A comprehensive analysis to investigate the Affordable Care Act's (ACA) Essential Health Benefit (EHB) has found that the EHB has resulted in a state-by-state patchwork of coverage for children and adolescents and has significant exclusions, particularly for children with developmental disabilities and other special health care needs. This analysis presents detailed evidence regarding the types of exclusionary practices that limit the effectiveness of coverage for children insured through health plans sold in the individual and small group markets.
The analysts compared benchmark plans at the state-by-state level. 'Pediatric services' is one of ten benefit classes required by the ACA that must be covered in all health insurance plans. However, neither the ACA nor the regulations for implementing it define 'pediatric services'. While the ACA gave the Health and Human Services (HHS) Secretary the ability to define a pediatric benefit standard at the national level, HHS chose instead a state-by-state benchmark plan approach. This approach has led to great variation among states regarding coverage of pediatric services.
The analysis suggests four potential policy steps-
1. Pediatric treatment limits and exclusions, particularly exclusions based on mental retardation, mental disability, or other developmental conditions should be barred.
2. The concept of 'medical necessity' should be incorporated into the pediatric benefit. Medical necessity should include the clinical utility and appropriateness of a covered service and also determine whether the service is appropriate in the pediatric developmental health context.
3. The essential health benefits standard for pediatric services should be revised to address both covered services, particularly for children with special needs, and actuarial value.
4. The use of CHIP plans as a benchmark plan for pediatric services should be permitted.