Pediatricians call for uniformity on kids’ essential benefits

Washington Citing inconsistencies between state plan options for upcoming minimum coverage standards, the American Academy of Pediatrics is urging the federal government to designate a public insurance program as the benchmark for children’s essential health benefits.

In 2011, the Dept. of Health and Human Services issued guidance that gave states the latitude to choose from one of several existing health plans to serve as the “benchmark” plan for their essential health benefits package under the Affordable Care Act. The health system reform law mandates that these minimum coverage standards be offered by all plans on health insurance exchanges and by some additional plans outside of the exchanges. Starting in 2014, plans will be required to cover 10 broad categories of essential health benefits services.

The HHS guidance specified that a state could look at some of the largest health plans operating in its jurisdiction and then select a benchmark plan from one of four plan types: small-group, federal employee, state employee or commercial HMO. Public insurance options, however, were not included in the mix.

In an Aug. 28 report, the AAP found wide discrepancies among some of these plans in terms of what they offer to children — and that none of them met the expansive coverage options of either Medicaid’s standard benefits package for children or of packages offered by individual state CHIP plans. The report focused on the largest federal employee, state employee and small-group plans in five states, then judged how well they covered the 10 categories of essential health benefits compared with each other and public insurance programs.

CHIP and Medicaid trumped other plans on cost-sharing protections and breadth of coverage, the association concluded. Outside of public coverage, federal employee plans were found to have the most comprehensive pediatric benefits, whereas small-group plans offered the least expansive options. Coverage gaps in the small-group plans “were mostly found for rehabilitative/habilitative services and especially for pediatric, oral, vision and hearing services,” the report stated, although these plans provided more generous coverage in other areas, such as ambulatory and emergency services.

The AAP said its findings run counter to what HHS concluded in its guidance: that these benchmark options did not vary significantly in terms of the range of services they provided. “We can’t allow children to have different health benefits depending on where they live,” said Robert W. Block, MD, the AAP’s president.

Even with variations in public coverage among the states, establishing a public insurance option such as CHIP or Medicaid as the benchmark for children’s essential health benefits would provide a broader, more robust range of benefits than some of these other plans, Dr. Block said. Over the long run, this approach would save more money by keeping children healthier, he said.

The AAP and the American Medical Association previously had expressed concerns about the benchmark-setting process. In letters to HHS earlier in 2012, the organizations observed that a majority of the benchmark plans did not cover some benefits that were medically necessary for children. In reading the AAP’s latest findings, other pediatric organizations, such as the Children’s Hospital Assn. and Voices for America’s Children, recommended that states use the CHIP program in particular as the benchmark for children’s benefits.

Applying just one insurance product uniformly across states as the minimum coverage benchmark does make sense, said Chantel Sheaks, a principal in government relations with Buck Consultants in Washington who specializes in health reform issues. It would level the playing field on benefits, she said, adding that many observers were surprised when HHS decided to defer to the states on choosing benchmark plans instead of just selecting one essential benefits plan for the country.

The situation may get more complex, however, if a program such as CHIP becomes the benchmark just for children while a range of other options applies to adults, Sheaks said. She said one plan should set the bar on essential benefits for all age groups.

At this article’s deadline, HHS had not responded to calls seeking comment.

The AAP released its report shortly before the Robert Wood Johnson Foundation came out with its own results on the impact of public insurance on closing health care access gaps for children. The ranks of uninsured children are decreasing due to more CHIP and Medicaid coverage despite a recent rise in the number of those living in poverty, the study found. Public insurance programs covered more than 31% of all children in the U.S. in 2010, an increase of more than five percentage points from 2008. In most states, these increases more than offset a drop in the portion covered by private insurance, resulting in an overall decline in kids’ uninsurance rates.

These findings “are no surprise,” Dr. Block said. “As the economy tanks, you have more people who are at the lower end of middle class who are now dumped into poverty. So, where they weren’t eligible for Medicaid and CHIP before, they are now,” meaning the public safety net is doing exactly what it’s designed to do, he said.