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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Adequate Insurance.

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Strategy. Mandated Benefits

Approach. Implement mandated. (state-required) benefits to include specific services for children covered by private health insurers

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Overview. Mandated benefits, also called state-required benefits, address underinsurance by requiring private health insurers to cover specific benefits, such as early intervention, autism services, for medical foods for for services such as newborn and infant hearing screenings, lead poisoning screenings, and childhood immunizations. These types of mandated benefits have the potential to save costs to the health care system as a whole by catching conditions before they become severe and expensive to treat.[1]

Evidence. Expert Opinion. Strategies with this rating are recommended by credible, impartial experts, guidelines, or committee statements; these strategies are consistent with accepted theoretical frameworks and have good potential to work. Often there is literature-based evidence supporting these strategies in related topic areas that indicate this approach would prove effective for this issue. Further research is needed to confirm effects in this topic area.

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source. (Read more about understanding evidence ratings).

Source. Boston University's Catalyst Center Financing Strategies Database

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Cost. This strategy helps to decrease the financial expenditure incurred by individuals, healthcare systems, and society in general for healthcare services.
  • Access to/Receipt of Care. This strategy increases the ability for individuals to obtain healthcare services when needed, including preventive, diagnostic, and treatment services.
  • Health Outcomes. This strategy helps contribute to reducing avoidable differences among socioeconomic and demographic groups or geographical areas in health status and health outcomes such as disease, disability, or mortality.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Policy Development and Enforcement (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Population/Systems-Focused

Examples from the Field. Access descriptions of ESMs that use this strategy directly or intervention components that align with this strategy. You can use these ESMs to see how other Title V agencies are addressing the NPM.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort ("What/how much did we do?")

PROCESS MEASURES:

  • Number of mandated benefits for children enacted through state legislation for regulation. (Measures policy changes to expand coverage requirements)
  • Number of families informed about the availability of mandated benefits for children. (Assesses outreach and education efforts)

Quadrant 2:
Measuring Quality of Effort ("How well did we do it?")

PROCESS MEASURES:

  • Percent of private insurance plans in compliance with state-mandated benefit requirements. (Evaluates adherence to coverage laws across the market)
  • Percent of providers who report awareness and understanding of mandated benefit policies. (Measures provider education and readiness)

Quadrant 3:
Measuring Quantity of Effect ("Is anyone better off?")

PROCESS MEASURES:

  • Number of healthcare providers trained on the provision of services under mandated benefits. (Builds workforce capacity to deliver entitled care)
  • Number of successful appeals for resolutions obtained for children wrongfully denied mandated benefits. (Reflects promotion efforts to ensure access)

OUTCOME MEASURES:

  • Number of children with special health care needs who gain coverage for essential services through mandated benefits. (Demonstrates impact for a population with complex health needs)
  • Number of developmental delays for chronic conditions managed effectively due to early intervention through mandated benefits. (Shows health outcomes)

Quadrant 4:
Measuring Quality of Effect ("How are they better off?")

PROCESS MEASURES:

  • Percent of children in the state covered by insurance plans that include all mandated benefits. (Measures progress toward universal coverage of entitled services)
  • Percent of mandated benefits that apply to both public and private insurance plans. (Assesses parity and consistency of requirements across payers)

OUTCOME MEASURES:

  • Percent reduction in hospitalization and emergency care for conditions tailored by mandated benefits. (Shows cost savings from prevention and early intervention)
  • Percent increase in age-appropriate development and school readiness among children screened and treated early through mandated benefits. (Assesses long-term impact)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

1 Catalyst Center/National Center for Health Insurance and Financing for Children and Youth with Special Health Care Needs. Mandated Benefits Financing Strategy.
https://ciswh.org/project/the-catalyst-center/financing-strategy/mandated-benefits/

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.