Trump Wants States To Define Essential Benefits, Lower MLR

New proposed health insurance regulations could give states more flexibility in defining "essential health benefits" that insurers must provide under the Affordable Care Act.

The Trump administration said the rules could loosen the benefit requirements. But if the rules become official, the changes in benefit requirements would not take effect until 2019.

The Centers for Medicare and Medicaid Services also wants to let states relax the ACA requirement that at least 80 percent of premium revenue received by individual-market plans be spent on members' medical care. It said states would be allowed to lower the 80 percent medical loss ratio standard if they demonstrate that a lower MLR could help stabilize their individual insurance market.

The proposed rule comes after health insurers and health care providers have begged the Trump administration for help in stabilizing the individual insurance market.

The administration proposed a complex new plan that would give states a potential path to easing some ACA requirements.

Starting in 2019, states could select from coverage levels in another state, which could be less generous. Ten broad categories of services required by the health law would still have to be covered, but the details could change.

Issued late in the day on Friday, the Trump administration proposal would affect basic benefits including:

— Outpatient, inpatient and emergency care

— Prescription drugs and labs

— Preventive care

— Pregnancy, maternity and newborn care

— Mental health and substance abuse

— Rehabilitation

— Children’s services, including vision and dental

Those benefit categories are established by law and can’t be changed in a regulation, but the details  can make a big difference. For example, insurers can cover certain drugs, but not others, for a given medical condition. Expensive treatments for complicated chronic illnesses can be subject to limits on the number of visits the plan will cover.

Susan Rupe is managing editor for InsuranceNewsNet. She formerly served as communications director for an insurance agents' association and was an award-winning newspaper reporter and editor. Contact her at [email protected]. Follow her on Twitter @INNsusan.

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Susan Rupe is editor in chief, magazine, for InsuranceNewsNet. She formerly served as communications director for an insurance agents' association and was an award-winning newspaper reporter and editor. Contact her at [email protected].