Essential Health Benefits update: ACA regulations finalized

An update to the ACA Marketplace regulations extends open enrollment. The Biden administration has finalized several changes to Affordable Care Act (ACA) Marketplace regulations that AOTA supported in a formal comment letter in July. These policies focus on increasing enrollment in comprehensive plans that guarantee coverage of the essential health benefits (EHBs), which include preventive and wellness services, mental health and substance use disorder services, and rehabilitative and habilitative services and devices.

• Adds an extra month to the annual open enrollment period, which will now run from November 1 to January 15. 
• Establishes a new, monthly enrollment opportunity for low-income consumers (people with income under 150% of the federal poverty level who qualify for $0-premium plans), so they don’t have to wait for the annual open enrollment period.
• Increases the user fees charged to insurance companies to provide more funding for outreach and assistance, including Navigators who provide one-on-one help to consumers.
• Requires Navigators to provide post-enrollment assistance, like explaining health insurance terms or helping to file an appeal. 
• Repeals a policy, finalized on January 19, 2021, that would have allowed states to shut off access to a centralized eligibility and enrollment website (HealthCare.gov or a state-based Marketplace site) and delegate enrollment to insurers, web-brokers, and agents and brokers.
• Repeals the previous administration’s standards for approving state waivers of certain ACA requirements. Those standards allowed waivers promoting enrollment in non-ACA forms of coverage – including plans that aren’t required to cover the EHBs. 

People who buy insurance in the individual market should have access to a meaningful package of benefits that covers essential services like rehabilitation and habilitation. Rehabilitative and habilitative care accounts for about 1% of the typical individual market premium but could burden individuals with very high out-of-pockets costs or unmet health and functional needs if those services are not covered.

The new regulations limit state flexibility to experiment with individual market models designed to promote enrollment in less comprehensive forms of coverage, like short-term plans. These alternative forms of coverage generally aren’t subject to the EHB requirements and can deny, delay, limit, or charge more for coverage based on health status. The new rules also give Marketplace consumers more time and assistance to find a comprehensive plan that meets their needs.