Underinsurance of Adolescents: Recommendations for Improved Coverage of Preventive, Reproductive, and Behavioral Health Care Services

INTRODUCTION

Having health insurance has been associated with better access and utilization of health care, whereas uninsured families are more likely to report experiencing “unmet” health care needs for their children and adolescents.^1,2 In 2006, 13.8% of adolescents 13 through 18 years of age and 28.4% of older adolescents aged 19 through 21 were uninsured.³ Adolescents at greatest risk of being uninsured are older, are Hispanic, and have low household income. The problems of uninsured adolescents have been a long-standing concern of the American Academy of Pediatrics (AAP) and the subject of several policy statements^4–6 and ongoing state and federal advocacy efforts.

Having health insurance that provides comprehensive and affordable coverage for preventive, behavioral, and reproductive care is particularly important for adolescents, because the major causes of morbidity and mortality in this age group are related to injuries from motor vehicle crashes, suicide, interpersonal violence, alcohol and drug use, and risky sexual behaviors. This policy statement presents a series of recommended strategies to address the serious underinsurance and payment problems affecting insured adolescents and the clinicians who care for them.

INSURANCE COVERAGE

There are no reliable national estimates on the extent of underinsurance among adolescents. Still, the literature on adolescent health care expenditures and private health insurance benefits reveal some important findings. With respect to health care expenditures, nearly 40% of adolescents' health care is paid out-of-pocket. Higher out-of-pocket liabilities are reported among adolescents with private insurance, those in fair to poor overall health, and those with disabilities.⁷

With respect to private health insurance coverage, benefits are often not well matched to meet the needs of adolescents. In a study examining the extent of private health insurance coverage available to hypothetical adolescents with various conditions or illnesses, substantial levels of underinsurance were found. The specific adolescent conditions that were examined included injuries resulting from motor vehicle crashes, pregnancy and sexually transmitted infections (STIs), major depressive disorder, anorexia nervosa, and bipolar and substance abuse disorders. Overall, physical therapy, occupational therapy, and nutritional counseling, as well as behavioral or mental health therapies, were least likely to be covered at the levels recommended by medical experts to treat adolescents.⁸ Additional insurance gaps relate to the refusal by many insurance companies to provide coverage for preexisting conditions when adolescents make transitions from one plan to another.

PROVIDER PAYMENT

In addition to underinsurance, payment problems in the form of inadequate payment, uncompensated care for confidential reproductive services, and rejection by insurers of certain billing and diagnostic codes disproportionately affect clinicians who care for teenagers. For example, fee-for-service Medicaid programs administered by states paid below Medicare reimbursement rates for 70% of the Current Procedural Terminology (CPT) codes in most commonly used in pediatric practices. Overall, Medicaid payments averaged only 80% of Medicare rates.⁹ Within Medicaid risk-based managed care systems, capitated rates of payment to cover 13- to 18-year-olds are often substantially lower than those to cover children 12 years old or younger and individuals older than 18 years, thus, penalizing physicians who see a large number of adolescents. Medicaid and State Children's Health Insurance (SCHIP) rates and, to a lesser extent, private health insurance rates do not cover the time needed to serve adolescents.¹⁰ Importantly, research has shown that differences in preventive health care visits by adolescents are linked to physician payment rates.¹¹

Providers also report that they are unable to get paid for confidential reproductive, mental health, and substance abuse evaluation and treatment services and for non–face-to-face services such as telephone calls and e-mails. Unfortunately, few insurers have adjusted their administrative and billing systems to protect adolescent confidentiality, and most states do not have fee-for-service payment mechanisms or carve-outs to reimburse providers for this important care. In addition, few public or private insurers reimburse CPT billing codes related to health education and chronic care management, and many also restrict coverage of certain diagnostic International Classification of Diseases, Ninth Revision (ICD-9) codes.^8,12

Adolescent medicine specialists are often not recognized by insurers as both primary care providers and specialists. Adolescent medicine is a specialty recognized by the American Board of Pediatrics, American Board of Family Medicine, and American Board of Internal Medicine and by all state medical organizations as both a primary care specialty and medical subspecialty. Thus, referrals to an adolescent medicine specialist made by other primary care providers often cannot occur when the adolescent medicine specialist also provides primary care services to other patients.

