National Academies Press: OpenBook

Essential Health Benefits: Balancing Coverage and Cost (2012)

Chapter: Appendix E: Description of Small Group Market Benefits, Provided by WellPoint

« Previous: Appendix D: Examples of Benefit Package Statutory Guidance
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×

Appendix E

Description of Small Group Market
Benefits, Provided by WellPoint

The IOM committee found the WellPoint analysis of their products helpful in understanding benefit inclusions and exclusions in the small group market to complement the listing of covered services and exclusions found in Appendix C and F, respectively.

Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×

image

Background

As outlined in our comments submitted to the Institute of Medicine (IOM) on December 6, 2010, WellPoint believes that when determining what benefits are essential, it will be imperative to balance the need for comprehensive, evidence-based coverage with the need to ensure access to affordable coverage for consumers. If “essential” is defined too broadly, such as by including benefits without a sound evidence base or items that are currently not included in many individual or employer benefit packages, consumers’ access to affordable coverage will be compromised.

In order to better understand what benefits should be considered essential, WellPoint has undertaken a process to evaluate our fully-insured, small group market (where a small group is defined as one with 1 or 2 to 50 employees) product offerings across the country to identify where there is consistency across our products, where there might be differences, and the cost impacts of these differences. The attached exhibits illustrate our findings. As you will see, there is little variation in our typical small group plans within and across states. However, the cost impact of those benefits that vary can be substantial, especially when taken in sum. We share this information in the hopes that it may be helpful as the IOM makes its recommendations to the Department of Health and Human Services regarding the determination of essential health benefits.

Large Group Benefits

Plans offered in the small group market are standardized and provide little or no flexibility to add or remove coverage for services. These standard plans are offered in all markets, small, mid-size and large, but large groups (those with over 100 employees) have the flexibility to customize their plans. Thus, because large groups also start with the same standard product portfolios in each state as offered to small groups, large group products generally cover the same services as the small group products in any given state. The level of flexibility a large group has to customize their benefits is determined by funding type (fully-insured versus self-insured) and the size of the account. For example, a 150 life fully-insured group has less flexibility to customize benefits than a 1,000 life self-insured group.

Most customization for large groups is around benefit cost share or benefit limits, not coverage/exclusions. Less than 5% of customization requests deal with adding coverage. Examples include requests to add coverage for specific non-covered prescription drugs or over-the-counter medications (majority), coverage for hearing aids, coverage for bariatric surgery, and coverage for infertility. Very few (only about 2%) of the large group customization requests are to remove coverage, and most of these are self-insured groups requesting to remove state mandated coverage (as such mandates generally apply only to fully-insured products).

Helpful Definitions for Exhibit A

“Anthem/Blue Standard Coverage/Typical SG Plans” cover a standard set of medically necessary services including inpatient and outpatient hospital services, diagnostic services, physician visits and medical care, maternity care, surgical services, mental health and substance abuse services, therapy services, skilled nursing facility services, home health care services, preventive care services, and medical equipment and supplies. For more details on inclusions and exclusions to the standard plan, please see Exhibits B and C, respectively.

images  Most variation across these standard plans is driven by differences in cost-sharing, not covered services.

Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×

images  There is some variation across these standard plans in the “amount” of benefit provided (for example, the number of visits or services covered).

images  Some variation exists across these standard plans regarding site of care requirements or limitations (for example, coverage may be limited to outpatient setting or coverage only provided if Center of Excellence used).

images  Some variation in medical management exists across these plans across states.

images  While the standard set of covered services in “Typical SG Plans” is generally consistent across plans in each state, regardless of the size of the small group, there are some differences across our plans from state to state resulting from state mandate requirements and/or market demand and competitor standards. The key differences are documented in Exhibit A.

images  As the membership numbers included in the Exhibit A indicate, the majority of WellPoint’s small group membership (90%+) are enrolled in standard coverage plans.

• In several states, we offer plans, “Anthem/Blue Limited Coverage”, in the small group market that provide for a more restricted set of covered services. These plans are low cost options that primarily cover hospital and surgical services, and provide limited or no coverage for other medical services that are generally covered under the more standard plans.

