Key Implementation Issues: Benefits

Children need access to health care benefits and services that support their developmental needs. Medicaid, through the provision of Early Periodic Screening, Diagnostic, and Treatment (EPSDT), provides the most comprehensive age-appropriate pediatric benefits. CHIP plans were also created with the developmental and physical needs of children in mind. The ACA offers states flexibility in designing their essential health benefits (EHB) package, which makes up the minimum coverage that all private plans are required to provide, as well as what Medicaid must offer adults. All states must design their EHB package to encompass 10 categories of benefits, including those critical to children such as habilitative services, preventive services, and pediatric services including oral and vision benefits. While states are required to include the ten benefit categories in their EHB package, federal guidance gives states much flexibility in defining the specific services offered. This flexibility raises questions of how benefits will be operationalized in the states, and particularly for children, how they will compare to the comprehensive benefits provided through Medicaid and CHIP plans. Some challenges and considerations for states include:

  • Defining the scope of habilitative and pediatric services: The final federal rule (Federal Register Vol. 78 No. 37) on EHB design highlighted that state benchmark plans may not include coverage for habilitative or pediatric services and that states will likely need to define the scope of these benefits. States will want to consider the needs of special populations—such as newborns, children and youth with special health care needs, and youth in the welfare system—when designing these categories of services.
  • Provision of dental benefits and coverage
    • Supplementing pediatric dental benefits: States have the option to choose the federal employees supplemental dental plan (FEDVIP) or the state’s S-CHIP dental benefit as their dental benchmark. Most states that have made decisions on their EHB have chosen the federal employees supplemental dental plan (FEDVIP) as their dental benefit. However, FEDVIP is considered to be a less comprehensive package than the CHIP dental benefit.
    • Pediatric Dental Benefits Under the ACA: Issues for State Advocates to Consider: This Georgetown University Center for Children and Families and Children’s Dental Health Project brief presents some of the key challenges for establishing children’s dental benefits within the framework of the ACA.
    • This Maryland Health Connection presentation offers insight into the state’s policy and operational decisions relating to pediatric dental plans.
    • Dental coverage offered in the marketplace: In the marketplace, insurers have the option of offering a comprehensive QHP that includes pediatric dental benefits, or a stand-alone dental plan that provides the EHB-required pediatric dental services. The ACA states that if at least one stand-alone dental plan is offered in the marketplace, then medical QHPs do not have to provide dental benefits themselves. Federal guidance (Federal Register Vol. 78 No. 37) states that there is no requirement that families in the marketplace purchase stand-alone dental coverage for a child along with medical coverage. This may result in parents foregoing necessary dental coverage for their children due to affordability concerns. States could consider encouraging or requiring families to purchase a stand-alone dental plan if dental coverage is not offered through a medical QHP.
  • Continuity of benefits: Children that transition between Medicaid, CHIP, and marketplace coverage may experience disruptions in care. States may want to consider aligning pediatric benefit packages across programs or using CHIP or Medicaid benefits to guide QHP benefit design decisions related to pediatric benefits and services.

Additional State Resources

California: This analysis compares benefits offered in California’s CHIP program, Healthy Families, and its Medicaid program, Medi-Cal. This California Health Benefits Review Program policy brief addresses policy and technical questions related to EHB requirements for pediatric dental and vision benefits.

NASHP Resources

The Affordable Care Act and Children with Special Health Care Needs: An Analysis and Steps for State Policymakers: This NASHP and Catalyst Center publication provides suggestions for state policymakers for leveraging ACA provisions to ensure the complex needs of children with special health care needs are met

Other Resources

A Comparative Review of Essential Health Benefits Pertinent to Children in Large Federal, State, and Small Group Health Insurance Plans Implications for Selecting State Benchmark Plans: This American Academy of Pediatrics analysis concluded that Medicaid and CHIP benefits are more comprehensive for children than qualified health plan benchmarks.