Provider Networks: Comparison of Child-Focused Network Adequacy Standards between CHIP and Private Health Plans
Published: 2016-02-05T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Federal funding for CHIP expires at the end of fiscal year 2017. Any state with insufficient federal CHIP funding is required to have procedures to enroll eligible children in QHPs certified by HHS as comparable to CHIP, if any such QHPs are available. Little is known about how provider networks offered in QHPs compare with those in CHIP plans.
GAO was asked to review the inclusion of pediatric providers, including children's hospitals—where many children access pediatric specialists—in CHIP and QHP networks. This report examines (1) federal and selected state CHIP and QHP network adequacy standards, (2) the extent to which selected issuers of CHIP plans and QHPs include children's hospitals and otherwise help ensure access to pediatric specialists, and (3) how CMS and selected states monitor CHIP plan and QHP compliance with adequacy standards. GAO selected five states—Alabama, Massachusetts, Pennsylvania, Texas, and Washington—that varied based on whether the state or CMS operated the exchange on which QHPs were offered, as well as in the number of children in CHIP and in the state overall. GAO then selected issuers of the largest CHIP plan and QHP in the states' largest county, based on the most recently available enrollment data, and at least one children's hospital in each state. GAO reviewed federal and state laws and regulations and interviewed officials from CMS, the selected states, issuers, and children's hospitals. GAO findings on selected states and entities are not generalizable.
section_title: What GAO Found
paragraphs: Broad federal provider network adequacy standards apply to health plans in the joint federal-state State Children's Health Insurance Program (CHIP) and to qualified health plans (QHP)—private health plans offered on health insurance exchanges. These standards measure the adequacy of the networks of physicians, hospitals, and other providers participating in each plan. The five selected states GAO reviewed had one or more specific network adequacy standards, including:
All five states required CHIP plans and QHPs to adhere to specific and quantitative standards for travel time or distance for the proximity of network providers' locations to enrollees' residences; some had both.
Three selected states required CHIP plan and QHP networks to follow provider capacity or availability standards, including, for example, specific limits on appointment wait times.
Two selected states required CHIP plan and QHP networks to follow specific provider-to-enrollee ratios.
More of the five states that GAO reviewed had child-focused network adequacy standards for CHIP plans than for QHPs. For CHIP plans, four of the five states had specific requirements for pediatric provider types, but, for QHPs, two of the five selected states had requirements for pediatric provider types.
Nearly all of the 19 selected issuers that GAO interviewed stated that they included at least one children's hospital in their CHIP and QHP networks. Most of the issuers noted they included more than one. One of the selected issuers—a QHP-only issuer—informed GAO that it did not include any children's hospitals, but noted having an arrangement with another hospital to provide certain pediatric services. Officials from most of the nine selected children's hospitals GAO interviewed raised concerns around not being included in all plan networks and the potential effect of this on children's access to specialty care they may need. Officials from the selected issuers also noted challenges recruiting certain types of pediatric specialists related to geographic location and compensation.
The Centers for Medicare & Medicaid Services (CMS)—the federal agency that oversees CHIP and QHPs—monitors state oversight of network adequacy for CHIP plans and is responsible for directly monitoring QHPs' network adequacy in states with federally facilitated exchanges. For CHIP, CMS officials told GAO they review state contracts and plans to assure compliance with access requirements, and, for QHPs, they monitor network adequacy through an annual certification process as well as other types of review. Officials from most of the five selected states told GAO they also monitored issuers' network adequacy compliance, but the frequency of monitoring varied. For example, three of the five selected states told GAO they require CHIP plan issuers to submit certain provider network information when the plan and network are established, then quarterly or annually thereafter. Officials from most of the selected states told GAO that they rely primarily on complaints, network changes, and other concerns to prompt the frequency with which they monitor QHPs' network adequacy. The Department of Health and Human Services (HHS) provided technical comments on a draft of this report that GAO incorporated, as appropriate.