To the extent that these insurance gaps and payment problems represent significant financial losses to the providers caring for adolescents, these issues also represent a very real deterrent to providers expanding their practices to include more adolescents. Moreover, these coverage and payment issues impose significant financial barriers and hardships on adolescents and their families.

PREVENTIVE CARE

The AAP recommends the following strategies to address underinsurance and payment problems among adolescents:

• All insurance plans, including newer consumer-driven health plans, should cover annual preventive health care visits and recommended immunizations for adolescents consistent with national medical guidelines.^13–15

• Copayments, coinsurance, and deductibles should be eliminated for preventive care visits and immunizations to reduce barriers to adolescents seeking such care.^4,14,16

• When health problems are identified during the adolescent preventive care visit, insurers should recognize the —25 modifier CPT code to allow for same-day treatment of issues that would otherwise require another separate health care visit.¹⁷ This represents an important window of opportunity for addressing problems in a timely, convenient manner and to reduce the risk of loss to follow-up.

• Insurers' claims systems should recognize and pay for preventive medicine codes for health and behavior assessment and counseling, risk screening, and intervention, which are more frequently needed and appropriate for adolescents.¹⁷

• Insurers should recognize that physicians trained in adolescent medicine may provide services as both primary care providers and specialists. Adolescent medicine subspecialists should be allowed to provide primary care for teenagers, particularly for those with more complicated problems such as chronic illnesses/disabilities, reproductive health concerns, and mental health/substance abuse conditions. This strategy would allow effective management of both the clinical needs and the health care costs of complicated adolescent patients.

• Insurers should reimburse physicians at higher rates for services provided during nontraditional hours (after 5 pm and on weekends) to increase access to care in the medical home and reduce emergency department and urgent care facility utilization.

The AAP recommends that adolescents have an annual preventive health care visit that includes disease detection and prevention, health promotion, and anticipatory guidance that addresses physical growth and development, social and academic competence, emotional well-being, risk reduction, and violence and injury prevention.¹³ This visit should also allow time to provide health guidance to parents, including a discussion of the ongoing psychosocial and physical changes in their adolescents along with ways to support them to adopt healthier lifestyles. In 1997, the National Committee for Quality Assurance, through its Health Employer Data and Information System (HEDIS), affirmed the importance of annual visits for adolescents by adding this yearly visit to its measurements.¹⁸ In addition, the current vaccine financing system and its gaps in coverage need to be addressed, because many underinsured adolescents are unable to access publicly funded vaccines in either the private or public sectors.¹⁶ Unfortunately, a sizeable proportion of Medicaid and private insurers fail to cover annual preventive benefits for adolescents, and almost all insurers exclude coverage for preventive counseling and also do not reimburse providers if more than 1 ambulatory service occurs on the same day.^8,12 Moreover, with the exception of separate SCHIP programs, few private insurers exempt preventive care from deductibles and other forms of cost sharing.

Even when preventive care is covered, low fees paid by Medicaid and SCHIP programs as well as most private health insurance plans fail to adequately cover the work required to perform a comprehensive adolescent preventive health care visit.¹⁰

The implications of inadequate coverage, significant cost sharing, and low payment rates are numerous: reduced access to preventive health care services to teenagers, including limited or no ongoing preventive counseling; inadequate compliance with recommended AAP guidelines; substitution of brief sports physicals for comprehensive examinations; financial losses for providers who elect to provide comprehensive preventive care services despite inadequate payment; and significant out-of-pocket payments for families. Research suggests that even modest cost sharing makes it less likely that teenagers from low-income families will get effective medical care.¹⁹

REPRODUCTIVE CARE

The AAP recommends the following strategies to protect teenagers' access to reproductive health care and to ensure adequate payment for comprehensive reproductive care, including confidential care:

• Insurers should cover all contraceptives, including emergency contraception and treatment of STIs, just as they do other medications.

• Copayments, coinsurance, and deductibles for reproductive health care visits and contraceptives should be reduced or eliminated.

• Policies that recognize the rights of adolescents to obtain confidential reproductive health care should be developed by insurers, their governing organizations, and physician offices.

• A unique coding and billing strategy should be implemented by insurers to protect the rights of teenagers to access confidential reproductive health care services.

• Explanations of benefits and other receipts for reproductive care services used by adolescents ideally should not be sent to parents.

• Insurers should recognize that physicians trained in adolescent medicine may provide services as both primary care providers and specialists. Allowing adolescent medicine specialists to provide reproductive health care for teenagers within the context of primary care or consultative services would be a management strategy that serves the needs of the patients clinically and provides cost-effective treatment.

