result of cancer chemotherapy. Many states have mandates “to offer” services such as orthotics and prosthetics. A mandate to offer requires the carrier to offer to sell, outside the basic benefit package, a supplemental benefit at an actuarially sound price. Mandates to provide are rarer and often occur within the context of care delivery. An example would be a mandate to provide a specific service (e.g., interpreter services) or a product when a diagnosis is made (e.g., a specific set of information produced by a federal or state agency relating to the condition).

For a closed network, integrated delivery system like KP, any willing provider and any willing pharmacy mandates are particularly problematic. KP’s ability to deliver coordinated care across the continuum, with close linkages among primary care, specialty care, ambulatory, and inpatient settings depends on having a dedicated delivery system in which all parties have the same incentives, access to the same information and the same information platforms, and operate in a linked and coordinated fashion based upon a consistent set of values relating to quality, safety, evidence, and resource stewardship. Dr. Levine said that this becomes very difficult to sustain in an “any willing provider” environment.

State mandates are a concern for plans, Dr. Levine said, not only because of state-by-state variation, but also because they tend to be static. The dynamic nature of science and technology means that guidelines evolve and practices change; once state mandates appear, however, they are rarely repealed. Georgia, for example, still mandates that plans offer coverage for autologous bone marrow transplant (ABMT) for breast cancer (NAIC, 2009), despite the fact that this treatment was found to be less effective than conventional therapies and harmful to patients (Stadtmauer et al., 2000). Given the evolving nature of science and technology, Dr. Levine suggested that the committee consider “how granular to get” in mandating specific EHB benefits: “the more granular, the more often they’ll need to be revisited.” She suggested, for example, that cancer screening mandates be broad because if specific technologies for cancer screening are mandated, many of these will be “obsolete long before anyone thinks to look at the regulation.”

Committee member Mr. Koller asked both Drs. Levine and Nussbaum how they would propose addressing this state-by-state variation in mandates if they were developing the EHB design. For mandates in which there is “absolute proof that something is beneficial,” Dr. Nussbaum recommends a “national coverage model.” Conversely, he said, for areas in which benefits are unproven or rapidly evolving, flexibility at the state and federal coverage levels may be necessary. Dr. Levine suggested that criteria regarding the level of evidence needed to mandate a benefit would be beneficial, as would “resistance to granularity.” Broader mandates, such as mandated coverage for cancer screening, would be more beneficial than mandated coverage for PSA testing for prostate cancer.


ACOG (American Congress of Obstetricians and Gynecologists). 2010. ACOG practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstetrics and Gynecology 116(2 Pt 1):450-463.

Levine, S. 2011. PowerPoint Presentation to the IOM Committee on the Determination of Essential Health Benefits by Sharon Levine, Associate Executive Medical Director, the Permanente Medical Group, Costa Mesa, CA, March 2.

Mangione-Smith, R., A. H. DeCristofaro, C. M. Setodji, J. Keesey, D. J. Klein, J. L. Adams, M. A. Schuster, and E. A. McGlynn. 2007. The quality of ambulatory care delivered to children in the United States. New England Journal of Medicine 357(15):1515-1523.

NAIC (National Association of Insurance Commissioners). 2009. NAIC’s compendium of state laws on insurance topics: Mandated benefits—other. Kansas City, MO: National Association of Insurance Commissioners.

Nussbaum, S. 2011. Health insurance plan variance in coverage (inclusions, exclusions, networks) and benefit design for quality improvement. PowerPoint Presentation to the IOM Committee on the Determination of Essential Health Benefits by Sam Nussbaum, Executive Vice-President, Clinical Policy and Chief Medical Officer, WellPoint, Inc., Costa Mesa, CA, March 2.

Short, L. J., M. D. Fisher, P. M. Wahl, M. B. Kelly, G. D. Lawless, S. White, N. A. Rodriguez, V. J. Willey, and O. W. Brawley. 2010. Disparities in medical care among commercially insured patients with newly diagnosed breast cancer. Cancer 116(1):193-202.

Stadtmauer, E. A., A. O’Neill, L. J. Goldstein, P. A. Crilley, K. F. Mangan, J. N. Ingle, I. Brodsky, S. Martino, H. M. Lazarus, J. K. Erban, C. Sickles, S. M. Luger, T. R. Klumpp, M. R. Litzow, D. L. Topolsky, J. H. Glick, and Philadelphia Bone Marrow Transplant Group. 2000. Conventional-dose chemotherapy compared with high-dose chemotherapy plus autologous hematopoietic stem-cell transplantation for metastatic breast cancer. New England Journal of Medicine 342(15):1069-1076.

Tita, A. T., M. B. Landon, C. Y. Spong, Y. Lai, K. J. Leveno, M. W. Varner, A. H. Moawad, S. N. Caritis, P. J. Meis, R. J. Wapner, Y. Sorokin, M. Miodovnik, M. Carpenter, A. M. Peaceman, M. J. O’Sullivan, B. M. Sibai, O. Langer, J. M. Thorp, S. M. Ramin, and B. M. Mercer. 2009. Timing of elective repeat cesarean delivery at term and neonatal outcomes. New England Journal of Medicine 360(2):111-120.

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