Exchange plans vary widely in pediatric coverage

Vague specifics in ACA lead to "patchwork" coverage, lack of benchmarks

Plans sold on health insurance exchanges include a wide array of "patchwork" pediatric coverage, while others don't cover services for children with special needs, according to a new study published this morning in the journal Health Affairs.

Although the Affordable Care Act requires exchange plans to cover pediatric care, the law is vague on what specific services must be included. Since the U.S. Department of Health and Human Services (HHS) decided to let states define their own benchmarks, no state has issued specific coverage requirements for pediatric services to supplement the ACA.

Using each state's essential health benefits benchmark plan, the study determined that no benchmark plan listed a specific benefit category as pediatric services, even though it's considered an essential health benefit.

"The result, according to our study, is a state-by-state patchwork of coverage for children and adolescents that has significant exclusions, particularly for children with developmental disabilities and other special healthcare needs," wrote study author Aimee Grace, fellow in general academic pediatrics at Children's National Health System, in the District of Columbia.

In fact, 92 percent of insurers in 2013 didn't offer children's dental check-ups and 87 percent didn't include children's eyeglasses in their health plans, FierceHealthPayer previously reported.

"It is clear that benchmark plans include treatment limits and exclusions aimed specifically at children that must be addressed," Grace and her co-authors wrote. "Pediatric treatment limits and exclusions--particularly exclusions based on mental retardation, mental disability or other developmental conditions--should be barred."

Because of these variations, the authors recommend that HHS review insurers' coverage for pediatric services, especially since the agency said it would analyze all essential benefits for the 2016 plan year. They also wrote that HHS should incorporate the concept of medical necessity into the ACA's of pediatric services benefit.

To learn more:
- read the Health Affairs study (subscription required)

Related Articles:
CMS invites states to change ACA benchmark plans
Despite reform, excluded benefits largely unchanged
10 services insurers are least likely to cover
Advocates fear limited coverage for habilitative services