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EssEntial HEaltH BEnEfits
Balancing Coverage and Cost
Cheryl Ulmer, John Ball, Elizabeth McGlynn, and Shadia Bel Hamdounia, Editors
Committee on Defining and Revising an Essential Health Benefits Package for Qualified Health Plans
Board on Health Care Services
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council,
whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering,
and the Institute of Medicine.
This study was supported by Contract No. HHSP 23320042509XI, Task Order HHSP23337027T between the National Academy
of Sciences and the Assistant Secretary for Planning and Evaluation of the U.S. Department of Health and Human Services.
Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not
necessarily reflect the view of the organizations or agencies that provided support for this project.
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Suggested citation: IOM (Institute of Medicine). 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington,
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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COMMITTEE ON DEFINING AND REVISING AN ESSENTIAL
HEALTH BENEFITS PACKAGE FOR QUALIFIED HEALTH PLANS
JOHN R. BALL (Chair), Former Executive Vice President, American Society for Clinical Pathology
MICHAEL S. ABROE, Principal and Consulting Actuary, Milliman, Inc.
MICHAEL E. CHERNEW, Professor of Health Care Policy, Harvard Medical School
PAUL FRONSTIN, Director, Health Research & Education Program, Employee Benefit Research Institute
ROBERT S. GALVIN, Chief Executive Officer, Equity Healthcare, Blackstone Group
MARJORIE GINSBURG, Executive Director, Center for Healthcare Decisions
DAVID S. GUZICK, Senior Vice President for Health Affairs, and President, UF&Shands Health System, Univer-
sity of Florida
SAM HO, Executive Vice President and Chief Medical Officer, UnitedHealthcare
CHRISTOPHER F. KOLLER, Health Insurance Commissioner, State of Rhode Island
ELIZABETH A. McGLYNN, Director, Kaiser Permanente Center for Effectiveness & Safety Research
AMY B. MONAHAN, Associate Professor, University of Minnesota Law School
ALAN R. NELSON, Internist-Endocrinologist
LINDA RANDOLPH, President and Chief Executive Officer, Developing Families Center
JAMES SABIN, Clinical Professor, Departments of Psychiatry and Population Health, Harvard Medical School,
and Director, Harvard Pilgrim Health Care Ethics Program
JOHN SANTA, Director of Consumer Reports Health Ratings Center, Consumer Reports
LEONARD D. SCHAEFFER, Judge Robert Maclay Widney Chair and Professor, University of Southern
California
JOE V. SELBY, Executive Director, Patient-Centered Outcomes Research Institute
SANDEEP WADHWA, Chief Medical Officer and Vice President of Reimbursement and Payer Markets, 3M
Health Information Systems
Study Staff
CHERYL ULMER, Study Director
SHADIA BEL HAMDOUNIA, Research Associate
CASSANDRA L. CACACE, Research Assistant
ASHLEY McWILLIAMS, Senior Program Assistant (through July 2011)
ROGER C. HERDMAN, Director, Board on Health Care Services
v
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Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical
expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee.
The purpose of this independent review is to provide candid and critical comments that will assist the institution
in making its published report as sound as possible and to ensure that the report meets institutional standards for
objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain
confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for
their review of this report:
Linda Burnes Bolton, Cedars-Sinai Medical Center
Troyen Brennan, CVS Caremark
Jon Gabel, National Opinion Research Center, University of Chicago
Neal Gooch, Utah Insurance Department
Jonathan H. Gruber, Massachusetts Institute of Technology
Gail Gibson Hunt, National Alliance for Caregiving
Michael M. E. Johns, Emory University
Timothy S. Jost, Washington and Lee University School of Law
Robert Krughoff, Center for the Study of Services
Eric Larson, Group Health Research Institute
Jerry Elizabeth Malooley, Benefit Programs and Health Policy for the State of Indiana
Wendy K. Mariner, Boston University School of Public Health
Debra L. Ness, National Partnership for Women and Families
Peter Neumann, Tufts University School of Medicine
Sara Rosenbaum, The George Washington University School of Public Health and Health Services
Alice Rosenblatt, AFR Consulting, LLC
Joshua M. Sharfstein, Department of Health and Mental Hygiene, State of Maryland
Gail Wilensky, Project HOPE
Matthew Wynia, American Medical Association
vii
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viii REVIEWERS
Although the reviewers listed above have provided many constructive comments and suggestions, they were
not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its
release. The review of this report was overseen by Christine K. Cassel, American Board of Internal Medicine
and Donald M. Steinwachs, Johns Hopkins University. Appointed by the National Research Council and the
Institute of Medicine, they were responsible for making certain that an independent examination of this report was
carried out in accordance with institutional procedures and that all review comments were carefully considered.
Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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Foreword
The Patient Protection and Affordable Care Act marks a milestone on a path toward substantially reducing
the number of uninsured and underinsured individuals in this nation. The lack of health insurance is harmful to
health, and equity in access to needed health care is one measure of a just society. But in creating the conditions
for expanded insurance coverage, how, exactly, should one go about deciding what to include as essential in a
health insurance plan?
This Institute of Medicine report Essential Health Benefits: Balancing Coverage and Cost answers this ques-
tion. The Patient Protection and Affordable Care Act sets out parameters and guidance that serve as a point of
departure and a constant reference for the committee’s deliberations. This report lays out criteria and methods
to define and update the essential health benefits package. The committee’s recommendations aim at promoting
evidence-based practices and prudent stewardship of resources. They encourage innovation and suggest ways to
remain sensitive over time to evolving public preferences for coverage. This study was initiated at the request of
the Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services, and we
sincerely hope the report will prove useful in the implementation of broader insurance coverage.
I am grateful for the support of our sponsors and to the committee, led by John Ball, which grappled with
the complexity of balancing coverage needs of individuals and the sustainability of the essential health benefits
package. Their work was reinforced by staff working under the direction of Cheryl Ulmer and including Shadia
Bel Hamdounia, Cassandra Cacace, and Ashley McWilliams. I commend both committee and staff for this product
and believe it provides a sound basis for the defining, and future refining, of an essential health benefits package.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
July 2011
ix
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Preface
A critical element of the Patient Protection and Affordable Care Act (ACA) is the set of health benefits—termed
“essential health benefits” (EHB)—that must be offered to individuals and small groups in state-based purchasing
exchanges and the existing market. If the package of benefits is too narrow, health insurance might be meaningless;
if it is too broad, insurance might become too expensive. The Institute of Medicine (IOM) Committee on Defining
and Revising an Essential Health Benefits Package for Qualified Health Plans concluded that the major task of
the Secretary of the Department of Health and Human Services (HHS) in defining the EHB will be balancing the
comprehensiveness of benefits with their cost.
Not surprisingly, the work of this committee drew intense public interest. Opportunity for public input was
offered through testimony at two public hearings and through the Web. The presentations at the hearings reinforced
for the committee the difficulty of the task of balancing comprehensiveness and affordability. On the one hand,
groups representing providers and consumers urged the broadest possible coverage of services. On the other,
groups representing both small and large businesses argued for affordability and flexibility. The committee thus
viewed its principal task as helping the Secretary navigate these competing goals and preferences in a fair and
implementable way.
The ACA sets forth only broad guidance in defining essential health benefits, and that guidance is ambigu -
ous—some would say contradictory. First, the EHB “shall include at least” 10 named categories of health services
per Section 1302. Second, the scope of the EHB shall be “equal to the scope of benefits provided under a typical
employer plan.” Third, there are a set of “required elements for consideration” in establishing the EHB, such as
balance and nondiscrimination. Fourth, there are several specific requirements regarding cost sharing, preventive
services, proscriptions on limitations on coverage, and the like. Taken together, these provisions complicate the
task of designing an EHB package that will be affordable for its principal intended purchasers—individuals and
small businesses.
The committee’s solution is this: build on what currently exists, learn over time, and make it better. That is,
the initial EHB package should be a modification of what small employers are currently offering. All stakehold -
ers should then learn enough over time—during implementation and through experimentation and research—to
improve the package. The EHB package should be continuously improved and increasingly specific, with the goal
that it is based on evidence of what improves health and that it promotes the appropriate use of limited resources.