section_title: Letter
paragraphs: The State Children’s Health Insurance Program (CHIP), a joint federal- state program established in 1997 to provide health coverage to certain  low-income children, currently finances health insurance for over 8 million  children whose household incomes are too high for Medicaid eligibility  but  may be too low to afford private insurance. Since the inception of CHIP,  the percentage of children without health insurance coverage has  decreased by more than half, from 13.9 percent in 1997 to 5.5 percent in  2014. Over the course of the program, Congress has enacted legislation  authorizing continued funding for CHIP. Most recently, the Medicare  Access and CHIP Reauthorization Act of 2015 appropriated federal CHIP  funding to states through fiscal year 2017.
Since January 2014, federal subsidies have been available to qualifying  individuals to offset the cost of private health insurance purchased  through health insurance exchanges—marketplaces where eligible  individuals may compare and select among qualified health plans (QHP)  offered by participating private issuers—established under the Patient  Protection and Affordable Care Act (PPACA).PPACA directed each  state to establish the exchange itself (referred to as a state-based  exchange) or cede the responsibility to the Department of Health and  Human Services (HHS) (referred to as a federally facilitated exchange  (FFE)). The federal government and states each play a role in  overseeing CHIP and the exchanges, including oversight of the CHIP  plans, the QHPs, and the adequacy of provider networks—that is, the  networks of physicians, hospitals, and other providers that contract with  the issuer of the CHIP plan or QHP.
PPACA also requires that, if a state’s federal CHIP funding is insufficient  to cover all CHIP-eligible  children, the state must establish procedures to  ensure that eligible children who are not covered by CHIP are screened  for Medicaid eligibility.  By law, any state with insufficient federal CHIP  funding is required to have procedures to facilitate the enrollment of  children found ineligible for Medicaid in QHPs certified by HHS as  comparable to CHIP, if any such QHPs are available. The Secretary of  HHS in November 2015 reported there were no QHPs comparable to  CHIP. Children transitioning from CHIP to exchange coverage may be  eligible for federal subsidies established through PPACA to offset the cost  of insurance purchased through the exchanges by eligible families. In  contrast to the more than 8 million children enrolled in CHIP, HHS  estimated that QHPs covered fewer than 1 million children in 2015,  comprising about 8 percent of total QHP enrollment.
Access to care from pediatric providers—including those practicing in and  outside of children’s hospitals—is important for children, given that they  have different health care needs than adults. Further, receiving regular  preventive care and vaccinations at a young age are a key factor in an  individual’s long-term health. Based on an analysis of the National Survey  of Children’s Health, the Medicaid and CHIP Payment and Access  Commission (MACPAC) reported that approximately one-quarter of  children likely to be covered by CHIP reported having special health care  needs. Even the majority of CHIP enrollees who are relatively healthy  may need occasional access to pediatric specialists, many of whom  provide services at children’s hospitals. More than two-thirds of CHIP  enrollees received coverage through states’ CHIP programs that were  administered separately from their Medicaid programs in fiscal year 2013,  and most of these children (80 percent) were enrolled in managed care  plans. In general, in both CHIP managed care plans and QHPs,  enrollees’ choice of providers is largely limited to providers within the  CHIP plan and QHP networks. MACPAC has raised concerns about  whether the provider networks used by QHPs are adequate to address  the health care needs of children. To date, however, little is known  about any differences in the inclusion of children’s hospitals and other  pediatric providers in the networks of CHIP and QHPs.
Because Congress will be deciding whether to extend CHIP funding  beyond fiscal year 2017, you asked us to examine the inclusion of  pediatric specialists and children’s hospitals in provider networks in CHIP  and QHPs. In this report, we examine:   1.  federal and state provider network adequacy standards CHIP plans  must meet, particularly for pediatric providers, and how these  compare to standards for QHPs;   2.  the extent to which selected issuers of CHIP plans and QHPs include  children’s hospitals in their networks and otherwise help to ensure  access to pediatric specialists; and   3.  how the federal government and selected states monitor CHIP plan  and QHP compliance with provider network adequacy standards.
To address all three objectives, we reviewed relevant laws, regulations,  and guidance documents to obtain information on network adequacy  standards and monitoring responsibilities at the federal level, and  interviewed knowledgeable officials from HHS’ Centers for Medicare &  Medicaid Services (CMS).  Additionally,  to obtain a broad perspective  on network adequacy for pediatric providers, we interviewed officials from  10 organizations, including the National Association of Insurance  Commissioners (NAIC), research organizations, and stakeholder  organizations representing consumers, issuers, and providers.
