CHILDREN’S HEALTH 

INSURANCE

Information on 

Coverage of Services, 

Costs to Consumers, 

and Access to Care in 

CHIP and Other 

Sources of Insurance

Report to the Chairman, Subcommittee 

on Health Care, Committee on Finance, 

U.S. Senate

November 2013

GAO-14-40

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-40, a report to the 

Chairman, Subcommittee on Health Care, 

Committee on Finance, U.S. Senate

November 2013

CHILDREN’S HEALTH INSURANCE

Information on Coverage of Services, Costs to 

Consumers, and Access to Care in CHIP and Other 

Sources of Insurance

Why GAO Did This Study

More than 8 million children were 

enrolled in CHIP—the federal and state 

children’s health program that finances 

health care for certain low-income 

children—in 2012. PPACA 

appropriated funding for CHIP through 

federal fiscal year 2015. Beginning in 

October 2015, any state with 

insufficient CHIP funding must 

establish procedures to ensure that 

children who are not covered by CHIP 

are screened for Medicaid eligibility, 

and if ineligible, are enrolled into a 

QHP that has been certified by the 

Secretary of Health and Human 

Services (HHS) as comparable to 

CHIP. Exchanges are marketplaces for 

QHP coverage effective in 2014. GAO 

was asked to review issues related to 

CHIP. This report provides a baseline 

comparison of coverage and costs to 

consumers in separate CHIP plans and 

benchmark plans in select states; 

describes how coverage and costs 

might change in 2014; and describes 

how access to care by CHIP children 

compares to other children nationwide. 

For the coverage and cost comparison, 

GAO reviewed Evidences of Coverage 

from separate CHIP plans and 

benchmark plans (base and 

supplemental) from five states—

Colorado, Illinois, Kansas, New York, 

and Utah—selected based on variation 

in location, program size, and design. 

GAO reviewed documents and spoke 

to officials from states’ CHIP programs, 

exchanges, and benchmark plans, and 

from the Centers for Medicare & 

Medicaid Services. To describe access 

to care by children in CHIP compared 

to others with Medicaid, private 

insurance or without insurance, GAO 

analyzed nationwide data from HHS’s 

MEPS from 2007 through 2010.

What GAO Found

In five selected states, GAO determined that the separate State Children’s Health 

Insurance Program (CHIP) plans were generally comparable to the benchmark 

plans selected by states in 2012 as models for the benefits that will be offered 

through qualified health plans (QHP) in 2014. The plans were comparable in the 

services they covered and the services on which they imposed limits, although 

there was some variation. For example, in coverage of hearing and outpatient 

therapy services, the benchmark plan in one of the five states—Kansas—did not 

cover hearing aids nor hearing tests, while the CHIP plans in all states covered at 

least one of these services. Similarly, two states’ CHIP plans and three states’ 

benchmark plans did not cover certain outpatient therapies—known as 

habilitative services—to help individuals attain or maintain skills they had not 

learned due to a disability. States’ CHIP and benchmark state plans were also 

similar in terms of the services on which they imposed day, visit, or dollar limits. 

Plans most commonly imposed limits on outpatient therapies and pediatric 

dental, vision, and hearing services. Officials in all five states expect that CHIP 

coverage, including limits on these services, will remain relatively unchanged in 

2014, while QHPs offered in the exchanges will be subject to certain Patient 

Protection and Affordable Care Act (PPACA) requirements, such as the 

elimination of annual dollar limits on coverage for certain services.

Consumers’ costs for these services—defined as deductibles, copayments, 

coinsurance, and premiums—were almost always less in the five selected states’ 

CHIP plans when compared to their respective benchmark plans. For example, 

the CHIP plan in the five states typically did not include deductibles while all five 

states’ benchmark plans did. Similarly, when cost-sharing applied, the amount 

was almost always less for CHIP plans, and the cost difference was particularly 

pronounced for physician visits, prescription drugs, and outpatient therapies. For 

example, an office visit to a specialist in Colorado would cost a CHIP enrollee 

$2 to $10 per visit, depending on their income, compared to $50 per visit for 

benchmark plan enrollees. GAO’s review of premium data further suggests that 

CHIP premiums are also lower than benchmark plans’ premiums. While CHIP 

officials in five states expect consumer costs to remain largely unchanged in 

2014, the cost of QHPs to consumers is less certain. These plans were not yet 

available at the time of GAO’s review. However, PPACA includes provisions that 

seek to standardize QHP costs or reduce cost-sharing amounts for certain 

individuals.

When asked about access to care in the national Medical Expenditure Panel 

Survey (MEPS), CHIP enrollees reported positive responses regarding their 

ability to obtain care, and the proportion of positive responses was generally 

comparable to those with Medicaid—the federal and state program for very lowincome children and families—or with private insurance. Regarding use of 

services, the proportion of CHIP enrollees who reported using certain services 

was generally comparable to Medicaid, but differed from those with private 

insurance for certain services. Specifically, a higher proportion of CHIP enrollees 

reported using emergency room services, and a lower proportion of CHIP 

enrollees reported visiting dentists and orthodontists. HHS provided technical 

comments on a draft of this report, which GAO incorporated as appropriate.

View GAO-14-40. For more information, 

contact Katherine Iritani at (202) 512-7114 or 

iritanik@gao.gov.
Page i GAO-14-40 Children's Health Insurance

Letter 1 

Background 6

In Five States, Coverage in CHIP and Benchmark Plans Was 

Generally Comparable; These States Expect Minimal Changes to 

CHIP and QHPs to Reflect PPACA Requirements in 2014 10

In Five States, Costs to Consumers Were Almost Always Less in 

CHIP than in Benchmark Plans; CHIP Costs Are Expected to 

Remain the Same and QHP Costs to Reflect PPACA Limits in 

2014 17

National Survey Data Suggest that CHIP Access to Care is 

Comparable to Medicaid and Lower than Private Insurance for 

Some Services 26

Concluding Observations 29

Agency Comments 30

Appendix I Scope and Methodology of the Medical Expenditure Panel 

Survey (MEPS) Analysis 32

Appendix II Coverage for Selected Services in CHIP and Benchmark 

Plans in Five States 37

Appendix III Copayments, Coinsurance, and Annual Coverage Limits 

for Selected Services in CHIP and Benchmark Plans in 

Five States 39

Appendix IV GAO Contact and Staff Acknowledgments 51

Related GAO Products 52

Contents 
Page ii GAO-14-40 Children's Health Insurance

Tables

Table 1: Annual Limits on Outpatient Therapies, Pediatric Hearing, 

and Home- and Community-Based Services in the State 

Children’s Health Insurance Program (CHIP) and 

Benchmark Plans of Five States 13

Table 2: Examples of Copayments and Coinsurance for 

Prescription Drugs, Office Visits, and Rehabilitative 

Outpatient Therapies in the State Children’s Health 

Insurance Program (CHIP) and Benchmark Plans of Five 

States 19

Table 3: Out-of-pocket Maximum Cost Amounts for Qualified 

Health Plan Enrollees in 2014 by Federal Poverty Level 

(FPL) 23

Table 4: Maximum Premium Contributions for Qualified Health 

Plan (QHP) Enrollees by Federal Poverty Level (FPL) in 

2014 25

Table 5: Percentage of Respondents Who Reported Positive 

Responses to Six Medical Expenditure Panel Survey 

(MEPS) Questions Related to Obtaining Needed Care, by 

Health Insurance Status, 2007 through 2010 27

Table 6: Percentage of Respondents Who Used Specific Services as 

Reported in Medical Expenditure Panel Survey (MEPS) 

Data Related to Health Care Service Visits within the Past 

12 Months, by Health Insurance Status, 2007 through 2010 28

Table 7: Description of the 12 Medical Expenditure Panel Survey 

(MEPS) Questions and Survey Items and Related 

Responses Included in Our Analysis of Survey Data from 

2007 through 2010 34

Table 8: Cost-Sharing Amounts and Annual Coverage Limits for 

Selected Services in the State Children’s Health Insurance 

Program (CHIP) and Benchmark Plans in Colorado 40

Table 9: Cost-Sharing Amounts and Annual Coverage Limits for 

Selected Services in the State Children’s Health Insurance 

Program (CHIP) and Benchmark Plans in Illinois 43

Table 10: Cost-Sharing Amounts and Annual Coverage Limits for 

Selected Services in the State Children’s Health Insurance 

Program (CHIP) and Benchmark Plans in Kansas 45

Table 11: Cost-Sharing Amounts and Annual Coverage Limits for 

Selected Services in the State Children’s Health Insurance 

Program (CHIP) and Benchmark Plans in New York 47
Page iii GAO-14-40 Children's Health Insurance

Table 12: Cost-Sharing Amounts and Annual Coverage Limits for 

Selected Services in the State Children’s Health Insurance 

Program (CHIP) and Benchmark Plans in Utah 49

Figure

Figure 1: Number of State Children’s Health Insurance Program 

(CHIP) and Benchmark Plans with Limits on Selected 

Services in Five States 12

Abbreviations

AHRQ Agency for Healthcare Research and Quality

CHIP State Children’s Health Insurance Program

CHIPRA Children’s Health Insurance Program Reauthorization Act

CMS Centers for Medicare & Medicaid Services

EHB essential health benefits

EPSDT Early Periodic Screening, Diagnosis, and Treatment

FEDVIP Federal Employees Dental and Vision Insurance Program

FEHBP Federal Employees Health Benefits Program

FPL federal poverty level

HHS Department of Health and Human Services

MEPS Medical Expenditure Panel Survey

PPACA Patient Protection and Affordable Care Act

QHP Qualified Health Plan

SADP stand-alone dental plan

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Page 1 GAO-14-40 Children's Health Insurance

441 G St. N.W.

Washington, DC 20548

November 21, 2013

The Honorable John D. Rockefeller IV

Chairman

Subcommittee on Health Care

Committee on Finance

United States Senate

Dear Mr. Chairman:

The State Children’s Health Insurance Program (CHIP), a joint federalstate program that was established by law in 1997, finances health 

insurance for over 8 million children whose household incomes are too 

high for Medicaid eligibility, but too low to afford private insurance.1 States 

administer CHIP under broad federal requirements, and the programs 

vary, for example, in the services covered, costs to individuals and 

families, and eligibility requirements. The Department of Health and 

Human Services’ (HHS) Centers for Medicare & Medicaid Services 

(CMS) is the federal agency responsible for overseeing CHIP, with states 

managing and administering the operations of their individual CHIP 

programs. States can operate CHIP as a separate program or include 

CHIP-eligible children in their Medicaid program.2 Congress has 

appropriated federal CHIP funding at various times since the creation of 

the program. Most recently, the Patient Protection and Affordable Care 

Act (PPACA) appropriated federal CHIP funding through federal fiscal 

year 2015, thus requiring Congress to act again to extend funding in the 

future.3

 

1

Medicaid is a joint federal-state program that finances health insurance coverage for 

certain categories of lower-income individuals, including children. Most states’ CHIP 

eligibility levels are between 200 and 300 percent of the federal poverty level (FPL), with 

the highest eligibility level being 400 percent of the FPL. We use FPL to refer to federal 

poverty guidelines issued by HHS each year in the Federal Register. These guidelines 

provide income thresholds that vary by family size and for certain states and are updated 

using the Consumer Price Index.

Among other provisions aimed at maintaining and increasing 

2

As of January 14, 2013, 43 states operated separate CHIP programs (15 states had a 

separate CHIP program only and 28 states covered CHIP children through a separate 

program and a Medicaid expansion).

3

Pub. L. No. 111-148, §10203, 124 Stat. 119, 927 (2010). In this report, references to 

PPACA include any amendments made by the Health Care Education Reconciliation Act 

of 2010, Pub. L. No. 111-52, 124 Stat. 1029 (2010), unless otherwise indicated.

 
 

Page 2 GAO-14-40 Children's Health Insurance

access to affordable health insurance, PPACA requires the establishment 

of health insurance exchanges in each state—marketplaces where 

eligible individuals can compare and select among qualified health plans 

(QHP) offered by participating private issuers of health coverage, 

hereafter referred to as issuers, beginning in 2014. PPACA also requires 

that, if a state’s CHIP funding is insufficient to cover all CHIP-eligible 

children, beginning in October 2015, the state must establish procedures 

to ensure that the children who are not covered by CHIP are screened for 

Medicaid eligibility, and if ineligible for Medicaid, are enrolled into a QHP 

in an exchange in that state if the QHP has been certified as comparable 

to CHIP by the Secretary of HHS.

4

To prepare for the offering of QHPs in 2014, HHS asked states to select 

benchmark health plans—plans intended as models for the benefits that 

will be offered through QHPs—by December 26, 2012. The most 

commonly selected base-benchmark plan by the states was the largest 

small group market health insurance plan by enrollment and product in 

the state, which reflected the scope of coverage available under a typical 

employer plan. If a state’s base-benchmark plan did not meet applicable 

PPACA requirements—such as coverage of certain essential health 

benefits (EHB) categories—the state (or HHS in the case of a federally 

established default plan) generally was required to supplement it by using 

the relevant benefits in that EHB category from another one of the plan 

options to bridge coverage gaps.5

 

4

The QHP must be certified by the Secretary of HHS as offering benefits and imposing 

cost-sharing for children in a manner that is at least comparable to the covered services 

and cost-sharing protections provided under the state’s CHIP plan. As of November 1, 

2013, CMS had not issued any guidance on how comparability between QHPs and CHIP 

will be defined.

To offer coverage starting in 2014, 

individual market and small group market insurance plan issuers must 

5

PPACA does not explicitly define the services included in the EHB categories, rather it 

identifies 10 broad categories of essential benefits that QHPs must provide: ambulatory 

patient services; emergency services; hospitalization; maternity and newborn care; mental 

health and substance use disorder services, including behavioral health treatment; 

prescription drugs; rehabilitative and habilitative services and devices; laboratory services; 

preventive and wellness and chronic disease management; and pediatric services, 

including oral and vision care. Rehabilitation is provided to help a person regain, maintain 

or prevent deterioration of a skill that has been acquired but then lost or impaired due to 

illness, injury, or disabling condition. While PPACA and its implementing regulations do 

not define habilitative services, habilitation has been defined by several advocacy groups 

as a service that is provided in order for a person to attain, maintain, or prevent 

deterioration of a skill or function never learned or acquired due to a disabling condition.
 

Page 3 GAO-14-40 Children's Health Insurance

offer QHPs that are substantially equal to their state’s EHB-benchmark 

plan (base and supplemental, if necessary). In this report, we refer to 

states’ EHB-benchmark plans as “benchmark plans.”

You asked for baseline information about how health care coverage, 

costs, and access to services in separate CHIP programs compare to

coverage provided to children and families through benchmark plans, and 

how this may change with QHPs offering coverage through the 

exchanges in 2014. In this report, we describe

1. how coverage in separate CHIP plans compares to benchmark plans 

in select states, and how coverage might change in 2014,

2. how costs to consumers in separate CHIP plans compare to 

benchmark plans in select states and how costs to consumers might 

change in 2014, and

3. how access to care by children covered by CHIP compares to other 

children.