The committee’s recommended modifications to the current small employer benefit package are (1) to take into
account the 10 general categories of the ACA; (2) to apply committee-developed criteria to guide aggregate and
xi
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Acknowledgments
The committee and staff are grateful for many individuals and organizations who contributed to the success of
the report. Many thanks go to the numerous individuals to whom staff spoke before and during the study process,
as well as those who submitted responses to the committee’s online comment form and other materials. In addition,
the committee wants to thank those who testified before it during the two public workshops:
Jessica Banthin, Agency for Healthcare Research and Quality
Carmella Bocchino, America’s Health Insurance Plans
Meg Booth, Children’s Dental Health Project
David Bowen, The Bill & Melinda Gates Foundation
Virginia Calega, BlueCross BlueShield Association
Arnold Cohen, American Congress of Obstetricians and Gynecologists
Rex Cowdry, Maryland Health Care Commission
Helen Darling, National Business Group on Health
Jina Dhillon, National Health Law Program
James Dunnigan, Utah State House of Representatives
Cindy Ehnes, California Department of Managed Health Care
John Falardeau, American Chiropractic Association
Linda Fishman, American Hospital Association
Marty Ford, The Arc and United Cerebral Palsy Disability Policy Coalition
Jean Fraser, San Mateo County Health System
Brian Gallagher, American Pharmacists Association
Alan Garber, Stanford University Center for Health Policy
Andrew George, California Department of Managed Health Care
Jonathan Gruber, Massachusetts Institute of Technology and the National Bureau of Economic Research
Gerald Harmon, American Medical Association
Mark Hayes, Greenberg Taurig, LLP
Leah Hole-Curry, Washington State Health Technology Assessment Program
Carolyn Ingram, Center for Health Care Strategies
Louis Jacques, Centers for Medicare & Medicaid Services
xv
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xvi ACKNOWLEDGMENTS
Jeffrey Kang, CIGNA Corporation
Jon Kingsdale, Wakely Consulting
Sharon Levine, The Permanente Medical Group
Jerry Malooley, U.S. Chamber of Commerce
Robert McDonough, Aetna
Maureen McKennan, California Department of Managed Health Care
Sean Morrison, National Palliative Care Research Center
Robert Murphy, American Society of Plastic Surgeons
Samuel Nussbaum, WellPoint
Kavita Patel, University of California, Los Angeles (UCLA) Semel Institute
Susan Philip, California Health Benefits Review Program
Joseph Piacentini, Employee Benefits Security Administration, Department of Labor (DOL)
Andrew Racine, American Academy of Pediatrics
Sara Rosenbaum, George Washington University School of Public Health and Health Services
Somnath Saha, Portland VA Medical Center and Oregon Health Services Commission
Matthew Salo, The National Governors Association
Beth Sammis, Maryland Insurance Administration
Paul Samuels, Legal Action Center and Coalition for Whole Health
Cathy Schoen, The Commonwealth Fund
David Schwartz, Senate Finance Committee
Thomas Sellers, National Coalition for Cancer Survivorship
Jeanene Smith, Office of Oregon Health Policy and Research
Richard Smith, Pharmaceutical Research and Manufacturers of America
Katy Spangler, U.S. Senate Committee on Health, Education, Labor, and Pensions
Stuart Spielman, Autism Speaks
Peter Thomas, Consortium for Citizens with Disabilities
Jeffery Thompson, Washington State Department of Social and Health Services
Michael Turpin, USI Insurance Services
Gary Ulicny, The Shepherd Center
Barbara Warren, Consumers United for Evidence-Based Healthcare
Kenneth B. Wells, David Geffen School of Medicine, UCLA
William Wiatrowski, Bureau of Labor Statistics, DOL
Bruce Wolfe, Obesity Action Coalition
Anthony Wright, Health Access California
Troy Zimmerman, National Kidney Foundation
Funding for this study was provided by the Assistant Secretary for Planning and Evaluation (ASPE). The
committee appreciates ASPE’s support for this project and would like to especially thank Sherry Glied, Richard
Kronick, Caroline Taplin, Lee Wilson, and Pierre Yong for their expertise and guidance on the project.
Lastly, many individuals within the Institute of Medicine were helpful throughout the study process, includ-
ing Clyde Behney, Daniel Bethea, Patrick Burke, Marton Cavani, Greta Gorman, Laura Harbold, Abbey Meltzer,
Elisabeth Reese, Vilija Teel, Stephanie Tioseco, and Lauren Tobias. We would also like to thank Florence Poillon
for assisting in copyediting this report. Christine Stencel of the National Academies’ Office of News and Public
Information provided substantial support in preparing for the public release of this consensus report and its com-
panion workshop report; Rachel Marcus of the National Academies Press helped facilitate the publication of both
manuscripts.
