Statement of Task
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 services and items that should be included in the EHB package (see Statement of Task in Box 1-1). Instead, the committee was asked to provide guidance on policy foundations, criteria, and methods the Secretary should consider in determining and updating the EHB package for qualified health plans, particularly in light of the 10 required categories of care outlined in Section 1302(b)(1) and the requirement in Section 1302(b)(2)(A) for the EHB to be “equal to the scope of benefits provided under a typical employer plan.” State-based health insurance exchanges (HIEs) are being established to provide a competitive market through which individuals as well as employees of small businesses will be able to obtain private health insurance coverage. Purchasers are allowed but not obliged to buy their coverage through newly established HIEs; however, subsidies will be available through the exchanges on the basis of a sliding scale for individuals whose incomes are 139-400 percent of the federal poverty level (FPL).3
A qualified health plan is a plan that meets the requirements to be sold in an HIE, such as including the EHB, being offered by a licensed insurer that charges the same premium inside and outside the exchange, and other insurance reform elements.4 Discussions with HHS further indicated that the committee should also recognize the applicability of these benefits to plans beyond the qualified health plans (QHPs) (i.e., Medicaid benchmark, benchmark-equivalent, state basic insurance plans, and certain private plans sold outside the exchanges). The Secretary is expected to issue guidance on the EHB package during 2012 because Section 1321(c) of the ACA requires the Secretary to make an assessment by January 2013 that the states will have operational exchanges by January 1, 2014.5
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 essential 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 the Department of Health and Human Services (HHS). The committee will provide an opportunity for public comment on the tasks of defining and revising the essential health benefits
3 Individuals whose incomes are at or below 133 percent of the FPL will be eligible for Medicaid, with an additional 5 percent income disregard, effectively raising the income eligibility level to 138 percent of FPL (§ 1902(e)(14) of the Social Security Act).
4 § 1301.
5 Personal communication with ASPE staff, October 26, 2010; updated by personal communication with Caroline Taplin, ASPE, June 14, 2011.