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Essential Health Benefits: Balancing Affordability and Adequacy

This article discusses the considerations and implications of essential health benefits, including legislative intent, cost containment strategies, governance, and oversight. It explores the implications for various stakeholders such as states, insurers, patients and families, policymakers, researchers, and health care leaders.

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Essential Health Benefits: Balancing Affordability and Adequacy

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  1. Essential Health Benefits: Balancing Affordability and Adequacy Kavita Patel MD, MS Engelberg Center for Health Care Reform The Brookings Institution February 3, 2012 Washington, DC kpatel@brookings.edu

  2. Issues to Consideration • Legislative Intent- set floor not ceiling? • This is NOT benefit design (next slide) or benefit administration • Outstanding issues around cost containment strategies, alignment with delivery systems • Governance/Administration • Medical necessity • Basis for evidence review, etc • Oversight and monitoring • Premium Issues

  3. Various Benchmark Plans

  4. Implications for Various Stakeholders • States • Variations in benefits and access to elements of care including behavioral health treatment, habilitative services, and routine pediatric oral/vision care • Legislative complications • Insurers • Flexibility • Lack of uniform standard • Patients and Families • Provide consumer feedback • Policymakers • Oversight and guidance for exchanges • Appeals process

  5. Opportunities for Various Stakeholders • Researchers • Development of methods for comparative effectiveness research • Better understanding of rapid cycle evaluation and its role in modifying an EHB at a federal and state level • Health Care Leaders • Act as the catalyst behind CMMI’s pilots and evaluation efforts • Affordability • State-Based Exchanges • Laboratories for initiatives • Increase consumer engagement

  6. Thank you kpatel@brookings.edu

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