To address the first two objectives—how coverage and consumers’ costs 

in separate CHIP plans compare to benchmark plans in select states and 

how coverage and costs might change in 2014 when QHP coverage in 

the exchanges begins—we reviewed federal statutes and regulations 

governing CHIP-eligible services and the required EHBs to identify a 

range of health care services for further review. Based on variations in 

CMS region, CHIP program design, and size of enrollment in the separate 

CHIP program, we also selected five states for further review: Colorado, 

Illinois, Kansas, New York, and Utah.6

 

6

CMS places states into one of 10 geographic regions. In this report, the term “state” 

includes the District of Columbia. Colorado, Kansas, and Utah operate separate CHIP 

programs. Illinois and New York operate both a Medicaid expansion and separate CHIP 

program; however, for our review, we only examined their separate CHIP programs.

In each of these five states, we 

contacted state officials to identify the plan within their separate CHIP 

program with the largest enrollment from late 2012 through early 2013. 

We also identified the base-benchmark and relevant supplemental plans 
 

Page 4 GAO-14-40 Children's Health Insurance

effective in each of these five states as of December 26, 2012.7 We then 

reviewed the Evidences of Coverage from each of the plans identified to 

determine whether the services we identified were covered and whether 

there were any annual limits on those services in terms of days, visits, or 

expenditures.8 Our analysis did not include other coverage limits, such as 

unspecified limits based on medical necessity, expected improvement 

deadlines (e.g., improvement must be expected within 2 months), and 

drug day limits (e.g., prescriptions filled 30 days at a time). We also 

reviewed plan Evidences of Coverage to identify cost-sharing amounts, 

including deductibles, copayments, and coinsurance, for each of the 

services and any stated out-of-pocket maximum cost amounts.9

 

7

States’ base-benchmark and supplemental plans were identified in the HHS Final Rule, 

PPACA Standards Related to Essential Health Benefits, Actuarial Value, and 

Accreditation, 78 Fed. Reg. 12834 (Feb. 25, 2012). HHS directed states to select a 

benchmark plan from among the following options: one of the three largest plans in the 

state’s small group health insurance market; one of the three largest health plans offered 

to state employees; one of the three largest national plans offered through the Federal 

Employees Health Benefits Program (FEHBP); or the largest commercial non-Medicaid 

plan offered by a health maintenance organization in the state. If a state did not select a 

benchmark plan, the default plan would be the largest plan by enrollment in the largest 

product by enrollment in the state’s small group market.

We 

contacted state officials in all five states to obtain historic and current 

CHIP premiums and relied on national survey data on private individual 

8

An Evidence of Coverage is a comprehensive guide to an enrollee’s health care 

coverage. It explains the benefits, premiums, cost-sharing, conditions and limitations of 

coverage, and plan rules. We reviewed these plan documents to identify whether the plan 

covered each of the following services: ambulatory patient services (primary care 

physician and specialist office visits and outpatient surgery); emergency care; inpatient 

hospital services (facility, professional, and ancillary); maternity care; mental health 

services (inpatient and outpatient); substance abuse services (inpatient and outpatient); 

prescription drugs; preventive care (well-child care, immunizations, and chronic disease 

management); outpatient therapies (physical, speech, and occupational for rehabilitation 

and habilitation); pediatric dental services (routine, emergency, and other); pediatric vision 

services(exams and corrective lenses); laboratory services (inpatient and outpatient); 

pediatric hearing services (testing and hearing aids); durable medical equipment; hospice; 

and home and community-based health care.

9

A deductible is a specified amount that must be paid by the consumer before the health 

plan will begin paying for covered services. A copayment is a fixed dollar amount that a 

consumer must pay at the time a covered service is provided, such as a $25 payment for 

a physician visit. Coinsurance is a fixed percentage of the total cost of covered services 

that a consumer must pay. Health plans may also have an explicit limit on the maximum 

out-of-pocket costs a consumer could incur.
 

Page 5 GAO-14-40 Children's Health Insurance

market premiums to approximate benchmark plan premiums.10

To describe how access to care for CHIP children compares to other 

children, we analyzed data from the Medical Expenditure Panel Survey 

(MEPS), a nationally representative survey that collects data from a 

sample of non-institutionalized Americans on their health insurance status 

and service utilization, among other factors. Our analysis covered the 

period of 2007 through 2010, the most recent complete data available at 

the time we did our work. We compared responses to a series of 

questions related to health care access and utilization by respondents 

with children eligible for CHIP to respondents with children covered under 

private insurance, Medicaid, and those who were uninsured.

Our 

coverage and cost comparison was limited to these five states. Our 

results cannot be generalized to other states. Coverage and cost 

information for QHPs was not available at the time of our analysis. 

Therefore, to determine how coverage and costs might change in 2014, 

we reviewed federal statutes and implementing regulations, interviewed 

federal and state officials about their expectations regarding the coverage 

and costs for CHIP and QHPs, and reviewed preliminary information 

available on state QHP premiums.

11

 

10At the time of our analysis, premiums for the benchmark plans were not readily available 

and were often not comparable. For example, the base-benchmark plan in the five states 

was a group plan, which does not reflect individual market premiums, which historically 

are higher for consumers and are the point of comparison for purposes of this report. In 

addition, while the national data we cite reflects individual market premiums, they may 

also have limited relevance because they are several years old and do not reflect 

coverage of the EHBs, which would result in more comprehensive—and likely more 

expensive coverage—than health plans represented in these data.

Although 

MEPS combines Medicaid- and CHIP-eligible respondents, we consulted 

with HHS’s Agency for Healthcare Research and Quality (AHRQ) to 

develop an analysis that disaggregated these responses. We analyzed 

responses from respondents who were enrolled in the program for at 

least 8 months. To determine the reliability of MEPS data, we reviewed 

related documentation describing how these data are collected and 

processed, and examined other research that has used these data to 

report on access to health care services. We also discussed the data and 

our analysis with AHRQ officials. We determined that the data we used in 

this report were sufficiently reliable for the purposes of our engagement.

(See app. I for additional information on our MEPS analyses.)

11We identified MEPS questions related to respondents’ experiences obtaining care and 

their utilization of specific services, including office and dental visits.
 

Page 6 GAO-14-40 Children's Health Insurance

We conducted this performance audit from September 2012 to November

2013 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

Consumers may obtain health insurance from a variety of public and 

private sources, which can help protect them from the costs associated 

with obtaining medical care. Health insurance typically includes costs to 

consumers, which may vary for a number of factors, including scope of 

coverage, cost-sharing provisions, and federal or state requirements. 

Recent federal laws —specifically, PPACA and the Children’s Health 

Insurance Program Reauthorization Act of 2009 (CHIPRA)—further 

define coverage and cost parameters for certain health insurance plans 

available to consumers now and in 2014, when exchanges are required to 

be operational, and include provisions to increase children’s access to 

coverage.

Unlike states that opt to include coverage for eligible children under a 

CHIP-funded expansion of Medicaid, and therefore, must extend 

Medicaid covered services to CHIP-eligible individuals, states with 

separate CHIP programs have flexibility in program design and are at 

liberty to modify certain aspects of their programs, such as coverage and 

cost-sharing requirements. For example, federal laws and regulations 

allow states with separate CHIP programs to offer one of four types of 

health benefit coverage and, regardless of the benefit coverage option 

states choose, require states’ separate CHIP programs to include 

coverage for routine check-ups, immunizations, and emergency 

Background 

Coverage and Cost 

Requirements for CHIP
 

Page 7 GAO-14-40 Children's Health Insurance

services.12 States typically cover a broad array of services in their 

separate CHIP programs and, in some states, adopt the Medicaid 

requirement to cover Early and Periodic Screening, Diagnostic and 

Treatment (EPSDT) services.13

With respect to costs to consumers, CHIP premiums and cost-sharing 

may not exceed minimum amounts as defined by law. States may vary 

CHIP premiums and cost-sharing based on income and family size, as 

long as cost-sharing for higher-income children is not lower than for 

lower-income children. Federal laws and regulations also impose 

additional limits on premiums and cost-sharing for children in families with 

incomes at or below 150 percent of the federal poverty level (FPL). For 

example, the range of copayments was $1.15 to $5.70 per service in 

2009 for children in families with incomes between 100 and 150 percent 

of FPL. In all cases, no cost-sharing can be required for preventive 

services—defined as well-baby and well-child care, including ageEffective October 1, 2009, CHIPRA 

required CHIP plans to cover dental services defined as “necessary to 

prevent disease and promote oral health, restore oral structures to health 

and function, and treat emergency conditions.” CHIPRA also required 

states to comply with mental health parity requirements—meaning they 

must apply any financial requirements or limits on mental health or 

substance abuse benefits under their separate CHIP plans in the same 

manner as applied to medical and surgical benefits. States covering 

EPSDT services under separate CHIP plans were deemed to comply with 

these requirements.

 

12Federal law defines four types of allowable coverage for separate CHIP plans: 

(1) benchmark health plan coverage, which must be one of the following plans: (i) Blue 

Cross Blue Shield FEHBP, (ii) a health benefits plan that is offered and generally available 

to state employees, or (iii) a health plan with the largest commercial enrollment in the 

state; (2) benchmark-equivalent health benefit coverage, which is a plan that must have 

an aggregate actuarial value that is at least equivalent to coverage under one of the 

benchmark plans identified above and must include inpatient and outpatient hospital 

services, physician surgical and medical services, laboratory and x-ray services, and 

routine check-ups; (3) comprehensive state-based coverage, which was offered by 

Florida, New York, and Pennsylvania as of August 5, 1997; and (4) Secretary–approved 

coverage, whereby the Secretary of HHS determines whether the coverage proposed by 

the state is appropriate for CHIP-eligible children. Actuarial value refers to the proportion 

of medical expenses an insurance plan is expected to cover.

13State Medicaid programs are required to cover EPSDT services for children under 

age 21. EPSDT services include comprehensive screenings, preventive health care 

services, and other services necessary to correct illnesses or conditions identified by the 

screenings.
 

Page 8 GAO-14-40 Children's Health Insurance

appropriate immunizations and pregnancy-related services. In addition, 

states may not impose premiums and cost-sharing, in the aggregate, that 

exceed 5 percent of a family’s total income for the length of the child’s 

eligibility period in CHIP.14

Children’s access to affordable health insurance and health care can be 

affected by many different factors, and CHIPRA and PPACA also contain

provisions to facilitate eligible children’s access to CHIP.15 For example, 

CHIPRA appropriated funding for state and other organization outreach 

grants to help increase enrollment of CHIP-eligible children for federal 

fiscal years 2009 through 2013 and performance bonuses for simplifying 

CHIP enrollment and retention by applying certain program reforms. 

PPACA provisions that aim to facilitate eligible children’s access to CHIP 

include appropriating additional funding for CHIPRA outreach grants 

through federal fiscal year 2015. PPACA also requires states to maintain 

CHIP eligibility standards for children through September 2019. In 

accordance with this requirement, states are prohibited from increasing 

existing premiums or imposing new premiums except in limited 

circumstances.16

PPACA requires the establishment of exchanges in all states by 

January 1, 2014, to allow consumers to compare health insurance options 

available in that state and enroll in coverage.17

 

14This annual cumulative cost-sharing maximum applies to all services with cost-sharing 

requirements, irrespective of the number of children in the family that are enrolled in CHIP.

The exchanges will offer 

15We have previously issued reports related to children’s access to affordable health 

insurance and to health care services, including reports on the extent uninsured children 

would be eligible for Medicaid, CHIP, or the premium tax credit under PPACA; children’s 

access to primary, specialty and dental care by type of coverage; providers’ willingness to 

serve children in CHIP and Medicaid, and on the association between parent and child 

insurance coverage. For a list of these and other related reports, see the Related GAO 

Products page at the end of this report.

16There are certain circumstances when states may increase CHIP premium levels. For 

example, states can routinely increase CHIP premiums if they obtained CMS approval 

prior to March 23, 2010, states can adopt certain types of inflation-related adjustments to 

CHIP premium levels, and states can impose new premiums for CHIP coverage offered 

after March 23, 2010.

17In states electing not to establish and operate their own state-based exchange, PPACA 

requires the federal government to establish and operate an exchange in the state, 

referred to as a federally facilitated exchange. Pub. L.No.111-148 §§ 1311(b)(1), 1321 (c), 

124 Stat. at 173, 186.

Coverage and Cost 

Requirements for QHPs
 

Page 9 GAO-14-40 Children's Health Insurance

QHPs that are certified and are offered by participating issuers of 

coverage.18 PPACA further requires QHPs offered through an exchange 

to comply with applicable private insurance market reforms, including 

relevant premium rating requirements, the elimination of lifetime and 

annual dollar limits on essential health benefits, prohibition of cost-sharing 

for preventive services, mental health parity requirements, and the 

offering of comprehensive coverage. With respect to comprehensive 

coverage, PPACA requires QHPs offered through an exchange to cover 

10 categories of EHBs, limit cost-sharing associated with this coverage, 

and provide one of four levels of coverage determined by the plan’s 

actuarial value.19

By the end of December 2012, states had either selected a basebenchmark plan or been assigned the default base-benchmark plan by 

HHS. In over 80 percent of states, the largest plan by enrollment in the 

largest product by enrollment in the state’s small group market was 

established as the base-benchmark plan. In addition, in states where the 

base-benchmark plan did not include coverage for pediatric dental or 

vision services, the state (or HHS, in the case of a federally established 

default benchmark plan) was required to supplement coverage with the 

addition of the entire category of pediatric dental or vision benefits from 

either (i) the Federal Employees Dental and Vision Insurance Program 

(FEDVIP) dental or vision plan with the largest national enrollment of 

federal employees, or (ii) the benefits available under the plan in the 

state’s separate CHIP program with the highest enrollment, if a separate 

CHIP program existed. PPACA also allows exchanges in each state the 

option of providing pediatric dental services using a stand-alone dental 

plan (SADP). In exchanges with at least one participating SADP, QHPs 

 

18In order to become certified, the QHPs offered through the exchanges are required to 

meet certain criteria such as benefit design, marketing, and other consumer protections, 

and issuers offering plans must meet requirements, such as being licensed in the state 

where the plan is being offered. 

19PPACA requires non-grandfathered health plans in the individual and small group 

markets, both inside and outside of the exchanges, to comply with these requirements. 

These requirements do not apply to CHIP. In implementing regulations, HHS has also 

defined EHB to include any state-mandates to cover benefits that were enacted on or 

before December 31, 2011, even if the mandated benefit has a later effective date. 

Actuarial value indicates the proportion of allowable charges that a health plan will pay, on 

average. Actuarial values will assist consumers in comparing and selecting health plans 

by allowing a potential enrollee to compare the relative payment generosity among plans.
 

Page 10 GAO-14-40 Children's Health Insurance

will have the option of excluding pediatric dental benefits from their 

covered services.

In our five selected states, CHIP and benchmark plans generally covered 

the services we reviewed and were similar in terms of the services on 

which they imposed day, visit, or dollar limits. CHIP officials in our 

selected states expected minimal or no changes to CHIP coverage in 

2014, and that the QHPs offered through the exchanges would reflect 

states’ benchmark plans and PPACA requirements.