• The response in the “State Mandated Benefit” column indicates whether or not states require coverage of this service under state law and should provide some indication as to why a service may be covered.

Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×

Exhibit A: Standard Plan Variances

Benefit Range of Impact State Mandated Benefit? (Fully Insured Group Market) Anthem/Btue Standard Coverage/ Typical Plan in the Small Group and Large Group Markets Anthem/Blue Limited Coverage Plan
Small Group Membership Allocation (Groups with up to 50 employees for all states) 99.70% 0.30%
Small Group Membership Allocation (Groups with up to 50 employees only for states where Anthem/Blue Limited Coverage is currently marketed) 99.25% 0.75%
Allergy Testing and Injections 0-1% No Covered Not covered
Alternative Medicine (Acupuncture, acupressure, massage therapy, etc.) 0-1% In few states Coverage varies across, but not within, states Not covered
Autism Services 0-1% In several states Coverage varies across, but not within, states Coverage varies across, but not within. states
Bariatric Surgery and Treatment of Morbid Obesity (Rider pricing can be 3 to 10 times higher) 0-1% In a few states Coverage varies across, but not within, states

Some change to coverage for services related to obesity resulting from PPACA preventive care implementation.
Coverage varies across, but not within. states

Some change to coverage for services related to obesity result ng from PPACA preventive care implementation.
Cardiac Rehabilitation 0-1% No Covered Not covered (optional coverage available)
Dental Care - Preventive and Basic (Beyond oral health screening) 1-3% No With very few exceptions. offered as optional rider coverage Not covered
Durable Medical Equipment 1-3% No Covered Not covered except if related to diabetes
Early Intervention Services 0-1% In several states Coverage varies across, but not within, states Coverage varies across, but not withn. states
Elective Abortion 0-1% In a few states the mandate prohib is embedding coverage for fully Insured products. but allows coverage to be offered via optional rider Coverage varies across, but not within, states Not covered
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Small Group Membership Allocation (Groups with up to 50 employees for all states) 99.70% 0.30%
Small Group Membership Allocation (Groups with up to 50 employees only for states where Anthem/Blue Limited Coverage is currently marketed) 99.25% 0.75%
Hearing Tests and Hearing Aids 0-1% In several slates Coverage varies across. but not within, states Not covered
Infertility and Assisted Reproduction Services 1-3% In a few stales Coverage varies across. but not within, states Not covered
Medical Nutrition Therapy (Diabetes-related) 0-1% In several stales Coverage varies across. but not within, states Not covered
Medical Nutritional Therapy (Obesity-related) 0-1% No Coverage varies across. but not within, states Some change to coverage for services related to obesity resulting from PPACA preventive care implementation. Not covered
Mental Health and Substance Abuse Services 1-3% In several slates Covered Not covered (optional coverage available)
Orthotics and Special Footwear 0-1% In a few stales Coverage varies across. but not within, states Not covered
Outpatient Physical Therapy, Occupational Therapy, Speech Therapy and Manipulation Services 3-5% No Covered Not covered
Pharmacy (Full Generic + Brand Coverage) 10+% No Generally generic and brand covered Generic only coverage (with some exceptions)
Pharmacy (Generic Only to Full Generic + Brand Coverage) 10+% No Generally generic and brand covered Generic only coverage (with some exceptions)
Pharmacy (Generic+1 to Full Generic + Brand Coverage) 5-10% No Generally generic and brand covered Generic only coverage (with some exceptions)
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Small Group Membership Allocation (Groups with up to 50 employees for all states) 99.70% 0.30%
Small Group Membership Allocation (Groups with up to 50 employees only for states where Anthem/Blue Limited Coverage is currently marketed) 99.25% 0.75%
Specific Types of Drugs (Not included in pharmacy impacts above): In a few states except contraceptive mandates in most states Coverage varies across, but not within, states Coverage varies across, but not within, states
Smoking Cessation Drugs 0-1%
Weight Loss Drugs 0-1%
Infertility Drugs 0-1%
Contraceptives 0-1%
Sexual Dysfunction Drugs 0-1%
statesPreventive Care Services Including Specific Screenings (Excludes vision exam cost listed below) 3-5% All states mandate at least some preventive services Coverage varies across, but not within, states

