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Manual Essential Health Benefits: Balancing Coverage and Cost

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State should have flexibility in adopting variants of the federal EHB package, provided that modifications are consistent with the federal package, not significantly more or less generous, and are subject to public input. Prior to the release of the IOM report, there was concern about how an EHB package would interact with the numerous state mandate for health care coverage. According to the Council on Affordable Health Insurance , there are states with as many as 69 mandates for coverage Rhode Island , so the language around state flexibility alleviates some of the concern regarding mandates as well as offering an opportunity for state-level advocates to augment the EHB as necessary.

Establish a National Benefits Advisory Council, with members appointed through a nonpartisan process, which should make recommendations annually stemming from its oversight of the EHB package. The essential health benefits statue is very unique; details were sparse in legislative language for reasons referenced above. This is in contrast to the very specific coverage terms in Medicare. On one hand, the EHB should be as inclusive as possible with as much emphasis on quality as statutory authority will allow. Balancing cost and coverage is not the only issue.

The EHB statutory language also raises the issue of how to balance nondiscrimination and affordability. For example, a limit on a particular treatment for all persons might be cost-effective and clinically effective, but it could be very limiting for a subpopulation and thus potentially discriminatory.

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The IOM recommended that HHS work with states to standardize and collect information to ascertain compliance, as well as any variations in the definition of medical necessity, network limitations and prior authorizations. Finally, the experiences in Massachusetts and Utah have illustrated that even once an EHB is determined, there are real information barriers which make it difficult for individuals and small businesses to understand how to choose products within the exchange. While the burden of bridging this information divide will largely fall on states, the federal government should consider how to share best practices as the states each deal with these challenges and identify solutions.

A key theme throughout the IOM report is the emphasis on evidence and value.

Despite the lack of specifics around the various benefit categories something the IOM was never charged with doing , the opportunity to innovate and align the recommendations for an EHB with various delivery system reforms, research efforts and policies has never been more timely. Researchers in health care will need to work on the development of methods for comparative effectiveness research to guide coverage policy and determine how best to incorporate cost in such research.

Additionally, rapid cycle evaluation will be critical in understanding how an EHB may need to be modified at the federal and state levels in a timely manner. For example, if primary care coordination models can help decrease total care cost in Medicare as well as the large and small group markets, consumers can benefit from improved coverage for clinically effective services. The timeline for these efforts is years, not months, but we will need to understand how to identify short-term successes and translate such information to a national benefit advisory council.

State-based exchanges themselves can serve as laboratories for initiatives such as value-based benefit design. The IOM report may have left readers with more questions rather than answers, but perhaps that will allow for various stakeholders to take a more active role in helping shape the trajectory on a path towards affordable and equitable health care coverage. Kavita Patel. October 14, Doi: The review of this report was overseen by Christine K. 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. 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 report lays out criteria and methods to define and update the essential health benefits package.

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. 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. If the package of benefits is too narrow, health insurance might be meaningless; if it is too broad, insurance might become too expensive.

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.

Understanding Your Health Insurance Costs - Consumer Reports

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.


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The ACA sets forth only broad guidance in defining essential health benefits, and that guidance is ambiguous—some would say contradictory. 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. That is, the initial EHB package should be a modification of what small employers are currently offering. All stakeholders 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.

Essential Health Benefits

Defining a premium target, which is a way to address the affordability issue, became a central tenet of the committee. Why the Secretary should take cost into account, both in defining the initial EHB package and in updating it, is straightforward: if cost is not taken into account, the EHB package becomes increasingly expensive, and individuals and small businesses will find it increasingly unaffordable.

If this occurs, the principal reason for the ACA—enabling people to purchase health insurance and thus covering more of the population—will not be met. At an even more fundamental level, health benefits are a resource, and no resource is unlimited. Defining a premium target in conjunction with developing the EHB package simply acknowledges this fundamental reality. How to take cost into account became a major task.

Since, however, this does little to stem health care cost increases, and since the committee did not believe the HHS Secretary had the authority to mandate premium or other cost targets, the committee recommends a concerted and expeditious attempt by all stakeholders to address the problem of health care cost inflation. For example, the insurance contract may specify that diabetes care is a covered benefit; whether it is paid for depends on whether that care is medically necessary for the particular patient—whether, for example, the patient has diabetes.