In addition, we selected five states—Alabama, Massachusetts,  Pennsylvania, Texas, and Washington—that administer the majority of  their CHIP programs separately from their Medicaid programs and cover  children ages 0 to 18 in these separate programs. These states varied in  the type of health insurance exchange (i.e., state-based exchange or  FFE), the size of their CHIP program, and their overall child population,  among other characteristics. In these five states, we reviewed  documents such as state laws and contracts between the states and  selected issuers of CHIP plans. We also interviewed or obtained  information in writing regarding network adequacy requirements and  monitoring from knowledgeable officials from state agencies that  administer the CHIP program and departments of insurance in each state,  as well as exchanges in the two state-based exchange states. For the  most populous county in each selected state, we selected issuers and  children’s hospitals from which to obtain information. We selected issuers  of the largest CHIP plan and largest QHP in the selected county, based  on the most recently available enrollment data. For QHPs, we selected  issuers based on total county enrollment in each issuer’s silver plan with  the lowest premium for 2014 or 2015. Where possible, within each state  we selected at least one issuer that offered: (1) only a CHIP plan, (2) only  QHPs, and (3) both a CHIP plan and QHPs. We also selected at least  one children’s hospital in each state. In total, we interviewed or obtained  information regarding the inclusion of children’s hospitals and providers in  networks from representatives of 19 selected issuers of CHIP plans and  QHPs and nine selected children’s hospitals. Our findings on state  network adequacy standards and plan inclusion of children’s hospitals  and pediatric specialists, as well as on state monitoring of compliance  with network adequacy standards, are not generalizable to all states,  issuers, or children’s hospitals, but provided us with valuable insight on  these issues. See app. I for more details on the selection criteria for the  states, issuers, and children’s hospitals we included in our review.
We conducted this performance audit from December 2014 through  February 2016 in accordance with generally accepted government  auditing standards. Those standards require that we plan and perform our  work 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.
subsections: section_title: Background
paragraphs: Through CHIP, states provide health insurance coverage for children in  families whose household incomes are too high to qualify for Medicaid.  CHIP is funded jointly by the federal government and states. States  administer CHIP under federal standards, and the state programs may  vary, for example, in the services covered, costs to individuals and  families, and eligibility  standards. Specifically, CHIP income eligibility  standards vary across states, with most states’ upper income eligibility  levels between 200 and 300 percent of the federal poverty level and the  highest eligibility  level being 400 percent of the federal poverty level.  PPACA requires states to maintain their current eligibility  levels for  children in CHIP and Medicaid through fiscal year 2019. Thus, under  current law, some states could choose to eliminate or scale back  coverage for children in their CHIP and Medicaid programs beginning in  fiscal year 2020, even if federal funds for these programs are available.
PPACA required the establishment of exchanges by January 1, 2014, to  allow consumers to compare individual health insurance options available  in each state and enroll in coverage. As of June 2015, 17 states had  established state-based exchanges and 34 states had FFEs. The  exchanges include certified QHPs offered in the states by the  participating issuers of coverage. QHPs are required to meet certain  benefit design, consumer protection, and other standards. Issuers may  offer multiple QHPs and may also offer other health insurance products  outside of the exchange, such as a CHIP managed care plan, Medicare  Advantage plan, Medicaid managed care plan, or other commercial  insurance products.
While the CHIP program was created to address the health care needs of  children in low-income families, QHPs offered through the exchanges  established by PPACA are intended to target a broader population.  Specifically, PPACA contained a number of provisions that were intended  to make coverage more available and affordable for individuals seeking  coverage in the private individual and small group health insurance  markets. Some of these provisions established new rules that limit how  much issuers can vary the premiums they charge certain individuals or  groups, as well as prohibiting issuers from denying coverage based on an  individual’s health status, among other things. With the introduction of  QHPs in 2014, researchers have found that issuers have increasingly  employed cost-containment tools—such as creating narrow networks that  include a smaller group of providers and hospitals—as well as by tiering  networks—that is, creating several networks of differing levels of  coverage that reflect different arrangements of out-of-pocket costs that  may be incurred by an enrollee.
