Pediatric MH Benefits Lacking in Several ACA-Based State Plans

While the Affordable Care Act (ACA) brought reforms to health care, it is still a work in progress as it aims to provide affordable yet substantial coverage to Americans. A state-by-state analysis published in the December 2014 Health Affairs highlights that children, in particular, are facing some troubling gaps in coverage when it comes to behavioral and developmental health.

While pediatric services are one of the 10 essential benefits that must be covered to some extent in an ACA plan, this study found a broad discrepancy in how states defined “to some extent.” As a result, many states exclude coverage for services required by children with autism or other special needs.

The problem arises because other than oral and vision care, the ACA has no national standard for what must be included in a state’s benefit plan. Therefore, the benchmark plans that states use as the templates for ACA insurance can vary based on what a “typical” employer insurance plan would offer in that state.

When a team led by Sara Rosenbaum, J.D., the Harold and Jane Hirsh Professor of Health Law and Policy at the George Washington University Milken Institute School of Public Health, investigated the resulting patchwork of pediatric benefits spread across the benchmark plans in the 50 states and the District of Columbia, they uncovered some notable exclusions.

On the positive side, 24 states did have specific language requiring coverage for autism spectrum disorder, though nine others specifically excluded these services, and the remainder did not mention them either way, which leaves every individual case open to interpretation.

The other benefits that were most commonly excluded in state plans fell under a similar rubric: learning disability services, speech therapy, services for developmental or mental delays, behavioral problem therapy, and parental therapy.

“Unfortunately, when many insurers see these types of services, they view them as something that falls under special education or social services and exclude them,” Rosenbaum told Psychiatric News.

In her view, though, it’s an explanation that doesn’t hold water. “These are clearly diagnosable health conditions that affect the developmental well-being of a child,” she said. “So the exclusions are basically discrimination, whether you consider it based on age or on the specific condition.”

Since the ACA provisions stipulate that coverage cannot “determine reimbursements, establish incentives, or design benefits in ways that discriminate [against] individuals because of age, disability, or expected length of life,” Rosenbaum believes that any claim denials for a service that improves a child’s developmental well-being should be appealed, but acknowledged broader steps need to be taken to remove this burden on the individual.

In an ideal world, the U.S. Department of Health and Human Services (HHS) would enact a national standard that ensures that special needs are included in health coverage, but in lieu of that, groups like APA need to step up and comment, Rosenbaum believes, and use their influence to raise these matters to state insurance commissions and HHS, which is planning to review the ACA essential health benefit regulations for the 2016 plan year.

It’s an urgent matter, for in addition to providing comprehensive and consistent care to the children who are enrolled in ACA plans, it’s possible that more will soon join.

Funding for the Children’s Health Insurance Program, which provides federal benefits to children who are just above the financial limits that qualify for Medicaid, is set to expire at the end of Fiscal 2015, with no guarantee of renewal. If it expires, more than 8 million children—of lower socioeconomic status, many with special needs—will enter the marketplace.

This study, which included financical contributions from George Washington University, Johns Hopkins University, and the University of Pennsylvania, was funded primarily by a grant from the National Institute on Minority Health and Health Disparities. ■