What the ACA means for pediatricians and children: Talking Points for AAP Media Spokespeople

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1 What the ACA means for pediatricians and children: Talking Points for AAP Media Spokespeople Overarching key messages The Affordable Care Act (ACA) provides children with the ABCs: Access to health care services, age appropriate Benefits and health care Coverage to meet their needs. Health insurance matters for children. Because of the ACA, families, parents and children have more options than ever before on accessing affordable, quality health insurance. The ACA works for children. Children are better off because of this law, and pediatricians are dedicated to helping parents understand the options available to them and their children as implementation continues. Pediatric patient impact: ACA s consumer protections Patients including children have new protections because of the law. Many of the law s key child health provisions have been in effect since 2010, including: Guaranteed health care coverage for children with pre existing conditions. This means that children with chronic ailments like asthma or diabetes, or children with life threatening illness or disease, can no longer be denied health insurance coverage. These are the children who need care the most, and who were often denied coverage before the law took effect. Insurance companies can no longer set lifetime dollar limits on health benefits, and there are more restrictions on annual limits. These limits have resulted in many families particularly those who have children with special health care needs struggling to cover the cost of their child s medical, behavioral and developmental care and services themselves. In the worst case scenario, a child would not receive the care he or she needs. o Now, thanks to the ACA, parents can seek the right services for their children without fear of running over their annual or lifetime limits. Essential preventive care services are provided without co pays. Thanks to the ACA, all pediatric well child visits including a physical exam, immunizations, hearing and vision screenings, developmental and behavioral screenings, and anticipatory guidance must be covered for children without cost sharing for families. o The American Academy of Pediatrics (AAP) worked hard to use ensure that these services were in accordance with its evidence informed Bright Futures guidelines, which serve as the definitive standard of pediatric well child and preventive care. Insurance companies can no longer drop coverage when a child or adult gets sick. This means children can get the care they need when they need it. Young adults can stay on their parents health insurance plan until they turn 26. Nationally, 28% of year olds remain uninsured. This provision has already provided an estimated 3 6 million young adults with coverage, and with the rollout of the health insurance marketplace, even more will be eligible for affordable coverage options. Out of pocket expenses are capped at $6,250/individual and $12,500/family. Parents can choose a pediatrician as their child s primary care provider. If you can speak firsthand to the impact of any of these provisions on your pediatric patients, please feel free to share your personal experience. Pediatric practice impact: Medicaid payment increase For decades, the AAP has worked to ensure that meaningful access to health services is available to children in the Medicaid program. The ACA includes a historic investment to expand access to Medicaid for children: As of January 1, 2013, Medicaid payment rates were raised to at least Medicare rates for primary care and immunization services. This

2 increase which runs through 2014 marks the first ever federal investment to raise Medicaid payment rates to at least those of Medicare. Pediatricians care for more Medicaid patients than other primary care physicians; on average, 30% of pediatric patients are covered by Medicaid. This program is vital for children from low income families and children with special health care needs. With nearly one in four children living in poverty in the United States, now is exactly the time to invest in programs like Medicaid. As part of the payment increase, qualifying pediatricians and pediatric subspecialists will be paid at least 100% of Medicare rates in 2013 and 2014 for immunization and primary care services. Pediatricians on the ground have already begun to see the increased payments, which will translate into increases in income, and which in turn should help lead to improved access to Medicaid services for especially vulnerable children. If you care for children in Medicaid and/or have observed an increase in Medicaid payments that impacts your practice, please feel free to share your personal experience. Pediatricians role in outreach and enrollment Starting on Oct. 1, 2013, as part of ACA implementation, a six month open enrollment period begins for individuals and families to sign up for health insurance in the new marketplaces (formerly known as exchanges) in every state. The marketplaces will allow millions of people to compare options and choose which type of insurance plan will work best for their family. Public health insurance programs like Medicaid and the Children s Health Insurance Program (CHIP) are still available before, during and after open enrollment, and one streamlined application will make it easier for people to find out which plan will best meet their needs. Pediatricians play an important role educating parents about what the ACA means for children and families. o Some of the law s consumer protections, like requiring insurance plans to cover kids with pre existing conditions and allowing young adults to get covered under their parents insurance until they turn 26, have been in effect since 2010 and are already being felt by our patients. While children were the first to benefit from them, many adults will be eligible for the first time in o Pediatricians care for children, but we also develop relationships with their parents as a result of treating their children as they grow. Because of this, parents come to trust pediatricians for much more than just check ups and immunizations. o As we turn to the next few months, part of this role may involve letting parents know that they will be newly eligible for protections like guaranteed coverage with pre existing conditions. Parents may also turn to pediatricians with questions about which health insurance plans are best for their children, and perhaps even how to enroll in health insurance themselves. AAP will be helping pediatricians prepare for open enrollment and answer questions for families about how to ensure the best health care coverage for their children. o The AAP has developed state specific resources for pediatricians and parents at which include information on how to sign up for health insurance and basic questions parents should ask about what their children need from their health insurance plans. The website links to each state s marketplace website and the federal website where parents and individuals o AAP is also working with state chapters across the country to help educate parents about the best coverage options for their families. Data demonstrates that when parents have health insurance, children are more likely to be healthy themselves. o Through AAP s parent facing website, HealthyChidlren.org (now also in Spanish), pediatricians will also have the opportunity to engage parents directly and educate them about how to enroll in health insurance in the health insurance marketplaces and how to make sure their children are enrolled in health insurance plans that are affordable and offer comprehensive, age appropriate benefits. On

