The Affordable Care Act includes provisions intended to improve access to health insurance coverage and ensure that such coverage provides essential health benefits for adolescents and young adults. Several of these provisions are already in effect for most plans, including requirements to cover preventive services without cost-sharing, a prohibition on pre-existing condition exclusions for children under age 19, a prohibition of lifetime or restrictive annual limits on essential health benefits, and coverage for dependents ages 19-25 on their parent’s health insurance plan. Several others, including the opportunity for states to expand Medicaid, coverage of essential health benefits, and the ability to get coverage through the new Health Insurance Marketplace with access to premium tax credits will apply for plan years beginning on or after January 1, 2014. Taken together, these provisions ensure that adolescents will have access to health insurance that covers benefits, particularly important for this population.
Preventive Health Services With No Co-Pay
Health promotion, disease prevention, early intervention, and timely treatment of conditions can improve the health status of adolescents and reduce the incidence of chronic conditions in adulthood. The Affordable Care Act (adding new Section 2713 to the Public Health Service Act) seeks to make prevention affordable by requiring most private health insurance plans to cover recommended preventive services without cost-sharing, meaning not subject to deductibles or co-pays/coinsurance. The Affordable Care Act identified specific sources for these recommendations for preventive services, including the United States Preventive Services Task Force’s recommendations with an “A” or “B” rating, the Advisory Committee on Immunization Practices, and guidelines supported by the Health Resources and Services Administration (such as Bright Futures for children and adolescents and the guidelines for women’s clinical preventive services).
Recommended preventive services and screenings are now covered with no out-of-pocket costs, including immunizations, behavioral assessments for adolescents, obesity screening, FDA-approved contraception and patient education counseling and sexually transmitted infection (STI) prevention counseling and screening for sexually active adolescents. In a national survey, about ten percent of youth ages 12-17 reported any illicit drug use in the past month and eight percent reported cigarette use in the past month. An estimated 31 percent of children ages 10-17 are overweight or obese. Teenagers are more likely to have an unintended pregnancy than older females. Among women ages 19 and younger, more than 4 out of 5 pregnancies are unintended.
Prohibition Of Pre-
existing Conditions Denials
An estimated 25 percent of all children between the ages of 12 and 17 have special health care needs. For example, about 11 percent of adolescents 12-17 have Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder (ADD/ADHD) and 10 percent have asthma.9 The Affordable Care Act (adding new Section 2704 to the Public Health Service Act) prohibits denial of coverage for pre-existing conditions.
For plan or policy years beginning on or after September 23, 2010, group health plans, group health insurance coverage, and non-grandfathered individual health insurance policies may not deny or limit coverage for children under the age of 19 because of a pre-existing condition.
For plan or policy years beginning on or after January 1, 2014, group health plans, group health insurance coverage, and non-grandfathered individual health insurance policies may not deny or limit coverage for any enrollee because of a pre-existing condition.
As of September 23, 2010, the Affordable Care Act (adding new Section 2714 to the Public Health Service Act) and its implementing regulations provide that new or renewing plans in the individual and group markets are required to cover dependents ages 25 and younger if they offer dependent coverage. This applies to young adults even if they are married, not living with their parent and/or not financially dependent on their parent. Grandfathered group health plans may exclude coverage of a dependent that has access to eligible employer-sponsored coverage. As of December 2011, 3.1 million young adults (ages 19-25) had gained coverage under this provision.
Medicaid/Children’s Health Insurance
The Affordable Care Act (Section 2001) requires maintenance of the pre-Affordable Care Act Medicaid and CHIP eligibility levels for children 18 and younger through 2019. In addition, the Affordable Care Act requires all states to provide Medicaid coverage for children ages 6-18 with incomes at or below 133 percent of Federal Poverty Level Guidelines beginning January 1, 2014. Beginning January 1, 2014, the Affordable Care Act (Section 2004) also generally makes current and former children in foster care eligible for Medicaid until they turn 26.
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.
Affordable Care Act Initiatives
In addition to coverage and benefit provisions, the Affordable Care Act includes several other provisions aimed at improving health and healthcare access among adolescents. These include funding for school-based health centers, teen pregnancy prevention programs, home visiting programs, a childhood obesity demonstration project, and the expansion of community health centers.
Because of the Affordable Care Act, more Americans will have access to affordable health insurance coverage. For adolescents, the Affordable Care Act expands health insurance coverage, increases access to comprehensive benefits, and places greater emphasis on prevention and wellness.