Policy Priorities

Policy Priorities image of kids

Benefits Must Be Comprehensive

Children are not little adults. They have unique health needs and these needs will not be met in a health system designed for adults. While vision, hearing and dental benefits are often seen as extras in adult health plans, they are essential elements of a child's benefit package. 

In 2007, 12-year-old Deamonte Driver died from a tooth abscess that spread to his brain. An $80 tooth extraction could have prevented the infection and saved his life, but Deamonte fell through the cracks of our broken child health system. Currently, children miss almost 13 million school days a year because of asthma-related illnesses and over 51 million hours of school each year because of dental-related illnesses. Vision problems are also common, and it has been shown that a child who does not have adequate health coverage and cannot see the blackboard will be more likely to drop out of high school than a child who is able to get the problem diagnosed and treated. 

Regular health screenings help identify, prevent and treat problems and ensure a child's well-being, healthy development and school-readiness. Health reform must address both prevention and physical and mental treatment to help children grow and develop into healthy adults.

All children in Medicaid receive child-specific coverage through Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. EPSDT is considered by experts to be the best standard for age-appropriate child health coverage. These benefits make it easier for children to receive the care and treatment they need by:

  • Making sure children are guaranteed all medically necessary treatments with no exclusions because of physical and mental health conditions;
  • Using a standard of pediatric medicine that focuses on prevention and ameliorative* care;
  • Ensuring that there are no limits placed on the care available to children or the length of time they can receive it; 
  • Covering case management, personal attendant services and other supports to help guarantee that children benefit from the treatment they receive; and
  • Allowing coverage of treatment in traditional and non-traditional care settings, including child care programs and schools;
  • Offering payment for transportation services and special nursing supports, as well as for community health centers and other safety net providers. (1)

Studies on state Children's Health Insurance Programs (CHIP) have found that children who are enrolled in coverage with these comprehensive benefits are more likely than uninsured children to have their health needs met, use preventive care and have a regular source of care, and to go to the dentist. They also show improvements in certain childhood chronic conditions, like asthma, and in academic performance. (2)

While Medicaid guarantees these essential comprehensive services, commercial health insurance plans in the form of private insurance as well as many CHIP plans provide “benchmark” benefit packages that generally do not include EPSDT services, and impose higher co-payments, premiums and arbitrary treatment limits that can prevent children from accessing needed care.

Real child health reform must guarantee all children up to age 21 access to coverage of all medically necessary services now covered under Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services to help children survive and thrive.

* As opposed to a "restorative" standard of benefits, which most commercial plans use. A plan that uses a restorative standard usually only covers the diagnosis and treatment of an illness or injury if the services will restore the patient to normal functioning or cure a particular ailment (1). This means that while most health plans would cover treatment for hearing loss caused by an accident, for instance, they would not cover the same treatment if this hearing loss had happened before birth.


References

1) Rosenbaum, S. et al. “Policy Brief #2: State Benefit Design Choices Under SCHIP – Implications for Pediatric Healthcare,” George Washington University School of Public Health and Health Services, Center for Health Services Research and Policy, May 2001.

2) National Academy for State Health Policy, “Building on Success to Effectively Integrate Current Children’s Coverage with National Health Reform: Ideas from State CHIP Programs,” September 2009.