Archive of Medicaid

05Jan2012
Essential health benefits – How will they be defined? Thumbnail

Essential health benefits – How will they be defined?

by Dan Pribe, consulting actuary, Optuminsight Imagine you’re a committee member for your state’s Medicaid program.  Your committee must decide the Essential Health Benefit (EHB) package provided to Medicaid beneficiaries while keeping within the budget your state legislature has provided.  Through some rather contentious meetings, you’ve all agreed to a package which includes most medications and services, but excludes some very expensive ones such as Elaprase, a medication costing nearly $400,000 per year to cover Hunter’s Syndrome, an extremely rare metabolic disorder affecting about 500 people in the United States.  Now imagine you come home from work a few weeks later and in some weird twist of fate your spouse informs you that your child has been diagnosed with Hunter’s syndrome.  You realize that if you had been on Medicaid, you’d be out of luck. While this particular situation is highly unlikely, it does draw our attention to how the EHB package required under the Patient Protection and Affordable Care Act (ACA) will be determined.  (more…)

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