The Essential Work of Defining Essential Healthcare Benefits

Margaret Dick Tocknell, October 5, 2011

Tucked away in section 1302 of the behemoth Patient Protection and Affordable Care Act (ACA) is the requirement that the Department of Health and Human Services define the essential healthcare benefits that must be offered – beginning in 2014 – by health insurance exchanges and health insurance policies, both individual and small-group.

This work is fundamental to the future state of healthcare. It will directly affect the medical benefits of many Americans, and therefore the functioning of hospitals and healthcare systems.  

The ACA specifies 10 broad categories of medical care for which essential benefits must be defined: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, lab services, preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care.

The idea is that the essential services will reflect the benefits provided in a typical employer health insurance package. Medical care that isn’t deemed essential can be excluded from coverage.

A committee at the independent Institute of Medicine has been hard at work since January on the first step in the process of creating the list of services to be deemed essential benefits. On Friday the IOM will unveil the methods and criteria that HHS will then use to develop the actual list. “IOM provides the guidance and HHS will define the benefits,” explains IOM spokesperson Christine Stencel.

The IOM committee has hosted two public workshops and heard from hundreds of stakeholders, including employers, insurers, healthcare providers, consumers, and healthcare researchers. These groups and individuals hope that benefits affecting their part of the medical world will be included.

Margaret Dick Tocknell Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.


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