• Incentives should be offered for increased availability of after-hours care in the medical home in the form of higher payments for visits after 5 pm and on weekends.

The AAP recommends that adolescents receive confidential counseling about sexual development, sexuality, and responsible personal decision-making.^20–22 In addition, the AAP recommends that sexually active teenagers receive reproductive health care, which includes appropriate genitourinary and gynecologic evaluations; counseling about contraceptive options, including abstinence; and counseling to prevent, screen for, and treat STIs, including HIV.^13,21 Although parental involvement is desired and encouraged, many sexually active teenagers will not seek reproductive health care services if parental consent is required.^23,24 All states allow minors to obtain confidential screening and treatment for STIs, and many states allow minors to receive contraceptive services without parental notification.^25,26 Yet, coverage of contraceptive services is often limited in Medicaid, SCHIP, and private health insurance plans. Insurance coverage for contraception is highest in states with mandates to cover such services.^27,28

Coverage of reproductive services, however, is limited in many public and private insurance plans. Routine gynecologic examinations, which are part of the routine preventive care visit for adolescents, are subject to the same limits as the preventive care benefit previously described. Also, a sizeable proportion of insurance plans treat contraceptives differently from other medications by limiting or failing to provide contraceptive coverage even when prescribed for the treatment of menstrual or other gynecologic disorders.⁸ In addition, health education and counseling about sexuality, sexual activity and contraception, pregnancy and STI prevention, and reproductive health services for adolescents are seldom covered.

Copayments, coinsurance, and deductibles are routinely applied for both reproductive care visits and contraceptives under private insurance plans.²⁹ There are many negative implications of these cost-sharing obligations, limitations of coverage, and failure to adopt confidential protections and billing arrangements, including lost opportunities for prevention and early intervention, financial disincentives for pediatricians to provide reproductive health care, and disruptions in continuity of care when adolescents are forced to seek reproductive care outside their primary care medical home. Programs that have been successful in providing reproductive care services to teenagers have been funded by public insurance, have ensured confidentiality, and have removed cost barriers.^10,30

In addition, the extended time and expertise required to provide routine pelvic examinations for teenagers is not recognized. Providing adequate information and education to the adolescent experiencing her first pelvic examination or to the adolescent with previous negative experiences requires more time. Providing contraceptive counseling and prescriptions may represent the first experience of obtaining medication in a confidential setting, thus requiring more time from health care providers and personnel to provide instructions regarding access to and proper use of medication. However, unlike adult gynecology codes, there is no separate billing code for routine gynecologic examinations. The adolescent gynecologic examination is incorporated into the preventive visit code.

BEHAVIORAL HEALTH CARE

The AAP recommends the following strategies for reducing underinsurance and payment problems that adversely affect adolescents' access to early and ongoing mental health and substance abuse prevention and treatment services. Unfortunately, coverage and payment of mental health and substance abuse services for all individuals is seriously flawed. These pervasive failures especially affect adolescents, because their main health issues are behavioral in nature.

• Insurers should cover comprehensive mental health and substance abuse services that are sufficient in amount, duration, and scope to effectively identify and treat such disorders in adolescents.¹⁴

• Parity in insurance coverage should be established between medical services and mental health and substance abuse services. Coverage of adolescent mental health and substance abuse disorders should be the same as coverage of other adolescent chronic health conditions and disabilities.^31,32

• Insurers should eliminate condition exclusions for enrollees with mental health and substance abuse disorders.

• Insurers should provide coverage for the care of youth with behavioral disorders affecting physical health, such as eating disorders, which should not be categorized exclusively as mental health disorders.³³

• All adolescents should have access to the annual adolescent preventive health care visit as a venue for screening for mental health problems and initiating treatment, as recommended in Bright Futures.^13,34

• When health problems are identified during the adolescent preventive care visit, insurers should recognize the —25 modifier CPT code to allow for same-day treatment of issues that would otherwise require another separate health care visit.¹⁷

• Insurers should recognize codes for providing care for adolescents in various settings, including telephone management and counseling, team conferences, and health and behavior assessment and intervention.¹⁷

• Insurers should recognize screening codes (V codes) that allow for early identification and treatment of adolescents at risk of mental health and substance abuse disorders.

