title: The ACA's pediatric essential health benefit has resulted in a state-by-state patchwork of coverage with exclusions.
abstract: The Affordable Care Act (ACA) establishes essential health benefits as the coverage standard for health plans sold in the individual and small-group markets for all fifty states and the District of Columbia, including the health insurance Marketplaces. "Pediatric services" is one of the required classes of coverage under the ACA. However, other than oral health and vision care, neither the act nor the regulations for implementing it define what these services should be. We investigated how state benchmark plans-the base plan chosen in each state as the standard or benchmark of coverage in that state under ACA rules-address pediatric coverage in plans governed by the essential health benefits standard. Our review of summaries of all the state benchmark plans found that no state specified a distinct pediatric services benefit class. Furthermore, although benchmark plans explicitly included multiple pediatric conditions, many plans also specifically excluded services for children with special health care needs. The Department of Health and Human Services has made a commitment in the essential health benefits regulations to review its approach for the 2016 plan year. Thus, our findings have implications for future regulations regarding the essential health benefits standard for pediatric services.
authors.affiliation: Aimee M. Grace (agrace@stanfordalumni.org) is a fellow in general academic pediatrics at Children's National Health System, in Washington, D.C.
authors.forename: Aimee M
authors.initials: AM
authors.lastname: Grace
authors.affiliation: Kathleen G. Noonan is codirector of the PolicyLab and a member of the Division of General Pediatrics, Children's Hospital of Philadelphia, and a faculty member in the Master of Public Health Program at the University of Pennsylvania, in Philadelphia.
authors.forename: Kathleen G
authors.initials: KG
authors.lastname: Noonan
authors.affiliation: Tina L. Cheng is chair of the Department of Pediatrics at Johns Hopkins Bayview Medical Center and both a professor of pediatrics and public health and division chief of general pediatrics and adolescent medicine at the Johns Hopkins University School of Medicine, in Baltimore, Maryland.
authors.forename: Tina L
authors.initials: TL
authors.lastname: Cheng
authors.affiliation: Dorothy Miller is a research scientist in health law and health policy in the PolicyLab, Children's Hospital of Philadelphia.
authors.forename: Dorothy
authors.initials: D
authors.lastname: Miller
authors.affiliation: Brittany Verga is a legal intern in the PolicyLab, Children's Hospital of Philadelphia.
authors.forename: Brittany
authors.initials: B
authors.lastname: Verga
authors.affiliation: David Rubin is codirector of the PolicyLab and a member of the Division of General Pediatrics, Children's Hospital of Philadelphia, and a professor of pediatrics at the Perelman School of Medicine, University of Pennsylvania.
authors.forename: David
authors.initials: D
authors.lastname: Rubin
authors.affiliation: Sara Rosenbaum is the Harold and Jane Hirsh Professor of Health Law and Policy at the Milken Institute School of Public Health, George Washington University, in Washington, D.C.
authors.forename: Sara
authors.initials: S
authors.lastname: Rosenbaum
mesh_terms: D019985:Benchmarking / Q000458:organization & administration; D002648:Child; D002662:Child Health Services / Q000458:organization & administration; D062265:Health Insurance Exchanges / Q000458:organization & administration; D006801:Humans; D019458:Insurance Coverage / Q000458:organization & administration*; D058991:Patient Protection and Affordable Care Act / Q000458:organization & administration*; D013219:State Government; D014481:United States
keywords: Children < Insurance; Children’s Health; Consumer Issues; Health Reform; Insurance Coverage < Insurance