Grace Aimee M, Noonan Kathleen G, Cheng Tina L, Miller Dorothy, Verga Brittany, Rubin David, Rosenbaum Sara
Aimee M. Grace (
Kathleen G. Noonan is codirector of the PolicyLab and a member of the Division of General Pediatrics, Children's Hospital of Philadelphia, and a faculty member in the Master of Public Health Program at the University of Pennsylvania, in Philadelphia.
Health Aff (Millwood). 2014 Dec;33(12):2136-43. doi: 10.1377/hlthaff.2014.0743.
The Affordable Care Act (ACA) establishes essential health benefits as the coverage standard for health plans sold in the individual and small-group markets for all fifty states and the District of Columbia, including the health insurance Marketplaces. "Pediatric services" is one of the required classes of coverage under the ACA. However, other than oral health and vision care, neither the act nor the regulations for implementing it define what these services should be. We investigated how state benchmark plans-the base plan chosen in each state as the standard or benchmark of coverage in that state under ACA rules-address pediatric coverage in plans governed by the essential health benefits standard. Our review of summaries of all the state benchmark plans found that no state specified a distinct pediatric services benefit class. Furthermore, although benchmark plans explicitly included multiple pediatric conditions, many plans also specifically excluded services for children with special health care needs. The Department of Health and Human Services has made a commitment in the essential health benefits regulations to review its approach for the 2016 plan year. Thus, our findings have implications for future regulations regarding the essential health benefits standard for pediatric services.
《平价医疗法案》（ACA）将基本健康福利确立为在五十个州及哥伦比亚特区的个人和小团体市场（包括健康保险市场）销售的健康计划的覆盖标准。“儿科服务”是ACA规定的必需覆盖类别之一。然而，除了口腔健康和视力保健外，该法案及其实施条例均未界定这些服务应包括哪些内容。我们调查了各州的基准计划——根据ACA规则在每个州选定作为该州覆盖标准或基准的基础计划——如何处理受基本健康福利标准约束的计划中的儿科覆盖问题。我们对所有州基准计划摘要的审查发现，没有一个州指定了独特的儿科服务福利类别。此外，尽管基准计划明确包括多种儿科病症，但许多计划也特别排除了为有特殊医疗需求的儿童提供的服务。美国卫生与公众服务部已在基本健康福利条例中承诺，在2016计划年度审查其方法。因此，我们的研究结果对未来有关儿科服务基本健康福利标准的法规具有影响。