We determined that the CHIP and benchmark plans in our five selected 

states were comparable in that they included some level of coverage for 

nearly all the services we reviewed. Exceptions were hearing-related 

services, such as tests or hearing aids, where both were not covered by 

the benchmark plan in Kansas, and outpatient therapies for habilitation, 

which were not covered by CHIP plans in Kansas and Utah or by the 

benchmark plans in Colorado, Kansas, or New York.20

 

20Rehabilitation is provided to help a person regain, maintain or prevent deterioration of a 

skill that has been acquired but then lost or impaired due to illness, injury, or disabling 

condition. While PPACA and implementing regulations do not define habilitative services, 

habilitation has been defined by several advocacy groups as a service that is provided in 

order for a person to attain, maintain, or prevent deterioration of a skill or function never 

learned or acquired due to a disabling condition.

(See app. II for a 

detailed list of selected services covered by each state.) The benchmark 

plan coverage for pediatric dental and vision services was often the same 

as that in the CHIP plan because the base-benchmark plan, which was 

typically based on the largest plan by enrollment from each state’s small 

group market, did not cover these services, and the states often selected 

CHIP as the supplementary coverage model. In particular, the basebenchmark plan in four states did not cover pediatric dental services and 

In Five States, 

Coverage in CHIP and 

Benchmark Plans Was 

Generally 

Comparable; These 

States Expect 

Minimal Changes to 

CHIP and QHPs to 

Reflect PPACA 

Requirements in 2014

Coverage in CHIP and 

Benchmark Plans Was 

Generally Comparable, 

with Some Variation in 

Hearing and Outpatient 

Therapy Services in Five 

States 
 

Page 11 GAO-14-40 Children's Health Insurance

in three states did not cover pediatric vision services.21 Because pediatric 

dental and vision services are EHBs, these states were required to select 

supplemental benchmark plans to bridge the coverage gaps, and often 

selected CHIP as the supplement.22 National data from HHS suggests 

that nearly all states supplemented the base-benchmark plan with 

pediatric dental and vision plans. According to HHS, 50 and 46 states had 

to identify supplemental pediatric dental and vision plans, respectively, 

and more than half of the states selected the FEDVIP plan as the 

supplement for each service.

23

The CHIP and benchmark plans we reviewed were also generally similar 

in terms of the services on which they imposed day, visit, or dollar limits. 

For example, the plans we reviewed were similar in that they typically did 

not impose any such limits on ambulatory patient services, emergency 

care, preventive care, or prescription drugs, but commonly did impose 

limits on outpatient therapies and pediatric dental, vision, and hearing 

services.24

 

21Utah’s plan was the only base-benchmark that included pediatric dental and vision 

services. The base-benchmark plans in the other four states did not include pediatric 

dental services, and these four states selected CHIP as the supplement. Three states—

Illinois, Kansas, and New York— did not include pediatric vision services. While Kansas 

and New York selected CHIP as their supplemental vision plan, Illinois selected FEDVIP 

as the supplement.

One notable difference between CHIP and benchmark plans 

we reviewed was the frequency by which they limited home- and 

community-based health care services. While the benchmark plans in 

four states imposed day or visit limits on these services, only one state’s 

CHIP plan did so. (See fig. 1.)

22Benchmark plans must also include relevant state-mandated benefits as an EHB. 

Among our five states, the number of mandated benefits ranged from 9 to 49, and these 

mandated benefits were typically included within the services we reviewed. The statemandated benefits that were not included among our services included services not 

associated with children, such as mammography, prostate cancer screening, osteoporosis 

screening, and shingles vaccinations.

23Nationally, for pediatric dental services, 26 states selected FEDVIP as the supplement, 

and 24 states selected CHIP. For pediatric vision services, 39 states selected FEDVIP as 

the supplement, and 7 states selected CHIP. For the full list of state selections, see 

Centers for Medicare & Medicaid Services, Additional Information on Proposed State 

Essential Health Benefits Benchmark Plans, accessed August 12, 2013, 

http://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html. 

24One state’s CHIP plan specified limits on rehabilitative services received in an inpatient 

setting, but not the number of days allowed for an inpatient admission.
 

Page 12 GAO-14-40 Children's Health Insurance

Figure 1: Number of State Children’s Health Insurance Program (CHIP) and 

Benchmark Plans with Limits on Selected Services in Five States

Notes: CHIP plan data for Colorado and Utah was effective from July 1, 2012, through June 30, 2013, 

and for Illinois, Kansas, and New York, it was effective calendar year 2013. Benchmark plan data was 

effective as of December 26, 2012, the deadline for benchmark plan selection. There were no limits 

on the following services in the CHIP and benchmark plans we reviewed: ambulatory services, 

emergency care, prescription drugs, and preventive services.

For services where both plan types imposed limits, our review of plan 

Evidences of Coverage found that, except for dental and vision services, 

the comparability between plan types in terms of annual limits was less 

clear, but at times was more generous for CHIP. For example, Utah’s 

benchmark plan limited home- and community-based health care services 

to 30 visits per year while the state’s CHIP plan did not impose any limits 

on this service. Comparability between annual service limits in states’ 

CHIP and benchmark plans was less clear for outpatient therapy 

services. For example, the Colorado CHIP plan limited outpatient therapy 

to 40 visits per diagnosis compared to 20 visits per therapy type in the 

benchmark plan. Similarly, the New York CHIP plan allowed a maximum 
 

Page 13 GAO-14-40 Children's Health Insurance

of six weeks for physical therapy while the benchmark plan allowed up to 

60 visits per condition per lifetime. Limits on dental and vision services 

were largely comparable, due to the selection of CHIP as the 

supplemental benchmark for those services in most of the selected 

states. Table 1 provides examples of annual limits for select services 

between CHIP and benchmark plans, and app. III lists annual limits for all 

services we reviewed.

Table 1: Annual Limits on Outpatient Therapies, Pediatric Hearing, and Home- and Community-Based Services in the State 

Children’s Health Insurance Program (CHIP) and Benchmark Plans of Five States

 CHIP plan Benchmark plan

Outpatient therapies CO Rehabilitative 40 visits 20 per therapy type a b

Habilitative 40 visits Not covered a

IL Rehabilitative None None

Habilitative None None

KS Rehabilitative None Physical and occupational: None

Speech: max 90 daysc

Habilitative Not covered Not covered

NY Rehabilitative Physical and occupational: 6 weeks

Speech: None

60 visits per condition per lifetime

Habilitative Physical and occupational: 6 weeks

Speech: None

Not covered 

UT Rehabilitative 20 visits 20 visits d d

Habilitative Not covered 20 visits

Pediatric hearing

d

CO Testing None None

Hearing aids 1 every 5 years 1 every 5 years

IL Testing None Not covered

Hearing aids None Unknowne

KS Testing None Not covered

Hearing aids Various Not covered f

NY Testing 1 exam None

Hearing aids None $1,500

1 every 3 years

UT Testing 1 exam None

Hearing aids Not covered Not covered

Home- and communitybased servicesCO None 28 hours per week

IL

g

None None

KS None 3 visits for home care education
 

Page 14 GAO-14-40 Children's Health Insurance

 CHIP plan Benchmark plan

NY 40 visits 40 visits

UT None 30 visits

Source: GAO analysis of CHIP and benchmark plan Evidences of Coverage and information from CHIP and benchmark plan officials 

in Colorado, Illinois, Kansas, New York, and Utah. 

Notes: CHIP plan data for Colorado and Utah was effective from July 1, 2012, through June 30, 2013, 

and for Illinois, Kansas, and New York, it was effective calendar year 2013. Benchmark plan data was 

effective as of December 26, 2012, the deadline for benchmark plan selection. Outpatient therapies 

consist of physical, occupational, or speech therapy. Rehabilitation is provided to help a person 

regain, maintain, or prevent deterioration of a skill that has been acquired but then lost or impaired 

due to illness, injury, or disabling condition. While PPACA and implementing regulations do not define 

habilitative services, habilitation has been defined by several advocacy groups as a service that is 

provided in order for a person to attain, maintain, or prevent deterioration of a skill or function never 

learned or acquired due to a disabling condition.

a

CHIP outpatient therapy visit limits are per diagnosis, per calendar year. Service is unlimited for

children under 3 years of age and speech therapy is unlimited for those with a cleft palate or lip.

b

Benchmark rehabilitative outpatient therapies are covered for children 3 to 6 years of age, and under 

3 years of age if not participating in early intervention services. Service is unlimited for children with 

autism spectrum disorder who are under age 19.

c

Speech therapy is limited to one service per day up to a maximum benefit of 90 daily services per 

insured per year.

d

The limit is for all therapy types combined.

e

The state official said there were no dollar limits but was unable to provide additional information on 

limits.

f

Hearing aid batteries are limited to 6 batteries per month for monaural aids and 12 per month for 

binaural aids. Batteries for use with cochlear devices are limited to lithium ion (3 per 30 days) or zinc 

air (6 per 30 days). Batteries for cochlear devices are covered for CHIP-eligible beneficiaries only. 

Only one type of battery is allowed every 30 days.

g

Home- and community-based services must not exceed 8 hours per day. Additional time up to 

35 hours a week may be approved by the health plan on a case-by-case basis. Those in the Special 

Services Program (individuals with a terminal illness with a life-expectancy of 1 year or less who are 

not yet receiving hospice care or benefits) are limited to 15 home health visits per lifetime.

CHIP officials in all five states said that they expect the services we 

reviewed that were covered by their respective CHIP plans and any 

relevant limits on these services to remain largely unchanged in 2014. 

With respect to QHP coverage, state officials in all five states expect 2014 

coverage to reflect PPACA and its implementing requirements, including 

being comparable to their respective benchmark plans. For example, 

QHPs must offer EHB services at levels that are substantially equal to 

their respective state’s benchmark plans. With state approval, QHPs may 

substitute services that are actuarially equivalent and from the same EHB 

category as the service being replaced. The actuarial equivalence 

requirement also applies to dental benefits provided by SADPs, which are 

expected to be available in all five selected states, according to state 

Selected States Expect 

CHIP Coverage Will Not 

Change and QHP Coverage 

Will Reflect PPACA 

Requirements in 2014
 

Page 15 GAO-14-40 Children's Health Insurance

officials.25

State officials said that they also expect QHPs to reflect additional 

PPACA requirements. For example, PPACA requires QHPs to include 

coverage for the categories of rehabilitative and habilitative services and 

devices. For benchmark plans that do not cover habilitative services, 

HHS’s implementing regulations provide three options to comply with the 

requirement. States can opt to (1) require QHPs to cover habilitative 

services in parity with rehabilitative services; (2) select specific services 

that would qualify as habilitative or, if the state neglects to choose either 

of these choices, (3) allow the QHP issuer to determine which services 

qualify as habilitative. Each of the three selected states that did not cover 

outpatient therapies for habilitation—Colorado, Kansas, and New York—

has opted to require QHPs to cover these services in parity with 

rehabilitative services. According to HHS, nationwide data show that in 

addition to these three states, 19 other states had benchmark plans that 

did not cover habilitation, and the majority chose to allow the issuers to 

determine which services would qualify as habilitative.

Exchange officials in three of the selected states—Colorado, 

Illinois, and Kansas—commented on the advantages and disadvantages 

of SADPs. While their availability could benefit consumers in terms of a 

broader set of options for dental services, their availability could also 

create confusion among consumers. For example, because QHPs are not 

required to include pediatric dental coverage in their plans if an SADP is 

available in their state’s exchange, some officials expressed concern that 

a consumer who needs the pediatric dental benefit may mistakenly 

purchase a plan in the exchange without such coverage or, conversely, 

could have duplicate coverage if they purchased an SADP in addition to a 

QHP that may include pediatric dental coverage.

26

 

25Data suggest that SADPs will be offered in most states. Specifically, on February 11, 

2013, CMS reported that an SADP is expected to be offered in each of the states in which 

federally facilitated exchanges, including a state partnership exchange, will be operating. 

In a federally facilitated exchange, the state may pursue a state partnership exchange, 

where a state may administer and operate exchange activities associated with plan 

management and/or consumer assistance. QHPs are not required to include the pediatric 

dental benefit in their plans if an SADP is available in their state’s exchanges. In such 

instances, consumers are not required to purchase an SADP if their QHP does not include 

the pediatric dental benefit.

26Specifically, 12 states chose to allow the issuers to determine which services would 

qualify as habilitative, four states chose to cover these services in parity with rehabilitative 

services, and three states chose to define specific services as habilitative.
 

Page 16 GAO-14-40 Children's Health Insurance

PPACA also eliminates the use of annual and lifetime dollar limits on any 

EHB services. The elimination of lifetime dollar limits was effective in 

September 2010 and the elimination of annual limits takes effect in 

January 2014.27

PPACA also extends the mental health parity requirements, which require 

that any lifetime limits placed on mental health or substance abuse

services be the same as those placed on physical health care services.

Among our five selected states, four states had 

benchmark plans that imposed an annual dollar limit on at least one of the 

service categories we reviewed; with limited exception, none of these 

dollar limits were imposed on EHB services. For example, Kansas’ 

benchmark plan limited hospice services to $5000 per insured person per 

lifetime. In general, state officials indicated that for these services, they 

expected that QHP issuers would eliminate the dollar limits.

28

The benchmark plans in two selected states—New York and Utah—

included such limits on mental health and substance abuse services. For 

example, both states’ benchmark plans limited inpatient mental health 

service to 30 days a year, where similar limits did not exist for inpatient 

physical health services. Officials in both states said that they expected 

that QHP issuers would eliminate such limits.

 

27Issuers offering QHPs and group health plans, and issuers offering group or certain 

individual plans outside of the exchanges, are prohibited from applying lifetime or annual 

limits on EHBs. Issuers may apply annual limits for EHBs prior to 2014 subject to certain 

limitations.

28PPACA requires issuers offering QHPs and individual plans outside of the exchanges to 

comply with requirements established under the Mental Health Parity and Addiction Equity 

Act of 2008 (MHPAEA). MHPAEA specifies that the financial requirements (such as cost 

sharing) and treatment limitations (such as the number of visits covered) imposed on 

mental health and substance use disorder benefits cannot be more restrictive than those 

that apply to medical and surgical benefits.
 

Page 17 GAO-14-40 Children's Health Insurance

In our five selected states, consumers’ costs were almost always less in 

CHIP plans when compared to the states’ benchmark plans. While CHIP 

officials said that they expect CHIP costs to consumers to remain largely 

unchanged in 2014, the cost of QHPs to consumers is less certain, since 

benchmarks are not models for QHP cost-sharing. Instead, PPACA 

includes provisions that will standardize QHP costs and reduce costsharing for certain individuals.

Based on the review of plan Evidences of Coverage in our five selected

states, costs to consumers were almost always less in the CHIP plans 

than in the states’ benchmark plans. For example, the CHIP plans in four 

of the five selected states did not include any deductibles, which means 

that enrollees in those states did not need to pay a specified amount 

before the plan began paying for services. Utah is the only selected state 

that imposed a deductible on a portion of its CHIP population, which 

applied to about 60 percent of its CHIP enrollees—those with higher 

incomes.29

Our review of plan Evidences of Coverage and information from state and 

plan officials also found that, for services we reviewed where the plan 

imposed copayments or coinsurance, the amount was almost always less 

In contrast, benchmark plans in all five selected states had 

deductibles, which ranged from $500 in Illinois and Kansas to $3,000 in 

Utah for an individual, and $1,000 in Kansas to $6,000 in Utah for a 

family.