The federal government and states each play a role in overseeing CHIP,  CHIP plans, exchanges, and QHPs:
CHIP. CMS is the federal agency responsible for overseeing states’  implementation and administration of their CHIP programs, including  establishing federal standards for these programs and ensuring that  states take steps to adequately oversee issuers’ compliance with  these standards. At the state level, state agencies such as the  Medicaid agencies or departments of health or social services are  responsible for administering CHIP programs and overseeing CHIP  plans. For CHIP programs operated through the use of managed  care, the relevant state agencies contract with managed care  organizations to provide services to CHIP enrollees. State  departments of insurance may also play a role in overseeing CHIP  plans, to the extent these plans are subject to state insurance rules.
QHPs. Regardless of the exchange type, CMS has direct oversight  responsibilities for the PPACA exchanges, as CMS is responsible for  certifying state exchanges for operation and directly operating the  FFE. In addition, CMS is responsible for establishing minimum QHP  certification requirements that all QHPs must meet in order to  participate in an exchange. In the FFE states, CMS oversees  compliance with these requirements; in the states with state-based  exchanges, the states are responsible for ensuring the plans comply.  Federal regulations require that all exchanges have procedures to  annually certify QHPs to ensure they are in compliance with exchange  requirements.
While we and others have reported on CHIP enrollees’ experiences with  access to health care compared to those with private insurance or without  insurance and comparisons of other aspects of CHIP and QHPs, little is  known about whether the provider networks used by QHPs are adequate  to address the health care needs of children or how CHIP networks  compare with those of QHPs. Specifically, we reported in November 2013  that survey data indicated that CHIP enrollees reported comparably  positive responses regarding their ability to obtain care when compared  with responses for enrollees with private insurance, but that  approximately 18 percent of CHIP enrollees reported difficulties seeing a  specialist. We also reported in February 2015 that coverage of services  by selected CHIP plans in five selected states was generally comparable  to that of the selected QHPs, with the notable exceptions of pediatric  dental and certain enabling services such as translation and  transportation services, which were covered more frequently by the CHIP  plans. However, as noted by MACPAC in its March 2015 report, little  has been reported on the provider network differences among CHIP,  Medicaid, and QHPs. HHS’ Assistant Secretary for Planning and  Evaluation contracted for studies looking at provider networks in CHIP,  Medicaid, and qualified health plans in six urban areas; but, as of  November 2015, HHS had not published the studies.
section_title: Federal Network Adequacy Standards Are Broad for Both CHIP Plans and QHPs, and Selected States Are More Focused on Pediatric Providers for CHIP Plans Than for QHPs
paragraphs: At the federal level, broad network adequacy standards apply to CHIP  plans and QHPs. At the state level, most of the five states we reviewed  required CHIP plans to adhere to network adequacy standards that  related specifically to pediatric provider types. The selected states  required QHPs to follow fewer pediatric provider-specific standards.
subsections: section_title: Broad Federal Network Adequacy Standards Apply to CHIP Plans and QHPs
paragraphs: Broad federal network adequacy standards apply to CHIP plans and  QHPs. States that administer their CHIP programs through managed care  plans must adhere to federal requirements governing CHIP managed  care organizations, while QHPs in both state-based exchanges and FFEs  are also subject to federal requirements for provider network adequacy.  Specifically:
Federal law requires that CHIP managed care plans provide  assurances that, within their service areas, they have the capacity to  serve their expected enrollment; that they maintain an adequate  number, mix and distribution of providers; and that they offer an  appropriate range of services and access to preventive and primary  care services for the expected population. Because CHIP managed  care plans primarily cover children, these plans are thus required to  include a sufficient network of pediatric providers.
Federal regulations require QHPs to maintain networks that are  sufficient in number and types of providers in order to ensure that all  services are accessible to enrollees without unreasonable delay.  Regulations also require that QHP networks include “essential  community providers” to ensure reasonable and timely access to a  broad range of providers for low-income and medically underserved  individuals.
