This blog is part of a series that will highlight how changes in the 2019 Notice of Benefit and Payment Parameters (NBPP) final rule will affect the comprehensive coverage that the essential health benefits (EHBs) package offers to consumers.

When the Affordable Care Act (ACA) passed and included pediatric services as an Essential Health Benefit (EHB) category, tentative excitement rippled through the children’s advocacy community. At last, policymakers were acknowledging children’s care as both different from that of adults and important. Since that statutory nod to pediatric services in the EHB provision of the ACA, health plans progressed in some important ways. Many plans now include preventive services, like pediatric dental and vision care and habilitative care that supports children with autism and other developmental challenges.

While there is still room for improvement to meet the needs of all children – particularly those with chronic care or special health care needs – maintaining coverage for the full array of pediatric EHBs is paramount. The movement forward must also create a broader system-wide shift toward robust pediatric coverage for all children, regardless of their health insurance pathway.

Why are these pediatric services at risk?

The new EHB selection process seeks to slim down plans, allowing states to pick and choose benefits as long as they are not more generous than the status quo. For pediatric services that are integral to children’s health, the outcome will simply be fewer service offerings, leaving many children without access to the health care they need.

Further, the 2019 NBPP allows issuers to substitute services both across and within the 10 EHB categories starting in 2020. In general, the number of adults enrolled in EHB plans far outnumber children utilizing those plans, resulting in a reduced focus on both pediatric benefits and services. Adding flexibility to adopt and swap benefits could be an invitation to swap and diminish existing pediatric services.

What is at stake?

The recently released 2019 Notice of Benefit and Payment Parameters, which sets rules for insurance issuers selling plans on the ACA exchanges, seeks to alter how states choose to cover EHBs, changing the building materials just as children’s health advocates have completed constructing the foundation. While the EHB categories stay intact, the benefits included in them are at risk. This shift in approach threatens the health and well-being of children and families who rely on EHB-conforming plans. Even small changes in the scope of benefits could negatively affect children by allowing states to choose benchmark plans that are less generous and less comprehensive than what children need to maintain their health and well-being. Here is what is at stake for children across the ten EHB categories:

  • Preventive Care: At the core of pediatric services is preventive care, which promotes healthy development and health and well-being throughout the lifespan. Any effort to diminish the preventive services included in the selection of benefits covered in a state’s EHB benchmark plan – by choosing a plan that covers a less comprehensive array of preventive services as the benchmark plan, for example – would be detrimental to children.
  • Pediatric Dental: Cavities are the most common chronic disease among children – four times more common than asthma – and structural barriers to care disproportionately impact children of color and low-income children. Protecting the pediatric dental EHB will maintain children’s access to routine dental care in addressing this chronic condition, preventing future disease and reducing oral health disparities. For example, allowing states to choose EHB benefits from other states’ benchmark plans, could allow states to eliminate coverage for some dental services. Oral health is integral to overall health, so protecting the pediatric dental EHB is also key in protecting and improving children’s overall health.
  • Pediatric Vision: As with pediatric dental, many states had to include pediatric vision benefits as supplemental in their EHB benchmark selection, creating a bare bones vision benefit. By way of example, some states’ pediatric vision benefit does not include or severely limits access to glasses, so children can access screening for vision problems, but not treatment. Because the broader benchmark selection rules in the 2019 NBPP allow states to model their EHB categories on other states’ benchmark plans, more and more states could limit vision benefits in this way moving forward.
  • Maternity Care/Newborn Care: We know that a full continuum of care for pregnant people is important to newborn and parent health. As the Administration pushes for greater latitude for short-term plan offerings, Kaiser Family Foundation reports that none will carry maternity coverage. That means that EHB plans are essential to ensure family health before and after pregnancy.
  • Behavioral and Mental Health Care: Before EHBs, some behavioral and mental health care services were included in small group plans, but they were often limited and varied from plan to plan. The EHB, coupled with the Mental Health Parity and Addiction Act, offered children more robust access to these important services. Greater EHB design flexibility could translate into more limited access to these important screenings and therapies, including substance use treatment for youth, anxiety disorder and autism therapies such as Applied Behavioral Analysis (ABA).     
  • Habilitative Care: During the initial EHB process, most states looked to HHS for guidance on a habilitative care benefit – sometimes turning to their Medicaid plans and at other times relying on a federal definition – as it did not exist in any of the benchmark plans. Especially for children with disabilities, the habilitative benefit is core to reaching their full potential and any benchmark that reduces the full array of these services will put the health and well-being of children with special health care needs at risk.

What do we do?

  • Review your EHB plan to refresh your understanding of how pediatric services is currently covered in your state and ask your key contacts at the Department of Insurance (DOI) if they are planning to review the state’s EHB benchmark and move ahead with a change.
  • Monitor any statements, alerts or information coming out the state DOI regarding public hearings.
  • Show up with your coalition and respond to any proposed changes to the EHB through a range of tactics.

As always, we are here to help!