 

29CHIP enrollees in Utah with family incomes at or below 100 FPL were not subject to a 

deductible. Those with family incomes between 101 and 150 percent FPL—about 

40 percent of enrollees—were subject to a deductible of $40 a year for the family. Those 

with family incomes between 151 and 200 percent FPL—about 20 percent of enrollees—

were subject to an annual deductible of $500 and $1,500 for a child and family, 

respectively.

In Five States, Costs 

to Consumers Were 

Almost Always Less in 

CHIP than in 

Benchmark Plans; 

CHIP Costs Are 

Expected to Remain 

the Same and QHP 

Costs to Reflect 

PPACA Limits in 2014

Costs to Consumers in 

Five States Were Almost 

Always Less in CHIP Plans 

than in Benchmark Plans 
 

Page 18 GAO-14-40 Children's Health Insurance

in a state’s CHIP plan that in its benchmark plan.30

In contrast, the benchmark plans in all five states imposed copayments or 

coinsurance on most services we reviewed. Further, the amounts did not 

vary by income level and were consistently higher than the CHIP plan in 

their respective state. These cost differences were particularly 

pronounced for certain services we reviewed, such as primary care and 

specialty physician office visits, prescription drugs, and outpatient 

therapies. For example, depending on income, the copayment for primary 

care and specialist physician visits ranged from $2 to $10 per visit for 

Colorado CHIP enrollees, but was $30 and $50 per visit, respectively, for 

benchmark plan enrollees in the state. In states where the benchmark 

plan charged coinsurance and the CHIP plan required a copayment, a 

direct comparison of cost differences could not be made, although data 

suggest CHIP costs would generally be lower in most cases. For 

example, while higher-income CHIP enrollees in Illinois paid $100 per 

admission for an inpatient hospital stay, state benchmark enrollees were 

responsible for 10 percent coinsurance after the deductible was met, an 

amount that was likely to be higher than the $100 given that 10 percent of 

the average price for an inpatient facility stay in 2011 was over $1,500.

For example, the 

CHIP plan in two of our five states—Kansas and New York—did not 

impose copayments or coinsurance on any of the services we reviewed. 

In two of the remaining three states, the CHIP plan imposed copayments 

or coinsurance on less than half of the services we reviewed, and the 

amounts were usually minimal and based on a sliding income scale. For 

example, for each brand-name prescription drug, the Illinois CHIP plan 

imposed a $4 copayment on enrollees with incomes between 134 and 

150 percent of the FPL, which was increased to $7 for enrollees with 

incomes between 201 and 300 percent of the FPL. Utah’s CHIP plan 

differed from the other states’ plans in that it imposed either a copayment 

or coinsurance on all services we reviewed—except preventive and 

routine dental services—which varied by income level.

31

 

30As consistent with federal requirements, none of the CHIP or benchmark plans we 

reviewed imposed cost-sharing requirements on preventive services. In addition, because 

most of the five states selected CHIP dental or vision as a supplemental plan, the costsharing for those services were the same (and often zero) for both plan types.

31According to the Health Care Cost Institute, the average price of an inpatient stay, which 

includes hospital stays, in 2011 was $15,674. See the Health Care Cost Institute, Health 

Care Cost and Utilization Report: 2011. (Washington, D.C., Health Care Cost Institute, 

2012), 9.
 

Page 19 GAO-14-40 Children's Health Insurance

Table 2 provides examples of differences in copayments and coinsurance 

for select services between CHIP and benchmark plans.

Table 2: Examples of Copayments and Coinsurance for Prescription Drugs, Office 

Visits, and Rehabilitative Outpatient Therapies in the State Children’s Health 

Insurance Program (CHIP) and Benchmark Plans of Five States

CHIP plan Benchmark plan

< 150% FPL 150-200% FPL > 200% FPL N/A

Prescription 

drugs

CO a Generic $1 $3 $5 $15

Brand-name 1 10 15 30

IL Generic 2 3 3 15b

Brand-name 4 5 7 30c

KS Generic 0 0 0 15d

Brand-name 0 0 0 30e

NY Generic 0 0 0 15

Brand-name 0 0 0 35

UT Generic 1-5 15 N/A 50%

Brand-name 1-5 25% N/A 50%

Office visit CO PCP 2 5 10 30

Specialist 2 5 10 50

IL PCP 4 5 10 20

Specialist 4 5 10 40

KS PCP 0 0 0 25

Specialist 0 0 0 25

NY PCP 0 0 0 25

Specialist 0 0 0 50

UT PCP 3-5 25 N/A 30%

Specialist 3-5 40 N/A 30%

Rehabilitative 

outpatient 

therapy 

session 

(physical, 

occupational, 

or speech)

CO 2 5 10 30

IL 0 0 0 10%

KS 0 0 0 25

NY 0 0 0 0%

UT 3-5 40 N/A 30%

Legend: FPL = federal poverty level; N/A = not applicable; PCP = primary care physician

Source: GAO analysis of Colorado, Illinois, Kansas, New York, and Utah CHIP and benchmark plan Evidences of Coverage and 

information from state and health plan officials.

Notes: CHIP plan data for Colorado and Utah was effective from July 1, 2012 through June 30, 2013 

and for Illinois, Kansas, and New York, it was effective calendar year 2013. Benchmark plan data was 

effective as of December 26, 2012, the deadline for benchmark plan selection.

a

Brand-name drugs include drugs designated by the plan as “preferred” or included in their formulary.
 

Page 20 GAO-14-40 Children's Health Insurance

b

Benchmark enrollees must pay $30 for generic prescription drugs obtained through a mail order 

service.

c

Benchmark enrollees must pay $60 for brand-name prescription drugs obtained through a mail order 

service.

d

Benchmark enrollees must pay $37.50 or less for generic prescription drugs obtained through a mail 

order service.

e

Our review of CHIP premiums and other sources of premium data 

suggest that CHIP premiums were also likely lower than benchmark 

plans. For example, 2013 CHIP annual premiums for an individual varied 

by income level and ranged from $0 for enrollees under 150, 160, and 

100 percent of the FPL in Illinois, New York, and Utah, respectively, to 

$720 for higher-income enrollees between 351 and 400 percent of the 

FPL in New York, with most enrollees across the five selected states 

paying less than $200 a year. Benchmark plan premium data were not 

readily available at the time of our study; however, national survey data 

from America’s Health Insurance Plans suggest that individuals under 

18 years of age enrolled in the private individual market paid annual 

premiums that averaged $1,350 in 2009.

Benchmark enrollees must pay $75 or less for brand-name prescription drugs obtained through a 

mail order service.

32

In addition, both CHIP and benchmark plans in all five states limited the 

total potential costs to consumers by imposing out-of-pocket maximum 

costs. For example, all five states applied the limit a family could pay in 

CHIP plans as established under federal law—including deductibles, 

copayments, coinsurance, and premiums—at 5 percent of a family’s 

income during the child’s (or children’s) eligibility for CHIP.33

 

32Per HHS’s Assistant Secretary for Planning and Evaluation, individual market premiums 

have increased 28.6 percent from 2009 to 2012 in a sample of states. In contrast, CHIP 

officials reported lower premium increases, if any. From 2009 to 2012, there were no 

increases in CHIP premiums in Colorado and Illinois. The monthly weighted average CHIP 

premium in New York increased approximately 14 percent and Kansas premiums 

increased by 23 percent for those who paid premiums. Utah CHIP premiums didn’t 

change for those with incomes up to 150 percent FPL and increased by 25 percent for 

those with incomes from 151 to 200 percent FPL.

This 

maximum applies to all services, irrespective of the number of children in 

the family enrolled. For benchmark plans, out-of-pocket maximum costs

were established by each plan. For the five benchmark plans we 

33This 5 percent cap results in limits that vary based on a family’s income level and in 

2013 ranged from $1,766 for a family of four with an income at 150 percent of the FPL to 

$4,710 for a family of four with an income at 400 percent of the FPL.
 

Page 21 GAO-14-40 Children's Health Insurance

reviewed, the annual out-of-pocket maximum costs ranged from $1,000 to 

$6,050 for an individual and $3,000 to $12,100 for a family. Additionally, 

the benchmark plans differed from the CHIP plans in that their maximum 

costs did not include premiums and may not have included deductibles or 

costs associated with all services. For example, three of the five 

benchmark plans had deductibles in addition to the out-of-pocket 

maximum costs. Additionally, copayments for office visits did not apply to 

the out-of-pocket maximum costs in four of the five states’ benchmark 

plans.

Some evidence suggests that most families in the five selected states and 

nationally—whether enrolled in CHIP or a benchmark plan—were unlikely 

to incur costs that reached the out-of-pocket maximum costs. Our 

interviews with CHIP officials in selected states and information in the 

states’ CHIP annual reports indicated that it was rare for families to 

exceed their 5 percent maximum costs. Utah was the only state that said 

they had more than a few families exceeding the maximum costs, with 

about 140 families reporting doing so in a given year, according to state 

officials. Similarly, existing national data on average out-of-pocket costs 

for individuals with employer-sponsored insurance suggested that 

individuals enrolled in the benchmark plans could also generally incur 

costs that are lower than the maximum costs established by their plan.

For example, the Health Care Cost Institute, an organization that provides 

information for researchers on health care spending and utilization trends, 

reported that the average out-of-pocket amount spent per consumer was 

$735 in 2011 for health care services through employer-sponsored 

insurance, which was lower than the lowest maximum costs established 

by our selected benchmark plans.34

 

34The Health Care Cost Institute, Health Care Cost and Utilization Report: 2011. 

(Washington, D.C., 2012), 8.
 

Page 22 GAO-14-40 Children's Health Insurance

According to state CHIP officials in all five states, CHIP costs to 

consumers, including premiums, copayments, coinsurance, and 

deductibles, are expected to remain largely unchanged in 2014. All five 

states said they currently have no plans to raise premiums or change 

cost-sharing amounts in 2014.

In contrast, QHP costs to consumers in 2014 may be different than those 

in the benchmark plans as benchmarks are not models for QHP costsharing. Instead, PPACA included provisions applicable to QHPs that will 

limit premium variation, standardize plan values, and limit out-of-pocket 

costs. For example,

• PPACA will limit premium variation in the individual market by 

prohibiting health plans from adjusting QHP premiums based on 

factors such as health status and gender. Instead, plans will only be 

allowed to adjust premiums for family size, geographic area, age, and 

tobacco use.

35

• PPACA standardizes plan values through QHP coverage level 

requirements. Specifically, QHPs must offer coverage that meets one 

of four metal tier levels, which correspond to actuarial value 

percentages that range from 60 to 90 percent: bronze (an actuarial 

value of 60 percent), silver (an actuarial value of 70 percent), gold (an 

actuarial value of 80 percent), or platinum (an actuarial value of 

90 percent). Actuarial value indicates the proportion of allowable 

charges that a health plan will pay, on average—the higher the 

actuarial value, the lower the cost-sharing expected to be paid by 

consumers. Deductibles, co-pays, and coinsurance amounts can vary 

within these plans, as long as the overall cost-sharing structure meets 

the required actuarial value levels.36

 

35States have the authority to determine the geographic rating area in their state, which 

the Secretary of HHS can review to ensure adequacy. If inadequate, the Secretary can 

establish the rating area. Additionally, the ratio of rates cannot vary by more than 3 to 1 for 

adults. This does not apply to children under age 21, who will instead have a single age 

rating band. The ratio of rates for tobacco vs. non-tobacco users cannot vary by more than 

1.5 to 1.

36Plans are allowed a de minimis variation of +/- 2 percent (e.g., a silver level plan can 

have an actuarial value between 68 and 72 percent). SADPs will have different actuarial 

value requirements and will be offered as “high” and “low” level plans, with 85 and 

70 percent actuarial value, respectively, and will have the same allowable de minimis 

variation.

Five States Expect CHIP 

Costs to Consumers to 

Remain the Same; QHP 

Costs to Consumers Will 

Be Subject to PPACA 

Provisions that Limit 

Consumers’ Costs in 2014
 

Page 23 GAO-14-40 Children's Health Insurance

• PPACA establishes out-of-pocket maximum costs on cost-sharing that 

apply to all QHPs and vary by income, a change from the nonincome-based out-of-pocket maximum costs found in our selected 

benchmark plans.37

Table 3: Out-of-pocket Maximum Cost Amounts for Qualified Health Plan Enrollees 

in 2014 by Federal Poverty Level (FPL)

These maximums for individual plans do not 

include premiums or costs associated with non-EHB services, but do 

include deductibles. See table 3.

Income level 

(as a percentage of FPL) Individual maximum Family maximum

250-400% $6,350 $12,700

200-250 5,200 10,400

100-200 2,250 4,500

Source: GAO analysis of Internal Revenue Service data related to out-of-pocket maximums for high deductible health plans (Internal 

Revenue Service Revenue Procedure 2013-25) and the Patient Protection and Affordable Care Act; HHS Notice of Benefit and 

Payment Parameters for 2014.

• SADPs have out-of-pocket maximum costs that are in addition to the 

QHP maximums described above and therefore may increase

potential maximum costs for families who purchase them.38 For 2014, 

the out-of-pocket maximum costs for SADPs offered in federally 

facilitated exchanges and state partnership exchanges are $700 for a 

plan with one child or $1,400 for a plan with two or more children.39

Additionally, PPACA includes provisions aimed at reducing cost-sharing 

amounts for certain low-income consumers and eligible Indians who 

purchase QHPs through an exchange in the individual market. For 

example, PPACA and federal regulations provide cost-sharing subsidies 

For example, a family at 225 percent of the FPL that enrolls their two 

children in an SADP in addition to their QHP would be subject to an 

out-of-pocket maximum cost of $11,800.

 

37In 2014, the maximum annual limitation on cost-sharing is based on the out-of-pocket 

limits established by the Internal Revenue Service that apply to high deductible health 

plans. In 2015 and thereafter, the maximum annual limitation on cost-sharing is based on 

a premium adjustment percentage index to be established by the HHS Secretary.

38SADPs must demonstrate they have reasonable annual limitations on cost-sharing as 

determined by their exchange. The annual limit is calculated without regard to the EHBs 

provided by the QHP and out-of-network services,

39State-based SADP out-of-pocket maximum costs will be determined by individual states.
 

Page 24 GAO-14-40 Children's Health Insurance

to individuals with incomes between 100 and 250 percent of the FPL to 

offset the costs they incur through copayments, coinsurance, and 

deductibles in a silver-level QHP.40 The cost-sharing subsidies will not be 

provided directly to consumers, instead, QHP issuers are required to offer 

three variations of each silver plan they market through an exchange in 

the individual market. These plan variations are to reflect the cost-sharing 

subsidies through lower out-of-pocket maximum costs, and, if necessary, 

through lower deductibles, copayments, or coinsurance. Once the 

adjustments are made, the actuarial value of the silver plan available to 

eligible consumers will effectively increase from 70 percent to 73, 87, or 

94 percent, depending on their income levels. However, cost-sharing 

subsidies are not available for pediatric dental costs incurred by a 

consumer enrolled in a QHP and an SADP.41

PPACA also provides a premium tax credit to eligible individuals with 

incomes that are at least 100 percent and no more than 400 percent of 

the FPL when purchasing a plan with a premium no more than the 

second-lowest cost silver plan in their state.