CMS has established more specific network adequacy criteria applicable  to QHPs participating in the FFE, which CMS operates. For example, in  its annual certification guidance to QHP issuers in FFE states for benefit  years 2015 and 2016, CMS instructed issuers to submit a list of providers  and their geographic locations so that CMS could determine whether an  issuer met the “reasonable access” standard—that is, that the issuer  maintains networks that are sufficient in number and types of providers in  order to ensure that all services are accessible to enrollees without  unreasonable delay. CMS also noted that it considers a QHP network to  meet the essential community provider requirement when:
The network includes at least 30 percent of available essential  community providers in the QHP’s service area and
The network covers at least one provider in each essential community  provider category in each county where an essential community  provider in that category is available.
For QHPs participating in the FFE, CMS specified that essential  community provider categories include, but are not limited to: federally  qualified health centers, Indian Health providers, and hospitals. None of  these specified categories are specific to pediatric providers.
CMS is considering changes to CHIP plan and QHP network adequacy  requirements. With regard to the CHIP program, CMS issued a proposed  rule in June 2015 that, if finalized as proposed, would amend current  Medicaid and CHIP managed care regulations to reduce variation in how  states evaluate and define network adequacy. With regard to QHPs in  FFE states, CMS issued a proposed rule in December 2015 that, if  finalized as proposed, would allow states in which an FFE operates to  select a quantifiable network adequacy standard—such as a travel time  or distance standard for the proximity of network providers’ locations to  enrollees’ residences—applicable to QHPs in that state.  If the state does  not adopt such a standard or does not review QHP network adequacy, a  default federal standard imposing specific time and distance requirements  would apply to QHPs in the state. CMS indicated that the agency  followed proposed changes to the NAIC network adequacy model in  considering modifications to the QHP network adequacy standards.
section_title: Selected States Also Had Network Adequacy Standards, but Held CHIP Plans More Often Than QHPs to Pediatric-Specific Standards
subsections: section_title: Overall Network Adequacy Standards in Selected States
paragraphs: The five selected states we examined had one or more specific network  adequacy standards for CHIP plans and QHPs. These standards  included the following:
Provider-to-enrollee ratios or quantitative standards for a minimum  number of providers per enrollee or set of enrollees. Two of the  selected states—Massachusetts and Washington—required CHIP  plan networks to follow specific provider-to-enrollee ratios. For  instance, in Massachusetts, managed care plans in which CHIP  children are enrolled must include one primary care provider for every  200 enrollees. These same two states also required at least some  QHPs to have a minimum provider-to-enrollee ratio for certain  provider types, such as primary care providers. These primary care  providers may include, but were not exclusive to, pediatric primary  care providers.
Travel time or distance standards for the proximity of network  providers’ locations to all or some proportion of enrollees’ residences;  such standards may differ for rural and urban areas. All five states  required CHIP plans to adhere to specific and quantitative travel time  standards, travel distance standards, or both. For example, Alabama  required that, for 90 percent of enrollees, one hospital must be  available within 30 miles of enrollees’ homes, and two behavioral  health providers must be available within 10 miles of enrollees’ homes  in urban areas or 45 miles in rural areas. All five selected states also  had specific quantitative travel time or distance standards for QHPs  for certain provider types, such as primary care providers. These  primary care providers may include, but were not necessarily  exclusive to, pediatric primary care providers.
Capacity or availability standards, which may include requirements  that a certain number or proportion of providers are accepting new  patients or may require specific limits on appointment wait times.  Three of the selected states—Massachusetts, Texas, and  Washington—required CHIP plan networks to follow provider capacity  or availability  standards. Washington, for example, required CHIP  plans to ensure that non-emergency, routine primary care be available  within 10 days. These same three states also required QHPs to take  into account the capacity or availability of network providers.
