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Essential Benefits Recommendations to HHS

“Essential Benefits” Recommendations to HHS

On October 7th, the Institute of Medicine (IOM) made its recommendations of “essential benefits” to the Department of Health and Human Services (HHS).  Under the Patient Protection and Affordable Care Act or Health Care Reform, there is a list of 10 health categories that are required to be included in any plan offered through the state insurance exchanges beginning in 2014.  These 10 categories include: 
  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care
     
The 297-page essential benefits package report released by the IOM on October 7th recommended the types of health care services that should be included in each of these categories.  The IOM’s focus was on the including services that would provide comprehensive coverage, be medically up to date, and with an emphasis on affordability.  It was not IOM’s role to provide any limitation on services or acceptable patient out-of-pocket costs.  Those will need to be determined by HHS.  There is no set timetable for HHS to provide the final rules and regulations on the essential benefits package, however, it is anticipated that HHS must release the guidelines in early 2012 for the health insurers and states to be able to create the insurance exchanges in time for 2014.