States and local stakeholders have a key role in determining how successful implementation of the Exchange-related provisions of the Affordable Care Act (ACA) will be for the nation’s children. Therefore, it is critically important that state policymakers understand and address the key components of Exchange design and implementation that will positively affect children and their access to care.
State-based, state partnership, and federally facilitated Exchanges will work for children only if they meet the following criteria:
- Pediatric representation in Exchange governance
- Effective consumer assistance
- Comprehensive child-specific Essential Health Benefits
- Seamless coverage and care through strong coordination with Medicaid and CHIP
- Access to the health care providers kids need
- Appropriate pediatric-focused quality measurement and improvement
- Transparent Exchange planning and operation
Pediatric Representation in the Exchange Governance Structure
Pediatric providers should be included in Exchange governance, policymaking entities, and stakeholder consultations.
Pediatric providers, including subspecialists, offer a critical perspective on insurance coverage, health benefits, health plan purchasing, health care delivery, and important public health issues pertaining to children. Many pediatric providers also have valuable insights about the challenges of moving between public and private coverage. These perspectives are invaluable to the design and implementation of an Exchange structure that effectively meets the health care needs of children and their families.
Effective Consumer Assistance
States must create a system that ensures there is someone knowledgeable about children’s health and health care to help connect families with coverage, regardless of where they begin their search for coverage.
The health care system is complicated and it can be difficult for a family to choose the health plan that best meets its needs. Families with a child with special health care needs will face particular challenges navigating health insurance options in the Exchanges. Effective consumer assistance (navigator and in-person assistance) programs will serve as a bridge between families, cost-effective medical assistance, and high quality care.
States must ensure their consumer assistance programs take into account children’s unique health care needs and connect children to appropriate coverage. In many states, existing community-based organizations have a proven track record of helping families connect with health coverage and navigate the health system. States should use the opportunities in the ACA to build and expand on the work of these organizations.
Comprehensive Child-specific Essential Health Benefits
Children have unique health care needs that require a comprehensive benefit package of health care services and devices.
Exchange plans must cover Essential Health Benefits (EHBs) that have been largely set through state and federal choices for 2014 and 2015. States, however, will continue to have opportunities to improve how the EHBs work for the first two years of Exchange coverage and should start now to prepare for a revised set of benefits to be offered in 2016. First, as federal rules allow, states should establish a definition of habilitation that ensures children access to all necessary services and devices to attain and maintain function. States should adopt a definition of habilitative services no more restrictive than the one put forth by the National Association of Insurance Commissioners.
Next, to ensure children have access to all necessary benefits in the EHB, states should create a definition of medical necessity that applies across health plans in the state, modeled on Medicaid’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) standard, which is based on children’s unique health care needs.
It is also critical that states develop methods for measuring children’s access to needed care under the state’s chosen EHB benchmark plan. States must monitor the EHBs for any gaps, with particular attention to children who may go without needed services because they are uncovered and to families who must pay out-of-pocket for uncovered but medically-necessary care.
Seamless Coverage and Care through Strong Coordination with Medicaid and CHIP
Aligned Medicaid/CHIP and Exchange application procedures, provider networks, and benefits are key to ensuring seamless coverage and care for children who move, or “churn,” between Medicaid or CHIP and coverage through the Exchange as a result of changes in family circumstances.
Continuity of coverage and care is a serious challenge for children in families with volatile income, complicated coverage scenarios, and/or ongoing health needs. Exchange policies must accommodate these realities and work toward the goal of seamless coverage and care. Coordinated and aligned application procedures and integrated eligibility and enrollment IT systems will prevent applicants and enrollees from being bounced back and forth between agencies or given conflicting information.
In addition, children with ongoing health concerns and their families often have a strong reliance on a particular provider and a change in provider networks or coverage can be catastrophic to their development and health. Aligned and overlapping provider networks and benefits can help ensure these children continue to receive the care they need.
Access to the Health Care Providers That Children Need
Network adequacy standards for health plans must ensure that children have access to the full spectrum of providers they need when they need them.
Pediatric provider networks in the Exchanges should include a full range of primary, specialty, and ancillary pediatric providers. The networks should also include contracts with all essential community providers as defined in the statute.
Pediatric-specific network adequacy standards (related to timeliness, quantity and types of providers, and monitoring); developed with input from pediatric health researchers, providers, and families; will ensure children have access to needed services without unreasonable delay.
Required contracts with all essential community providers will ensure access to especially qualified providers with expertise in the care of low-income and critically or chronically ill and disabled children. In addition, network standards that require or encourage shared or overlapped networks with Medicaid/CHIP will allow for continuity of care for children who move between public and private coverage.
Appropriate Pediatric-focused Quality Measurement and Improvement
All health plans should be required to report on a common set of federal pediatric quality measures and plan an active role in health care quality improvements that address children’s unique health care needs.
Regardless of their source of coverage, children should have access to high-quality care. Therefore, it is vital that states build the infrastructure to ensure health plans comply with nationally developed reporting standards for pediatric quality measures, beginning with the 24 core quality measures already developed under the Children’s Health Insurance Program Reauthorization Act, as required in the ACA.
Aligned pediatric quality standards and measures with those in the state’s Medicaid/CHIP program and the private insurance market outside the Exchange will allow the state to fully assess the quality of care for children throughout the public and private markets. In addition, states’ quality improvement incentives can drive the development of delivery reforms that improve pediatric care while controlling costs, such as medical homes, accountable care organizations, and other integrated care models.
Transparency in Exchange Planning and Operation
Exchange planning documents, including blueprints, should be publicly available so that stakeholders can access whether the needs of all children, including children with special health care needs, are taken into account as key decisions are made and operationalized.
Exchanges (state-based, state partnership, and federally-facilitated) must engage in open and transparent planning and implementation. Exchanges must collect and share with the public and key stakeholders all relevant data and documents to demonstrate potential and real impact on children’s health and health care.
First, Exchanges must provide appropriate opportunities for comment before policy decisions are finalized to ensure concerns regarding the implications of policy options on child health are collected and addressed.
Second, data collection by the Exchanges must document impacts on children of benefit packages, network design, cost sharing requirements, quality incentives and measures, and other plan design features. The Exchanges must report that data to the state and the public recurrently in a public forum in order to make informed policy decisions.
When gaps or other problems with access to care for children are identified, the Exchange must develop, with public input, a timely plan to address those gaps and ensure Exchanges meet the needs of children and families. Exchange decision makers need sufficient and reliable data to be responsive to market changes and take action in real-time.
For further information on making Exchanges work for kids:
- A Comprehensive Review of Essential Health Benefits Pertinent to Children in Large Federal, State and Small Group Health Insurance Plans: Implications for Selecting State Benchmark Plans, American Academy of Pediatrics. Released July 2012. Available at: http://www.aap.org/en-us/about-the-aap/aap-press-room/Documents/AAP_EHB_Report_FinalPress.pdf
- Federally-facilitated Exchanges: Implications for Children’s Health Care, Children’s Hospital Association (March, 2013)
- State Partnership Exchanges: Implications for Children’s Health Care, Children’s Hospital Association (February 2013)
- Georgetown Center on Children and Families Resources on Health Reform and Exchanges: http://ccf.georgetown.edu/aca/exchange/.
Authored by Lincoln Nehring, JD, Senior Policy Analyst, Voices for Utah Children