The ACA's pediatric essential health benefit has resulted in a state-by-state patchwork of coverage with exclusions

Area of Science:

• Health Policy and Law
• Pediatric Healthcare
• Insurance Regulation

Background:

• The Affordable Care Act (ACA) mandates essential health benefits (EHBs) for individual and small-group markets.
• Pediatric services are a required EHB class, but definitions remain vague beyond oral and vision care.
• State benchmark plans set the EHB standard for each state under ACA rules.

Purpose of the Study:

• To investigate how state benchmark plans define and cover pediatric services under the ACA's EHB standard.
• To identify variations and potential gaps in pediatric coverage across state benchmark plans.

Main Methods:

• Reviewed summaries of all state benchmark plans.
• Analyzed how each plan addressed pediatric services within the EHB framework.
• Identified specific inclusions and exclusions related to pediatric healthcare needs.

Main Results:

• No state established a distinct "pediatric services" benefit class in their benchmark plans.
• While many pediatric conditions were covered, numerous plans explicitly excluded services for children with special healthcare needs.
• Significant variation exists in how pediatric care is delineated across state benchmark plans.

Conclusions:

• Current state benchmark plans do not offer a standardized approach to pediatric services under the ACA.
• Exclusions for children with special healthcare needs highlight a critical gap in essential health benefits.
• Findings inform the Department of Health and Human Services' upcoming review of EHB regulations for pediatric services.