Introduction Employers, governmental agencies and families are seeking to purchase comprehensive, high quality, family-centered and affordable health care for children, including those with chronic conditions. Today, employers insure close to two-thirds of all children and Medicaid almost one-fourth. Families also contribute to the purchase of private health insurance. On average, they pay 25% of the premium share along with additional cost-sharing requirements. Together these purchasers have an important stake in the design of children's coverage policies and in the selection of qualified managed care plans. Decisions about plan choice are made on the basis of a combination of factors - costs, scope of benefits, experience with plan providers and quality performance. Each of these factors is addressed below to help purchasers make informed choices. Overall, when selecting plans that best meet the needs of children, purchasers are seeking.

reasonable premiums and out-of-pocket expenditures, coverage that will assist in recruitment and retention efforts and improve worker productivity, continuity of care with a child's primary and specialty care clinician, mechanisms for early detection and intervention, state-of-the-art treatment of acute and chronic childhood conditions, ease of access to pediatric health care services, family participation and satisfaction with care, and improved child and family health and functional outcome.

All children require ongoing preventive and primary care to assure their healthy growth and development and to treat acute conditions, which are so common in childhood. Although many believe that chronic conditions in children are rare, national data reveal that approximately 20% of all children have a chronic physical or mental condition requiring services that typically extend beyond those needed by healthy children. These conditions include, for example, asthma, attention deficit disorder, sickle cell disease, cerebral palsy and adolescent depression. Many children with chronic conditions require specialized medical and nursing services; prescription medications; medical supplies and equipment; physical, speech and occupational therapies; mental health services; home health services; and comprehensive case management. Given the prevalence of chronic conditions among children and the potential risk for chronic conditions in all families, purchasers need to evaluate how each competing managed care plan is designed to offer not only basic preventive and primary care services but also specialized or chronic care services in an organized system of care. While many employers and families may assume that health plans provide the full range of services needed, this may not be the case. Moreover, even when plans expressly cover pediatric specialty services, many families experience difficulties in accessing these services and are often diverted to adult providers. With careful oversight by purchasers, families whose children have chronic conditions may gain improved access to medically necessary specialty services and thus assume lower out-of-pocket costs. This evaluation tool will assist purchasers in selecting and evaluating the capacity of health plans to serve children, with or without chronic conditions. The first section on pediatric services covered and cost-sharing requirements can be used to guide decisions about plan affordability. Purchasers can complete the sample form to evaluate the comparative value of each plan option. The second section on pediatric provider network capacity lists questions to inform buyers about how to assess the comprehensiveness and organization of each plan's pediatric service delivery system. The third section on quality assurance, which also includes a series of questions, can be used to better understand how pediatric services are authorized and evaluated within each plan. Index | Introduction Pediatric Services Covered and Cost-Sharing Requirements Pediatric Provider Network Capacity Evaluating Quality Management