Open AccessThe ACA’s Pediatric Essential Health Benefit Has Resulted In A State-By-State Patchwork Of Coverage With Exclusions
Author(s) -
Aimee M. Grace,
Kathleen Noonan,
Tina L. Cheng,
Dorothy Miller,
Brittany Verga,
David M. Rubin,
Sara Rosenbaum
Publication year - 2014
Publication title -
health affairs
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 3.837
H-Index - 178
eISSN - 2694-233X
pISSN - 0278-2715
DOI - 10.1377/hlthaff.2014.0743
Subject(s) - benchmark (surveying) , human services , health care , health plan , business , actuarial science , plan (archaeology) , state (computer science) , patient protection and affordable care act , health insurance , medicine , economic growth , computer science , economics , geodesy , archaeology , algorithm , geography , history
The Affordable Care Act (ACA) establishes essential health benefits as the coverage standard for health plans sold in the individual and small-group markets for all fifty states and the District of Columbia, including the health insurance Marketplaces. "Pediatric services" is one of the required classes of coverage under the ACA. However, other than oral health and vision care, neither the act nor the regulations for implementing it define what these services should be. We investigated how state benchmark plans-the base plan chosen in each state as the standard or benchmark of coverage in that state under ACA rules-address pediatric coverage in plans governed by the essential health benefits standard. Our review of summaries of all the state benchmark plans found that no state specified a distinct pediatric services benefit class. Furthermore, although benchmark plans explicitly included multiple pediatric conditions, many plans also specifically excluded services for children with special health care needs. The Department of Health and Human Services has made a commitment in the essential health benefits regulations to review its approach for the 2016 plan year. Thus, our findings have implications for future regulations regarding the essential health benefits standard for pediatric services.