Scope of Health Care Benefits for Children From Birth Through Age 26

All infants, children, adolescents, and young adults through 26 years of age must have access to comprehensive health care benefits to ensure their optimal health and well-being. These benefits must be available through Medicaid, the Children’s Health Insurance Program (CHIP), and private health insurance plans, whether the plan sponsor is a commercial insurance company, a self-funded employer, or other arrangement. The Patient Protection and Affordable Care Act of 2010 (Pub L No. 111-148) also mandated the establishment of health insurance exchanges, wherein health plans must provide a minimum set of health benefits. The minimum health benefits for pediatrics include essential services, such as preventive care, hospitalization, ambulatory patient services, emergency medical services, maternity and newborn care, and mental health and substance abuse disorder services. Also included in the set of benefits are behavioral health, rehabilitative, and habilitative services and devices; laboratory services; chronic disease management; and oral, hearing, and vision care. Some of these benefits may be available or provided through the educational and public health systems for children with special needs and children who are uninsured or have inadequate coverage.

Health care benefits should begin with the full array of services recommended by the American Academy of Pediatrics (AAP). Coverage determinations of existing interventions should be based on evidence of usefulness and understanding of risks. Health care benefit coverage should reflect changes in treatment modalities and should adapt to new evidence and changes in standards of care, as well as innovations in care. 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 is not available, professional standards of care must be considered. If professional standards of care do not exist or are outdated or contradictory, decisions about existing interventions must be based on consensus pediatric expert opinion (according to the AAP working definition in “Model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”).³ The benefits should be delivered in an efficient manner by appropriately trained professionals, including primary care pediatricians and other generalists, pediatric medical subspecialists, pediatric surgical specialists, and pediatric dental professionals. These services should be delivered and coordinated in a comprehensive, patient- and family-centered, physician-led 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. These services should include but are not limited to the following broad categories: preventive services; physician/health care provider services; emergency care; hospitalization and other facility-based care; therapeutic services/durable medical equipment/ancillary services; and laboratory, diagnostic, assessment, and testing services.

Preventive services primarily assess risk factors for, or prevent the development of, medical conditions or developmental disorders that affect health or development. Preventive services include the following:

• A. Health supervision with comprehensive preventive care, according to the AAP “Recommendations for Preventive Pediatric Health Care,”⁴ and Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents.⁵ 

• B. Immunizations according to recommendations included in the most current version of the “Recommended Childhood and Adolescent Immunization Schedules.”⁶ 

• C. Educational, counseling, and support services for all children, including but not limited to the following:

  1. Anticipatory guidance relating to normal growth and development;

  2. Tobacco-cessation counseling and treatment services for children and/or household contacts; and

  3. Services related to the maintenance of a healthy weight—prevention, management, and treatment of pediatric obesity, malnutrition, eating disorders, or nutritional deficiency, including nutrition counseling and follow-up with physician or credentialed nutritionist and all necessary laboratory services, including evaluation of risk factors.

• D. Preventive pediatric oral health services, including the following:

  1. Oral health risk assessment, fluoride varnish, sealants, and similar preventive oral care;

  2. Provision of anticipatory guidance examinations and/or diagnostic investigations; and

  3. Oral surgery, including moderate sedation and general anesthesia services, as indicated, to treat oral health problems.

• E. Early intervention services for mental health/substance abuse.

• F. Preventive vision services, including screenings and examinations by individuals trained in the care of children for the purpose of early identification of vision problems.

• G. Preventive audiology services, including screening and evaluations by professionals trained in the care of children to provide early detection and diagnosis of hearing problems. These services include newborn and other age-appropriate hearing screenings.

• H. Preventive reproductive health services, including coverage for counseling and education to promote healthy choices regarding sexuality, as well as appropriate and effective means of minimizing risks of sexually transmitted diseases and preventing unintended pregnancy. Coverage should also be provided for transition of care to other specialists for treatment of pregnancy in young women or appropriate specialists for children with sexually transmitted diseases for whom treatment is beyond the scope of usual pediatric care.

