The essential benefits report, created by the Institute of Medicine (IOM), has been released. The Affordable Care Act requires the package to reflect benefits covered by a typical employer plan and include 10 categories. According to the report, HHS officials will compare potential services and products against a set of critera, created by the IOM, including medial effectiveness, safety and relative value compared with alternative options, and evaluate whether the package as a whole protects the most vulnerable individuals, promotes services that have proved effective and addresses the medical concerns of greatest important to the public. In keeping with their assigned task, the IOM did not address and specific types of benefits in their recommendations. It instead tells the Secretary  of HHS how to define the minimum benefits. Click here to view additional recourses by the IOM including the IOM’s press release, criteria, report brief and report release presentation.

What does this mean to you?

Starting with plan years or policy years that began on or after September 23, 2010, health plans can no longer enforce a lifetime dollar limit on spending for services defined under essential health benefits. All plans, except grandfathered individual health insurance policies, must phase out annual dollar spending limits for these services by 2014. PPACA defines essential health benefits to include at least the following general categories and the items and services covered within the categories: 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; and pediatric services, including oral and vision care. Insurance policies must cover these benefits in order to be certified and offered in Exchanges, and all Medicaid State plans must cover these services by 2014.