said these Medicaid benchmark plans are a “distinct entity” from current Medicaid programs. Benchmark plans may have a scope of coverage different from the usual mandatory Medicaid coverage.

Further, Dr. Glied noted, the ACA explicitly permits continuation of utilization management practices in common use at the time of enactment by group health plans and health insurance issuers, and bars the issuance of regulations that would prohibit their use.5 In response to further inquiry from Dr. Santa, Dr. Glied clarified that ASPE does not expect the IOM committee to identify these commonly used utilization management practices, but said that when the Chief Actuary of the Centers for Medicare & Medicaid Services determines the EHB package is equal in scope to that of a typical employer and determines actuarial value, the actuary “will look at what is actually in practice in the world and make estimates on that basis.”

Dr. Glied drew attention to several elements of Section 1302, including those pertaining to the need for the EHB to be balanced among categories, be non-discriminatory, and include a scope of benefits equal to the scope of benefits provided under a typical employer plan. In addition, she said the committee could provide ASPE with guidance on the following types of questions:

  • At what level of specificity should EHB be framed?
  • What can be learned about plan design, consistency, and fairness from the practices of employers who offer multiple plans?
  • Assuming that insurers continue to have a role in deciding which services to pay for, what information is needed to monitor the decisions that are made, how should that information be collected, and how should that information be used, if at all, in updating the EHB? What are the roles of exchanges, states, and the federal government in this task?
  • How are issues of time, duration, frequency, scope, and specific services best addressed?
  • What defines and distinguishes a medical service from a nonmedical service? How should this distinction be considered and applied in the context of defining EHB?
  • How can a federal standard for benefit coverage best reconcile existing state and regional variations in practices and benefit coverage patterns, including variations in state-mandated benefits?
  • How much flexibility should be given to states and/or the exchanges?
  • What criteria should be used to adjust EHB over time and what should the process be for their modification? How can modifications to EHB remain consistent with the initial benefit design while reflecting evolving science?

Committee member Dr. Alan Nelson asked Dr. Glied to further elaborate on ASPE’s request that the committee “define and distinguish a medical service from a nonmedical service.” The EHB package, Dr. Glied responded, is intended to cover “those medical services that are required under essential health benefits.” One of the considerations that will logically arise, then, is what actually defines a medical service. While there are “many, many things that contribute to a person’s health,” not all of them are medical services. ASPE envisions the EHB package as including only those components deemed to be “medical,” and that would fall within a typical insurance package.

Given the legislative requirement that EHB are equal in scope to the benefits under a typical employer plan, committee chair Dr. John Ball asked Dr. Glied to speak about the potential contradiction between benefits that may be essential vs. those that may be typical. Dr. Glied noted that this contradiction may be particularly apparent around the issue of nondiscrimination. “Thinking through how we develop an essential health benefits plan that meets both the requirements of the law that says ‘typical employer’ and says ‘nondiscriminatory’ is something we would like your advice about,” she said. Committee member Ms. Marjorie Ginsburg noted that other contradictions may arise if “typical” plans include benefits that are not “essential.” Dr. Glied confirmed the truth in this observation, but suggested the committee “focus more on the process than on the content of the plan.” This exchange prompted committee member Dr. Elizabeth McGlynn to ask for more details on what is “typical,” asking, “Should typical reflect the markets that these plans will be issued in” or should it be the “average” typical plan? Because

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5 § 1563(d)(1).



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