• Insurers should recognize that physicians trained as adolescent medicine specialists may provide services as both primary care providers and specialists. Allowing adolescent medicine specialists to provide care for mental health problems and substance use problems within the context of primary care or consultative services would be a management strategy that serves the needs of the patient clinically and provides cost-effective treatment.

• Purchasers and payers should be encouraged to establish pilot projects that integrate mental health programs into primary care and other programs, such as reproductive, school health, and community-based programs. Care in these venues improves access and reduces the stigma associated with mental health care.³⁵

The AAP recommends that adolescents receive behavior risk assessment and health education at least annually, usually within the context of the preventive health care visit,²³ including screening specifically for substance abuse, depression, anxiety, and other mental health disorders. The role of the pediatrician is critically important in providing early identification and referral to mental health and substance abuse treatment clinicians and in establishing collaborative relationships with these professionals to clarify their respective roles in treatment, coordination, and exchange of information.

Evidence indicates that most psychiatric disorders present during childhood or adolescence.³⁶ Yet, all too often, adolescents' mental health and substance abuse problems go undiagnosed and untreated. According to the US Surgeon General, 80% of adolescents who need mental health treatment are not receiving care, ultimately at a huge cost to society. This lack of treatment results in worsening symptoms, disability, difficulties with interpersonal relationships, and poor school performance.^37,38 Childhood and adolescent mental disorders typically persist into adulthood; 74% of 21-year-olds with mental disorders had previous problems.^38,39 It has been estimated that for 15- to 44-year-olds, psychiatric illnesses are associated with >50% of disability-adjusted life-years, a measure of the number of expected years of life lost (to death) or lived with disability.³⁶

Problems with insurance coverage, payment, and provider availability have all been associated with restricted access to behavioral health care. With respect to mental health and substance abuse benefits, most private insurers and some SCHIP plans limit outpatient benefits, unlike for other ambulatory services. Inpatient benefits are similarly restricted, and authorization for inpatient care among most insurers and managed care plans is extremely limited. In addition, benefit restrictions, as well as condition and treatment exclusions (such as self-inflicted injuries and family therapy) and high cost-sharing levels, are applied.²⁹

Low payment rates and service carve-out arrangements further limit mental health and substance abuse treatment access. Many payers, especially Medicaid and SCHIP plans, reimburse clinicians at extremely low rates.⁹ Not surprisingly, a large proportion of mental health clinicians no longer participate in either public or private plans, which makes the already small number of qualified clinicians even smaller.¹⁰ This lack of available mental health providers often leaves primary care physicians to manage adolescents with very difficult, complex problems and disorders. Moreover, assessment, treatment, and collaborative care provided by pediatricians and adolescent medicine specialists are often rejected because of mental health service carve-out arrangements and exclusion of these physicians as participating providers. As a result, adolescents and their families delay seeking care, incur high out-of-pocket-costs, and fail to complete the recommended course of treatment.

SUMMARY

Improvements in the quality of health insurance coverage for adolescents and the adequacy of provider payment for preventive, reproductive, and behavioral health care are critically important for advancing adolescents' access to health care and improving their health and well-being.

COMMITTEE ON ADOLESCENCE, 2008–2009

*Margaret J. Blythe, MD, Chairperson

Michelle S. Barratt, MD

Paula K. Braverman, MD

Pamela J. Murray, MD MPH

David S. Rosen, MD

Warren Siegel, MD

Charles J. Wibbelsman, MD

PAST COMMITTEE MEMBERS

Angela Diaz, MD

Jonathan D. Klein, MD

LIAISONS

Jorge Pinzon, MD

Canadian Paediatric Society

Lesley L. Breech, MD

American College of Obstetricians and Gynecologists

Benjamin Shain, MD

American Academy of Child and Adolescent Psychiatry

PAST LIAISON

Miriam Kaufman, MD

Canadian Paediatric Society

STAFF

Karen Smith

COMMITTEE ON CHILD HEALTH FINANCING, 2007–2008

Steven E. Wegner, MD, JD, Chairperson

*Charles Barone II, MD

Anthony Dale Johnson, MD

Richard Lander, MD

Mark S. Reuben, MD

Corinne Anne Walentik, MD, MPH

Thomas Chiu, MD

Russell Clark Libby, MD

Thomas F. Long, MD

CONSULTANT

Margaret McManus

STAFF

Teri Salus, MPH, CPC