• I. Preventive prenatal care, including prenatal consultation with a pediatrician, as well as counseling and services for all pregnancy and fetal management options, including evaluation of psychological risk factors that may affect the health and safety of the infant or family.

• J. Preventive postpartum care, including the following:

  1. Newborn screening for metabolic and genetic disorders, as well as hearing screening and other appropriate tests;

  2. Prompt follow-up visit in the physician’s office (as in between 48 and 72 hours following discharge) when indicated by the infant’s condition and/or on the recommendation of the infant’s physician;

  3. Lactation counseling to increase successful breastfeeding initiation and duration; and

  4. A reasonable length of stay for the newborn infant to permit identification and treatment of early problems and to ensure that the family is able and prepared to care for the infant at home.

Physician/health care provider services are delivered (1) in the primary care/medical home setting, (2) by a medical subspecialist or surgical specialist in coordination with the child’s primary care physician, or (3) under the direction of the primary care physician in the patient’s home or other setting. These services are directed toward diagnosis, appropriate treatment, rehabilitation, or palliative care of diseases and congenital or acquired health conditions. Physician/health care provider services include the following:

• A. Diagnosis and treatment of medical conditions.

• B. Educational counseling and support services for all children (see also the previous section on preventive services).

• C. Transition to adult medical care services for youth.

• D. Palliative and hospice care for children with serious or life-threatening conditions.

• E. Pediatric medical subspecialty services, including team subspecialty care, family planning, and reproductive services.

• F. Pediatric surgical care, including the following:

  1. Pediatric surgical care and surgical specialty services, including comprehensive repair of congenital anatomic malformations; and

  2. Anesthesia and acute and chronic pain management services provided by clinicians with training and expertise in special considerations of pediatric anesthesia care.

• G. Behavioral health services, including the following:

  1. Mental health services, including (a) diagnostic evaluation and care planning/coordination services; (b) age-appropriate counseling interventions, including individual, group, or family therapy; family-child interaction training; and behavioral therapy training; (c) psycho-educational testing; (d) crisis management; (e) inpatient and day treatment; and (f) residential care. These services should be covered for behavioral and mental health problems that occur in childhood, impair child or family function, threaten the future health of the child, or impair social relationships and/or academic success.

  2. Services for disorders relating to substance use, abuse, and dependence, including (a) screening, early intervention, and crisis management; (b) appropriate treatment interventions; (c) inpatient and outpatient treatment; and (d) residential care.

  3. Comprehensive medical and psychological evaluation, treatment, and care coordination for suspected or substantiated child physical, emotional, or sexual abuse and/or neglect in both inpatient and outpatient settings.

  4. Individual and family grief and bereavement counseling.

• H. Prenatal and neonatal services, including the following:

  1. Genetic counseling and related services, as indicated;

  2. Prenatal case management, including consultation with a pediatrician;

  3. Care in response to complications resulting from problems during pregnancy, labor, or delivery;

  4. Care of all newborn infants, including the following:

• a. attendance of a pediatric- or neonatology-trained provider for management of high-risk deliveries or where mandated by hospital regulations;

• b. health supervision;

• c. treatment of congenital anomalies and other medical and surgical conditions; and

• d. newborn intensive care services.

• I. Physician-directed, accurate pediatric medical information shared by telephone, telemedicine, e-mail, and/or other Internet services for established and new patients related to pediatric care. This information may include responses to patient or family questions, or may consist of outreach to specific patients relating information deemed important to their health, which may not merit the need for an office visit intervention. These communications should be compliant with regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA [Pub L No. 104-191]).

• J. Home health care services, where appropriate.

• K. Coverage of medical home– or physician-based care coordination and/or case management services (case management may be provided by a case manager or other qualified health care provider working collaboratively with the patient’s family and health care team to develop, monitor, and revise a plan to meet the patient’s immediate and ongoing health care needs; all children with special health care needs and women with high-risk pregnancies should have access to and coverage for case-management services), including arrangement, coordination, sharing of information among care providers, and monitoring of health care and developmental services to meet the needs of a patient and his or her family.⁷ 

These services address acute health care needs, ongoing illness, health or developmental conditions, or injury.

