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Journal Issue: Children and Divorce Volume 4 Number 1 Spring/Summer 1994

REVISITING THE ISSUES: Children and National Health Care Reform
Sara Rosenbaum

Benefits

Of the six bills, only the President's bill and the McDermott/Wellstone bill guarantee coverage for a specific benefit package. Both bills extend first-dollar coverage for preventive services, as well as coverage for vision and dental care.

The McDermott/Wellstone bill is particularly notable for its coverage of benefits used by children with disabilities. Mandatory benefits include items and services specified in a child's individualized treatment plan under Part B or H of the Individuals with Disabilities Education Act (IDEA). Also covered as mandatory benefits are services furnished by school health clinics and other "community-based primary health care" services.

Unlike the McDermott/Wellstone bill, however, the President's bill does not include either long-term care or rehabilitation and associated services for children with birth-related conditions in the guaranteed benefit package. Instead, these benefits are covered through a separate long-term care program for severely disabled children and supplemental Medicaid coverage for services used by low-income children with chronic conditions and disabilities. The other four measures specify no benefit package but, instead, leave to the rule-making process the development of a standard benefit package.

All measures use a "medical necessity" standard to determine the amount and scope of covered benefits. None of the bills, however, amplifies what is meant by medical necessity in the context of pediatric care or other care, for that matter. This may make it difficult to obtain coverage for treatment services which promote child health and prevent disease and disability. Services at an early, preventable stage of illness rather than after the onset of disease is measurable and more serious are covered under the liberal medical necessity standard in the current Medicaid Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program.

All six measures contain provisions curbing discrimination in the coverage of benefits based on preexisting conditions. However, the Cooper/Breaux, Chafee/Thomas, Michel/Lott, and Stearns/Nickles bills permit the application of six-month waiting periods for preexisting conditions except for pregnant women and newborns.