42 Depending on their income, 

this provision limits the amount families must contribute to QHP premiums 

to 2 to 9.5 percent of their annual income; in 2014 these premium

contributions will range from $471 to $8,949 for a family of four.43

 

40PPACA directs issuers to reduce cost sharing for EHB for eligible individuals enrolled in 

certain silver level QHP plans with household incomes between 100-400% of the FPL by 

first reducing the maximum annual limitation on cost-sharing to achieve certain actuarial 

value levels. As specified in the 2014 payment notice, the maximum annual limitation on 

cost-sharing for individuals with incomes between 250-400% of FPL for 2014 was not 

reduced for the 2014 benefit year.

Unlike 

cost-sharing subsidies, which generally do not apply to costs incurred for 

services by a consumer enrolled in an SADP, the maximum contribution 

amount on premiums includes premiums for both QHPs and SADPs, if 

41PPACA provides that, if an individual is enrolled in both a QHP and an SADP, costsharing reductions do not apply to the portion of the cost-sharing reductions related to the 

pediatric dental EHB. This means that if an individual is enrolled in both a QHP and an 

SADP, cost-sharing reductions are not payable with respect to pediatric dental benefits 

offered through the SADP.

42Advance payments of the premium tax credit are made directly to the issuer of the QHP 

in which a taxpayer enrolls. The premium tax credit is computed by taking into account 

only the premiums for QHPs and may not be increased for premiums a taxpayer pays for 

other minimum essential coverage.

43These amounts apply in the 48 contiguous states and the District of Columbia.
 

Page 25 GAO-14-40 Children's Health Insurance

relevant.44

Table 4: Maximum Premium Contributions for Qualified Health Plan (QHP) Enrollees 

by Federal Poverty Level (FPL) in 2014

See table 4 for maximum premium contribution amounts by 

federal poverty level.

Income level 

(% of FPL)

Maximum premium 

(% of Income)

Individual

maximum premium

contribution

Family of four 

maximum premium 

contribution

400% 9.5% $4,366 $8,949

250 8.05 2,312 4,739

200 6.30 1,448 2,967

150 4.00 689 1,413

100 2.00 230 471

Source: GAO analysis of the Internal Revenue Service Health Insurance Premium Tax Credit Final Rule and the Department of Health 

and Human Service 2013 Poverty Guidelines for the 48 Contiguous States and the District of Columbia.

Note: The maximum premium contribution amounts are for the 48 contiguous states and the District 

of Columbia. 

Preliminary information released by some states suggests that this tax 

credit could defray the premium cost for certain lower-income individuals. 

For example, QHP premium data available in California indicates that, on 

average, it may cost a family of four with an income above 400 percent of 

the FPL over $9,700 a year to enroll in the most affordable silver-level 

QHP.45

 

44If an individual who is eligible for premium tax credits enrolls in a QHP and an SADP, 

the portion of the SADP that is allocable to the pediatric dental EHB must be considered 

part of the QHP premium to which the individual’s premium tax credit applies. However, 

unless the consumer purchases a QHP with a premium that is less than the second lowest 

cost silver plan, e.g., a bronze plan, the consumer would likely pay the premium for the 

SADP. 

Additionally, if the parents chose to purchase pediatric dental 

coverage for their children, annual SADP premiums could range from 

about $120 to $360 per child depending upon the region and type of plan 

chosen. If a state exchange does not offer the pediatric dental benefit 

through an integrated QHP and only offers it through an SADP, as is 

expected to be the case in California, all exchange enrollees in that state 

will pay a separate premium for pediatric dental coverage. Together, the 

lowest annual premium cost for the family of four with an income above 

400 percent of the FPL would be close to $10,000. However, if the family 

had an income at 150 percent of the FPL, and was therefore eligible for 

45The family of four includes two parents age 40 and two children under the age of 21.
 

Page 26 GAO-14-40 Children's Health Insurance

the premium tax credit, their annual premium contribution for the QHP 

and SADPs combined would be much lower, no more than the PPACAestablished annual maximum of $1,413 plus the cost of the SADP. 

Therefore, this family with an income at 150 percent of the FPL could 

have a premium payment over $8,000 less annually than if their income 

was over 400 percent FPL, and they were not eligible for the premium tax

credit.46

When asked a series of questions about access to care, MEPS 

respondents with children covered by CHIP reported positive responses 

to nearly all questions regarding their ability to obtain care and at levels 

that were generally comparable to those with other types of insurance. 

MEPS includes questions about respondents’ ability to obtain care, and 

responses to these questions can provide insight to an individual’s access 

to services. In examining questions related to having a usual source of 

care, getting appointments and care when needed, and accessing care, 

tests, or treatment or seeing specialists when needed, most respondents 

with children enrolled in CHIP had positive responses to questions for 

calendar years 2007 through 2010.47

 

46Premium data included in a September 2013 Kaiser Family Foundation report also 

suggest that QHP enrollees in other states who were eligible for the premium tax credit 

could also experience a significant reduction in their annual premium contribution. For 

example, without the tax credit, the annual QHP premium for the second lowest cost 

silver-level QHP—not including any SADP premium—for a family in Denver, Colorado, 

would be about $9,000, and it would be about $13,000 for a family in New York City. 

However, if these families had incomes at 255 percent of the FPL, and were therefore 

eligible for the premium tax credit, their annual maximum premiums would be much lower 

at about $4,900. The Henry J. Kaiser Family Foundation, An Early Look at Premiums and 

Insurer Participation in Health Insurance Marketplaces, 2014. (Menlo Park, CA. Henry J. 

Kaiser Family Foundation, 2013), 10, 19.

Specifically, five of the six MEPS 

questions we analyzed related to respondents’ ability to obtain care. At 

least 88 percent of CHIP enrollees responding to these questions 

reported they had a usual source of care and usually or always got the 

care they needed. When compared to respondents with other sources of 

insurance, the proportion of CHIP enrollees’ with positive responses to 

47For purposes of our analysis, we considered certain responses to be positive. For the 

question about a usual source of care, we considered all “yes” responses to be positive. 

For the question about how difficult it is to reach the usual source of care by telephone, we 

considered the “it was not at all difficult” or “was not too difficult” responses as positive. 

For the remaining four questions, which measured perceptions on accessing health care, 

we considered answers of “usually” or “always” to be positive.

National Survey Data 

Suggest that CHIP 

Access to Care is 

Comparable to 

Medicaid and Lower 

than Private 

Insurance for Some 

Services 
 

Page 27 GAO-14-40 Children's Health Insurance

these questions were, for most questions, comparable to respondents 

with Medicaid or with private insurance—that is, within 5 percentage 

points. For example, about 89, 91, and 93 percent of CHIP, Medicaid, and 

privately insured respondents, respectively, reported that they had a 

usual source of care. The proportions of CHIP enrollees and those who 

were uninsured reporting positive responses were also within 

5 percentage points on four of the six questions, but the differences were 

larger for the remaining two questions. Specifically, about 56 percent of 

those who were uninsured reported having a usual source of care 

compared to about 89 percent of CHIP enrollees, and about 75 percent of 

those who were uninsured reported that it was usually or always easy to 

see a specialist compared to about 81 percent of CHIP enrollees. The 

area of greatest dissatisfaction appeared to be related to ease in seeing a 

specialist. Approximately 18 percent of CHIP enrollees reported that it 

was sometimes or never easy to see a specialist. (See table 5.)

Table 5: Percentage of Respondents Who Reported Positive Responses to Six Medical Expenditure Panel Survey (MEPS) 

Questions Related to Obtaining Needed Care, by Health Insurance Status, 2007 through 2010

Insurance status

MEPS question CHIP Private insurance Medicaid Uninsured

Do you have a usual source of care? 88.6% 92.6% 90.5% 55.9%

How difficult was it to reach the usual source of care by telephone 

during office hours? 88.2 89.9 86.2 88.3

Did you usually or always get care as soon as was needed? 91.6 96.6 92.3 90.6

Did you usually or always get an appointment for health care as soon 

as was needed? 92.2 95.0 92.4 91.6

Was it usually or always easy to get a person the care, tests or 

treatment that the parent or a doctor believed necessary? 91.5 96.7 91.9 89.9

Was it usually or always easy to see a specialist? 81.4 86.9 79.0 74.5

Source: GAO analysis of MEPS data from surveys conducted in 2007 through 2010.

Notes: For our analysis, we pooled MEPS data from surveys conducted in 2007 through 2010. For 

purposes of our analysis, we considered the following responses to be positive: for the question about 

a usual source of care, we considered all “yes” responses to be positive; for the question about how 

difficult it is to reach the usual source of care by telephone, we considered the “it was not at all 

difficult” or “was not too difficult” responses as positive; for the remaining four questions, which 

measured perceptions on accessing health care, we considered answers of “usually” or “always” to 

be positive. Questions “was it usually or always easy to get a person the care, tests or treatment that

the parent or a doctor believed necessary” and “was it usually or always easy to see a specialist” 

were added in 2008, therefore, we pooled MEPS data from surveys conducted in 2008 through 2010 

for these two questions.

Additional MEPS questions related to respondents’ use of certain medical 

and dental visits also provide insight on respondents’ access to services 

and suggest that, for most services, access to care for individuals 
 

Page 28 GAO-14-40 Children's Health Insurance

covered by CHIP is comparable to that of those with Medicaid and lower 

than that of the privately insured, particularly for dental care.

48

Table 6: Percentage of Respondents Who Used Specific Services as Reported in Medical Expenditure Panel Survey (MEPS) 

Data Related to Health Care Service Visits within the Past 12 Months, by Health Insurance Status, 2007 through 2010

MEPS 

questions ask about respondents’ health care visits, including officebased health provider, emergency room, and dental visits, in the year 

prior to the survey. Respondents with children in CHIP reported using 

services at rates generally comparable to those with Medicaid and 

lower—except for emergency room visits, which were higher—than those 

with private health insurance, particularly for oral health care. A higher 

proportion of CHIP respondents reported using health care services 

compared to those who were uninsured. For example, about 51 percent 

of those with private insurance reported visiting a dentist in the past 

12 months compared to about 42 percent of CHIP respondents. 

Additionally, 69 percent of CHIP respondents reported having an officebased provider visit compared to about 50 percent of respondents who 

were uninsured. (See table 6.)

Insurance status

MEPS data related to health care service visits CHIP Private insurance Medicaid Uninsured

Had an office–based provider visit 69.1% 76.9% 70.2% 49.9%

Had an outpatient department provider visit 6.8 7.0 6.4 2.8

Had an emergency room visit 14.1 10.4 16.6 9.0

Had any dental care visit 45.9 55.8 36.8 21.2

Had a general dentist visit 42.4 50.9 34.1 18.3

Had an orthodontist visit 4.9 11.2 2.6 3.9

Source: GAO analysis of MEPS data from surveys conducted in 2007 through 2010.

Notes: For our analysis, we pooled MEPS data from surveys conducted in 2007 through 2010. The 

“had any dental care visit” variable includes visits to a broad group of dental providers, including 

general dentists, dental hygienists, dental technicians, dental surgeons, orthodontists, endodontists, 

and periodontists. The “had a general dentist visit” and “had an orthodontist visit” variables are more 

narrowly defined and refer specifically to visits to general dentists and orthodontists, respectively.

 

48The MEPS questions we reviewed included three related to respondents’ use of various 

dental services. The MEPS question, which asked whether the respondent “had any 

dental care visit,” includes visits to a broad group of dental providers, including general 

dentists, dental hygienists, dental technicians, dental surgeons, orthodontists, 

endodontists, and periodontists. The “had a general dentist visit” and “had an orthodontist 

visit” questions are more narrowly defined and refer specifically to visits to general dentists 

and orthodontists, respectively.
 

Page 29 GAO-14-40 Children's Health Insurance

Because factors other than insurance coverage may affect these 

observed differences in responses about obtaining care or utilization of 

health care services, we ran a logistic regression to determine whether 

differences between CHIP respondents and those with other sources of 

insurance coverage were significant after controlling for other factors, 

such as age, race, and income levels. (See app. I for more detailed 

information on our model and results.) After controlling for these factors, 

we found that differences between CHIP and Medicaid responses were 

not statistically significant for any of the 12 questions we reviewed, and 

that the differences between CHIP and privately insured respondents 

were statistically significant for 4 questions, which related to respondents’ 

reported use of emergency rooms, dentist visits, orthodontist visits, and 

their reported ease in getting needed care, tests, or treatment. CHIPcovered individuals were more likely to report emergency room visits and 

visits to a general dentist, and less likely to report orthodontist visits and 

ease in getting needed care than the privately insured. More pronounced 

differences in reported access existed between CHIP enrollees and those 

who were uninsured. When comparing CHIP to the uninsured, differences 

in responses were statistically significant for 8 of the 12 questions we 

reviewed.49

Congress, HHS, and the states have important decisions to make 

regarding the future of CHIP. Congress will face decisions concerning 

CHIP funding as current funding has been appropriated only through 

federal fiscal year 2015. The Secretary of HHS will face decisions around 

parameters by which QHPs offered by exchanges can be considered to 

be comparable to CHIP plans. Beginning in October 2015, if CHIP 

funding is insufficient, states will need to have procedures in place to 

enroll CHIP-eligible children in Medicaid, if eligible, and, if not, in QHPs as 

long as the Secretary of HHS has certified the QHPs are comparable to 

CHIP in covered services and cost-sharing protections.

 

49We found there was a statistically significant difference between CHIP and the 

uninsured with respect to differences in having a usual source of care; the ease of getting 

a person the care, tests or treatment that the parent or a doctor believed necessary; the 

ease of seeing a specialist; or having had an office-based provider visit, outpatient 

department provider visit, emergency room visit, any dental care visit, and a visit to a 

dentist within the past 12 months.

Concluding 

Observations 
 

Page 30 GAO-14-40 Children's Health Insurance

Although state officials in the five states we reviewed expect the CHIP 

landscape to remain relatively stable over the next year, uncertainty 

remains regarding issuer decisions and the implementation of other 

PPACA provisions. This uncertainty complicates making a definitive 

determination of what CHIP enrollees would face if they were to obtain 

QHP coverage rather than be enrolled in CHIP. To some extent, 

coverage and costs in QHPs will be determined by individual states, 

issuers, and families’ choices. For example, individual issuers of QHPs in 

many states will define the habilitative services they cover and the limits 

on services they cover, including ones that are required under PPACA but 

that they may not have previously covered. In many states, families 

seeking coverage through exchanges will be allowed to choose whether 

to obtain pediatric dental coverage by enrolling in a stand-alone dental 

plan, which will affect upfront and other costs they face. Yet, some—or 

many—families may choose not to purchase dental coverage that all 

CHIP plans must cover. PPACA provisions, which seek to standardize 

QHP costs and reduce cost-sharing for certain individuals, could narrow 

the cost gap we identified, but will vary by consumers’ income level and 

plan selection. Assessing the comparability of CHIP and QHP plans will 

require ongoing monitoring of a complex array of factors.