• A. Emergency medical and trauma services specifically for children. These services should be covered without regard to preferred provider networks or preferred facility designations, if facility selection is involuntary.

• B. Inpatient hospital and critical care services, including labor and delivery/birth center services, acute care, psychiatric care, inpatient rehabilitation, and substance abuse services.

• C. Intermediate or skilled nursing facility care in residential and rehabilitative/habilitative settings.

• D. Telemedicine services for emergency departments or inpatient facilities that do not have pediatric coverage for critically ill children.

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

These include specialty services performed in the health care provider’s office or delivered in the patient’s home or a health care facility, as well as products needed for maintenance of health or treatment of disease.

• A. Coverage for medications, biologics, or other compounds included in the US Pharmacopeia with evidence of safety and effectiveness for the treatment of specific conditions.

• B. Pediatric oral health services, including the following:

  1. Restorative pediatric dental care, including oral surgery with appropriate sedation or anesthesia as needed to correct dental or oral health problems; and

  2. Orthodontic services and appliances to correct problems with tooth and jaw alignment that contribute to other medical conditions.

• C. Vision services, including corrective lenses, surgery, or other treatments by professionals trained in the care of children, and access to pediatric ophthalmologists for treatment of medical conditions of the eye.

• D. Corrective audiology and speech therapy services, delivered by those trained in the care of children. These services include assistive technology (hearing aids, cochlear implants, and so forth) and speech therapy services for children with speech delay.

• E. 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.

• F. Special diets, infant formulas, nutritional supplements, and delivery (feeding) devices for nutritional support and disease-specific metabolic needs.

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

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

• I. Rehabilitative and habilitative services and devices.

• J. Rental, purchase, maintenance, and service of durable medical equipment, including but not limited to the following:

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

  2. Glucometers, insulin pumps, and enteral nutrition pumps;

  3. Breast pumps and accessories;

  4. Prostheses/braces, wheelchairs, lifts, and other mobility aids;

  5. Ventilators, positive airway pressure devices, and other pulmonary treatment and monitoring equipment;

  6. Cardiorespiratory monitors, such as pulse oximeters or apnea monitors;

  7. Home dialysis equipment;

  8. Automated home blood pressure monitors; and

  9. Equipment for home-based treatment of newborn jaundice.

• K. Disposable medical supplies, including but not limited to the following:

  1. Diapers for developmentally compromised patients;

  2. Urine catheters and ostomy supplies;

  3. Tracheostomy care needs, suction catheters for managing pulmonary secretions, and other tubing and/or mask needs;

  4. Tubing for delivering intravenous or enteral fluids; and

  5. Test strips, lancets, syringes, needles, insulin pump supplies, and other diabetic supplies.

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

These include services that determine the risk, presence, severity, prognosis, or cause of an illness or testing for diagnosing a specific illness, injury, or disability.

• A. Laboratory and pathology services.

• B. Diagnostic, assessment, and therapeutic services, such as radiology services, and including age-appropriate sedation as needed.

• C. Standardized assessment and monitoring tools for identification, diagnosis, and monitoring of educational, developmental, behavioral, and mental health conditions.

Mark E. Helm, MD, MBA

Patience Haydock White, MD, MA

Thomas F. Long, MD, Chairperson

Thomas Chiu, MD, MBA

Mark E. Helm, MD, MBA

Russell Clark Libby, MD

Andrew D. Racine, MD, PhD

Budd N. Shenkin, MD

Iris Grace Snider, MD

Patience Haydock White, MD, MA

Jay E. Berkelhamer, MD

Norman “Chip” Harbaugh, Jr, MD

Earnestine Willis, MD, MPH – National Medical Association

Ed Zimmerman, MS

AAP

American Academy of Pediatrics