The federal government missed an opportunity when it did not define pediatric essential health benefits for plans offered in the health insurance marketplace under the Affordable Care Act, Dr. Aimee Grace and her colleagues wrote in a study.

Dr. Grace of Children’s National Health System in Washington, and her colleagues urged the U.S. Health & Human Services department to revisit essential health benefits regulations and make some changes (Health Affairs 2014;33:2136-43 ) .

“HHS could revise the standard to bar pediatric limits and exclusions, particularly exclusions based on mental retardation, mental disability, or other developmental conditions; incorporate the concept of medical necessity into a defined pediatric benefit; address both covered services and actuarial value; and permit CHIP plans to be used as a benchmark for pediatric services,” Dr. Grace recommended.

The researchers examined each state’s essential health benefits benchmark plan and found a lack of consistent coverage, the result of HHS declining to implement a national standard for pediatric essential health benefits.

They found that is no state benchmark plan summary “included a specific benefit category classified as pediatric services, despite the fact that those services constitute a specific category of essential health benefits. … As in the HHS regulations, the only pediatric categories expressly mentioned in the summaries were oral and vision care.”

Dr. Grace and colleagues found specific pediatric exclusions within certain treatment categories, typically associated with pediatric developmental and mental health conditions.

“For example, thirteen states specifically excluded services for children with learning disabilities, and ten states excluded speech therapy for developmental delays, stuttering, or both,” researchers note.

The study was supported by the DC-Baltimore Research Center on Child Health

Disparities (Grant No. P20 MD000198 from the National Institute on Minority Health and Health Disparities).


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