We provided a draft of this report for comment to HHS. HHS officials 

provided technical comments, which we incorporated as appropriate.

As agreed with your office, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from its 

date. At that time, we will send copies to the Secretary of Health and 

Human Services and other interested parties. In addition, the report will 

be available at no charge on the GAO website at http://www.gao.gov.

Agency Comments
 

Page 31 GAO-14-40 Children's Health Insurance

If you or your staff have any questions about this report, please contact 

Katherine Iritani at (202)512-7114 or iritanik@gao.gov. Contact points for 

our Offices of Congressional Relations and Public Affairs may be found 

on the last page of this report. GAO staff who made key contributions to 

this report are listed in appendix IV.

Sincerely yours,

Katherine M. Iritani

Director, Health Care
Appendix I: Scope and Methodology of the 

Medical Expenditure Panel Survey (MEPS) 

Analysis

Page 32 GAO-14-40 Children's Health Insurance

To describe how access to care for CHIP children compares to other 

children, we analyzed data from the Medical Expenditure Panel Survey 

(MEPS), a nationally representative survey that collects data from a 

sample of non-institutionalized Americans on their health insurance status 

and service utilization, among other factors. MEPS is administered by the 

Department of Health and Human Services’ (HHS) Agency for Healthcare 

Research and Quality (AHRQ) and collects information from respondents 

on many topics, including demographic characteristics, insurance status, 

health conditions, and their use of specific health services. We analyzed 

results from the MEPS household component, which collects data from a 

sample of families and individuals in selected communities across the 

United States and is drawn from a nationally representative subsample of 

households that participated in the prior year’s National Health Interview 

Survey.1

To identify MEPS questions related to health care access, we reviewed 

the MEPS codebook, which lists all of the MEPS variables available for 

data analysis, and reviewed prior analyses that used MEPS data to 

compare access to care in public and private insurance by AHRQ and the 

Urban Institute. Through these efforts, we identified for further review 29 

MEPS questions related to health care access.

The MEPS household component features five rounds of 

interviews, which occur over two full calendar years. MEPS collects 

information for each person in the household, and information is generally 

provided by an adult member of the household.

2 Once we identified the 

relevant questions, we compared responses of MEPS respondents in 

households with children from ages 0 to 19 years who were eligible for 

the State Children’s Health Insurance Program (CHIP) to those who were 

covered under private insurance, Medicaid, and who were uninsured.3

 

1

The National Health Interview Survey is one of the major data collection programs of the 

Centers for Disease Control and Prevention’s National Center for Health Statistics. It

provides a cross-sectional household interview survey with participants in each state and 

the District of Columbia and is used to monitor the health of the United States population 

through data collection and analysis on a broad range of health topics.

Although MEPS combines responses from Medicaid and CHIP-eligible 

individuals, we consulted with AHRQ to disaggregate these responses. 

Specifically, we applied the Medicaid and CHIP income eligibility and 

earnings disregard rules for all 50 states and the District of Columbia to 

2

We did not include questions that focused on the quality of care received.

3

The six access to care questions reflect an age range of 0 to 18 years of age.

Appendix I: Scope and Methodology of the 

Medical Expenditure Panel Survey (MEPS) 

Analysis
Appendix I: Scope and Methodology of the 

Medical Expenditure Panel Survey (MEPS) 

Analysis

Page 33 GAO-14-40 Children's Health Insurance

identify which respondents were eligible for CHIP versus Medicaid.4 To 

ensure we had a large enough sample size for our analysis of CHIPeligible respondents, we included respondents who were continuously 

enrolled in CHIP for at least 8 months, and we analyzed responses from 

respondents enrolled in CHIP, Medicaid, or private insurance for at least 

eight months or who were uninsured at least 8 months out of the year.5 In 

addition, we pooled MEPS survey results from 2007 through 2010, the 

most recent, complete MEPS data available at the time of our analysis, 

and combined response choices for some of the MEPS questions. For 

example, some questions had several response choices, such as 

“always,” “usually,” “sometimes,” or “never.” We combined the four 

response choices into two response choices (e.g., “usually or always” and 

“sometimes or never”). Despite these efforts, 8 questions that we 

originally selected for analysis were excluded because of an insufficient 

number of responses. Nine additional questions were excluded due to our 

determination that they were redundant of other questions. As a result, 

our analyses focused on 12 MEPS questions: 6 questions asked about 

respondents experiences obtaining care and 6 questions asked about 

their utilization of specific services. (See table 7.)

 

4

An earnings disregard is a portion of earnings from a working family’s income that states 

can exempt in determining income eligibility for certain children’s health coverage 

programs. We obtained information on each state’s Medicaid and CHIP income disregards 

and income eligibility rules for years 2007 through 2010 from Kaiser Family Foundation 

and state Medicaid and CHIP officials. See http://kff.org/Medicaid/ and http://kff.org/healthreform/ for the Kaiser Family Foundation websites where the annual reports on Medicaid 

and CHIP are posted. We did not apply earnings disregards related to child care 

expenses, child support paid, or child support received.

5

Our analysis did not include responses from individuals who reported more than one 

source of insurance during a given year. 
Appendix I: Scope and Methodology of the 

Medical Expenditure Panel Survey (MEPS)

Analysis

Page 34 GAO-14-40 Children's Health Insurance

Table 7: Description of the 12 Medical Expenditure Panel Survey (MEPS) Questions and Survey Items and Related Responses 

Included in Our Analysis of Survey Data from 2007 through 2010

MEPS questions related to experiences 

obtaining care

Do you have a usual source of care?

How difficult was it to reach the usual source of care by telephone during office hours?a

Did you usually or always get care as soon as was needed?b

Did you usually or always get an appointment for health care as soon as was needed?b

Was it usually or always easy to get a person the care, tests or treatment that the parent 

or a doctor believed necessary?b

Was it usually or always easy to see a specialist?

MEPS survey items related to service 

utilization

b

Had an office–based provider visit

Had an outpatient department provider visit

c

d

Had an emergency room visite

Had any dental care visitf

Had a general dentist visitf

Had an orthodontist visit

Source: GAO analysis of MEPS data from 2007 through 2010.

f

Note: Questions are paraphrased from the MEPS survey.

a

The answer choices for this question were: “very difficult, somewhat difficult, not too difficult, not at 

all difficult, refused and don’t know.” Certain answer choices were combined as follows: very or 

somewhat difficult were coded as “difficult”; and not too or not at all difficult were coded as “not 

difficult.” 

b

The answer choices for this question were: “never, sometimes, usually, always, refused, and don’t 

know.” Certain answer choices were combined as follows: never or sometimes; usually or always. 

Also, the age range for this question was from age 0 to age 17 years.

c

This category of services includes encounters that took place primarily in office-based settings and 

clinics for all survey years included in our analysis. This category includes the number of office-based 

visits to physicians and non-physician providers, such as chiropractors, midwives, nurses and nurse 

practitioners, optometrists, podiatrists, physician’s assistants, physical therapists, occupational 

therapists, psychologists, social workers, technicians, receptionists/clerks/secretaries, or other 

medical providers.

d

This category of services includes the reported visits to hospital outpatient departments for all survey 

years included in our analysis. It includes the number of outpatient department visits to physicians 

and non-physician providers.

e

This variable represents a count of all emergency room visits reported for all survey years included in 

our analysis.

f

Because factors other than insurance coverage—such as income, parent 

education, and family composition, may affect access to care, we also ran 

a multivariate logistic regression analysis of responses to these 12 

questions. Based on the literature and in consultation with experts at 

AHRQ and the Urban Institute, an organization that has conducted past 

The “had any dental care” variable includes visits to any person or persons for dental care including 

general dentists, dental hygienists, dental technicians, dental surgeons, orthodontists, endodontists, 

and periodontists for all survey years included in our analysis. The “had a general dentist visit” and 

“had an orthodontist visit” variables are more narrowly defined and refer specifically to visits to 

general dentists and orthodontists, respectively.
Appendix I: Scope and Methodology of the 

Medical Expenditure Panel Survey (MEPS) 

Analysis

Page 35 GAO-14-40 Children's Health Insurance

research on access to care using MEPS data, we identified a number of 

factors in addition to insurance that could influence access to care and 

constructed logistic regression models to control for the effects of these 

factors on our results. The factors we included were age, race, income, 

total number of parents in the household, parent education, family size, 

health status, mental health status, children with special needs, total 

number of workers in the household, metropolitan statistical area, sex, 

whether the respondent was born in the United States, and English 

versus non-English speakers.6 We then tested whether there was a 

statistically significant difference in the effect of enrollment in CHIP versus 

other types of insurance coverage on responses to questions about 

access to care after controlling for these factors.7

To determine the reliability of the MEPS data, we reviewed related 

documentation, identified other studies, including our prior reports, that 

used MEPS data to address similar research questions, and consulted 

researchers at AHRQ and the Urban Institute about our analysis. We 

determined that the MEPS data were sufficiently reliable for the purposes 

of our report. However, there were several limitations to our analysis. 

First, to separate CHIP and Medicaid respondents, we relied on state 

CHIP and Medicaid income eligibility and income disregard rules reported 

by Kaiser between 2007 through 2010, and did not independently verify 

For 9 of the 12 

questions in our analysis, there were statistically significant differences 

between CHIP and certain comparison groups after controlling for other 

factors. 

 

6

The MEPS Survey factor we used to control for children with special health care needs 

applies to children age 0 to 17 years.

7

Statistical significance indicates that the difference between observations is unlikely due 

to chance alone.
Appendix I: Scope and Methodology of the 

Medical Expenditure Panel Survey (MEPS) 

Analysis

Page 36 GAO-14-40 Children's Health Insurance

these data.8 In addition, the information available from Kaiser on each 

state’s income disregard rules was limited and had not been uniformly 

updated since 2008. Therefore, to account for potential gaps in 

information, we applied the income disregard rules from the 2008 Kaiser 

report to MEPS results from 2007 and 2008, and applied unverified 2010 

income disregard rules from Kaiser to MEPS results from 2009 and 2010. 

When discrepancies between the 2008 and 2010 Kaiser data existed, we 

contacted states for clarification. In the event we could not verify the 

change in income disregard rules, which was the case with two states, we 

applied the 2008 income disregard rules for MEPS survey results to all 

4 years of our analysis, 2007 through 2010. In addition, our analysis did 

not account for earnings disregards related to child care expenses, child 

support paid, or child support received; therefore, the groups we identified 

as Medicaid- or CHIP-eligible may be understated. Further, our analysis 

also did not account for income-ineligible respondents. Therefore, there 

may be some overlap between Medicaid and CHIP respondents or underreporting of CHIP respondents.9

 

8

Kaiser Commission on Medicaid and the Uninsured, Health Coverage for Children and 

Families in Medicaid and SCHIP: State Efforts Face New Hurdles: A 50-State Update on 

Eligibility Rules, Enrollment and Renewal Procedures, and Cost-Sharing Practices in 

Medicaid and SCHIP in 2008 (Washington, D.C.: Kaiser Family Foundation, 2008); 

Challenges of Providing Health Coverage for Children and Parents in a Recession: A 50 

State Update on Eligibility Rules, Enrollment and Renewal Procedures, and Cost-Sharing 

Practices in Medicaid and SCHIP in 2009 (Washington, D.C.: Kaiser Family Foundation, 

2009); A Foundation for Health Reform: Findings of a 50 State Survey of Eligibility Rules, 

Enrollment and Renewal Procedures, and Cost-Sharing Practices in Medicaid and CHIP 

for Children and Parents During 2009 (Washington, D.C.: Kaiser Family Foundation, 

2009); Holding Steady, Looking Ahead: Annual Findings of a 50-State Survey of Eligibility 

Rules, Enrollment and Renewal Procedures, and Cost-Sharing Practices in Medicaid and 

CHIP, 2010-2011 (Washington, D.C.: Kaiser Family Foundation, 2011); and Determining 

Income Eligibility in Children’s Health Coverage Programs: How States Use Disregards in 

Children’s Medicaid and SCHIP (Washington, D.C.: Kaiser Family Foundation, 2008).

Finally, because our analyses reflect an 

eight-month period of enrollment or uninsurance, the responses may not 

precisely align with the respondents’ current health insurance status,

particularly because several MEPS questions refer to respondents’ 

experiences and utilization over the prior 12 months.

9

For example, an income-ineligible respondent could be an individual who reported being 

enrolled in Medicaid, but whose income exceeded the state’s Medicaid income eligibility 

and earnings disregard rules we applied. These individuals would not be included in the 

Medicaid group. Similarly, survey respondents who reported being enrolled in CHIP, but 

whose incomes exceeded the state’s CHIP income eligibility and the earnings disregard 

rules we applied, were not included in our CHIP group.
Appendix II: Coverage for Selected Services in 

CHIP and Benchmark Plans in Five States

Page 37 GAO-14-40 Children's Health Insurance

CHIP plan Benchmark plan

Service CO IL KS NY UT CO IL KS NY UT

Ambulatory patient 

services

Provider office visits          

Outpatient surgery          

Emergency care          

Inpatient hospital Facility          

Professional          

Ancillary          

Maternity care          

Mental health Inpatient          

Outpatient          

Substance abuse 

treatment

Inpatient          

Outpatient          

Prescription drugs          

Outpatient therapies Physical Rehabilitative          

Habilitative          

Speech Rehabilitative          

Habilitative          

Occupational Rehabilitative          

Habilitative          

Laboratory services Inpatient          

Outpatient          

Preventive care Well-child          

Immunizations          

Chronic disease 

management

         

Pediatric dental Routine        a  a  a  a

Emergency        a  a  a  a

Other        a  a  a  a

Pediatric vision Exams         b  c  c

Corrective lenses         b  c  c

Pediatric hearing Testing          

Hearing aids          

Durable medical 

equipment

         

Appendix II: Coverage for Selected Services 

in CHIP and Benchmark Plans in Five States
Appendix II: Coverage for Selected Services in 

CHIP and Benchmark Plans in Five States

Page 38 GAO-14-40 Children's Health Insurance

CHIP plan Benchmark plan

Service CO IL KS NY UT CO IL KS NY UT

Home- and 

community-based 

health care

         

Hospice          

Legend: = yes;  = no.

Source: GAO analysis of data from CHIP and benchmark plan Evidences of Coverage and contact with state and health plan officials in 

Colorado, Illinois, Kansas, New York, and Utah.

Notes: CHIP plan data for Colorado and Utah was effective from July 1, 2012, through June 30, 2013, 

and for Illinois, Kansas, and New York, it was effective calendar year 2013. Benchmark plan data was 

effective as of December 26, 2012, the deadline for benchmark plan selection.

