The AAP has long advocated that all children should have timely and affordable access to quality care through a comprehensive set of benefits tailored to meet their unique needs from the prenatal period through young adulthood.
An updated policy statement provides a brief history of the evolution of health care benefits for children, offers a recommended set of benefits and identifies barriers that may prevent a uniform standard all payers can adopt.
The policy Scope of Health Care Benefits for Neonates, Infants, Children, Adolescents, and Young Adults Through Age 26, from the Committee on Child Health Financing, is available at https://doi.org/10.1542/peds.2022-058881 and will be published in the September issue of Pediatrics.
Establishment of a core set of health care benefits for children began in 1967, when Congress through landmark legislation established the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) standard as the mandatory pediatric health benefit in Medicaid. Another milestone occurred with passage of the Affordable Care Act (ACA) of 2010 that memorialized EPSDT as the pediatric core benefit standard and included “pediatric services, including oral and vision care” as the last in a set of 10 essential health benefits (EHBs) for certain non-Medicaid plans.
A number of factors have hindered realization of an operational standard for a core set of health care benefits for children across public and private payers. These factors include differences in how state Medicaid and managed care Medicaid adjudicate issues related to medically necessary care and how benefits change due to Medicaid state plan amendments and federal waivers. For instance, 1115 waivers have proposed elimination of EPSDT benefits for previously covered 19- and 20-year-olds.
In addition, Children’s Health Insurance Programs that are not extensions of state Medicaid plans can benchmark pediatric benefits to a less robust private plan that operates in the state. Each state also has the discretion to define its own set and range of pediatric EHBs.
Although the ACA did articulate 10 categories of EHBs, discretionary administrative authorities allow plans great flexibility to achieve their defined actuarial value by reducing individual benefits, swapping benefits between categories or increasing cost-sharing.
The latter action raises the fiscal barriers for children to access some nonpreventive but necessary benefits.
Finally, the ACA does not regulate many health plans, so no requirements for the provision of key pediatric benefits apply to these plans. A number of federal administrative rules in the 2018 final rule pertaining to association health plans and “short term, limited-duration insurance” potentiated increasing market share of plans exempt from ACA regulation.
New or expanded benefits
The statement recommends a core set of benefits that include but are not limited to the following categories: preventive services; physician and other health care services, including mental health; facility-based care; therapeutic and ancillary services; durable medical equipment; and laboratory, diagnostic, assessment and testing services.
Following are examples of key new or revised benefits recommended by the AAP:
- preventive pediatric oral health services;
- early intervention services for mental and behavioral health disorders and for alcohol and substance use disorders;
- preventive reproductive and sexual health services;
- transition to adult care services for adolescents and young adults;
- palliative and hospice care for children with serious or life-threatening conditions;
- expanded behavioral and mental health services;
- expanded services for substance use and substance-related disorders;
- prenatal genetic counseling and postnatal testing, as indicated, if the testing is likely to clarify diagnosis and/or prognosis, influence the approach to care or identify treatment(s) specific for a condition;
- gender-affirming care for individuals with gender dysphoria, transgender children or children who identify as nonbinary, including access to mental health services, and medical and surgical therapy as and when appropriate;
- expanded pediatric pharmacopeia to include “off label” use of medications, biologics and other compounds that can be anticipated to be effective by legitimate extrapolation of adult findings or by evidence-based literature or expert consensus;
- donor milk and human-based milk fortifiers as appropriate for infants in the hospital and after discharge;
- respite care for caregivers of children with special health care needs; and
- interpreter services when deafness or limited English proficiency prevents clear communication during office, facility or telehealth visits.
The statement articulates five guiding principles pertaining to pediatric scope of benefits:
- A new federal standard should be developed to guide decisions related to medical necessity and align with the definition in an updated AAP policy statement on medical necessity.
- A family’s responsibility for total child health care plan payments should be affordable in relation to a family’s disposable income.
- Policymakers should create legislation that ensures all children have timely access to the full range of age- and developmentally appropriate health care without administrative barriers and by the most appropriate method, even if out-of-state expertise is required.
- Policymakers should consider the return on investment of child health, which may be reflected in greater educational accomplishment, higher earnings and improved and less costly adult health.
- Stakeholders and payers should take steps to ensure all children have access to the core benefits outlined in this policy statement.
Dr. Hudak is lead author of the policy, former chair of the AAP Committee on Child Health Financing and immediate past chair of the Section on Neonatal-Perinatal Medicine Executive Committee.