Public and Private Payer Advocacy

The Academy works on payer issues, both private (commercial) and public (Medicaid). Learn more about these advocacy efforts below through the work of the Payer Advocacy Advisory Committee (PAAC). Over the past few years, the Academy has increased its advocacy efforts in response to the membership's growing frustration with inequities in both the public and private sectors.

For payer-related questions/hassles (Formerly know as the Hassle Factor Form) contact the Coding Hotline.

Private Payer Advocacy

​​​​​The Academy works to address pediatric issues in the private payer sector. This includes the commercial plan lines for payers. Due to the large market for commercial payers, the AAP and PAAC focuses most of its efforts on the national payers. In addition, AAP and PAAC work closely with AAP Chapters to collaborate and help deal with issues on state and local level for commercial payers.

Public Payer Advocacy

​​​After the markets opened more in states for the expansion of Medicaid and thus expanding managed Medicaid plans, PAAC took up working on payer issues within Medicaid. The main reason was that PAAC already worked closely with the payers that now also held the Medicaid managed care contracts in the states.

Medicaid is a vital safety net for children that must be maintained. It is the largest single insurer of children, yet millions of children who are eligible remain unenrolled. Every effort should be made to implement expanded eligibility and streamlined enrollment procedures. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefits should be maintained for all eligible children.

Medicaid benefits vary by state as well as payments.  Inadequate payment affects children's access to care. The AAP recommends that states should increase reimbursement to at least parity with Medicare and that Medicaid continue to offer all eligible children the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit and all other mandatory and optional benefits. In addition:

• Clearly specify the full scope of pediatric Medicaid benefits, including EPSDT, in consumer brochures, state plan documents, and managed care contracts. States should also inform families about Medicaid benefits excluded from managed care contracts and educate them on how to access these carved-out but covered services.
• Encourage states to ensure that EPSDT, in combination with other mandatory and optional benefits, covers the benefits outlined in the AAP policy statement "Scope of Health Care Benefits for Newborns, Infants, Children, Adolescents, and Young Adults Through Age 21 Years."
• Ensure that states' EPSDT periodicity schedules are consistent with the AAP periodicity schedule in "Recommendations for Preventive Pediatric Health Care" and Bright Futures and that immunization schedules are consistent with the recommended childhood and adolescent immunization schedule published annually by the AAP, the Advisory Committee on Immunization Practices and the American Academy of Family Physicians.
• Ensure that states' medical necessity definitions, consistent with EPSDT policy, are included in all consumer brochures, state plan documents, and managed care contracts. When making medical necessity determinations, state Medicaid agencies should consider whether health interventions for children assist in achieving, maintaining, or restoring health and functional capacity; are appropriate for age and developmental status; and will take into account the specific needs of the child.
• Encourage states to offer the full scope of pediatric Medicaid benefits, including EPSDT, for children under Section 1115 demonstration waivers and Health Insurance Flexibility and Accountability waivers.
• Promote parity of behavioral health benefits with medical benefits in insurance plans.
• Maintain the policy prohibiting cost sharing on all Medicaid benefits for children, particularly preventive services.

As part of the Payer Advocacy Advisory Committee’s work, monthly updates are provided to AAP Members to keep them informed on the work being done. Review the updates here.