section_title: Specific Network Adequacy Standards for Pediatric Provider Types in Selected States
paragraphs: While federal network adequacy standards for QHPs do not impose  requirements specifically related to pediatric providers, individual states  may adopt such requirements. For CHIP plans, most selected states had  specific requirements for pediatric provider types, but, for QHPs, only two  states had specific requirements for pediatric provider types. (See fig. 1.)  Specifically, four of the selected states—Alabama, Massachusetts,  Texas, and Washington—required CHIP plans to meet certain pediatric  provider standards. This was particularly true for travel time and distance  standards, as well as capacity or availability  standards. For example,  Texas required CHIP plans to include in their networks one age- appropriate primary care provider within 30 miles of enrollees’ homes for  90 percent of enrollees, and Alabama required CHIP plan networks to  provide access to two pediatric primary care providers within a 20-mile  radius of enrollees’ homes for 90 percent of enrollees. In addition, Texas  required CHIP plans to make preventive health service appointments for  children available within a timeframe that is in accordance with standards  set by a national pediatric provider group. For QHPs, fewer of the  selected states had adopted standards related to pediatric provider types  than for CHIP plans. Specifically, two of the five selected states—Texas  and Washington—had QHP standards containing requirements specific to  pediatric provider types. For example, Washington required QHP  issuers to demonstrate that 80 percent of the covered children in a given  service area have access to a pediatrician within 30 miles of their homes  for an urban area or 60 miles for a rural area and to pediatric specialty  services within 60 miles of their homes for an urban area and 90 miles for  a rural area. In another example, Texas required that QHP issuers  provide routine care for children within two months of the request.
section_title: Nearly All Selected Issuers Included at Least One Children’s Hospital in Their Networks, but Many Expressed Challenges Recruiting Certain Specialists
paragraphs: Eighteen of 19 selected issuers that offered CHIP plans, QHPs, or both,  in the most populous counties of the five selected states reported  including at least one children’s hospital in their provider networks for  their CHIP plans and QHPs. Most of them—16 of the 18—reported  including more than one children’s hospital. Representatives from one  QHP-only issuer told us they did not include a children’s hospital in their  QHP network, but they instead provide access to children’s pediatric  services—such as neonatal intensive care and general pediatric  surgery—through an agreement with four hospitals that treat children but  are not limited to children. All of the selected issuers of CHIP plans and  QHPs told us they had a policy to allow for enrollees to obtain case-by- case exceptions when certain services or providers are unavailable  in- network.
Officials representing some of the children’s hospitals we spoke with,  however, raised concerns around not being included in all plan networks  and the potential effect on children’s access to specialty care they may  need. Representatives from all nine selected children’s hospitals we  contacted in the selected states told us that their hospitals are currently  included in networks of many—but not all—CHIP plans and QHPs that  are offered in the selected counties. Representatives from five of the nine  children’s hospitals located in four different states noted concerns about  some aspects of network inclusion that could affect access for children  who need specialty care through their hospitals. Specifically:
Representatives from three of these five children’s hospitals told us  that, in some QHPs that have tiered networks, their hospitals are  included in tiers that are associated with higher enrollee cost-sharing.
Representatives from two of these five children’s hospitals told us  they were concerned about their future inclusion in CHIP and QHP  networks, explaining that their hospital’s inclusion in networks could  vary from year to year. A representative from one of these two  children’s hospitals also noted that the fundamental network  adequacy issue for the pediatric population is the small percentage of  children with complex health care needs, which typically account for a  large percentage of pediatric medical costs.
Representatives from three of these five children’s hospitals noted  that when their hospitals are not in a CHIP or QHP network, treating  CHIP or QHP enrollees at their facilities increases the administrative  burden placed on the hospitals as they have to arrange case-by-case  exceptions with plan issuers.
The selected issuers that offered both CHIP plans and QHPs told us they  had the same or similar provider networks for their CHIP plans and  QHPs. For example, one issuer told us that in 2014 its Medicaid and  CHIP plan networks were different in that some Medicaid providers did  not initially  join QHP networks. However, the issuer told us there was an  increase in the number of Medicaid providers willing to join QHP networks  in 2015. Representatives from another issuer told us they had one  provider network for all plans, including CHIP plans and QHPs.
All of the 19 selected issuers we contacted indicated that pediatric  specialists are included in each of their networks. However, many  expressed challenges recruiting certain types of pediatric specialists.  Many of the challenges related to location or compensation as well as  reflecting provider availability nationwide:
Location. Representatives from four issuers—one QHP issuer, two  issuers of CHIP plans, and one issuer of both a CHIP plan and  QHP—in two states told us that it is difficult to recruit and retain  pediatric behavioral health providers. These representatives further  noted that this problem is not specific to their county or state, but  related to a nationwide shortage of children’s behavioral health  providers. In addition, representatives from four issuers of CHIP plans  in three states told us that recruiting specialists in metropolitan  counties is generally not as difficult as recruiting specialists in rural  counties, and difficulties recruiting specialists in rural counties is a  problem affecting all of their insurance plan networks, not just CHIP  plans.
