December 1997, VOLUME100 /ISSUE 6

Scope of Health Care Benefits for Newborns, Infants, Children, Adolescents, and Young Adults Through Age 21 Years

  1. Committee on Child Health Financing


The optimal health of children can best be achieved by providing access to comprehensive health care benefits. This policy statement replaces the 1993 statement, “Scope of Health Care Benefits for Infants, Children, and Adolescents Through Age 21 Years.” Changes involve services and procedures specific to the delivery of comprehensive preventive, prenatal, postnatal, and mental health care. These services should be delivered by appropriately trained and board-eligible/certified pediatric providers, including primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists.

All newborns, infants, children, adolescents, young adult patients through age 21 years, and pregnant women must have access to comprehensive health care benefits that will ensure their optimal health and well-being. The following services should be included in the health benefit plans offered by all private and public insurers. These services should be delivered by appropriately trained and board eligible/certified pediatric providers, including primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists. All providers of prenatal care should be able to identify a full range of medical and psychosocial risks and to refer patients for appropriate care throughout pregnancy.1 These services should be delivered in a variety of appropriate settings, and coordinated through the child's medical home.2 They also should be delivered in an efficient manner that does not compromise the quality of care. As these services are physician-directed and prescribed, they should include but are not limited to all of the following:

  1. Medical care including: a) health supervision with preventive care and immunizations according to the American Academy of Pediatrics' “Recommendations for Preventive Pediatric Health Care,”3 and b) diagnosis and treatment of acute and chronic illness, developmental disabilities, learning disorders, and behavioral problems.

  2. Surgical care.

  3. Mental health, substance abuse, and services for other psychosocial problems including therapy, crisis management, day treatment, and residential care. This should also include evaluations and treatment of learning disabilities and related disorders such as attention deficit hyperactivity disorder.

  4. Emergency medical and trauma care services for children.

  5. Inpatient hospital and critical care services.

  6. Pediatric critical care, pediatric medical subspecialty, and pediatric surgical specialty consultations occurring either in the inpatient or outpatient setting.

  7. Family planning services.

  8. Pregnancy services including: a) genetic counseling and related services as needed; b) prenatal care; c) prenatal consultation with a pediatrician or board eligible/certified provider of pediatric care; d) care for all complications; e) counseling and services for all pregnancy management options; and f) care for the pregnancy of a dependent of a policyholder.

  9. Care of all newborn infants including: a) attendance at and management of high-risk deliveries or those mandated by hospital regulations; b) health supervision; c) treatment of congenital anomalies and other medical and surgical conditions; d) newborn intensive care services; and e) when indicated by the infant's physician, a follow-up visit in the child's home or in the physician's office within 48 hours of discharge.

  10. Laboratory and pathology services including screening for metabolic and other congenital disorders.

  11. Diagnostic and therapeutic radiology services.

  12. Anesthesia services including anesthesia when appropriate for all “covered” procedures.

  13. Early intervention services and therapies for developmental, rehabilitative, and habilitative purposes including, but not limited to: a) physical therapy; b) speech therapy and language services; c) occupational therapy; and d) audiology.

  14. Home health care services including, but not limited to, private duty nursing, attendant care, and respite care.

  15. Intermediate or skilled nursing facility care in lieu of hospital care.

  16. Hospice care.

  17. Case management and care coordination integrated with child's primary care provider and family as required by those with special health care needs.

  18. Medical and social services required to evaluate and treat suspected child physical and sexual abuse in both inpatient and outpatient settings.

  19. Transfer/transport to a hospital or health facility.

  20. Preventive and restorative dental care and oral surgery.

  21. Nutritional and lactation counseling services.

  22. Prescription drugs, medical and surgical supplies, and special nutritional supplements, including, but not limited to, those prescribed under national clinical trials for acquired immunodeficiency syndrome/human immunodeficiency virus and other conditions.

  23. Rental or purchase and service of durable medical equipment including, but not limited to, equipment necessary to administer aerosolized medication and to monitor their effects, corrective eyeglasses or lenses, hearing aids, breast pumps, prostheses/braces, electrical and other types of ventilators, cardiorespirator monitors, oxygen concentrators, and customized wheelchairs.

Committee on Child Health Financing, 1996 to 1997

Stephen Berman, MD, Chairperson

Joseph C. Bogdan, MD

John S. Curran, MD

Arthur Garson, Jr, MD, MPH

Neal Halfon, MD, MPH

Robert Kay, MD

Beverly L. Koops, MD

Maria E. Minon, MD

Richard P. Nelson, MD


  • The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.