Journal Issue: Health Insurance for Children Volume 13 Number 1 Spring 2003
Improving Health Care for Adolescents through Public Health Insurance Programs (2/2)
Offering a Broad Range of Services
Adolescents require a broad range of health care services to address their multiple needs. Services of particular importance include preventive services, family planning and reproductive health services, mental health and substance- abuse services, dental care, and services related to chronic illnesses or disabilities.73 Medicaid and SCHIP both offer opportunities to ensure the provision of these services for adolescents.
Preventive services represent a key set of benefits in Medicaid and SCHIP, because many common health problems faced by adolescents are preventable. The rapid developmental changes that occur in adolescence necessitate frequent health assessments in order to identify new health issues and risk behaviors early. Medicaid requires states to establish a schedule for comprehensive health assessments in consultation with professional medical and dental organizations involved in child health care,74 and there is broad consensus among professional groups that annual health assessments for adolescents are needed.75
In Medicaid, EPSDT is the cornerstone of preventive care for children and could result in the provision of comprehensive care for adolescents. Yet, full implementation of EPSDT has not been achieved.76 (See Box 3 for one example of a state's effort to enhance delivery of EPSDT services.) Also, not all states have provided for annual well-adolescent exams in their state-designed SCHIP programs.
To provide for annual well-adolescent visits consistent with the most current recommendations for adolescent care:
- States should update their EPSDT periodicity schedules and ensure that all health plans and providers are using the updated schedules.
- States with separate (non-Medicaid) SCHIP programs should incorporate requirements for annual comprehensive well-adolescent evaluations into their benefit packages.
- States should ensure that their Medicaid and SCHIP programs cover appropriate preventive services for adolescents in accordance with the most current guidelines.
Family Planning and Reproductive Health Services
Among adolescents, high rates of unintended pregnancy and sexually transmitted infection (including HIV) make access to family planning and reproductive health services critical. A broad range of federal programs, including Medicaid and SCHIP, can help states meet adolescents' needs for reproductive health services. In Medicaid and Medicaid expansion SCHIP, family-planning services are a mandatory and confidential benefit. In state-designed SCHIP programs, states may include family-planning services as a benefit. Recent data indicate that although most states have provided coverage for reproductive health services for adolescents in their SCHIP programs, fewer require providing adolescents with information about the full range of reproductive health services or how to access care.77 In addition, although many laws protect the confidentiality of adolescents (as discussed later), few states report guaranteeing confidentiality.78
To ensure adolescents' access to essential family-planning services:
- States should ensure that adolescents enrolled in Medicaid and SCHIP are informed of the family-planning services available to them and how to access them.
Mental Health and Substance-Abuse Services
High rates of suicide, depression, and substance abuse in adolescents79 suggest that many teens need access to mental health and substance-abuse services. Although Medicaid and SCHIP provide the possibility of broad coverage for mental health and substance-abuse services, numerous limitations exist, such as high cost sharing and restrictions on numbers of outpatient visits per year, numbers of inpatient days permitted, and the types of providers who can deliver services and be reimbursed.80–83 While these limitations generally also apply to younger children and adults, they are likely to have greater significance for adolescents: During this developmental period, many behaviors and illnesses that require mental health services—such as drug use, depression, and eating disorders—have their onset.
Many adolescents could be helped by receiving preventive mental health services before emotional or behavioral problems become severe. But often, services are not available through Medicaid, SCHIP, or private insurance without a diagnosis. Nevertheless, some states are beginning to adopt innovative approaches to increase adolescents' access to mental health and substance- abuse services,84 and at least one state, North Carolina, has made a significant effort to address these problems (see Box 4).
To address the mental health and substance-abuse problems of adolescents:
- States should include coverage in their Medicaid and SCHIP programs for a limited number of preventive mental health visits without a diagnosis being required.
- States should include coverage in their Medicaid and SCHIP programs for care coordination to help families and primary care providers integrate medical care, mental health care, substance-abuse treatment, and social services for adolescents.
