Federal health officials are proposing changes to rules for coverage sold through the Affordable Care Act’s insurance marketplaces that, starting in 2019, would let states alter the benefits that health plans must provide and limit enrollment help for consumers.

The proposals reflect Republicans’ broad desire to weaken federal powers under the 2010 health-care law and remove various props that have led millions of Americans to get ACA insurance. Yet as rules, rather than changes in law, the revisions would not be as far-reaching as the GOP bills that Congress failed to pass this year.

In envisioning a larger role for states in setting benefits, the draft rule would still require ACA plans to cover 10 categories of medical services. But for the first time, any state could adopt benefits standards already in use by another state — or rewrite its own standards. This could lead to fewer visits being covered for certain types of care or to shorter hospital stays, health policy experts said.

The proposal also would undo a requirement that each ACA marketplace’s geographic area have at least two enrollment-assistance organizations, known as navigators, and that one of them be a consumer-oriented nonprofit. One navigator would suffice, and it would no longer need to be physically in the area served. The reduction, the proposed rule says, would allow ACA exchanges “to more easily operate these programs with limited resources.”

In addition, the draft rules would shift responsibility entirely to states — or outside accreditors — to decide whether each marketplace health plan has enough doctors and other providers of care in its network to guarantee patients “reasonable access.” The move would reverse government moves in recent years to strengthen federal network standards under the ACA.

Yet another proposed rule would allow states, with federal permission, to release insurers selling individual health plans from a requirement that they devote at least 80 percent of the premiums they collect toward customers’ care. The shift would essentially allow insurers in volatile markets to take more of their revenue as profits.

Posted at the end of last week by the Office of Management and Budget, without any announcement as has been customary from the Health and Human Services Department, the 365-page draft is the latest version of an annual ritual in which federal health officials suggest updates to ACA marketplace rules for the year after next.

In this first "notice of benefit and payment parameters" since President Trump took office, the tone differs substantially from the three notices of the Obama era. About a year ago, the last such notice of the Obama administration began its executive summary by saying that the ACA was "making high quality health insurance coverage and care more affordable and accessible to millions of Americans." The new draft contains no such statement and instead reiterates Trump's frequent contention that the law has destabilized insurance marketplaces in many parts of the country.

Several health policy experts said it is difficult to predict the impact the draft rules would have because it would hinge on what states do. Michael Adelberg, a principal at Faegre Baker Daniels Consulting who helped to implement parts of the ACA during the previous administration, said Monday that “allowing substitutions” within the law’s benefit categories could affect available health plans, “assuming the states want to go there.”

At Families USA, a liberal consumer health lobby, Claire McAndrew said that the prospect of fewer navigators, looser benefits rules and a decrease in the percentage of revenue that insurers must spend on health services “will harm consumers’ ability to get and maintain high-quality, affordable, comprehensive health coverage and care.”

Juliet Eilperin contributed to this report.

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