Performance Improvement 2011-2012. What Process Should the Department of Health and Human Services Use in Defining and Updating Essential Health Benefits as Required by the Affordable Care Act?


The Affordable Care Act identified at least ten essential categories of items and services known as essential health benefits (EHBs) that must be included in packages of benefits to be offered by qualified health plans participating in Exchanges beginning in 2014, issuers in the individual and small group markets, Medicaid benchmark and benchmark-equivalent plans, and State basic health programs for low-income individuals not eligible for Medicaid. The scope of these EHBs should be guided by the content of a typical employer plan. The Institute of Medicine (IOM) at the Department's request convened an expert panel, held two public hearings with over 50 witnesses, received 345 responses to questions posed on line, and issued two reports.

The IOM recommended that the scope and design of EHBs should reflect those packages offered by small employers, that suggested criteria guide the aggregate package of EHBs and specific inclusions and exclusions, and that costs be considered in both the initial design and update of EHBs and that a public deliberative process should guide both efforts. The IOM further proposed a process for updating EHBs, encouraged state innovation, recommended data gathering and research efforts across the health care system to control costs and recommended the creation of a National Benefits Advisory Council.

Report Title: Essential Health Benefits: Balancing Coverage and Cost
Agency Sponsor: OASPE-OHP, Office of Health Policy
Federal Contact: Caroline Taplin, 202-690-7906
Performer: Institute of Medicine
Record ID: 9634 (Report issued October 1, 2010)

View full report


"PerformanceImprovement2011-2012.pdf" (pdf, 701.44Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®