Pediatric Coverage a "Patchwork" Under Affordable Care Act

Miriam E. Tucker

December 08, 2014

Washington, DC — The approach used to establish the Affordable Care Act's pediatric essential health benefit has resulted in a state-by-state patchwork of coverage with inconsistent exclusions, particularly of services for children with mental or developmental disabilities, a new study finds.

The results were published in the December children's health-themed issue of Health Affairs, and presented in a briefing by Aimee M. Grace, MD, a fellow in general academic paediatrics at Children's National Health System (Washington, DC).

The Affordable Care Act (ACA) established 10 essential health benefits that must be covered by qualified health plans sold in the marketplaces, and in nongrandfathered individual and small group plans. These benefits include maternity and newborn care, rehabilitation services and devices, and "pediatric services," but the only specified services are oral and vision care.

"Theoretically, such provision of pediatric services under the ACA as an essential health benefit is a big win for kids. However, such broad categories of essential health benefits left significant room for regulatory definition and interpretation by the [US Department of Health and Human Services (HHS)]," Dr Grace said during her presentation.

"As HHS revisits the standard during the next year, it is critical to improve the essential health benefits regulations for pediatric services. Without a federal child health benefits standard, which could be based on national models, the current system of pediatric coverage under the Affordable Care Act is neither comprehensive nor consistent," she said.

Asked to comment, American Academy of Pediatrics (AAP) president James M. Perrin, MD, professor of pediatrics at Harvard Medical School, Boston, Massachusetts, told Medscape Medical News, "We've been hearing that all around the country from pediatricians, that there are lots of benefits that were not covered that really should be covered for a lot of kids…AAP worked from the very beginning to get a national standard for what should be the benefits for children in the exchange plans."

Rather than establish a national standard — which had also been suggested by the Institute of Medicine — HHS elected to use a "benchmark plan" approach similar to that used in the current Children's Health Insurance Program (CHIP). With that approach, each state selects a commercial plan sold in the state in 2011 to serve as the "benchmark" standard — in theory, to reflect a state's typical employer-sponsored plan — to be adjusted as necessary to ensure inclusion of all 10 essential health benefit classes.

In an effort to determine how state benchmark plans address pediatric coverage, Dr Grace and colleagues analyzed summaries from the Center for Consumer Information and Insurance Oversight, the federal HHS center responsible for insurance regulation.

Aside from oral and vision services, the most frequently included benefit categories relevant to pediatrics were orthodontia, covered in 32 states, specific services for congenital defects in 25 states, hearing aids in 24 states, and at least partial coverage for services related to autism spectrum disorders in 24 states.

Laws requiring coverage of these services were likely the result of condition-specific advocacy efforts, although that aspect was not examined in this study, Dr Grace noted.

On the flip side, 13 states specifically excluded services for children with learning disabilities, 10 states excluded coverage for speech therapy for developmental delays and/or stuttering, and nine states at least partially excluded services for children with autism spectrum disorders.

"As such, a child with autism, speech delay, or other developmental disabilities could have different health outcomes, depending on the state in which he or she lives. This was, in all likelihood, not the intention of the ACA," Dr Grace said.

While some of the exclusions may have been based on the fact that such services are offered in schools, school-based services are not appropriate for all children, the authors note.

In their paper, Dr Grace and colleagues make four recommendations to HHS for its review of the essential health benefit guidelines for the 2016 plan year:

(1)  Revise the pediatric standard to bar pediatric treatment limits and exclusions, particularly exclusions based on intellectual disability, special health care needs, or other developmental conditions.

(2)  Incorporate the concept of medical necessity into a defined pediatric benefit, including clinical utility and appropriateness of a covered service, and whether the service is appropriate in a pediatric developmental health context.

(3)  Revise the pediatric benefit standard to address both covered services and actuarial value. The authors recommend a value of 90%, consistent with current CHIP practice.

(4)  Permit CHIP plans to be used as a benchmark for pediatric services.

"These recommendations are crucial to ensure a higher national standard for pediatric heath care coverage. Our children deserve no less," Dr Grace concluded.

Dr Perrin told Medscape Medical News that the AAP is advocating for a four-year extension of CHIP funding, currently set to expire at the end of fiscal 2015. This contrasts with a two-year recommendation from the federal Medicaid and CHIP Payment and Access Commission. If CHIP funding is not extended, many of the eight million children currently ensured under the program will likely be funneled into the exchanges.

"We're worried about the CHIP extension. We think it should be at least 4 years rather than 2. We don't think it's very likely the exchange plans are going to get themselves together in 2 years' time and provide the services that children actually need," Dr Perrin said.

He added that the US Secretary of Health and Human Services is required to assess the adequacy of the exchange plans to make sure that they are actuarially equivalent to CHIP programs. "Well, they won't be… It's a huge issue because she may drop the ball and not enforce it. And we're worried about that."

The AAP would like pediatricians to get involved. "We're asking pediatricians from the states to band together to demand that their states include adequate benefits for children," Dr Perrin told Medscape Medical News.

The study was funded by the DC-Baltimore Research Center on Child Health Disparities, with a grant from the National Institute on Minority Health and Health Disparities .

Health Affairs. Published online December 8, 2014. Abstract.


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