Online Program

Evaluating the ACA's Pediatric Essential Health Benefit: A State-by-State Patchwork of Coverage with Exclusions

Monday, November 2, 2015 : 3:00 p.m. - 3:15 p.m.

Rachel Meadows, MPA, PolicyLab The Children’s Hospital of Philadelphia, Philadelphia, PA
Kathleen Noonan, JD, Children's Hospital of Philadelphia, Philadelphia, PA
Pediatric services is one of the 10 Essential Health Benefits (EHB) under the Affordable Care Act. However, the act and regulations do not define what these services should be other than oral and vision care. Instead, states must select a benchmark plan to serve as a template for plans sold on the federal or state exchanges. To assess how states address pediatric coverage, each state’s benchmark plan summary was reviewed. No state benchmark plan summary included a specific pediatric benefit category. However, specific treatment or services for children were both included and excluded in the summaries. For example, 32 states required coverage of orthodontia treatment while 13 states specifically excluded services for children with learning disabilities. Therefore, the coverage governed by EHB is a state-by-state patchwork with notable exclusions for children, particularly those with special needs and disabilities. Because the U.S. Department of Health and Human Services (HHS) used 2011 as the base benchmark year, states had no time to develop newer benchmark plans that better met children’s needs. If CHIP funding is not extended beyond September 2015, many of the children currently insured by CHIP will enter the state Marketplaces. Therefore, the appropriateness of the standard for children is one of the most important issues in child health policy today. As HHS plans to review its approach to EHB for the 2016 plan year, several policy recommendations should be considered: 1) Bar pediatric treatment limits and exclusions, particularly for mental health or development; 2) Incorporate the concept of medical necessity into a defined pediatric benefit; 3) Address both covered services and actuarial value; and 4) Permit CHIP plans to be used as a benchmark for pediatric services.

Learning Areas:

Public health or related laws, regulations, standards, or guidelines
Public health or related public policy

Learning Objectives:
Identify how state benchmark plans address pediatric coverage. Describe how state benchmark standards fail to respond to children’s needs. Name four policy recommendations for improving pediatric coverage under health plans governed by the essential health benefits standard.

Keyword(s): Affordable Care Act, Health Insurance

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: Communications and policy associate at PolicyLab at The Children’s Hospital of Philadelphia (CHOP) and a member of the PolicyLab leadership team. I provide strategic policy and planning support for research projects throughout PolicyLab, and oversee all of PolicyLab’s external communications, including a comprehensive redesign of PolicyLab’s web site. I am focused on understanding the larger policy environment and using both traditional media and social media to ensure that PolicyLab research informs program and policy decisions.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.