The optimal health of children can best be achieved by providing access to comprehensive health care benefits. This policy statement outlines and defines the recommended set of health insurance benefits for children through age 21. These services encompass medical care, critical care, pediatric surgical care, behavioral health services, specialized services for children with special health care needs, and oral health. It replaces the 1997 statement, “Scope of Health Care Benefits for Newborns, Infants, Children, Adolescents, and Young Adults Through Age 21 Years.”

Subjects:
For Your Benefit
Topics:
behavioral medicine, birth, care of intensive care unit patient, durable medical equipment, oral health, consultants, child health, comprehensive health care, funding, young adult

All infants, children, adolescents, and young adults through 21 years of age must have access to comprehensive health care benefits that will ensure their optimal health and well-being. These benefits should be available through Medicaid, the State Children's Health Insurance Program (SCHIP), and private health insurance plans. Some of these benefits should also be available through the educational and public health systems for children with special needs and for children who are uninsured or have inadequate coverage.

Health care benefits for children and adolescents should begin with the full array of services recommended by the American Academy of Pediatrics (AAP). They should also reflect changes in treatment modalities and new technologies and should be evidence-based. Recognizing the importance of scientific evidence does not mean that coverage of existing interventions should be denied in the absence of conclusive scientific evidence. If sufficient scientific evidence for an intervention for children is not available, professional standards of care for children must be considered. If professional standards of care for children do not exist or are outdated or contradictory, decisions about existing interventions must be based on consensus pediatric expert opinion (according to the AAP working definition in “Model Contractual Language for Medical Necessity for Children”1 ). Benefits should also be of high quality and should be delivered in an efficient manner by appropriately trained pediatric professionals including primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists. These services should be delivered in a comprehensive medical home, the setting for primary care delivered or directed by well-trained physicians who are known to the child and family, who have developed a partnership of mutual responsibility and trust with them, and who provide accessible, continuous, coordinated, and comprehensive care.2  Services provided in other settings should be coordinated through the child's medical home. These services should include but are not limited to the following.

  1. Medical care including (a) health supervision with preventive care (including immunizations, hearing and vision screening, developmental surveillance, and anticipatory guidance) according to the AAP “Recommendations for Preventive Pediatric Health Care,”3  the most current version of the “Recommended Childhood and Adolescent Immunization Schedule,”4  Guidelines for Health Supervision III,5  and Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents6  and (b) diagnosis, treatment, and educational counseling of children with acute and chronic conditions, including developmental delays and disabilities, behavioral and emotional problems, and learning disorders

  2. Pediatric medical subspecialty services

  3. Family planning and reproductive health services

  4. Pregnancy services including (a) genetic counseling and related services as needed, (b) prenatal care, (c) prenatal consultation with a pediatrician, (d) perinatal case management, (e) care of all complications, (f) counseling and services for all pregnancy and fetal management options, and (g) care for the pregnancy of a covered dependent of a policyholder; prenatal care should include evaluation of psychologic risk factors

  5. Care of all newborn infants, including (a) attendance and management at high-risk deliveries or those mandated by hospital regulations, (b) health supervision, (c) treatment of congenital anomalies and other medical and surgical conditions, (d) newborn intensive care services, (e) newborn hearing screening,7  (f) newborn screening for metabolic and genetic disorders, (g) a follow-up visit in the child's home or in the physician's office within 48 hours of discharge when indicated by the infant's physician, (h) lactation counseling to increase successful breastfeeding initiation and duration, and (i) a reasonable pediatric length of stay to allow for identification of early problems and to ensure that the family is able and prepared to care for the infant at home if the mother has to remain hospitalized because of complications8 

  6. Vision services including screening, examinations, corrective lenses, and access to pediatric ophthalmologists for diagnostic and therapeutic services

  7. Audiology services including screening, evaluations, hearing aids, cochlear implants, and recommended therapy

  8. Physician-directed, accurate pediatric medical information by telephone, telemedicine, e-mail, and other Internet services for established patients related to pediatric care compliant with regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA [Pub L No. 104-191])

  9. Laboratory and pathology services

  10. Screening for metabolic and genetic disorders

  11. Diagnostic and therapeutic radiology services, including age-appropriate sedation as needed

  12. Coverage for prescription drugs determined by pediatric standards of care and not limited to labeled indications only9 

  1. Emergency medical and trauma care services specifically for children, including while traveling outside of the coverage network area

  2. Pediatric inpatient hospital and critical care services

  3. Emergent and nonemergent transfer/transport to a hospital or health facility, between health facilities, and between home and health facilities when indicated

  1. Pediatric surgical care including comprehensive repair of congenital anatomic malformations

  2. Pediatric surgical subspecialty services

  3. Anesthesia services including monitored anesthesia care and appropriate pain management for acute and chronic pain management

  1. Mental health services including (a) individual, group, and family therapy, (b) psychoeducational testing, (c) evaluation, (d) crisis management, (e) inpatient and day treatment, (f) residential care, and (g) pharmacotherapy; this should also include the following services: the evaluation and treatment of attention-deficit/hyperactivity disorder and other related behavioral disorders and treatment of eating disorders, learning disabilities, and related disorders10,11 

