Children’s benefits under ACA vary by state

Federal rules put forth under the Affordable Care Act (ACA) have meant that some services covered for children vary from state to state, a recent study in Health Affairs points out. Those findings are particularly important considering the federal government plans to continue to allow individual states to choose the plans on which they base coverage, at least for now.

When the US Department of Health and Human Services began to write the rules for the ACA in 2011, it decided to let individual states make some important decisions on what constitutes “essential health benefits.” Although the ACA legislation itself lists 10 basic benefits, each state was asked, within limits, to name a plan available in the state to be its model of essential health benefits.

More: Expect changes to CHIP as ACA ramps up

The Commonwealth Fund says that although many state officials liked those rules, “The approach came as a surprise to many, including the Institute of Medicine and some of the law’s drafters, who had anticipated a more uniform standard.”

However, 25 states did not identify a plan and were assigned a default benchmark plan.

The recent Health Affairs review, “The ACA’s Pediatrics Essential Health Benefit Has Resulted in a State-by-State Patchwork of Coverage With Exclusions,” looked at the summaries of state health coverage standards and found some serious state-by-state differences in coverage for children.

The differences impact all plans sold in small and individual markets that are not grandfathered under the ACA and therefore are not expected to meet all ACA rules. The Kaiser Family Foundation indicates a minority of such plans is grandfathered and the percentage is likely to drop each year because they are no longer grandfathered after they make major changes.

Exclusions abound

Specific pediatric exclusions in the state standards, says the Health Affairs review, “appear to be associated with pediatric development and mental health conditions. They tend to cluster within certain benefit groups such as habilitative and therapy service.”

For example, the review found 12 state plans that exclude benefits for services for learning disabilities; 10 that exclude speech therapy for developmental delays and/or stuttering; and 9 that exclude autism spectrum disorders (ASDs), at least in part. On the other hand, some states specifically include certain benefits for children. The most frequently mentioned was orthodontia, in over 30 plans, followed by congenital defects, services for ASDs, hearing aids, and enteral formulas. 

The review notes that even when a service is shown as covered in a state summary, “actual level of coverage may be relatively low, depending on the cost sharing that applies.”

Marketplace or Medicaid? What to do with kids?

On November 26, 2014, the Centers for Medicare and Medicaid Services (CMS) published new proposed rules in the Federal Registerthat will allow states to choose their own benchmark plans for essential health benefits for some time.

Among the 316 comments CMS received on the proposed new rules by the December 2014 deadline, several focus on children’s benefits. For example, the group First Focus called for a full range of services based either on a state’s Children’s Health Insurance Program (CHIP) plan in 2014 or on the American Academy of Pediatrics (AAP) “Scope of Health Care Benefits for Children.”

First Focus says a study by the Wakely Consulting Group from July 2014 “shows that CHIP is substantially more affordable and offers more child-specific benefits than what is offered” in qualified health plans.

The AAP also calls for the adoption of its scope of benefits, but it says that if CMS retains the rules allowing the state benchmark plans, AAP would support allowing states to supplement plans that are “deficient in a benefit category” by choosing the state’s CHIP plan benchmark.

The CMS should be finalizing the new rules in upcoming weeks.

Ms Foxhall is a freelance writer in the Washington, DC, area. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that might have an interest in any part of this article.