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Children Need Exchange Coverage Too


This post was originally from Georgetown Center for Children and Families’ Say Ahhh! blog

By Maureen Hensley-Quinn, National Academy for State Health Policy

As state and federal government officials race to meet Affordable Care Act (ACA) implementation deadlines much of their attention has been focused on adults who will be newly eligible for health coverage.  Health insurance exchanges (exchanges) or marketplaces need to be prepared to serve children’s needs as well.  The Children’s Health Insurance Program (CHIP), an already established and tested program, could be used to help states meet ACA requirements for exchanges while establishing good coverage for children.  A recent issue brief and compendium released by the National Academy for State Health Policy (NASHP) explores how CHIP could inform children’s coverage provided through exchanges.

Children have specific health care needs related to their growth and development that are distinct from those of adults.  Health benefits that support a child from infancy through adolescence and appropriate, available providers are essential.  Children are recognized in the ACA as a “diverse segment of the population” whose health care needs should be taken into account in defining the Essential Health Benefit (EHB) package.

There are a number of ACA exchange provisions that aim to support children’s health needs.  Exchanges are required to offer child-only plans that are available only to children up to age 21 at the same level (silver, gold, etc.) as other Qualified Health Plans (QHPs).  Child-only plans will be important in providing coverage options for millions of families where parents and children have different coverage situations.  Catherine Hess, Managing Director at NASHP outlines this and other issues for children that states should consider as ACA implemented in a previous NASHP blog post.

The ACA also explicitly includes “pediatric benefits” and “habilitative services” within the EHB package that must be offered in individual and small group markets inside and outside the exchanges.  States are afforded a lot of flexibility in defining each of these benefit categories.  While benchmark benefit plans serve as a “reference plan” that reflects a “typical employer plan”, HHS recognizes states may need to define and supplement benefits to ensure all 10 EHB categories are covered.  Habilitative services, which are critical to children with special health needs, will likely need to be supplemented, as most benchmark plans do not include such services.

The Children’s Health Insurance Program has been providing coverage designed for children for over 15 years and can inform or serve as a model to meet the ACA’s child specific requirements in the exchange.  Separate CHIP programs, which generally tend to be more like plans offered in the private market than through Medicaid, may be more easily aligned with exchange requirements.  For instance, separate CHIP programs offer federally identified benchmark benefit plans or approved alternatives and are usually delivered by managed care organizations.  A recent study commissioned by the American Academy of Pediatrics that compared benefit packages in five states found CHIP covers the 10 EHB categories more completely than the benchmark plan options.

Considering the ACA’s requirements as well as the flexibility afforded to states, exchanges could use CHIP as a tool in the following ways:

  • Use the separate CHIP benefit package to define the “pediatric services” category within the EHB
  • Engage health plans and their provider networks that are contracted to deliver CHIP services to participate as QHPs in the exchange
  • Implement premium assistance by using CHIP funds to purchase coverage in the exchange
  • Use CHIP to guide development of wrap-around for QHP coverage to ensure there is a comprehensive benefit package for children in the exchange.

Although many assume children are taken care of as a result of steady progress to reduce the number of uninsured low-income children, many children will gain coverage through the exchange.  According to the Urban Institute, nearly 4 million children will enroll in Qualified Health Plans (QHPs) through exchanges in 2014.

If federal funding for CHIP is not renewed after October 2015, there will be millions more children that will likely turn to exchanges for their health coverage.  ACA requires that before children eligible for CHIP can be transitioned to an exchange, the U. S. HHS Secretary must certify there is exchange coverage comparable to CHIP in both benefits and cost sharing.  While federal guidance related to the comparability study has not yet been released, states may want to consider ways to incorporate CHIP features into exchange coverage to provide child specific coverage now and in the future.

How will your state ensure children’s coverage needs are met in the exchange?