Merriam-Webster defines essential as: of the utmost importance.
How would you apply that to health benefits?
That’s the request the federal government made to the Institute of Medicine (IOM) –
Help define the essential benefits package required by
health reform’s Affordable Care Act
The Provision in the Affordable Care Act
Like many of the health reform provisions of the Affordable Care Act, those applying to essential benefits take effect in 2014.
The creation of the state insurance exchanges are also due in 2014. Insurance policies offered by the exchanges must be certified and cover the “essential benefits.” Up to this point, health reform provisions used only broad categories in defining essential benefits.
It was left up to the Department of Health and Human Services (HHS) to further define essential health benefits, with input from IOM. I believe the term “health” was added so the health care industry could create yet another acronym – EHB (essential health benefits).
But is is Affordable?
After much anticipation, the IOM released its nearly 300-page report. This is health care, after all. Anything less than 200 pages is just the summary.
IOM clarified that the charge of its committee was NOT to decide what is covered in the EHB package, but “rather to propose a set of criteria and methods that should be used in deciding what benefits are most important for coverage.”
Good thing we have until 2014.
Here are some of the highlights of the report.
- Affordable – sressed the package has to be affordable – must balance cost with benefits
- Budget – used the analogy of grocery shopping – recommended “going to the store” on a budget and purchase within that budget
- Build framework - recommended a framework for EHB package that considers health needs as a whole, encourages scientific evidence, promotes good use of resources and tools for improving value and performance
- Public involvement - seek public input while offering state flexibility in plan design as long as it meets standards
IOM recommended the EHB package include the following categories:
- Ambulatory
- Emergency
- In-patient treatment
- Maternity care
- Pediatric, including oral and vision care
- Laboratory
- Prescriptions
- Preventive and wellness, including chronic disease management
- Mental health and substance abuse
- Rehabilitative
HHS plans a series of “listening sessions” where Americans can share their opinions. That should prove interesting.
Here’s your chance – how do you define essential benefits?
Notice of Disclaimer –Cathy Miller is not a health care professional or attorney and cannot provide medical or legal advice. The information provided is for your general background only, and is not intended to constitute medical or legal advice as to your specific circumstances. We recommend you review medical issues with your physician and legal issues with an attorney.
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{ 3 comments… read them below or add one }
Great post, Cathy. This reform is such a huge deal. It definitely aims to do the right thing, but it’s a huge can of worms at the same time. I’m still on the fence at the moment – so I am indeed glad that we have until 2014! I do like the list of 10 from the IOM though.
Nicky Parry´s last [type] ..What Is Colorectal Cancer?
Thanks, Nicky. It is so challenging to balance the cost with what’s covered.
In my last Corporate America job I worked for a brokerage/consulting firm that has the right approach-in my humble opinion. It is focusing on managing health and removing barriers to good health instead of the traditional approach of managing disease-you get sick-they pay the claim. It’s a huge shift in thinking, but one we need.
Thanks again for sharing your thoughts, Nicky.
I really like that idea. I often feel saddened though when I realize that the biggest barrier to good health is often the individual person. Sometimes I feel that the insurance companies are between a rock and hard place when some folk won’t get proactive about their own health. But that’s another can of worms, & I don’t want to open this one for you right now, lol!
Nicky Parry´s last [type] ..What Is Colorectal Cancer?