Dental and oral health problems are particularly severe for adolescents of all races and ethnic groups who live in poverty, compared with higher-income youth.85 For youth who smoke, tobacco use contributes to significant oral health problems, and adult gum disease may have its onset at this time.86 Nonetheless, access to dental care for adolescents is particularly limited, with lack of insurance and low family income being major barriers to adolescents' use of preventive dental care.87
Medicaid provides dental coverage for children and adolescents, and most non-Medicaid SCHIP programs provide dental coverage, but many limitations exist with respect to scope of coverage and cost sharing.88 As with younger children, even adolescents with insurance coverage often have difficulty finding providers who accept Medicaid payments, and they encounter long waiting lists.89
To help ensure that adolescents receive adequate dental care:
- States should implement comprehensive strategies to increase adolescents' access to dental services in Medicaid and SCHIP.
Services for Chronic Illness or Disability
Approximately 1.8 million adolescents ages 12 to 17 experience some degree of limitation due to chronic conditions, a prevalence rate that is higher than the rate for younger children.90 The breadth and depth of the benefit package is particularly critical for adolescents with chronic illnesses or disabilities, who often require services of greater variety, intensity, and duration than do other youth. For example, these adolescents may need physical, occupational, or speech therapy, for which benefit limitations are often imposed.91 While Medicaid and SCHIP offer the potential to provide comprehensive care to adolescents with special health care needs, services are not always accessible, and important benefits for this population are sometimes limited.92–94
Assessing the relative effectiveness of Medicaid and state-designed SCHIP programs in meeting the needs of adolescents with chronic illnesses or disabilities is difficult. State-designed SCHIP programs have greater latitude in shaping their benefit packages, and the effect varies among the programs: Some states have elected to limit the types of benefits important for adolescents with chronic conditions, but some have chosen to offer an enriched benefit package for children and adolescents with special health care needs that is equivalent to the breadth of the Medicaid benefit package.95 (See the article by Szilagyi in this journal issue for a more complete discussion of children with special health care needs.)
To address the needs of adolescents with chronic illnesses or disabilities:
- States should offer an expanded benefit package in state-designed SCHIP programs for children and adolescents with chronic illnesses or disabilities.
Many adolescents will seek health care services—particularly for such issues as pregnancy, sexually transmitted infections, or substance abuse—only if they can receive services confidentially.96–98 Studies show that assurances of confidentiality increase adolescents' willingness to disclose information, report truthfully, and consider a return visit, and that without confidentiality protection, some adolescents will forgo care.99,100
Numerous federal and state laws affect the confidentiality of adolescents' health care information, addressing issues such as when adolescents may give their own consent for care and when information is shared with parents. At the federal level, new medical privacy regulations, initially issued in late 2000, contain specific requirements regarding the confidentiality of medical records and information pertaining to the care of minors, including adolescents who are under age 18.101 These rules, which went into effect in 2001 and were modified in August 2002,102 stipulate that when minors can receive health care based on their own consent—that is, without parental consent—they can exercise most of the privacy rights provided under the federal privacy regulations.103 However, the rules give states greater latitude to determine the extent of privacy protections for minors than for adults and defer to "state or other law" on the question of when otherwise protected information may or must be disclosed to parents. The federal Title X Family Planning Program and the federal confidentiality regulations for drug and alcohol programs also include strong confidentiality protections for adolescents who seek treatment on their own.104 Finally, both Medicaid and SCHIP include some confidentiality protections that should extend to adolescents receiving services.105
At the state level, every state has laws that control the confidentiality of medical information and records106 and allow minors to give their own consent for health care in specific circumstances.107 The minor consent laws generally are based either on the status of the adolescent minor or on the services being sought.108 Overall, every state offers some confidentiality protections to adolescents who are minors (under age 18), while adolescents age 18 or older generally receive the same confidentiality protections as other adults.
To ensure that adolescents who are served in Medicaid and SCHIP are able to access essential services on a confidential basis:
- The federal government and states should ensure that health plans and health care providers adopt medical record, billing, and laboratory procedures that protect the confidentiality of services provided to adolescents.
- States and health plans should provide health care providers and enrollees with specific information about minor consent and confidentiality protections that exist for adolescents.