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Contents
ABSTRACT 1
SUMMARY 3
1 INTRODUCTION 13
Committee Charge, 14
Major Issues, 15
Status of Current Health Insurance Coverage, 16
Impact of the EHB Across Insurance Programs, 18
Stakeholder Decisions Will Reshape Health Insurance Markets, 21
Organization of the Report, 22
References, 23
2 APPROACHES TO DETERMINING COVERED BENEFITS AND BENEFIT DESIGN 25
Understanding Terms, 25
Understanding Contributors to Costs, 32
Illustrative Approaches to Coverage Decisions, 35
References, 44
3 POLICY FOUNDATIONS AND CRITERIA FOR THE EHB 47
Policy Foundations, 48
Criteria, 54
References, 57
xvii
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xviii CONTENTS
4 RESOLVING ACA INTENT 59
Finding the Meaning of Essential, 60
10 Categories of Care vs. Typical, 61
Essential vs. Nonessential, 63
Boundaries or Not, 63
Understanding Typical Specificity in Scope of Benefits, 64
Typical Employer: Small vs. Large, 65
State Mandates, 71
Medical vs. Nonmedical, 74
References, 75
5 DEFINING THE EHB 79
Step 1: Develop the Starting Point, 80
Step 2: Incorporate Cost into the Development of the Initial EHB, 82
Step 3: Reconcile Initial List to the Premium Target, 87
Step 4: Issue Guidance on Inclusions and Permissible Exclusions, 87
Committee Recommendation on Defining the EHB, 90
Other Areas for the Secretarial Guidance Related to the EHB, 91
References, 100
6 PUBLIC DELIBERATION 103
The Public Voice, 103
Components of Public Deliberation Processes, 107
Examples of Public Participation and Deliberative Processes, 110
Summary of Guidelines for Public Participation, 112
References, 113
7 PROGRAM MONITORING AND RESEARCH 115
Setting a Research Framework for Data Collection and Analysis, 116
Program Monitoring and Research, 118
Broad Areas of Research, 123
References, 126
ALLOWANCE FOR STATE INNOVATION 129
8
Authority for State Variation, 129
Flexibility in Determining the EHB, 130
Criteria for Approving a State-Specific EHB Definition, 131
Political Implications, 132
References, 132
9 UPDATING THE EHB 135
ACA Direction to the Secretary on Updating the EHB, 135
Goals for Updating, 136
Considering Typical Employer in the Future, 138
Methods for Incorporating Costs into Updates to the EHB, 138
Consequences for the EHB and ACA of Failing to Address Rising Health Care Costs, 142
National Benefits Advisory Council, 145
Conclusion, 149
References, 150
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xix
CONTENTS
APPENDIXES
A Patient Protection and Affordable Care Act, Section 1302, and Web Questions for Public Input 153
B Stakeholder Decisions on Health Insurance 159
C Examples of Possible Degrees of Specificity of Inclusions in Small Group and Individual Markets 169
D Examples of Benefit Package Statutory Guidance 191
E Description of Small Group Market Benefits, Provided by WellPoint 197
F General Exclusions 209
G Medical Necessity 225
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Boxes, Figures, and Tables
Summary
Box
S-1 Essential Benefits Categories in the Patient Protection and Affordable Care Act, 6
Figures
S-1 Four policy domains with associated foundational principles for thinking about essential
health benefits development and implementation, 4
S-2 Criteria for assessing content of essential health benefits (EHB) in the aggregate,
for specific components, and for methods, 5
Chapter 1
Boxes
1-1 Statement of Task for the Institute of Medicine Committee, 14
1-2 Which Programs Incorporate Essential Health Benefits (EHB)?, 19
Figures
1-1 Nonelderly population with selected sources of health insurance coverage, 2009, 17
1-2 Different stakeholder considerations during implementation of the Patient Protection and
Affordable Care Act (ACA), 21
1-3 Learning cycle for defining and revising essential health benefits (EHB), 22
Table
1-1 Transitions from Status Quo Insurance Status to Post-Reform Insurance Status, 18
xxi
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xxii BOXES, FIGURES, AND TABLES
Chapter 2
Boxes
2-1 Understanding Basic Terms Used in This Chapter and Report, 26
2-2 Description of Benefit Design, 30