The committee believes that medical necessity determinations are both appropriate and necessary and serve as a context within which the EHB package is developed by a health insurer into a specific benefit design and that benefit design is subsequently administered. The committee favors transparency both in the establishment of the rules used in making those determinations and in their application and appeals processes. Indeed, since the design and administration of health benefits rather than the scope of benefits themselves are what appear to differentiate small employer plans from each other and from large employer plans, monitoring benefit design and administration is an important step in the learning process and updating of the EHB.

Further, the committee states that a goal of the updated EHB package is that its content becomes more evidence-based. The committee wishes to emphasize the importance of research about the effectiveness of health services and to emphasize that the results of this research, including costs, should be taken into account in designing the EHB package. New and alternative treatments, in the view of the committee, should meet the standard of providing increased health gains at the same or lower cost.

Report at a Glance

Thus, the committee recommends that both in the determination of the initial EHB package and in its updates, structured public deliberative processes be established to identify the values and priorities of those citizens eligible to purchase insurance through the exchanges, as well as members of the general public. Such processes will enhance both public understanding of the tradeoffs inherent in establishing an EHB package and public acceptance of what emerges. The committee recommends that the Secretary develop a process that facilitates discovery and implementation of innovative practices over time.

A key source for this information will come from what states are observing or enabling in their own exchanges. Moreover, the committee recommends that for states that operate insurance exchanges, requests to adopt alternatives to the federal essential health benefits package be granted only if they are consistent with ACA requirements and the criteria specified in the report and they are not significantly more or less generous than the federal package.


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  • Essential Health Benefits: Balancing Coverage and Cost : Health and Medicine Division?
  • Essential Health Benefits Balancing Coverage and Cost Public Briefing, October 7, ppt download.
  • State packages also should be supported by meaningful public input. The committee hopes that its work will be useful in assisting the Secretary of HHS to determine and update the essential health benefits and that its deliberations will be informative to the public.

    As with most issues of. We hope this work is a positive step toward effective implementation of a key provision of the ACA. On a personal note, the chair wishes to thank the committee members for their tireless efforts in the work of the committee. When qualified people of good intent, of whatever political persuasion, come together for a common purpose, the process is full of learning and enjoyable.

    Thus it was with this committee, and I thank its members for the experience. In addition, no work of this sort can be done without a highly qualified professional staff. The committee and staff are grateful for many individuals and organizations who contributed to the success of the report. In addition, the committee wants to thank those who testified before it during the two public workshops:.

    Katy Spangler , U. We would also like to thank Florence Poillon for assisting in copyediting this report. Status of Current Health Insurance Coverage. Understanding Contributors to Costs. Illustrative Approaches to Coverage Decisions. Finding the Meaning of Essential. Understanding Typical Specificity in Scope of Benefits. Typical Employer: Small vs. Step 1: Develop the Starting Point. Components of Public Deliberation Processes.

    Examples of Public Participation and Deliberative Processes. Summary of Guidelines for Public Participation.

    Essential Health Benefits | Illinois Health Matters

    Program Monitoring and Research. Flexibility in Determining the EHB. Considering Typical Employer in the Future. National Benefits Advisory Council. In , an estimated 50 million people were uninsured in the United States. A portion of the uninsured reflects unemployment rates; however, this rate is primarily a reflection of the fact that when most health plans meet an individual's needs, most times, those health plans are not affordable.

    Research shows that people without health insurance are more likely to experience financial burdens associated with the utilization of health care services. But even among the insured, underinsurance has emerged as a barrier to care. The Patient Protection and Affordable Care Act ACA has made the most comprehensive changes to the provision of health insurance since the development of Medicare and Medicaid by requiring all Americans to have health insurance by An estimated 30 million individuals who would otherwise be uninsured are expected to obtain insurance through the private health insurance market or state expansion of Medicaid programs.

    Essential Health Benefits Balancing Coverage and Cost Public Briefing, October 7, 2011.

    Essential Health Benefits recommends a process for defining, monitoring, and updating the EHB package. Department of Health and Human Services agencies, state insurance agencies, Congress, state governors, health care providers, and consumer advocates. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.