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Register for a free account to start saving and receiving special member only perks. Introduction 1. Several provisions of the law went into effect in including requirements to cover children up to age 26 2 and to prohibit insurance companies from denying coverage based on preexisting conditions for children 3. Other provisions will go into effect during , including the requirement for all individuals to purchase health insurance. The exchanges will offer a choice of private health plans, and all plans must include a standard core set of covered benefits, called essential health benefits EHB.

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The health insurance exchanges will only offer qualified health plans QHPs , meaning the plans are deemed to cover the EHB and to meet other requirements set by the ACA. In the initial years, the exchanges are open to individual purchasers and employees of small businesses i. Additionally, the EHB are required to be included in new private individual and small group health. Of note, figures, sources, and citations were provided by presenters in support of their testimony, and are not necessarily endorsed by the committee.

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Publicly supported subsidies, however, will only be available to those purchasing private plans through the exchanges, and these subsidies will be computed on a sliding schedule for individuals whose incomes are between and percent of the federal poverty level. It is important to note that the IOM Committee on Defining and Revising an Essential Health Benefits Package for Qualified Health Plans was not formed to detail the specific service elements of the benefits package, but rather, the committee was asked to offer advice on policy foundations, criteria, and methods for defining and periodically updating the benefits package.

The specific statement of task for this committee is presented in Box Experts from federal and state government, employers, insurers, providers, consumers, and health care researchers were asked to identify current methods for determining medical necessity, express state-specific concerns, and share decision-making approaches to determining which benefits would be covered and other benefit design practices,. An ad hoc IOM committee will make recommendations on the methods for determining and updating essential health benefits for QHPs based on examination of the subject matter below.


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The committee will also take into account language in Section on periodic review of essential health benefits, and other sections of the Affordable Care Act: for example, coverage of preventive health services Section , utilization of uniform explanation of coverage documents and standardized definitions Section , and other relevant tasks found in the Affordable Care Act for the Secretary of HHS.

The committee will provide an opportunity for public comment on the tasks of defining and revising the essential health benefits. A month prior to the first workshop, the committee posted a set of questions online for public comment Appendix B ; these questions were posted for six months and the comments informed the committee study process.

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This document does not summarize the responses to the public comment form, which were provided to ASPE in their entirety. The views expressed are those of the workshop participants, not necessarily those of the committee.

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While committee members often ask probing questions, those questions should not be interpreted as positions indicative of personal or committee views. At the time of the workshops, the committee had not reached any conclusions; similarly, this workshop report does not present committee conclusions. Rather, this document is a factual summary of the two workshops, focusing in turn on each panel discussion.

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Every presenter was afforded the opportunity to review their individual portion of the following chapters prior to publication. The committee acknowledges that this workshop report includes a variety of viewpoints about which different conclusions and therefore ramifications may result; however, these differences will not be reconciled in this report.

Instead, the committee will use this information along with other sources when drafting its separate consensus report to provide guidance to the Secretary on defining and revising the essential health benefits.


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  • Furthermore, the content of this workshop report is limited to the views presented and discussed during the workshops and is not intended to be a comprehensive assessment of all issues pertaining to this subject. Readers should be aware that there may not always be countervailing opinions pressed on each issue. This package—commonly referred to as a set of essential health benefits EHB —constitutes a minimum set of benefits that the plans must cover, but insurers may offer additional benefits.

    The ACA requires that the EHB include at least 10 general categories of health services, and have benefits similar to those currently provided by a typical employer. To assist with this, HHS asked the IOM to recommend a process that would help HHS define the benefits that should be included in the EHB, and update the benefits to take into account advances in science, gaps in access, and the effect of any benefit changes on cost. The task of the IOM was not to decide what is covered in the EHB, but rather to propose a set of criteria and methods that should be used in deciding what benefits are most important for coverage.

    The committee recognized that the benefits included in the EHB must be sufficiently inclusive to enable access to essential services but must also be affordable so that as many as possible can purchase the coverage.

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    The committee saw its primary task as finding the right balance between making a breadth of coverage available for individuals at a cost they could afford. This balance will help ensure that an estimated 68 million people have access to care covered by the EHB.

    View Full Committee Roster.