2-3 The BlueCross and BlueShield Association Technology Evaluation Center’s Clinical Coverage
Criteria, 38
2-4 UnitedHealthcare’s Hierarchy of Criteria for Benefit or Coverage Determination, 38
2-5 Hierarchy of Evidence Employed by Washington State, 40
2-6 Oregon Treatment-Condition Pair Examples, 42
2-7 Inclusion Criteria for Oregon’s Value-Based Services (VBS), 43
Figures
2-1 Illustration of multiple medical management tools used by UnitedHealthcare, 32
2-2 Real spending on health care in selected categories, 1965-2005, 34
2-3 WellPoint, Inc. has various paths for reviewing benefit coverage to make medical
policy decisions, 37
Tables
2-1 Estimated Contributions of Selected Factors to Growth in Real Health Care Spending
per Capita, 1940 to 1990, 35
2-2 The State of Oregon Uses a Prioritized List of Services to Make Coverage Decisions, 42
Chapter 3
Box
3-1 The American Medical Association’s (AMA’s) Ethical Force Program Five Content Areas for
Performance Measurement in Designing and Administering Health Benefits, 51
Figures
3-1 Four policy domains with associated foundational principles for thinking about essential
health benefits development and implementation, 48
3-2 Criteria for assessing content of essential health benefits (EHB) as a whole and for specific
components, 55
3-3 Criteria to guide methods for defining and updating the essential health benefits (EHB), 57
Table
3-1 Uses of Evidence for Decision Making, 53
Chapter 4
Figure
4-1 Comparison of UnitedHealthcare (UHC) Federal Employees Health Benefit (FEHB) program plan
offered in Virginia (VA) vs. other UHC small business plans offered in the state, 70
Table
4-1 Percentage of Firms Offering Health Benefits, by Firm Size, 1999-2011, 66
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xxiii
BOXES, FIGURES, AND TABLES
Chapter 5
Boxes
5-1 Steps in Recommended Process for Defining an Essential Health Benefits (EHB) Package, 80
5-2 General Exclusions: Federal Employee Health Benefit Program Fee-for-Service Option, 89
5-3 Selected Required Elements for Consideration, 92
Tables
5-1 Congressional Budget Office (CBO) Estimates of the Effect of the Law on Premiums in the Small
Group Market, in November 2009 Letter to Senator Bayh, 83
5-2 Congressional Budget Office (CBO) Estimates of the Effect of the Law on Premiums in the
Individual Market, in November 2009 Letter to Senator Bayh, 84
5-3 Congressional Budget Office (CBO) Estimated Premiums for Individual and Family Policies
in Exchange Markets, in Letter to Senator Bayh, Converted to 2014 Dollars, 84
5-4 Premiums for Single Coverage in the Exchange Market in the Absence of the Patient Protection and
Affordable Care Act (ACA) Compared with After Implementation of the ACA (in 2014 dollars), 85
5-5 Individual and Small Group Premiums in Exchange Markets When Risk Pools Are Split or Combined
(in 2014 dollars), 85
5-6 Sample Approach to Incorporating Costs into the Definition of Essential Health Benefits, 86
5-7 Key Elements in Definitions of Medical Necessity, 97
Chapter 6
Tables
6-1 Summary of Opportunities for Patient or Public Input in Selected Technology Coverage Processes
in Different Regions, 105
6-2 CHAT Results from Medi-Cal Survey of Users’ Views (Adults with Disabilities) on Public Input
in Areas of Budget Cut, 112
Chapter 7
Figures
7-1 CIGNA coverage decisions and appeals for preauthorization of health benefits (2010), 122
7-2 Health Technology Assessment (HTA) program coverage decisions vary between Washington (WA)
state and private insurers, 124
Table
7-1 Comparison of 2010 Independent Medical Review (IMR) Results in California Managed Care, 121
Chapter 9
Tables
9-1 Illustrative Comparison of Current and Future Scope of Benefits for the Essential Health
Benefits (EHB), 138
9-2 Existing Entities Considered by the Committee to Advise the Secretary on Updates to the
Essential Health Benefits (EHB), 147
Figures
9-1 U.S. health care expenditure trends, 143
9-2 U.S. national health care spending relative to growth in gross domestic product (GDP), 143
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