The Affordable Care Act and Adolescents. Essential Health Benefits

08/01/2013

For plan or policy years beginning on or after January 1, 2014, non-grandfathered individual and small group market insurance plans must cover benefits in ten categories of services and items included in the definition of essential health benefits (EHBs).  The ten categories include: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care (Section 1302 of the Affordable Care Act and Section 2707(a) of the Public Health Service Act).  In addition, the Affordable Care Act prohibits annual and lifetime limits on coverage of essential health benefits.

  • Some benefits particularly relevant to adolescents include:
  • Pediatric dental and vision services must be offered for children up to age 19. Based on the 2011-2012 National Survey of Children’s Health, an estimated 19 percent of adolescents ages 12-17 had oral health problems in the 12 months prior to the survey and 2 percent had vision problems.11
  • Habilitative services are particularly relevant for children and adolescents with developmental disorders.
  • Mental health and substance use disorder services, including behavioral health treatment, are subject to federal parity requirements. Based on the 2010-2011 National Survey on Drug Use and Health, about 994,000 youth ages 12-17 (4 percent) needed but did not receive treatment for alcohol use in the past year and 1,070,000 youth (4.3 percent) needed but did not receive treatment for illicit drug use in the past year. 12

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