Perspectives on Essential Health Benefits Workshop Report (2012) / Chapter Skim
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Purchasers are allowed but not obliged to buy their coverage through newly established health insurance exchanges -- marketplaces designed to make it easier for customers to comparison shop among plans. The exchanges will offer a choice of health plans, and all plans must include a standard core set of covered benefits, called essential health benefits (EHB)
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The com mittee 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 (Sec tion 2713) , utilization of uniform explanation of coverage documents and standardized definitions (Section 2715)
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Any conclusions, recommendations, or supporting documentation offered in this publication are those of the speakers and not the IOM committee, whose own consensus recommendations are featured in a companion report called Essential Health Benefits: Balancing Coverage and Cost. BALANCING GENEROSITY AND AFFORDABILITY Numerous speakers noted the clear tension between the desire to make the EHB package as comprehensive as possible and the need to make the EHB package affordable for individuals, families, employers, states, and the federal government.
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DEFINING A "TYPICAL" EMPLOYER PLAN Section 1302 of the ACA states that the scope of the essential health benefits should be "equal to the scope of benefits provided under a typical employer plan" and required the Secretary of Labor (DOL) to conduct a survey of employer-sponsored coverage.
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She suggested that HHS consider not only how the contents of a typical employer plan should influence essential health benefits but also those of traditional Medicaid and existing Medicaid expansions. She expressed concern that if the public and private packages differ substantially in benefits, people might not "want to migrate out of the Medicaid program and into the exchange." EVALUATING STATE MANDATES FOR INCLUSION The ACA allows states to require QHPs to offer benefits beyond the defined set of EHB as long as the state assumes the incremental costs of subsidies for the additional mandated benefits.
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described the DMHC's experiences with health benefits provided under California's Knox-Keene Health Care Service Plan Act of 1975. While broad categories of benefits allow for flexibility as new diagnoses and treatments become recognized standards, broad categories create uncertainty about whether a treatment must be covered by a plan.
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Ms. Meg Booth of the Children's Dental Health Project endorsed the definition of dental necessity in The Children's Health Insurance Program Reauthorization Act of 20098 (CHIPRA)
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Dr. Jeffery Thompson, the chief medical officer of Washington State's Department of Social and Health Services and the Health Care Authority, described how a service supported by "A-level evidence based on randomized trials" is likely to be added to the state benefit package.
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Similarly, Ms. Fishman said, limits placed on the EHB package could focus on services that are marginally effective and could change as underlying scientific evidence or CER informs clinical best practices.
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INSTITUTING AN APPEALS PROCESS ACA requires health insurance plans to have internal and external grievance and appeals processes; there fore, appeals processes were discussed by several presenters. Health plans, Ms.
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PowerPoint Presentation to the IOM Committee on the Determina tion of Essential Health Benefits by Jessica Banthin, Economist, Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Costa Mesa, CA, March 2. CAHI (The Council for Affordable Health Insurance)
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