This has changed to comply with PPACA and standard non-grandfathered plans now include full preventive care coverage
Coverage varies across, but not within, states

This has changed to comply with PPACA and standard non-grandfathered plans now include full preventive care coverage
Private Duty Nursing 0-1% No Coverage varies across, but not within, states Not covered
Prosthetics 0-1% In several states Covered Not covered (with some exceptions)
Pulmonary Rehabilitation 0-1% No Covered Not Covered (optional coverage available)
TMJ Treatment and Appliances 0-1% In several states Coverage varies across, but not within, states Coverage varies across, but not within. states
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Small Group Membership Allocation (Groups with up to 50 employees for all states) 99.70% 0.30%
Small Group Membership Allocation (Groups with up to 50 employees only for states where Anthem/Blue Limited Coverage is currently marketed) 99.25% 0.75%
Urgent Care Facility Services 0-1% No Covered Not covered
Vision Exam/Refraction 0-1% No Coverage varies across, but not within, states Coverage varies across, but not within, states

Actuarial Pricing Assumptions

•  All cost impacts were trended to 1/1/2011 based on HAUS or Cost of Care Trends projections through 1/1/2011.

•  WellPoint’s commercial group pricing model was utilized to value cost impacts where claims experience was not readily available.

•  Network discounts used to value claims impacts were averaged across the company.

•  Impact estimates are relative to discounted allowed amounts (exclude impacts of member cost-sharing).

•  These assumptions are only estimates of the impact and cannot be relied upon for the purpose of setting rates.

Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×

Exhibit B: Standard Plan Inclusions

Preventive Care

Outpatient Care (In a Clinician’s Office)

images  Primary Care Office Visit

images  Specialist Office Visit

images  Pre and Post Natal Visits

images  Counseling (Family Planning, Nutritional, Other)

images  Allergy Testing

images  Allergy Shots

images  Diagnostic Lab (Non-Preventive)

images  Diagnostic X-Ray (Non-Preventive)

images  Other Diagnostic Tests (Hearing, EKG, etc.) (Non-Preventive)

images  Advanced Imaging (MRI, CT Scan, etc.)

images  Office Surgery

images  PT / OT / ST

images  Chiropractic Care / Spinal Manipulation

images  Therapy: Radiation / Chemo / Non-Preventive Infusion & Injection

images  Prescription Drugs and Administration (For the Drug Itself Dispensed In-Office via Infusion / Injection)

images  Dialysis / Hemodialysis

Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×

images  Outpatient Mental Health and Substance Abuse (Psychotherapy, etc.)

Emergency Room (ER) Care

images  Facility ER Chargeo Other Facility Charges (Diagnostic Lab, X-Ray, Supplies, etc.)

images  Facility Advanced Diagnostic Imaging (CT Scan, etc.)

images  Physician Services (ER Physician, Radiologist, Anesthesiologist, Surgeon, etc.)

Outpatient Care in a Hospital, Free-Standing Facility or Urgent Care Facility

images  Facility Surgery Charge (Surgery Suite)

images  Other Facility Surgery Charges (Diagnostic Lab / X-Ray, Supplies, etc.)

images  Physician Surgery Chargeso Facility Charge (Charge for Procedure Room, Other Ancillary Facility Services)

images  Physician Charges (Radiologist, Pathologist, Anesthesiologist, etc.)

images  Outpatient Mental Health and Substance Abuse (Facility)

images  Outpatient Mental Health and Substance Abuse (Professional)

images  Diagnostic Labo Diagnostic X-Rayo Other Diagnostic (EKG, EEG, etc.)

images  Advanced Diagnostic Imaging (MRI, CT Scan, etc.)

