It is critical federally facilitated Exchanges (FFEs), including state partnership Exchanges, meet the unique health care needs of children. Key issues to consider include:
Essential health benefits
The essential health benefits (EHB) benchmark plans must be strengthened for children through the adoption of strong medical necessity definitions by health plans based on the Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) standard and through a comprehensive definition of habilitative services that does not impose arbitrary limits on services.
Pediatric provider networks
Network adequacy standards for qualified health plans (QHPs) must ensure that children have reasonable and timely access to the full spectrum of pediatric providers they need.
Essential community providers
QHPs must be required to contract with all essential community providers, including children’s hospitals eligible to participate in the federal 340B Drug Discount program, that serve low-income and medically under-served populations.
Continuity of care
Continuous coverage, particularly for children with special health care needs, must be ensured even when a child’s provider leaves a health plan’s network or the child moves back and forth between subsidized Exchange coverage and Medicaid or CHIP.
Consumer assistance programs
Consumer assistance and education efforts must take into account children’s unique health care needs and provide pediatric-specific information to families.
Pediatric stakeholder involvement
Pediatric providers and other individuals with experience with the utilization of pediatric health care should be included in FFE policy-making entities and stakeholder consultations.
All health plans should be required to report on a common set of federal pediatric quality measures that are aligned with those in the state’s Medicaid program, beginning with the 24 core quality measures already developed under the Children’s Health Insurance Program Reauthorization Act; health plans must also play an active role in health care quality improvements that address children’s unique health care needs.
Association Contact: Jan Kaplan, (202) 753-5384