3 parents can find basic information about health insurance and an interactive map linking them to their state s health insurance marketplace. If you have any experience navigating your state s health insurance marketplace, please feel free to share your perspective. Why health insurance matters for children Children who have health insurance are healthier. Research demonstrates that insured children are less likely to get sick, in part because they are more likely to receive preventive care to help keep them well and more likely to get the treatment they need when they are sick or injured. Insured children are also more likely to receive needed immunizations to help protect them from disease, seek treatment for recurring illnesses like ear infections and asthma, and access dental care. Compared to children with insurance, uninsured children are: five times more likely to have an unmet need for medical care; three times more likely not to have access to a needed prescription medication; much less likely to receive preventive services, including check ups, immunizations and medical care for conditions like sore throats, ear infections and asthma; and thirty percent less likely to receive medical treatment if they are injured. Because of the ACA, parents will be able to pick a pediatrician for their child so they can get the health care they need when they need it. With health insurance, children will be able to get immunizations and well child visits required to attend school and often required to play sports. Health insurance can also help children s ability to learn in school; children with health insurance are less likely to miss school because they are sick. In addition, students who can hear their teacher, read the blackboard and aren t distracted by dental pain have an easier time focusing on their school work. Why Medicaid and CHIP matter for children While families can enroll in private insurance plans in the health insurance marketplace from Oct. 1, 2013 through March 31, 2014, Medicaid and CHIP are available for eligible parents, children and families all year round. Medicaid and CHIP provided health insurance to more than 50 percent of American children at some point in 2012, making these programs together the largest insurer of children in the country. Under the ACA, parents don t have to worry about where to go to sign up for which kind of insurance plan. The law s approach to enrollment one single, streamlined application that works for private insurance, Medicaid and CHIP is estimated to help lower the numbers of uninsured children by 40 percent. According to new research from the Urban Institute, more than 87 percent of children who are eligible for Medicaid and CHIP are enrolled in coverage. The total number of eligible but uninsured children dropped to 4.0 million in 2011 from 4.9 million in CHIP provides coverage to more than eight million children whose family incomes are too high to qualify for Medicaid, but who don t earn enough to purchase private health insurance on their own. States design and operate their CHIP programs, which can be run as an expansion of a state s Medicaid program, as a stand alone program or as a combination of the two.