Compensation. Representatives from one issuer of a CHIP plan told  us that some specialists generally require significantly higher  compensation than CHIP plans typically pay, making it difficult for the  issuer to recruit certain pediatric specialists—such as cardiologists,  cardiovascular surgeons, neurologists, neurosurgeons, and  urologists—to its network. In addition, the issuer noted that these  specialists are difficult to contract with due to the limited number of  providers practicing in these specialties.
subsections: section_title: CMS Monitors State Oversight of Network Adequacy for CHIP Plans and Directly Monitors Adequacy for QHPs in Federally Facilitated Exchanges; Selected States’ Monitoring Varied CMS Monitored State Oversight of CHIP Network Adequacy through Contract and State Plan Reviews, and Directly Monitored Adequacy for QHPs in Federally Facilitated Exchange States
paragraphs: States have primary responsibility for administering CHIP and for  overseeing CHIP plan compliance with network adequacy standards, and  CMS monitors these state oversight activities. CMS officials reported  conducting certain monitoring activities for QHPs to assess the adequacy  of provider networks in FFE states. Officials from most of the selected  states’ CHIP agencies and departments of insurance reported monitoring  issuers’ compliance with state CHIP and QHP standards, but states’  frequency of monitoring varied.
subsections: section_title: Federal Monitoring of CHIP Network Adequacy
paragraphs: CMS officials told us that the agency monitors the oversight activities of  states, which have primary responsibility for administering CHIP and for  overseeing CHIP plan compliance with network adequacy standards,  primarily by reviewing state contracts with plan issuers and requiring  certain assurances from states and issuers. Federal law requires states to  establish standards for access to care under CHIP managed care plans  to ensure that covered services are available within reasonable  timeframes and in a manner that ensures both continuity of care and  adequate primary care and specialized services capacity; states must  also provide assurances to CMS that these standards are met. These  standards may include, for example, provider-to-enrollee ratios, travel  time or distance standards, and capacity or availability  standards. CMS  monitors states’ CHIP oversight activities in the following ways:
Reviews state contracts with issuers of CHIP plans. Since July 1,  2009, CMS has required states to submit for CMS review all new,  extended, renewed, or amended CHIP managed care contracts that  states enter with managed care organizations to ensure these  contracts comply with federal requirements, including those relating to  access to care.
Requires states to develop and implement plans that include  access standards. States must operate their CHIP programs in  accordance with a CMS-approved state CHIP plan that must include a  description of the methods the states use to ensure the quality and  appropriateness of care provided under the plan. Each state that  contracts with managed care organizations to provide CHIP benefits  also must develop and implement a Quality Assessment and  Improvement Strategy, which must include access to care standards  that ensure covered services are available within reasonable  timeframes and in a manner that ensures continuity of care and  adequate primary care and specialized services capacity. CMS is  required to monitor the development and implementation of this  plan. In addition, each contract that a state enters into with a  managed care organizations to provide CHIP benefits must include a  requirement for an annual external independent review to ensure the  plan’s quality and timeliness of, and access to, covered items and  services under the contract.
CMS officials told us that they are not aware of any concerns about  children enrolled in CHIP not having access to pediatric specialists, and  that they think states make a concerted effort in establishing provider  networks for their CHIP plans for children to ensure sufficient  pediatricians and pediatric specialists.