images  PT / OT / ST / Spinal Manipulation

images  Therapy: Radiation / Chemo / Non-Preventive Infusion / Injection

images  Prescription Drugs and Administration (Drug Dispensed in Outpatient Facility via Infusion / Injection)

images  Dialysis / Hemodialysis

Inpatient Care

images  Facility Room and Board Charge for:

•  Hospital (Acute Care Facility)

•  Skilled Nursing Facilities (SNF)

•  Mental Health / Substance Abuse Facility

•  Residential Treatment Center

images  Facility Other Charges (Diagnostics Lab / X-Ray, Supplies, etc.)

images  Physician Services for:

•  General Medical Care

•  Surgery

•  Maternity

•  Mental Health

•  Substance Abuse

Home Care

images  Home Health Care Services

images   Home Dialysis

images  Home Infusion Therapy

Other

images  Ambulance (Ground and Air)

images  Durable Medical Equipment (DME), Prosthetics, Medical Devices, Medical Supplies Received from Supplier

images  Hospice

images  Dental Services related to an Accident (Dentist’s Office)

images  Vision Services (Exam)

Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×

Exhibit C: Standard Plan Exclusions

Charges for Administrative Services

images  Exclude charges for administration or other service fees when not directly providing medical care. This includes, but is not limited to: completion of claim forms, charges for medical records or reports, missed or canceled appointments, storage or other administrative actions.

Commercial Weight Loss

images  Exclude Commercial Weight Loss Programs from core medical benefit.

Complications of Experimental Services

images  Exclude services related to complications resulting or arising from excluded services except where mandated or where DOI agreements have been made to cover.

Cosmetic Surgery

images  Exclude cosmetic surgery or other procedures performed solely for beautification or to improve appearance.

Custodial Care

images  Exclude custodial care (such as feeding, dressing, bathing, transferring, and activities of daily living). Does not apply to hospice.

Dental Services

images  Exclude routine dental services, including topical and oral fluoride preparations, from standard medical and pharmacy benefits except where mandated.

images  This does not apply to products with embedded dental coverage.

images  Exclusion does not apply to:

•  Anesthesia and associated facility charges as a result of age and/or disability criteria.

•  Dental accidents-treatment, sought within 12 months, of an injury to natural teeth and when a treatment plan submitted for prior approval. Injuries resulted from biting and/or chewing are not considered a dental accident.

•  Radiation-dental services to prepare the mouth for radiation therapy to treat head and/or neck cancer.

Educational Services; Self-Training; Vocational Services

images  Exclude educational services, self management / help training services, and vocational services except where mandated for diabetes and asthma, or where explicitly covered by another benefit.

Experimental or Investigational Services

images  Exclude services deemed to be experimental or investigational unless specifically covered (e.g., Clinical Cancer Trials).

Food and Dietary Supplements

images  Exclude benefits for food or food supplements, except formulas and/or food products that are:

•  Prescribed, ordered or supervised by a physician; and

•  Medically necessary as defined by medical policy.

Foot Care

images  Exclude routine or palliative foot care (comfort or cosmetic) unless medically necessary.

Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×

Gastric Bypass or Bariatric Surgery

images  Exclude Gastric Bypass and Bariatric surgery except where mandated.

Gynecomastia

images  Exclude surgical treatments of gynecomastia for cosmetic purposes.

Health Club Memberships

images  Exclude Health Club Memberships from core medical benefit.

Hearing Aids and Routine Hearing Tests

images  Exclude coverage for hearing aids. Cover routine hearing screenings as a part of preventive care. Cochlear implants are not included in the exclusion.

Infertility Services

images  Exclude all assisted reproductive technologies (ART) and the associated diagnostic testing and Rx treatments to support ART. Examples include:

•  Artificial insemination

•  In-vitro fertilization

•  ZIFT—Zygote Intrafallopian Transfer

•  GIFT—Gamete Intrafallopian Transfer

Legal Liability

images  Exclude services for which the member has no liability to pay in the absence of this plan's coverage. This includes, but is not limited to: government programs; incarceration; workers compensation; and free clinics.