Rehabilitation is provided to help a person regain, maintain or prevent deterioration of a skill that has 

been acquired but then lost or impaired due to illness, injury, or disabling condition. While PPACA 

and its implementing regulations do not define habilitative services, habilitation has been defined by 

several advocacy groups as a service that is provided in order for a person to attain, maintain, or 

prevent deterioration of a skill or function never learned or acquired due to a disabling condition.

a

State selected CHIP plan as its supplemental dental benchmark plan.

b

State selected FEDVIP as its supplemental vision benchmark plan.

c

State selected CHIP as its supplemental vision benchmark plan.
Appendix III: Copayments, Coinsurance, and 

Annual Coverage Limits for Selected Services 

in CHIP and Benchmark Plans in Five States

Page 39 GAO-14-40 Children's Health Insurance

Tables 8 through 12 provide information on copayments, coinsurance, 

and annual coverage limits for selected services in the State Children’s 

Health Insurance Program (CHIP) and benchmark plans in each of the 

five states we reviewed: Colorado, Illinois, Kansas, New York, and Utah.1

States’ CHIP and benchmark plans may also include a deductible, which 

was the case for all five states’ benchmark plans and one state’s CHIP 

plan. For all five states, cost-sharing for individuals and families was also 

subject to an out-of-pocket maximum cost. For CHIP enrollees, the out-ofpocket maximum cost amount was applied by the plans as established by 

federal statute, limited to 5 percent of a family’s income, and included all 

consumer costs, including premiums.2 For the benchmark plans, the outof-pocket maximum cost for benchmark plans was established by each 

issuer, did not include premium costs, and was sometimes in addition to 

the deductible.

 

1

Mental health and substance abuse services had the same cost-sharing amounts and 

annual coverage limits in three of the five states, and were therefore combined into a 

single category for all states except New York and Utah.

2

All CHIP costs (deductibles, cost-sharing amounts, and premiums) count toward a 

5 percent out-of-pocket maximum cost, which varies by income level, and in 2013 ranged 

from $1,766 for a family of four at 150 percent of the FPL to $4,710 for a family of four at 

400 percent of the FPL.

Appendix III: Copayments, Coinsurance, and 

Annual Coverage Limits for Selected Services 

in CHIP and Benchmark Plans in Five States
Appendix III: Copayments, Coinsurance, and 

Annual Coverage Limits for Selected Services 

in CHIP and Benchmark Plans in Five States

Page 40 GAO-14-40 Children's Health Insurance

Table 8: Cost-Sharing Amounts and Annual Coverage Limits for Selected Services in the State Children’s Health Insurance 

Program (CHIP) and Benchmark Plans in Colorado

CHIP plan

Copay ($)/coinsurance (%) by 

federal 

poverty level (FPL) Benchmark plans

Service 101-150% 151-200% 201-250%

Annual 

coverage 

limits

Copay ($)/ 

coinsurance (%)

Annual 

coverage limits

Ambulatory 

patient 

services: 

office visits

Primary care 

physician

$2 $5 $10 None $30 None

Specialty 

physician

$2 $5 $10 None $50 None

Emergency care $3 $30 $50 None 20% None

Inpatient hospital $2 $20 $50 30 days for 

rehabilitation 

therapies

20%

a

100 days for 

skilled nursing 

hospital bed

Maternity care $0 $0 $0 1 metabolic 

screening, 

1 postpartum 

visit, and 

1 prescreening 

visit

$0 None

Mental health 

and substance 

abuse

Inpatient $0 $0 $0 None 20% None

Outpatient 

therapy

$2 $5 $10 None $15 per group 

therapy session

$30 per individual 

therapy session

None

Prescription 

drugs

Generic $1 $3 $5 None $15b None

Brand-name $1 $10 $15 None $30b,c None

Outpatient 

therapies 

(occupational, 

physical, 

speech)

Rehabilitative $2 $5 $10 40 visits $30 d 20 visits per 

therapy type

Habilitative

e

$2 $5 $10 40 visits Not covered d Not covered

Preventive care $0 $0 $0 None $0 None

Pediatric 

dental

Routine $0 $0 $0 $600 Same as CHIP f Same as CHIP

Other $0 g $5 $10 $600 Same as CHIP f Same as CHIP

Pediatric 

vision

Optometrist exam $0 $0 $0 1 exam $30 None

Corrective lenses $0 $0 $0 $150 Not covered Not covered

Pediatric 

hearing

Testing $0 $0 $0 None $30 None

Hearing aids $0 $0 $0 1 aid every 

5 years

20% 1 aid every 

5 years
Appendix III: Copayments, Coinsurance, and 

Annual Coverage Limits for Selected Services 

in CHIP and Benchmark Plans in Five States

Page 41 GAO-14-40 Children's Health Insurance

CHIP plan

Copay ($)/coinsurance (%) by 

federal 

poverty level (FPL) Benchmark plans

Service 101-150% 151-200% 201-250%

Annual 

coverage 

limits

Copay ($)/ 

coinsurance (%)

Annual 

coverage limits

Durable medical 

equipment

$0 $0 $0 $2,000 20% $2,000

Home- and 

community-based

health care

$0 $0 $0 None 20% 28 hours per 

week

Hospice

h

$0 $0 $0 9 months 20% i None

Source: GAO analysis of the Colorado Access HMO+ plan CHIP plan and the Kaiser Foundation Health Plan of Colorado HMO 1200D 

benchmark plan Evidences of Coverage and information from state and plan officials.

Notes:

The CHIP plan was in effect July 1, 2012, through June 30, 2013. The benchmark plan was in effect 

as of December 26, 2012, the deadline for benchmark plan selection, with the Colorado Access 

HMO+ CHIP plan supplementing the pediatric dental benefit. For the benchmark plans, the 

coinsurance amounts (numbers given as percentages) apply once the deductible is met and count 

toward the out-of-pocket maximum cost. Copayments (numbers given as dollars) are paid each time 

a consumer receives a service, are not subject to the deductible, and do not count toward the out-ofpocket maximum cost. The Colorado CHIP plan did not include a deductible while the benchmark 

plan included a deductible, which was $1,200 for an individual and $3,600 for a family. The 

benchmark plan out-of-pocket maximum costs were in addition to the deductible and were $2,500 for 

an individual and $5,000 for a family.

Rehabilitation is provided to help a person regain, maintain or prevent deterioration of a skill that has 

been acquired but then lost or impaired due to illness, injury, or disabling condition. While PPACA 

and implementing regulations do not define habilitative services, habilitation has been defined by 

several advocacy groups as a service that is provided in order for a person to attain, maintain, or 

prevent deterioration of a skill or function never learned or acquired due to a disabling condition.

a

Rehabilitation therapies are occupational, physical, and speech therapies.

b

The Colorado benchmark plan subjects enrollees to a separate $100 pharmacy deductible. 

Payments for prescription drugs are applied to this deductible and accumulate separately from the 

plan deductible for covered medical services. Each covered family member must meet their individual 

annual pharmacy deductible before any prescription drug benefit is paid by the health plan.

c

Brand-name drugs include drugs designated by the plan as “preferred” or included in their formulary.

d

Outpatient therapy visit limits are per diagnosis, per calendar year. Service is unlimited to children 

under 3 years of age and speech therapy is unlimited for those with a cleft palate or lip.

e

Outpatient rehabilitative therapies are covered for children 3 to 6 years of age, and under 3 years of 

age if not participating in early intervention services. Service is unlimited for children with autism 

spectrum disorder who are under age 19.

f

The CHIP plan imposes a $600 maximum benefit for all dental services. Additional limits on routine 

dental services include: two fluoride varnish treatments per calendar year for children ages 0 to 

4 years of age. Full mouth x-ray every 5 years; one panoramic film every 5 years; one prophylaxis per 

year; two oral evaluations per year; two topical fluoride treatments per year; and one bitewing x-ray 

per year. Additional limits on other dental services include one amalgam or resin restoration every 

2 years; one prefabricated crown per tooth every 2 years.
Appendix III: Copayments, Coinsurance, and 

Annual Coverage Limits for Selected Services 

in CHIP and Benchmark Plans in Five States

Page 42 GAO-14-40 Children's Health Insurance

g

Other dental services include such services as root canals and fillings.

h

Home- and community-based health care must not exceed 8 hours per day. An additional 35 hours a 

week may be approved by the health plan on a case-by-case basis. Those in the Special Services 

Program (individuals with a terminal illness with a life-expectancy of 1 year or less that are not yet 

receiving hospice care or benefits) are limited to 15 home health visits per lifetime.

I

Hospice is available in 3 month increments, which do not have to be consecutive.
Appendix III: Copayments, Coinsurance, and 

Annual Coverage Limits for Selected Services 

in CHIP and Benchmark Plans in Five States

Page 43 GAO-14-40 Children's Health Insurance

Table 9: Cost-Sharing Amounts and Annual Coverage Limits for Selected Services in the State Children’s Health Insurance 

Program (CHIP) and Benchmark Plans in Illinois

CHIP plan

Copay ($)/coinsurance (%) by 

federal poverty level (FPL) Benchmark plans

Service 134-150% 151-200% 201-300%

Annual 

coverage 

limits

Copay ($)/

coinsurance (%)

Annual 

coverage limits

Ambulatory 

patient services: 

office visits

Primary care 

physician 

$4 $5 $10 None $20 None

Specialty physician $4 $5 $10 None $40 None

Emergency care $0 $5 $30 None Hospital: $0; 

Emergency 

room: $150a

None

Inpatient hospital $4 $5 b $100 b None 10% None

Maternity care $0 $0 $0 None $20 1 routine 

inpatient 

newborn exam 

and 1 hearing 

screening

Mental health 

and substance 

abuse

Inpatient $4 $5 b $100 b None 10% None

Outpatient therapy $0 $0 $0 None $20 None

Prescription 

drugs

Generic $2 $3 $3 None $15c None

Brand-name $4 $5 $7 None $30d None

Outpatient 

therapies 

(occupational, 

physical, speech)

Rehabilitative $0 $0 $0 None 10% None

Habilitative $0 $0 $0 None 10% None

Preventive care $0 $0 $0 None $0 None

Pediatric dental Routine $4 $5 $10 None $0 Same as CHIP

Other $4 e $5 $10 None $0 Same as CHIP

Pediatric vision Optometrist exam $0 $0 $0 None $0 1 exam

Corrective lenses $0 $0 $0 None $0 FEDVIP

Pediatric hearing

f

Testing $0 $0 $0 None Not covered Not covered

Hearing aids

g

$0 $0 $0 None Not covered Not covered

Durable medical

equipment

$0 $0 $0 None 10% None

Home- and 

community-based 

health care

$0 $0 $0 None 10% None
Appendix III: Copayments, Coinsurance, and 

Annual Coverage Limits for Selected Services 

in CHIP and Benchmark Plans in Five States

Page 44 GAO-14-40 Children's Health Insurance

CHIP plan

Copay ($)/coinsurance (%) by 

federal poverty level (FPL) Benchmark plans

Service 134-150% 151-200% 201-300%

Annual 

coverage 

limits

Copay ($)/

coinsurance (%)

Annual 

coverage limits

Hospice $0 $0 $0 None 10% None

Source: GAO analysis of the Illinois CHIP State plan, Illinois Medicaid State plan, and the Blue Cross Blue Shield of Illinois 

BlueAdvantage Entrepreneur PPO benchmark plan Evidence of Coverage and information from state and plan officials.

Notes:

The CHIP and Medicaid plans were in effect in calendar year 2013. The benchmark plan was in effect 

as of December 26, 2012, the deadline for benchmark plan selection, with the Illinois CHIP and 

Medicaid plans supplementing the pediatric dental benefit, and the Blue Cross and Blue Shield 

Association Federal Employee Program Blue Vision-High plan supplementing the pediatric vision 

benefit. For the benchmark plans, coinsurance amounts (numbers given as percentages) apply once 

the deductible is met and count toward the out-of-pocket maximum cost. Copayments (numbers given 

as dollars) are paid each time a consumer receives a service, are not subject to the deductible, and 

do not count toward the out-of-pocket maximum cost. The Illinois CHIP plan did not include a 

deductible while the benchmark plan included a deductible, which was $500 for an individual and 

$1,500 for a family. The benchmark plan out-of-pocket maximum costs were in addition to the 

deductible and were $1,000 for an individual and $3,000 for a family.

Rehabilitation is provided to help a person regain, maintain or prevent deterioration of a skill that has 

been acquired but then lost or impaired due to illness, injury, or disabling condition. While PPACA 

and implementing regulations do not define habilitative services, habilitation has been defined by 

several advocacy groups as a service that is provided in order for a person to attain, maintain, or 

prevent deterioration of a skill or function never learned or acquired due to a disabling condition.

a

The emergency room copayment is waived if consumer is admitted to hospital as an inpatient 

immediately following.

b

The copayment amount is charged per day.

c

If generic prescription drugs are ordered through the mail, the cost per prescription is $30.

d

If brand-name prescription drugs are ordered through the mail, the cost per prescription is $60. 

Brand-name drugs include drugs designated by the plan as “preferred” or included in their formulary.

e

Other dental services include such services as root canals and fillings. 

f

The 2012 Federal Employee Dental and Vision Insurance Program annual coverage limits for 

corrective lenses includes: one pair of standard eyeglass lenses or contact lenses; and one frame (or 

contacts in lieu of glasses). The plan pays for non-collection frames up to $150 and up to $600 for 

medically necessary contact lenses.

g

Pediatric hearing testing was not covered with the exception of one hearing screening for newborns.
Appendix III: Copayments, Coinsurance, and 

Annual Coverage Limits for Selected Services 

in CHIP and Benchmark Plans in Five States

Page 45 GAO-14-40 Children's Health Insurance

Table 10: Cost-Sharing Amounts and Annual Coverage Limits for Selected Services in the State Children’s Health Insurance 

Program (CHIP) and Benchmark Plans in Kansas

CHIP plan Benchmark plans

Service

Copay ($)/ 

coinsurance

(%)

Annual 

coverage limits

Copay(S)/ 

coinsurance ($) 

Annual 

coverage limits

Ambulatory patient 

services: office visits

Primary care physician $0 None $25 None

Specialty physician $0 None $25 None

Emergency care $0 None $100a None

Inpatient hospital $0 None 20% None

Maternity care $0 None 20% None

Mental health and 

substance abuse

Inpatient $0 None 20% None

Outpatient therapy $0 None $25 None

Prescription drugs Generic $0 None $15b None

Brand-name $0 None $30c None

Outpatient therapies 

(occupational, 

physical, speech)

Rehabilitative $0 None $25 Physical and 

occupational: 

None

Speech: 90 days

Habilitative

d

Not covered Not covered Not covered Not covered

Preventive care $0 None $0 None

Pediatric dental Routine $0 Variouse $0 Same as CHIP

Other $0 f Variousg $0 Same as CHIP

Pediatric vision Optometrist exam $0 None $0 Same as CHIP

Corrective lenses $0 4 pair $0 Same as CHIP

Pediatric hearing Testing $0 None Not covered Not covered

Hearing aids $0 Varioush Not covered Not covered

Durable medical 

equipment

$0 None 20% None

Home- and 

community-based 

health care

$0 None $0 3 visits for home 

care education

Hospice $0 None $0 $5,000 per 

insured per 

lifetime

Source: GAO analysis of the Kansas Sunflower State Health CHIP plan and the Blue Cross and Blue Shield of Kansas Comprehensive 

Major Medical Blue Choice PPO GF 500 deductible with Blue Rx card benchmark plan Evidence of Coverage and information from 

state officials.