4 Since CHIP was first created in 1997, the number of uninsured children has been cut in half, even as the number on uninsured adults continues to rise. The ACA strengthens CHIP for children by: o Extending CHIP through Sept. 30, 2019, with full funding provided through o Preventing states from scaling back Medicaid and CHIP eligibility levels or benefits for children through Sept. 30, Pediatricians are committed to protecting CHIP and making sure Congress gives it the support it needs to remain an option for children to access high quality, affordable coverage. Medicaid matters for children. In fact, Medicaid is a vital health care program for children from low income families and children with special health care needs, currently covering 32 million children nationwide. Although children make up more than half of Medicaid patients, they account for less than one quarter of all Medicaid spending. Medicaid s benefit package for children is considered the gold standard of care. It includes medically necessary services through a benefit called Early and Periodic Screening, Diagnosis, and Treatment, or EPSDT. o Unlike private insurance coverage, which is designed around the needs of adults, EPSDT was developed for and designed to meet the unique growth and developmental needs of children, including early recognition of treatable conditions, well child checkups, immunizations, dental and vision screenings. The ACA strengthens and supports Medicaid for children by: o Investing $13 billion in access to care for children by increasing historically low Medicaid payment rates to at least Medicare rates for primary care services and immunizations. o Extending Medicaid coverage through age 26 for foster children who have aged out of the foster care system. o Preventing states from scaling back Medicaid and CHIP eligibility levels or benefits for children, through Sept. 30, o Giving states an option to expand their Medicaid program to cover families earning about $32,500 for a family of four (138% of the federal poverty line). The federal government pays most (90%) of the cost for expansion when it is implemented in 2014, and states will eventually pay for 10% by If every state chooses to expand Medicaid, an estimated 17 million people can gain health insurance. Expanding Medicaid is the right thing to do. o While the Supreme Court ruled that it was optional for states to expand their Medicaid programs, pediatricians urge states across the country to do so. Strong evidence suggests that children s health improves as their parents gain insurance. o Many children now covered by Medicaid lose health insurance as they become young adults. How states choose to respond to the ACA s opportunity to participate in the adult Medicaid expansion will impact children and young adults. Medicaid helps lift children out of poverty. o The effects of poverty on children s health are well documented. The 22 percent of children currently living in poverty in the United States are more likely to suffer from health and developmental problems related to low birth weight or succumb to infant mortality, have increased frequency and severity of chronic diseases like asthma, greater food insecurity, worse access to quality health care, poorer oral health, lower immunization rates, and increased rates of obesity and its complications. These health effects are often sustained throughout a child s lifetime. o Medicaid is one of the most important anti poverty programs in U.S. federal policy, efficiently financing the needs of healthy children and helping families avoid medical bankruptcy due to the costs of medically necessary health services. Frequently asked questions Does health care reform change how someone gets billed at the doctor s office?

5 Yes. There are a host of new changes under the ACA including eliminating copays for well child check ups and other preventive services for children that will streamline patient billing. In new insurance plans, a patient will NOT have to pay another charge at the check out desk for well child and well baby services. If you shop for a plan out of state, what are the implications should you need to go to the doctor? The implications of out of state coverage don t change because of the ACA. Just like what happens now when someone accesses health care services in another state, each health insurance plan offers different levels of coverage for services and providers that are out of network or out of state. Just like is the case now, depending on what state you re in, what state your coverage is from, and what service you are seeking treatment for, there will be implications of what could be covered by your insurance plan. Do doctors have to accept your insurance? No, your doctor does not have to accept your insurance plan. That is why it s important to consider a plan that your doctor or child s doctor will join when selecting the best option for your family. Pediatricians encourage families to become informed consumers. For example, CHIP may actually have better benefits than private plans offered in the marketplace. Parents should make sure that their doctor accepts CHIP and see if CHIP could be an option for their child. The ACA gives families choices but also the responsibility to learn about what s best for them. The marketplace offers at least 4 different choices of health insurance plan types. Those least expensive (bronze) have higher out of pocket costs and may have fewer benefits. Those that are the most expensive (platinum) have lower out of pocket costs and may have more benefits. Families, especially those who have children with special health care needs, should make sure the plan they choose includes access to the child s pediatrician, and any needed pediatric specialists and pediatric surgical specialists. Other factors AAP recommends families consider when choosing a plan include preventive care, adequate habilitative services to help a child keep, learn, or improve functioning, rehabilitative services such as physical or speech therapy, and vision and dental care (dental plans may be sold separately). If I still don t have insurance even though I m supposed to, what does this mean? It most likely means you will make a small extra payment on your tax return. The penalty for the first year is $95, but it increases in later years. There are some exceptions to the requirement, but if you don t meet them, you will be required to have insurance, either through your employer or a private or public plan you purchase on your own. Tax credits will become available to make coverage more affordable for many currently uninsured families and individuals. In addition, some states have opted to expand Medicaid to cover even more individuals earning up to 138% of the federal poverty line, so you may be eligible now if you weren t eligible before for Medicaid coverage. If you aren t sure which plans you qualify for or aren t sure what your options are, can help you navigate the health insurance marketplace to find a plan. The site has one streamlined, single application that works for all types of plans. Are there new benefits that insurance will cover that it may not have in the past? Yes. The most notable example for children is that the ACA requires many essential preventive benefits for kids to be covered at no out of pocket cost to families. AAP worked hard to make sure these benefits

6 followed Bright Futures guidelines and in fact got Bright Futures written into the law itself to determine which benefits would be included for children. In addition, children with pre existing conditions are guaranteed coverage and dependent children can stay on their parents plan until they turn 26. And, since the law also eliminates lifetime coverage limits and restricts yearly caps on coverage, children with costly, chronic illness will see more of their services covered because they won t max out their insurance allowance as soon or at all. Adult medicine will also see new services covered at no cost and additional consumer protections.