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The Essential Work of Defining Essential Healthcare Benefits

Margaret Dick Tocknell, for HealthLeaders Media, 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.

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1 comments on "The Essential Work of Defining Essential Healthcare Benefits"


Matthew Bassett (10/7/2011 at 4:37 PM)
You were spot on when pointing out that the devil is in the details. The White House will carefully watch the response to the IOM report which will likely not satisfy anyone and only raise politically difficult questions. HHS is already saying that the final rule will not be out until May of next year at the earliest. This would be in the heat of the Presidential election and right around when the Supreme Court could rule on the constitutionality of the ACA. No one should be surprised if this is not settled definitely until after the election. At least this means that providers have time to express their views to state and federal officials. Payors' views are already well established and it seems the provider community is very late to the game. Providers need to make their voices heard now to help shape this important rule. Matthew Bassett, Revive PR