  2. Services for substance use disorders, including (a) screening and early intervention, (b) individual, group, and family therapy, (c) psychological testing, (d) crisis management, (e) inpatient and outpatient treatment, and (f) residential care

  3. Comprehensive medical and psychologic evaluation and treatment for suspected child physical, emotional, and sexual abuse and neglect in both inpatient and outpatient settings

  1. Care coordination in the pediatric medical home and comprehensive case management from other community agencies and insurers12 

  2. Intermediate or skilled nursing facility care in residential and rehabilitation settings

  3. Physical, occupational, speech (including speech generation), and respiratory therapy for rehabilitation and habilitation provided in medical centers, private/public-sector offices, schools, residential settings, and the home

  4. Home health care services including but not limited to physician supervision of care, therapies, private-duty nursing, and home health aides13 

  5. Nutritional evaluation and counseling services by pediatricians, dietitians, nutritionists, and other therapists for eating disorders (including primary obesity, anorexia, and bulimia) and specific nutritional deficiencies

  6. Special diets, special infant formulas, nutritional supplements, and delivery (feeding) devices for nutritional support and disease-specific metabolic needs14 

  7. Rental or purchase, maintenance, and service of durable medical equipment (see Appendix)

  8. Disposable medical equipment (see Appendix)

  9. Respite services for caregivers of children with special health care needs

  10. Palliative and hospice care for children with terminal illnesses

  1. Preventive and restorative pediatric dental care including fluoride varnish, sealants, and oral surgery, including moderate sedation and general anesthesia

  2. Functional orthodontia

  1. Equipment necessary to administer aerosolized medications and monitor their effects (nebulizer, spacers for inhalers, peak flow meters)

  2. Glucometers, insulin pumps

  3. Breast pumps

  4. Prostheses/braces

  5. Electrical and other types of ventilators

  6. Cardiorespiratory monitors

  7. Oxygen concentrators

  8. Pulse oximeters

  9. Wheelchairs

  10. Hearing aids

  1. Diapers for physically compromised patients

  2. Urine catheters

  3. Feeding supplies (tubing, pumps, etc)

  4. Intravenous line tubing and intravenous catheters

  5. Ostomy supplies

  6. Test strips, lancets, and other diabetic supplies

Thomas K. McInerny, MD, Chairperson

*Charles J. Barone II, MD

Jeffrey M. Brown, MD, MPH

Richard Lander, MD

John Richard Meurer, MD, MBA

Richard Y. Mitsunaga, MD

Steven E. Wegner, MD

Mark J. Werner, MD, CPE

*Maria Minon, MD

Past Committee Member

Margaret McManus

Lou Terranova

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

*

Lead authors

1
American Academy of Pediatrics, Committee on Child Health Financing. Model contractual language for medical necessity for children.
Pediatrics.
 
2005
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116
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261
–262
2
American Academy of Pediatrics, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. The medical home.
Pediatrics.
 
2002
;
110
:
184
–186
3
American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Recommendations for preventive pediatric health care.
Pediatrics.
 
2000
;
105
:
645
–646
4
American Academy of Pediatrics, Advisory Committee on Immunization Practices, American Academy of Family Physicians. Recommended childhood and adolescent immunization schedule: United States, January–June 2004.
Pediatrics.
 
2004
;
113
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142
–147
5
American Academy of Pediatrics.
Guidelines for Health Supervision III
. Elk Grove Village, IL: American Academy of Pediatrics;
1997
6
Green M, Palfrey JS, eds.
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents
. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health; 2000
7
American Academy of Pediatrics, Task Force on Newborn and Infant Hearing. Newborn and infant hearing loss: detection and intervention.
Pediatrics.
 
1999
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103
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527
–530
8
American Academy of Pediatrics, Committee on Fetus and Newborn. Hospital stay for healthy term newborns.
Pediatrics.
 
2004
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113
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1434
–1436
9
American Academy of Pediatrics, Committee on Drugs. Uses of drugs not described in the package insert (off-label uses).
Pediatrics.
 
2002
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110
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181
–183
10
American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder, Committee on Quality Improvement. Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder.
Pediatrics.
 
2000
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105
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1158
–1170
11
American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder, Committee on Quality Improvement. Treatment of the school-aged child with attention-deficit/hyperactivity disorder.
Pediatrics.
 
2001
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108
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1033
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12
Nelson RP, Minon ME, eds.
A Pediatrician's Guide to Managed Care
. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2001
13
McConnell MS, ed.
Guidelines for Pediatric Home Health Care
. Elk Grove Village, IL: American Academy of Pediatrics; 2002
14
Greer FR; American Academy of Pediatrics, Committee on Nutrition. Reimbursement for foods for special dietary use.
Pediatrics.
 
2003
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1117
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Copyright © 2006 by the American Academy of Pediatrics
2006