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The Institute of Medicine (IOM) is undertaking a study that will make recommendations on the criteria and methods for determining and updating the essential health benefits package in health care reform. As you may recall, HFA submitted comments to the initial survey conducted in December. The outcome of this study will be a published report released in September which will lay out the criteria the U.S. Department of Health and Human Services should use in crafting federal regulations on essential health benefits offered in the health insurance exchanges states will need to set up by 2014.

IOM has entered the next phase of this process and will be holding a serious of public meetings to hear from various stakeholders regarding essential benefits. The first meeting took place this week January 12 -14, 2011 and covered numerous topics within essential health benefits including:  the original legislative intent of health care reform regarding essential health benefits, stakeholder recommendations for defining health insurance packages, issues regarding medical necessity, how insurers determine benefit design and coverage and various perspectives from patients and health advocacy groups.

Some common themes emerged from the presentations:

Insurers argue that essential benefits should not be heavily prescribed through regulation to allow for the market to determine which benefits provide the best coverage options. They also cautioned against adopting state mandates, because of the tens of thousands already in existence across the country. They argue that adopting a multitude of mandates on the national level will bring a dramatic rise in health insurance premiums.

Patient and health advocacy groups argue that patients need access to treatment and providers of their choice especially those patients with chronic disease. Essential benefits must be designed so that this access is not denied. They urged the panel to ensure that the benefits reflect the diverse health care needs of the U.S. population and are based on appropriate standards of care and practice. According to the advocacy groups, the inclusion of some state mandates are necessary to maintain comprehensive care for those with complex health needs.

For more information on the Institute of Medicine and Essential Benefits please visit the study’s website.

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