Health Reform Update: Panel Issues Recommendations on Essential Benefits
An advisory panel has recommended that federal officials balance cost and comprehensiveness to maintain affordability in crafting the minimum benefits package (also called Essential Health Benefits or EHB) required under state-based health insurance exchanges that will be established under the health reform law.
The recommendations, which were issued by the Institute of Medicine (IOM), were requested by the Department of Health and Human Services (HHS) to propose methods for creating and updating the benefits package. The health reform law requires HHS to establish a minimum benefits package—known as essential health benefits to be offered by the exchanges. The package must cover 10 categories of health care services, including mental health and substance use services. States may choose to require plans in their exchanges to offer greater benefits, but the additional costs would come out of the state's coffer.
The report stresses prioritizing clinically appropriate care and those medical concerns that are of greatest importance to plan users. Maximizing the number of people accessing coverage, utilizing evidence-based medicine, and protecting vulnerable populations were also highlighted as guiding principles for HHS.
When determining specific benefits, the IOM advised utilizing small employer plans as a model, as opposed to larger plans that tend to have similar services offered but more expansive provider networks and more lenient utilization management practices. It was also recommended that the services included in the plan be primarily medical services not serving a social or educational function, unless they are secondary to the health benefit.
Mental Health America has joined with a number of organizations in recommending to HHS that the exchanges provide comprehensive mental health and substance use benefits and services. Although the Mental Health Parity and Addiction Equity Act (MHPAEA) will apply to exchange plans, the IOM report did not address how that will be determined. Mental Health America will continue to advocate for specific inclusion and guidance regarding the application of MHPAEA. The IOM recommended that HHS not consider state mandates in establish essential benefits, which could have ramifications for states with generous parity statutes. If the minimum benefit required by HHS is less generous than state mental health mandates, states will have to decide if they will pay for the difference or begin stripping away their requirements.
Although essential benefits apply initially only to individual and small group plans offered both inside and outside of the state-based health insurance exchanges, the essential health benefits could apply to some large group plans. In 2017, states have the option of allowing large employers to participate in the exchange. The benefits also will apply to some Medicaid expansion programs.
The IOM recommended HHS release their initial draft EHB package by May 1, 2012, and HHS Secretary Kathleen Sebelius has promised to hold listening sessions around the country to receive public feedback. MHA will monitor opportunities to comment and inform stakeholders how to be involved.