Notes:

The CHIP plan was in effect in calendar year 2013. The benchmark plan was in effect as of 

December 26, 2012, the deadline for benchmark plan selection, with the Kansas Sunflower State 

Health CHIP plan supplementing the pediatric dental and vision benefits. For the benchmark plans, 

coinsurance amounts (numbers given as percentages) apply after the deductible is met and count 

toward the out-of-pocket maximum cost. Copayments (numbers given as dollars) are paid each time 
Appendix III: Copayments, Coinsurance, and 

Annual Coverage Limits for Selected Services 

in CHIP and Benchmark Plans in Five States

Page 46 GAO-14-40 Children's Health Insurance

a consumer receives a service, are not subject to the deductible, and do not count toward the out-ofpocket maximum cost. The Kansas CHIP plan did not include a deductible while the benchmark plan 

included a deductible, which was $500 for an individual and $1,000 for a family. The benchmark plan 

out-of-pocket maximum costs were in addition to the deductible and were $1,000 for an individual and 

$2,000 for a family.

Rehabilitation is provided to help a person regain, maintain or prevent deterioration of a skill that has 

been acquired but then lost or impaired due to illness, injury, or disabling condition. While PPACA

and implementing regulations do not define habilitative services, habilitation has been defined by 

several advocacy groups as a service that is provided in order for a person to attain, maintain, or 

prevent deterioration of a skill or function never learned or acquired due to a disabling condition.

a

The emergency care copayment is paid after the Enhanced Accidental Injury Benefit is reached. 

Under this provision, the consumer pays $0 for covered services associated with any and all 

accidental injuries incurred up to a maximum of $1,000 per insured per benefit period.

b

If generic prescription drugs are ordered through the mail, the cost per prescription is $37.50 or less.

c

If brand-name prescription drugs are ordered through the mail, the cost per prescription is $75 or 

less. Brand- name drugs include drugs designated by the plan as “preferred” or included in their 

formulary.

d

Speech therapy is limited to one service per day up to a maximum benefit of 90 daily services per 

insured per year.

e

Routine pediatric dental services include: two exams per year; one comprehensive exam per lifetime; 

one re-evaluation per year; one set of full mouth (or panoramic x-rays and bitewings) every 3 years: 

three topical fluoride treatments per year; one sealant per tooth per year; one space maintainer-fixedunilateral per quadrant per year; one space maintainer-fixed-bilateral per arch per year; one space 

maintainer-removable-bilateral per arch per year.

f

Other dental services include such services as root canals and fillings.

g

Other dental services include one porcelain, resin, or full cast base metal crown every 5 years; one 

prefabricated steel crown every 2 years; one endodontic therapy and pulpectomy per tooth per 

lifetime; and dentures every 5 years.

h

Hearing aid batteries are limited to 6 batteries per month for monaural aids and 12 per month for 

binaural aids. Batteries for use with cochlear devices are limited to lithium ion (3 per 30 days) or zinc 

air (6 per 30 days). Batteries for cochlear devices are covered for CHIP-eligible beneficiaries only. 

Only one type of battery is allowed every 30 days.
Appendix III: Copayments, Coinsurance, and 

Annual Coverage Limits for Selected Services 

in CHIP and Benchmark Plans in Five States

Page 47 GAO-14-40 Children's Health Insurance

Table 11: Cost-Sharing Amounts and Annual Coverage Limits for Selected Services in the State Children’s Health Insurance 

Program (CHIP) and Benchmark Plans in New York

CHIP plan Benchmark plans

Service

Copay ($)/ 

coinsurance

(%)

Annual 

coverage limits

Copay ($)/ 

coinsurance

(%)

Annual coverage 

limits

Ambulatory patient 

services: office visits

Primary care physician $0 None $25 None

Specialty physician 0 None $50 None

Emergency care 0 None 0% None

Inpatient hospital 0 None 0% None

Maternity care 0 1 home care visit for 

early discharge

0%a 1 home care visit 

for early discharge

Mental health Inpatient 0 None 0% 30 days

Outpatient therapy 0 None 0% 30 days

Substance abuse Inpatient 0 None $0 30 days

Outpatient therapy 0 None 0% 60 days

Prescription drugs Generic 0 None $15b None

Brand-name 0 None $35b,c None

Outpatient therapies 

(occupational, 

physical, speech)

Rehabilitative 0 Physical and 

occupational: 6 weeks

Speech: None

0% 60 visits 

per condition 

per lifetime

Habilitative 0 Physical and 

occupational: 6 weeks

Speech: None

Not covered Not covered

Preventive care 0 None $0 None

Pediatric dental Routine 0 Variousd Same as CHIP Same as CHIP

Other 0 e None Same as CHIP Same as CHIP

Pediatric vision Optometrist exam 0 1 examf Same as CHIP Same as CHIP

Corrective lenses 0 1 pairg Same as CHIP Same as CHIP

Pediatric hearing Testing 0 1 test $0 None

Hearing aids 0 None 0% $1,500 

1 aid every 

3 years

Durable medical 

equipment

0 None 0% $1,500

Home- and 

community-based 

health care

h

0 40 visits 0% 40 visits

Hospice 0 None 0% 210 days

Source: GAO analysis of the Fidelis Care New York CHIP plan and the New York Oxford Health Insurance, Inc. Oxford EPO 

benchmark plan Evidence of Coverage and information from state and plan officials.
Appendix III: Copayments, Coinsurance, and 

Annual Coverage Limits for Selected Services 

in CHIP and Benchmark Plans in Five States

Page 48 GAO-14-40 Children's Health Insurance

Notes:

The CHIP plan was in effect in calendar year 2013. The benchmark plan was in effect as of 

December 26, 2012, the deadline for benchmark plan selection, with the Fidelis Care New York CHIP 

plan supplementing the pediatric dental and vision benefits. For the benchmark plans, coinsurance 

amounts (numbers given as percentages) apply after the deductible is met and count toward the outof-pocket maximum cost. Copayments (numbers given as dollars) are paid each time a consumer 

receives a service, are not subject to the deductible, and do not count toward the out-of-pocket 

maximum cost, unless otherwise indicated. The New York CHIP plan did not include a deductible 

while the benchmark plan included a deductible, which was $2,850 for an individual and $5,700 for a

family. The benchmark plan out-of-pocket maximum costs included the deductible and were $2,850 

for an individual and $5,700 for a family.

Rehabilitation is provided to help a person regain, maintain or prevent deterioration of a skill that has 

been acquired but then lost or impaired due to illness, injury, or disabling condition. While PPACA 

and implementing regulations do not define habilitative services, habilitation has been defined by 

several advocacy groups as a service that is provided in order for a person to attain, maintain, or 

prevent deterioration of a skill or function never learned or acquired due to a disabling condition.

a

Maternity care is only subject to the deductible for the initial visit.

b

Enrollees pay 100 percent of costs for prescription drugs until they’ve reached their deductible, after 

which they pay the copayment amount listed here.

c

Brand-name drugs include drugs designated by the plan as “preferred” or included in their formulary.

d

Routine pediatric dental services include prophylasis every 6 months; topical fluoride at 6 month

intervals where the local water supply is not fluoridated; one exam every 6 months; full mouth x-rays 

at 36 month intervals if necessary; bitewing x-rays at 6-to12-month intervals or panoramic x-rays at 

36 month intervals.

e

Other dental services include such services as root canals and fillings.

f

Optometrist exams are limited to one per year, unless they are required more frequently, and the 

enrollee has the appropriate documentation.

g

Enrollees are limited to one frame and one set of lenses per year, unless they are required more 

frequently, and the enrollee has the appropriate documentation.

h

This limit is on non-essential durable medical equipment. 
Appendix III: Copayments, Coinsurance, and 

Annual Coverage Limits for Selected Services 

in CHIP and Benchmark Plans in Five States

Page 49 GAO-14-40 Children's Health Insurance

Table 12: Cost-Sharing Amounts and Annual Coverage Limits for Selected Services in the State Children’s Health Insurance 

Program (CHIP) and Benchmark Plans in Utah

CHIP plan

Copay ($)/coinsurance (%) 

by federal poverty level (FPL) Benchmark plan

Service <100% 100-150% 151-200%

Annual

coverage 

limits

Coinsurance 

(%)

Annual 

coverage 

limits

Ambulatory 

patient services: 

office visits

Primary care physician $3 $5 $25 None 30% None

Specialty physician $3 $5 $40 None 30% None

Emergency care $3 $5 $300a None 30% None

Inpatient hospital $50 $150 20% a None 30% None

Maternity care 20% 20% 20% None 30% None

Mental health Inpatient $50 $150 20% a None 30% 30 days

Outpatient therapy $3 $5 b $40 b b None 30% 8 visits

Substance abuse Inpatient 20% 20% 20% None 30% Combined 

with mental 

health

Outpatient therapy 20% 20% 20% None 30% Combined 

with mental 

health

Prescription 

drugs

Generic $1 $5 $15 None 50% None

Brand-name $1 5% 25% c c None 50%d None

Outpatient 

therapies 

(occupational, 

physical, speech)

Rehabilitative $3 $5 $40a 20 visits 

(all therapies 

combined)

30% 20 visits 

(all therapies 

combined)

Habilitative Not covered Not covered Not covered N/A 30% 20 visits 

(all therapies 

combined)

Preventive care $0 $0 $0 None $0 None

Pediatric dental Routine $0 $0 $0 2 cleanings 30% Various

Other

e

$0 f 5% 20% c None Not covered Not covered

Pediatric vision Optometrist exam $3 $5 $40 1 exam 30% 1 exam

Corrective lenses

g

Not covered Not covered Not covered Not covered Not covered Not covered

Pediatric hearing Testing $3 $5 $40 1 test $0 Not covered

Hearing aids Not covered Not covered h Not covered h h Not covered Not covered Not covered

Durable medical 

equipment

$3 5% 20% None 30% Various

Home- and 

community-based 

health care

i

$3 5% 20% None 30% 30 visits
Appendix III: Copayments, Coinsurance, and 

Annual Coverage Limits for Selected Services 

in CHIP and Benchmark Plans in Five States

Page 50 GAO-14-40 Children's Health Insurance

CHIP plan

Copay ($)/coinsurance (%) 

by federal poverty level (FPL) Benchmark plan

Service <100% 100-150% 151-200%

Annual

coverage 

limits

Coinsurance 

(%)

Annual 

coverage 

limits

Hospice $3 5% 20% None 30% Up to 

6 months 

within 3 years

Source: GAO analysis of the Utah CHIP Select Health plan and the Utah Public Employee’s Health Program Utah Basic Plus 

benchmark plan Evidences of Coverage and information from state and plan officials. 

Notes:

The CHIP plan was in effect in July 2012, through June 30, 2013. The benchmark plan was in effect 

as of December 26, 2012, the deadline for benchmark plan selection. Coinsurance amounts 

(numbers given as percentages) apply once the deductible is met unless otherwise indicated. 

Copayments (numbers given as dollars) are paid each time a consumer receives a service and are 

not subject to the deductible, unless otherwise indicated. The Utah CHIP plan did not include any 

deductibles for enrollees at or below100 percent of the FPL; had a $40 deductible for individuals and 

families for enrollees from 101 to150 percent of the FPL, with no dental deductible; and a $500 

individual deductible and $1,500 family deductible for enrollees between 151 and 200 percent of the 

FPL, with a $50 and $150 dental deductible for a child and family, respectively. The Utah benchmark 

plan deductible were $3,000 for an individual and $6,000 for a family. The benchmark plan out-ofpocket maximum costs included the deductible and were $6,050 for an individual and $12,100 for a 

family.

Rehabilitation is provided to help a person regain, maintain or prevent deterioration of a skill that has 

been acquired but then lost or impaired due to illness, injury, or disabling condition. While PPACA 

and implementing regulations do not define habilitative services, habilitation has been defined by 

several advocacy groups as a service that is provided in order for a person to attain, maintain, or 

prevent deterioration of a skill or function never learned or acquired due to a disabling condition.

a

This copayment is paid after the deductible is met.

b

This is the copayment for outpatient therapy office visits.

c

This coinsurance is not subject to the deductible.

d

Brand-name drugs include drugs designated by the plan as “preferred” or included in their formulary.

e

Routine pediatric dental services include oral exams 2 times a year, ages 3 to18; complete mouth 

x-rays, once a year for members ages 13 to18 (or panorex once during any 3 year period in lieu); full 

series bitewing x-rays, twice a year; vertical bitewings up to eight films; cleaning two times a year; 

sealants on permanent molars once during any 5 year period for eligible dependents through 

17 years. 

f

Other dental services include such services as root canals and fillings.

g

This annual limit is for children 5 to18 years; one routine vision exam per plan year for children 

between 3 and 5 is covered as a preventive service.

h

Hearing aids are not covered by CHIP unless following cochlear implants.

i

Pre-authorization is required for durable medical equipment over $750 and rentals that exceed 

60 days; one lens after corneal transplant surgery; one pair of ear plugs within 60 days following 

surgery; continuous passive motion machines up to 21 days; one artificial eye prosthetic every 

5 years; one breast prosthetic per affected breast every 2 years; one wheelchair every 5 years; one 

knee brace per knee every 3 years.
Appendix IV: GAO Contact and Staff 

Acknowledgments

Page 51 GAO-14-40 Children's Health Insurance

Katherine M. Iritani, 202-512-7114 or iritanik@gao.gov

In addition to the contact named above, Susan T. Anthony, Assistant 

Director; Carolyn Fitzgerald; Toni Harrison; Laurie Pachter; Teresa Tam; 

and Hemi Tewarson made key contributions to this report.

Appendix IV: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 
Related GAO Products

Page 52 GAO-14-40 Children's Health Insurance

Children’s Mental Health: Concerns Remain about Appropriate Services 

for Children in Medicaid and Foster Care. GAO-13-15. Washington, D.C.: 

December 10, 2012.

Medicaid: States Made Multiple Program Changes, and Beneficiaries 

Generally Reported Access Comparable to Private Insurance. 

GAO-13-55. Washington, D.C.: November 15, 2012.

Children’s Health Insurance: Opportunities Exist for Improved Access to 

Affordable Insurance. GAO-12-648. Washington, D.C.: June 22, 2012.

Medicaid and CHIP: Most Physicians Serve Covered Children but Have 

Difficulty Referring Them for Specialty Care. GAO-11-624. Washington, 

D.C.: June 30, 2011.

Medicaid and CHIP: Given the Association between Parent and Child 

Insurance Status, New Expansions May Benefit Families. GAO-11-264. 

Washington, D.C.: February 4, 2011.

Oral Health: Efforts Under Way to Improve Children’s Access to Dental 

Services, but Sustained Attention Needed to Address Ongoing Concerns. 

GAO-11-96. Washington, D.C.: November 30, 2010.

Medicaid: State and Federal Actions Have Been Taken to Improve 

Children’s Access to Dental Services, but Gaps Remain. GAO-09-723. 

Washington, D.C.: September 30, 2009.

Related GAO Products

(291052)
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