does not have laws that would continue those benefits if they’re removed as a result of the Republican reform effort.
House Republicans, who gave up Friday on the American Health Care Act rather than see it defeated, had considered scrapping a requirement for individual health insurers to cover 10 “essential health benefits.” Those benefits are:
▪ Pediatric services, including oral and dental care
▪ Pregnancy, maternity and newborn care
▪ Outpatient care
▪ Emergency services
▪ Prescription drugs
▪ Mental health and substance abuse services
▪ Laboratory services
▪ Rehabilitative services
▪ Prevention services and chronic disease management
If lawmakers chose to chop those, “insurers could again effectively cap the amount they would pay for a consumer with a high-cost or long-term health need such as cancer treatment,” according to a blog post by Sarah Lueck, a senior policy analyst at the liberal Center on Budget and Policy Priorities.
The benefits are a popular part of the Affordable Care Act for many consumers. Before the law was passed, the market for individual coverage sold outside the workplace was treacherous for consumers. High coverage-denial rates, lean benefits and premiums subject to frequent increases were the norm.
Plans had basically no national rules governing what must be the covered. Those rules were left to the states.
Some states require dozens of health care services to be covered by insurers. For example, Minnesota requires a long list of benefits — such as hearing aids, prostate cancer screening, emergency medical care and radiation therapy — to be covered in some or all health insurance plans.
Idaho requires two benefits in all insurance plans: mammograms and congenital anomalies such as cleft lip. If mastectomies are part of a plan, Idaho requires the plan also to cover breast reconstruction. If maternity is covered, insurers also must cover a minimum number of hours in the hospital for that maternity patient.
Idaho requires an additional nine benefits for plans that are sold directly to individuals. Those benefits include these six:
▪ Hospital room and board, with certain cost limits allowed
▪ Surgical services
▪ In-hospital medical services
▪ Outpatient care that is medically necessary
They also include at least three of the following:
▪ In-hospital private duty registered nurse services
▪ Convalescent nursing home care
▪ Diagnosis and treatment by a radiologist or physiotherapist
▪ Rental of special medical equipment
▪ Artificial limbs or eyes, casts, splints, trusses or braces
▪ Treatment for functional nervous disorders, and mental and emotional disorders
▪ Prescription drugs and medications
Benefits that aren’t required in Idaho — and that could be removed from insurance plans if the Affordable Care Act’s mandate is removed — include lab tests, treatment for addiction, and medical care for pregnant women and newborns.
However, some insurance companies may decide to continue offering those benefits. Some Idaho health insurers began selling more robust insurance plans before the law changed in 2010.
“My understanding is that, in the 10 years prior to the Affordable Care Act, carriers started introducing wellness-type benefits that they may not have had prior to that,” said Wes Trexler, product review bureau chief and actuary at the Idaho Department of Insurance. “But there was never a requirement.”
The federal health law’s essential health benefit rules do not apply to “self-insured” or large-employer plans.
A government report in 2011 found that:
▪ 62 percent of individual plan members in the U.S. had no maternity coverage
▪ 34 percent lacked coverage for substance abuse treatment
▪ 18 percent had no mental health services
▪ 9 percent lacked coverage for prescription drugs.
“Essential health benefits guarantee to the parent of a child with a developmental disability that his therapy will be covered; to a woman that she will not have to pay for each of her prenatal care visits; and to a daughter with a father with dementia that his mental health care will be covered,” wrote Jeanne Lambrew, senior fellow The Century Foundation, a left-leaning think tank.