One of the hallmarks of the Patient Protection and Affordable Care Act is that people with preexisting medical conditions will no longer be denied coverage by insurance companies. For adults, this protection begins in 2014, but for many of those younger than age 19 years, it takes effect on Sept. 23. New regulations from the U.S. Department of Health and Human Services bar health plans from refusing to offer a policy because of a child's preexisting medical condition, and from imposing benefit limitations once the child is on a plan.

Dr. Judith S. Palfrey, president of the American Academy of Pediatrics, explains what this part of the law will mean for children.

PEDIATRIC NEWS: How important is the ban on preexisting condition exclusions in children, in terms of access to insurance and coverage for treatments?

Dr. Palfrey: This is one of the most significant provisions within the health reform law in terms of what it means for improved access and care for some of the country's most vulnerable children. Before, if a child had a chronic condition like asthma, or a debilitating disease like cancer, it was possible for insurers to deny them care, when—ironically—they were the ones who needed treatment the most.

Although this provision is an enormous step forward, there is work to be done to make sure children can benefit whether they are enrolled in a new health insurance plan or an existing one. The AAP is working with Obama administration officials to make sure that the ACA provides access to as many children with preexisting health conditions as possible.

The ACA also guarantees an array of preventive services for all children, to be offered without copay or deductible, including a yearly physical, well-child visits, and routine immunizations as well as hearing, vision, developmental, and behavioral screenings. This will help physicians detect many diseases before they cause morbidity, then treat and monitor them as needed. These essential benefits could be life saving, especially for children with preexisting and often chronic or complex conditions.

PN: How many children are likely to benefit from this provision in the near future, and what are the implications for their future health?

Dr. Palfrey: We don't have data specifically on how many children are expected to benefit from this provision, but the Congressional Budget Office estimates that about 200,000 Americans will enroll in the Preexisting Condition Insurance Plan during 2011–2013. The plan will provide an option for many sick children to gain access to coverage they don't currently have, and since a good number of these children may have forgone care or treatment because of costs or being denied insurance, the enactment of this provision should improve their future health.

PN: Will this change the way pediatricians and other physicians who treat children and adolescents are able to care for their patients?

Dr. Palfrey: This should certainly make it easier to provide care to more children, because services now will receive some level of payment. This provision also should help provide a pathway for families to get private insurance for their children, increasing access to care.

PN: Will this new requirement apply to all health plans, and what can physicians do to ensure that their patients are protected under the new law?

Dr. Palfrey: This provision applies to all new health insurance plans that begin after Sept. 23 It does not apply to plans that were already in existence when the ACA was signed into law last March, as long as those plans have not made any significant changes in coverage, like raising premiums or cutting benefits. The administration has issued additional guidance on the preexisting condition exclusions ban after some insurance companies threatened to drop child-only coverage options, citing concern about families who might enroll children only when they fall ill and drop coverage if their children are healthy.

The guidance allows insurers to limit families to specific periods of “open enrollment” when they can apply for insurance coverage for their children, rather than giving families the flexibility of applying throughout the year. The AAP is concerned that restricting families to an open-enrollment season prevents many vulnerable children from attaining health insurance when they need it. For example, if a child becomes ill outside of the open-enrollment period, parents may have to wait for months to get the child coverage. The AAP has commented publicly on this provision, and we hope to work with the administration to make sure that children can access care when they need it, regardless of their health status or the time of year.

DR. PALFREY is a professor of pediatrics at Harvard Medical School in Boston and directs the children's international pediatric center at Children's Hospital Boston.

Ending Preexisting Condition Exclusions for Kids