Essential Health Benefits Balancing Coverage and Cost (2012) / Chapter Skim
Currently Skimming:
1 Introduction
1 Introduction
Pages 13-24
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From page 13... ...
1 seeks to reduce the number of uninsured people in this country by providing access to affordable health insurance. As a result of implementation of the ACA, an estimated 30 million currently uninsured individuals are anticipated to obtain insurance through the private health insurance market or state expansion of Medicaid programs.2 Central to the development of private insurance packages under the ACA is the definition of what the law calls the essential health benefits.
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From page 14... ...
. Instead, the committee was asked to provide guidance on policy foundations, criteria, and methods the Secretary should consider in determining and updating the EHB package for qualified health plans, particularly in light of the 10 required categories of care outlined in Section 1302(b)
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From page 15... ...
A companion workshop report summarizes the presentations from the two workshops: Perspectives on Essential Health Benefits: Workshop Report.7 The workshop report is distinct from this consensus report in that it summarizes the individual perspectives of the speakers, rather than includes conclusions or recommendations from the committee. During its deliberations, the committee took into account all of the comments received, not just those received through the workshop venue, as it formulated its approach to identifying and addressing key issues.
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From page 16... ...
The committee kept these issues in mind as it developed its recommendations on the criteria and methods for defining and updating the EHB package. STATUS OF CURRENT HEALTH INSURANCE COVERAGE Before embarking upon a more detailed discussion of the issues related to the EHB, it is useful to understand what health insurance is, who has and does not have health insurance now, and the transitions in insurance status under health reform.
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From page 17... ...
KFF estimates that the distribution of the Congressional Budget Office's (CBO's) projected 24 million enrolling as individuals in the exchanges in 2019 would be 16 million individuals otherwise uninsured, 3.5 million who lost their ESI, 1.5 million whose previous ESI took more than 9.5 percent of their total family income and are looking for more affordable coverage, 11 2 million adults above 138 percent of the federal poverty level who lose Medicaid coverage, and 1 million who would have purchased individual coverage anyway (CBO, 2010; KFF, 2011a)
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From page 18... ...
the federal Office of Personnel Management (OPM) to enter into contracts with health insurers to offer at least two multi-state qualified health plans through the exchanges;12 these are distinct from the Federal Employees Health Benefits Program (FEHBP)
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From page 19... ...
? The EHB Apply to Multiple Insurance Programs, Starting in 2014 Individual Private Market • Qualified health plans (QHPs)
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From page 20... ...
The benefit plans do not need to follow all Medicaid rules and can be modeled on "benchmark" or "benchmark-equivalent" plans in the private sector such as a FEHBP standard plan.15,16 These programs will have to include the EHB starting in 2014. State basic health insurance programs are another optional vehicle for states to develop coverage for persons whose income falls between 133 and 200 percent FPL and for low-income legal resident immigrants who are not eligible to receive Medicaid.
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From page 21... ...
Just as in current health insurance practice, plans developed with the EHB will not pay for anything the consumer wants, unless it is a covered benefit and it is medically appropriate for the particular patient. Plans may add additional benefits beyond those in the EHB package, and a consumer could choose to purchase a plan with additional benefits if that best suits his or her needs, although purchasing additional benefits could mean a higher premium.
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From page 22... ...
Secretary updates the EHB guidance to field. FIGURE 1-3 Learning cycle for defining and revising essential health benefits (EHB)
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From page 23... ...
Chapter 8 allows for the possibility of alternative ways of defin ing essential health benefits through a state-initiated process. In Phase III, the learning culminates with updating the EHB.
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From page 24... ...
2011. Testimony to the IOM Committee on the Determination of Essential Health Benefits by Katy Spangler, Senior Health Policy Advisor, Senate Health, Education, Labor and Pensions (HELP)
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