Evaluating the ACA's Pediatric Essential Health Benefit: A State-by-State Patchwork of Coverage with Exclusions

Pediatric services is one of the 10 Essential Health Benefits (EHB) under the Affordable Care Act. However, the act and regulations do not define what these services should be other than oral and vision care. Instead, states must select a benchmark plan to serve as a template for plans sold on the federal or state exchanges. To assess how states address pediatric coverage, each state’s benchmark plan summary was reviewed. No state benchmark plan summary included a specific pediatric benefit category. However, specific treatment or services for children were both included and excluded in the summaries. For example, 32 states required coverage of orthodontia treatment while 13 states specifically excluded services for children with learning disabilities. Therefore, the coverage governed by EHB is a state-by-state patchwork with notable exclusions for children, particularly those with special needs and disabilities. Because the U.S. Department of Health and Human Services (HHS) used 2011 as the base benchmark year, states had no time to develop newer benchmark plans that better met children’s needs. If CHIP funding is not extended beyond September 2015, many of the children currently insured by CHIP will enter the state Marketplaces. Therefore, the appropriateness of the standard for children is one of the most important issues in child health policy today. As HHS plans to review its approach to EHB for the 2016 plan year, several policy recommendations should be considered: 1) Bar pediatric treatment limits and exclusions, particularly for mental health or development; 2) Incorporate the concept of medical necessity into a defined pediatric benefit; 3) Address both covered services and actuarial value; and 4) Permit CHIP plans to be used as a benchmark for pediatric services.