BOX 1-1
Essential Health Benefits Categories in ACA

Essential Health Benefits

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

SOURCE: § 1302(b)(1)(A)-(J).

insurance plans offered outside of the exchanges. Publicly supported subsidies, however, will only be available to those purchasing private plans through the exchanges, and these subsidies will be computed on a sliding schedule for individuals whose incomes are between 133 and 400 percent of the federal poverty level.6 Certain public insurance programs (i.e., Medicaid benchmark/benchmark-equivalent plans; state basic insurance) also must include the EHB package.7

Section 1302 of the ACA stipulates that the Secretary of the U.S. Department of Health and Human Services (HHS) is to define the EHB (Appendix A). The EHB must include “at least” 10 general categories of care and be “equal in scope to those offered by a typical employer plan.”8 The 10 broad categories are outlined in Box 1-1.

STUDY CHARGE AND APPROACH

At the request of the Secretary of HHS, the Assistant Secretary for Planning and Evaluation (ASPE) contracted with the IOM to make recommendations on criteria and methods for determining and updating the EHB package. It is important to note that the IOM Committee on Defining and Revising an Essential Health Benefits Package for Qualified Health Plans was not formed to detail the specific service elements of the benefits package, but rather, the committee was asked to offer advice on policy foundations, criteria, and methods for defining and periodically updating the benefits package. The specific statement of task for this committee is presented in Box 1-2.

To hear a variety of viewpoints on issues contained within the committee’s charge, the committee held public workshops on January 13-14, 2011, in Washington, DC, and March 2, 2011, in Costa Mesa, California. Experts from federal and state government, employers, insurers, providers, consumers, and health care researchers were asked to identify current methods for determining medical necessity, express state-specific concerns, and share decision-making approaches to determining which benefits would be covered and other benefit design practices,

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6 Individuals whose incomes are at or below 133 percent of the federal poverty level (FPL) will be eligible for Medicaid (a 5 percent income disregard effectively raises the eligibility level to 138 percent of FPL). The EHB do not apply to the traditional Medicaid program, although they are applicable to state expansions of insurance for low-income individuals, called Medicaid benchmark or benchmark-equivalent plans (§ 2001(c)), and state basic health insurance (§ 1331).

7 Exchanges may also be a vehicle for determining eligibility for traditional Medicaid and other state programs, even though those do not require inclusion of the EHB, and for matching individuals to the appropriate public or private options.

8 The Department of Labor was required by law to conduct a survey on the typical employer plan. Survey results can be found at: http://www.bls.gov/ncs/ebs/sp/selmedbensreport.pdf (accessed April 19, 2011).



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