Not Medically Necessary

images  Exclude services deemed not medically necessary.

Oral Surgery

images  Exclude teeth extractions, surgical removal of impacted teeth, and other oral surgical services (not to include pharmacy services) for care of the teeth or of the bones and gums directly supporting the teeth. These services are dental in nature and not covered under medical.

images  Other Oral Surgical Services are covered, including:

•  Treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia;

•  Orthognathic surgery that is required because of a medical condition or injury which prevents normal function of the joint or bone and is deemed medically necessary to attain functional capacity of the affected part;

•  Oral/surgical correction of accident related injuries

•  Treatment of lesions, removal of tumors and biopsies

•  Incision and drainage of infection of soft tissue not including tooth-related cysts or abscesses.

Private Duty Nursing

images  Exclude private duty nursing provided in an inpatient setting (acute care or skilled nursing facility).

images  Nursing services in a home or hospice setting are covered as a part of Home Health Care benefits and Hospice benefits.

Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×

Provider Not Recognized by Plan

images  Exclude services, supplies, or devices if they are not prescribed, performed, or directed by a provider or facility not defined by us as such, or not licensed to do so.

Reversal of Sterilization

images  Exclude reversal of elective sterilization.

Services from Relatives or Members of Immediate Family

images  Exclude services (applies to medical and pharmacy services) performed by a provider who is a family member by birth, marriage, or adoption, or by the provider to self.

Services Related to Surrogacy

images  Exclude services related to surrogacy.

Sexual Dysfunction

images  Exclude drugs and devices used for the treatment of sexual dysfunction.

images  Exclude services related to sexual transformations.

Smoking Cessation Programs

images  Exclude smoking cessation programs that are not affiliated with WellPoint.

Standby Physician Charges

images  Exclude all standby physician service charges.

Unlisted Services

images  Exclude services not explicitly listed as covered.

Vein Surgery

images  Exclude treatments of all varicose and spider vein surgeries for cosmetic purposes.

Vision Services

images  Exclude the following:

•  Vision Correction Surgery (e.g. Lasik, radial keratotomy, etc.) to correct refractive error, including near sightedness, far sightedness, and/or astigmatism;

•  Orthoptics and vision therapy/training; and

•  Prescription and non-prescription eyewear.

images  Exclusion does not apply to medical and surgical services for the treatment of injuries and diseases affecting the eye (examples include eye exams for diabetics, eyewear/contacts and related services to replace human lenses following surgery or injury, etc.).

Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 197
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 198
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 199
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 200
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 201
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 202
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 203
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 204
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 205
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 206
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 207
Suggested Citation:"Appendix E: Description of Small Group Market Benefits, Provided by WellPoint." Institute of Medicine. 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press. doi: 10.17226/13234.
×
Page 208
Next: Appendix F: General Exclusions »
Essential Health Benefits: Balancing Coverage and Cost Get This Book
×
Buy Paperback | $54.00 Buy Ebook | $43.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

In 2010, an estimated 50 million people were uninsured in the United States. A portion of the uninsured reflects unemployment rates; however, this rate is primarily a reflection of the fact that when most health plans meet an individual's needs, most times, those health plans are not affordable. Research shows that people without health insurance are more likely to experience financial burdens associated with the utilization of health care services. But even among the insured, underinsurance has emerged as a barrier to care.

The Patient Protection and Affordable Care Act (ACA) has made the most comprehensive changes to the provision of health insurance since the development of Medicare and Medicaid by requiring all Americans to have health insurance by 2016. An estimated 30 million individuals who would otherwise be uninsured are expected to obtain insurance through the private health insurance market or state expansion of Medicaid programs. The success of the ACA depends on the design of the essential health benefits (EHB) package and its affordability.

Essential Health Benefits recommends a process for defining, monitoring, and updating the EHB package. The book is of value to Assistant Secretary for Planning and Evaluation (ASPE) and other U.S. Department of Health and Human Services agencies, state insurance agencies, Congress, state governors, health care providers, and consumer advocates.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!