By Sean Miskell and Kelly Whitener
The Marketplaces created under the Affordable Care Act (ACA) have played an important role in expanding access to health insurance. Though relatively few children (approximately one million) receive their coverage through the Marketplace compared with Medicaid and CHIP, it is nonetheless an important option for children not eligible for public coverage or lacking access to affordable employer-sponsored insurance.
In this context, a new CCF report considers how the Marketplace compares to other sources of coverage with regard to benefits and costs. In the first of a series of reports on the future of children’s coverage, Georgetown researchers Kelly Whitener, JoAnn Volk, Sean Miskell, and Joan Alker consider how well Marketplace plans are serving children along three primary dimensions: adequacy of coverage, affordability of coverage, and access to providers. It also includes recommendations on how to ensure that Marketplace plans meet the unique needs of children.
Adequacy of Coverage
Qualified Health Plans (QHPs) available in the Marketplace must cover the Essential Health Benefits, which are 10 categories of services including “pediatric services, including oral and vision care.” The definition of pediatric services was intended to be broad, but it has been implemented only with respect to oral and vision care. Compared with benefits available to children under CHIP, studies have found that Marketplace plans either do not provide certain benefits including dental, vision, audiology, habilitative, physical, occupational, and speech therapy or do so with limits. These benefit limitations in Marketplace plans have the most profound effects on children with special health care needs. Medicaid covers all of these services as part of its EPSDT benefit, as do CHIP programs that provide EPSDT benefits.
Affordability of Coverage for Children and Families
Despite the financial assistance available in conjunction with the Marketplaces, many families nonetheless face considerable costs that can put care out of reach. For example, a recent congressionally mandated analysis conducted by the Centers for Medicare & Medicaid Services (CMS) found that families can expect to pay higher costs for QHPs compared with CHIP in all 36 states that operate a separate CHIP program. Similarly, a March 2016 report from the Medicaid and CHIP Payment and Access Commission (MACPAC) concluded that, due to their higher out-of-pocket costs, Marketplace plans are not ready to serve as an adequate alternative for children enrolled in CHIP. The study found that out-of-pocket costs (including copayments and deductibles) for Marketplace coverage are higher than those in separate state CHIP programs. Families in states that provide health insurance to CHIP-eligible children through Medicaid also get more value than they would in the Marketplace given Medicaid’s robust EPSDT benefit package and very low cost-sharing.
Increasing out of pocket costs are not a phenomenon exclusive to the Marketplace. Indeed, a recent study by the Commonwealth Fund found that rising out of pocket costs have been slowly eroding the value of private insurance for years.
Access to Providers
The ACA requires Marketplace plans to “maintain a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance abuse services, to assure that all services will be accessible without unreasonable delay.” But to date, there has been relatively little data on how Marketplace plans are meeting network adequacy standards and what it means for children’s access to needed providers. However, even networks that work relatively well for most enrollees do not necessarily work well for those with special health care needs, especially children. Families that must get care out-of-network are subject to higher cost-sharing and their out-of-pocket costs do not count toward the ACA out-of-pocket cap. Families may face surprise medical bills for out-of-network services when they seek care during emergencies (and thus are not able to choose where they receive care) or receive care at an in-network facility that incorporates out-of-network providers for some services (such as anesthesia). Medicaid managed care plans, in contrast, are required to cover contracted services out-of-network if they are unable to cover them in-network and must coordinate with the provider to ensure the cost to the enrollee is no greater than it would have been in-network. The final rule on Medicaid and CHIP managed care subjects CHIP managed care plans to this same requirement.
Policy Options to Strengthen Marketplace Coverage for Children
Despite the important role that the ACA’s Marketplaces have played in expanding access to insurance, families may still have difficulty affording this coverage and getting the care they need. Policymakers can act and make changes to Marketplace coverage that will better suit the needs of children. A summary of recommendations for changes is included in the report.