BOX S-1
Statement of Task for the IOM Committee

The Patient Protection and Affordable Care Act (Affordable Care Act) established criteria for qualified health plans (QHPs) to participate in exchanges as defined in Section 1301 of the statute. An ad hoc IOM committee will make recommendations on the methods for determining and updating essential health benefits for QHPs based on examination of the subject matter below.

In so doing, the committee will identify the criteria and policy foundations for determination of the essen tial health benefits offered by QHPs taking into account benefits as described in Sections 1302(b) (1) and 1302(b)(2)(A), and the committee will assess the methods used by insurers currently to determine medical necessity and will provide guidance on the “required elements for consideration” taking into account those outlined in Section 1302(b)(4)(A-G), including ensuring appropriate balance among the categories of care covered by the essential health benefits, accounting for the health care needs of diverse segments of the population, and preventing discrimination against age, disability, or expected length of life. The committee will also take into account language in Section 1302 on periodic review of essential health benefits, and other sections of the Affordable Care Act: for example, coverage of preventive health services (Section 2713), utilization of uniform explanation of coverage documents and standardized definitions (Section 2715), and other relevant tasks found in the Affordable Care Act for the Secretary of HHS. The committee will provide an opportunity for public comment on the tasks of defining and revising the essential health benefits.

insurers, health care providers, consumers, and health care researchers) contributed to the policy debate; their presentations are the subject of this summary report. This report only contains the summaries of presentations from the two workshops, which were just one aspect of the committee’s information gathering steps. Thus, the workshop report is not intended to provide recommendations in response to the statement of task.

To explain HHS’s expectations of the committee, Dr. Sherry Glied, the Assistant Secretary for Planning and Evaluation and the study sponsor, remarked at the first workshop that we do not expect this committee “to identify the individual elements or the detailed provisions” of the EHB package. Instead, she asked the committee to develop a framework for considering the EHB package “that will be logically cohesive, address statutory requirements, and serve HHS now and in the future.”

KEY ISSUES

Over the course of the workshops, participants noted many potential implications of the definition of the EHB, recognizing both the promise and challenges that lie ahead. Discussion of the committee’s charge coalesced around the following topics, including:

  • Balancing the generosity of coverage with affordability of insurance products;
  • Defining a “typical” employer plan;
  • Evaluating existing state mandates for inclusion into the EHB;
  • Considering the degree of specificity versus flexibility in forthcoming secretarial guidance;
  • Determining the medical necessity of care;
  • Promoting value in benefit design;
  • Applying evidence to benefit coverage;
  • Monitoring Section 1302’s “required elements for consideration";
  • Instituting an appeals process as a safeguard; and
  • Ensuring fair processes.


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