This blog is part of a series that will highlight how changes in the 2019 Notice of Benefit and Payment Parameters (NBPP) final rule will affect the comprehensive coverage that the essential health benefits (EHBs) package offers to consumers.

Before the Affordable Care Act (ACA), only 12 percent of individual health insurance plans covered maternity care. Some plans offered separate “ridersfor maternity care, but charged women exorbitant amounts for this “extra” coverage. These riders could also include waiting periods intended to exclude coverage for women who were already pregnant.

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Thirty-eight year-old Trei Clark of Atlanta remembers these pre-ACA days well: “I was penalized for being a woman of childbearing age. You could get regular insurance for like $200 a month but if you wanted maternity care, it was $350 a month extra,” she said

The ACA established maternity care as one of the 10 Essential Health Benefits (EHBs) insurers are required to cover, helping women like Trei Clark get the health care they need. Yet, that guarantee could be undermined by the Trump administration’s recently finalized Notice of Benefit and Payment Parameters (NBPP) rule.

While insurers will still be required to cover the 10 EHBs to at least some degree, the rule grants significant leeway to states to determine which services to offer under each broad category of benefits. If pre-ACA days are any indication of what states and insurers will do with this newfound “flexibility,” some states will no doubt choose to water down health benefits essential to women, such as maternity coverage and mental health care.

How might maternity and newborn care be affected?

Thanks to the ACA, close to 13 million women gained access to maternity care as one of the 10 EHBs that insurers are required to cover. Coverage includes prenatal care, labor and delivery, and postpartum care. As a previous blog post in this series notes, access to this full continuum of care during one’s pregnancy is critical to newborn and maternal health. Maternity care lowers the risk of pregnancy related complications such as hemorrhaging, high blood pressure, blood clots, gestational diabetes and postpartum depression.

Under this new rule, states could redefine their EHB package in new ways, enabling a state to approve a plan with maternity care that only covers a few prenatal visits and screenings, for example. Changes like this, coupled with other proposed regulations that will make it easier for states to offer plans that don’t cover maternity care, will further reduce access to basic women’s health services. Each of these changes take place in a system where insurers are already violating the ACA’s EHB requirements. Even under the Obama administration, a vast majority of insurers had maternity coverage violations, the National Women’s Law Center found. These included arbitrary limits on maternity benefits; excluding maternity coverage of dependents; missing services such as pre-conception, prenatal, delivery and postpartum care; and stricter coverage limits of emergency services outside of the plan’s service area.

While decreased access to comprehensive maternity care would be harmful to women of all backgrounds, the effects would be particularly severe for Black women, who are three to four times more likely to die from pregnancy or childbirth-related causes than are white women due to systemic racism and health care inequalities.

Mental Health and Substance Use Disorder Services

Another Essential Health Benefit jeopardized by the NBPP rule is mental health and substance use disorder services. Women are more likely than men to experience certain mental health issues, including anxiety disorder, PTSD resulting from gender based violence, as well as issues relating to post-partum depression. Before the ACA, many health plans excluded mental health coverage, leaving close to one in five people without needed mental health care. There were also pre-ACA gaps in coverage for substance use disorder treatment, when one in three people lacked coverage. The new NBPP rule would give states the option to skimp on mental health care and substance use disorder treatment, leaving women with nowhere to turn.

Financial Impact on Women

Under the NBPP rule, people who rely on services that are no longer covered EHBs will have to pay out-of-pocket for those services or forgo the care needed care. In addition, the out-of-pocket maximum, and annual and lifetime limit consumer protections, will no longer apply to services no longer considered EHBs, since these protections only apply to EHBs. It’s not just people with individual market plans who will be affected; EHBs affect annual and lifetime caps in employer-provided insurance, too. This change will increase health care costs for many, including people with preexisting conditions. It will also drive up medical debt and health-related bankruptcies, which  have lessened since the ACA became law. Women are already uniquely affected by medical debt and are more likely than men to report having such problems. In 2016, 42 percent of women, or 40 million, reported having a medical bill problem in the past year or medical debt.

Before the ACA, women who had just delivered babies were leaving the hospital with bills ranging from $32,093 for an uncomplicated birth to $52,125 or more for more complicated births. The NBPP rule takes us backward and dangerously close to the bad old days when women did not have adequate coverage, and faced exorbitant out-of-pocket costs.

What can you do? 

Thanks to our hard work, Congress has repeatedly rejected repeal of the ACA and its critical consumer protections for women. Now, we must fight back against some of those same threats implemented through regulatory changes. Women’s health advocates should work alongside consumer health advocates to engage state officials early on to make sure they don’t make harmful changes that would roll back the progress made for women’s health under the ACA.

As an earlier blog post in this series notes, states have until July 2, 2018, to change the “benchmark” plan for 2020. Advocates should target the entity in their state that is responsible for selecting their states’ EHB. This varies by state, ranging from the governor, legislators or departments of insurance.

States can also work to protect EHBs broadly at the state level through state-level policies or regulations. In Connecticut, advocates successfully built support for a policy (currently under review by the Governor) that requires individual and small group health insurance policies to cover the same 10 EHBs required under the ACA. In New York, the Governor made a policy pronouncementthat requires plans regulated by the state to cover the same categories of essential health benefits and be subject to the same benchmark plan rules that currently apply through the ACA. Your action today could make a profound difference for women for years to come.