Define the benefit package & cost sharing

Months 0–12 · Congress (statutory categories); UHA Chief Medical Officer; HTA InstituteDiscuss this step

Every concrete action this step requires, who is responsible, and when it happens relative to enactment.

#	Action	Owner	When	Trade-off
1.5.1	Enact statutory benefit categories: hospital, physician, outpatient, mental health & substance use, maternity & newborn, prescription drugs, lab & imaging, rehabilitation & habilitation, dental, vision, hearing, home- and community-based long-term services, and the clinical component of nursing-facility care.	Congress	Drafting	Broad statutory categories maximize protection but raise utilization and cost.
1.5.2	List statutory exclusions: over-the-counter products, cosmetic procedures, premium eyewear and hearing-aid upgrades, nursing-home room and board, and services the HTA Institute finds ineffective.	Congress	Drafting	Explicit exclusions keep costs predictable but leave real out-of-pocket costs for things like nursing-home room and board.
1.5.3	Set $0 cost sharing for all covered services; write the standby prescription copay schedule ($0/$5/$15, $200 annual cap, waived below 200% FPL) that Congress can switch on.	Congress	Drafting	Zero cost sharing removes financial barriers but removes the price signal against low-value care.
1.5.4	Publish a national coverage manual by converting Medicare's National Coverage Determinations and adding pediatric, maternity, dental, vision, and hearing coverage rules.	UHA CMO	Months 3–12	Converting Medicare coverage rules is fast but carries Medicare's gaps in pediatric and maternity coverage that must be filled.
1.5.5	Define the nursing-home room-and-board contribution: residents keep a personal-needs allowance and contribute up to 80% of income above it.	UHA	Month 6	Requiring room-and-board contributions keeps LTC from becoming a housing program but leaves nursing-home residents with little income.
1.5.6	Decide the contested services (abortion / Hyde Amendment, gender-affirming care) by explicit vote; see Design.	Congress	Drafting	An explicit vote on contested services is transparent but can split the coalition needed to pass the bill.
1.5.7	Create a public petition process to add services, with HTA review within 180 days.	HTA Institute	Month 12	A petition process keeps the package responsive but invites advocacy campaigns for costly additions.