section_title: Federal Monitoring of QHP Network Adequacy
paragraphs: In contrast with its indirect oversight role over CHIP plans, CMS is  responsible for directly monitoring QHPs’ compliance with QHP  certification standards in FFE states. CMS officials reported using three  types of monitoring activities to assess the adequacy of QHPs’ provider  networks in FFE states—through the annual QHP certification process,  comprehensive issuer compliance reviews, and post-certification reviews,  as follows:
Annual QHP certification process. CMS conducts an annual  certification process of QHPs in FFE states. CMS officials told us that  during this process they assess QHPs’ provider networks using the  “reasonable access” standard in order to identify networks that  potentially fail to provide access without unreasonable delay, as  required by federal regulations. CMS officials told us they do not  assess QHP networks for their adequacy of pediatric providers or  pediatric specialists because there have not historically been network  adequacy concerns with these types of providers. During the  certification process, CMS officials told us they analyze issuers’ QHP  provider network data on the providers and types of providers in the  networks for each service area using a computerized geographic  mapping and analytics tool. CMS compares the QHPs’ network data  against internal CMS metrics, including time and distance standards  for certain provider categories that have historically raised network  adequacy concerns—hospitals, mental health, oncology, primary  care, and dental. According to CMS officials, 17 QHP issuers were  flagged as having potential network adequacy concerns during the  certification process for benefit year 2015, resulting in CMS  communicating with the issuers through an iterative process to obtain  more information. CMS officials reported that these issuers either  provided what CMS officials deemed to be a reasonable justification  for the lack of providers, such as a lack of available providers in a  specialty or patterns of care that reasonably justify the lack of  providers, or they provided CMS with data to indicate they included  additional providers in their networks since their initial data  submission. CMS officials said that, for benefit years 2014 and 2015,  all issuers ended up providing adequate information about their  networks to be able to attain QHP certification.
Comprehensive issuer compliance reviews. CMS officials reported  monitoring QHPs’ compliance with provider network standards in FFE  states through comprehensive issuer compliance reviews, though  network adequacy is only one of many elements in these reviews.  During a compliance review, CMS reviews an issuer’s policies and  procedures related to CMS’s internally established availability  and  accessibility standards and also reviews issuers’ compliance with  other federal standards, such as QHPs’ rates, benefit design, and  marketing. CMS officials reported that for benefit year 2014 they  conducted compliance reviews of 21 issuers; for benefit year 2015,  CMS reported having conducted such reviews of 30 issuers.
Post-certification reviews. CMS officials reported that they also  conduct post-certification reviews, which focus on a specific topic and  may be conducted for a sample of issuers or for all issuers, depending  on the focus of the review. For example, prior to the start of benefit  year 2015, officials said they reviewed all certified QHP issuers’  websites to make sure the links to their provider directories were  compliant with CMS network adequacy standards—that is, that the  links worked and were easily accessible.
In addition to these monitoring activities, CMS officials told us they also  receive and respond to consumer complaints about QHPs. According to  officials, when a complaint of that nature reaches CMS, the agency will  follow up with the consumer on an ad hoc basis. While officials reported  that they have heard anecdotally of problems with network adequacy from  advocacy groups, they were not aware of any complaints specific to  pediatric providers.
section_title: Most Selected States Monitored CHIP and QHP Network Adequacy, but the Frequency of Monitoring Varied
subsections: section_title: Selected States’ Monitoring of CHIP Network Adequacy
paragraphs: Officials from CHIP agencies in three of the five selected states— Massachusetts, Texas, and Washington—told us they regularly monitor  CHIP plan issuers’ compliance with the states’ CHIP network adequacy  standards, but the frequency with which they reported doing this varied.  Specifically:
CHIP officials from these three states told us they require CHIP plan  issuers to submit certain provider network information at the time the  plan and network are established and then quarterly or annually  thereafter. For example, in Washington, issuers must demonstrate the  ability to service 80 percent of the eligible CHIP population in a given  service area. Washington CHIP officials told us that issuers must  submit information at least quarterly on all of their providers in each  service area; this information is entered into a computerized  geographic access program that assesses the locations of providers  in relation to all potential CHIP enrollees in a service area and  measures the results against the state’s distance standards. The  officials said they specifically focus on an issuer’s network inclusion of  17 provider types, 6 of which they deem to be “critical” for CHIP and  Medicaid, including hospitals, pharmacies, primary care providers,  pediatric primary care providers, obstetricians, and behavioral health  providers. Additionally,  issuers must annually report information to the  state CHIP agency, such as their provider-to-enrollee ratios and  provider utilization ratios.
In contrast, CHIP officials in the other two selected states—Alabama  and Pennsylvania—told us they assess CHIP plan issuers’  compliance with state network adequacy standards at the time the  network is established and then on an ad hoc basis thereafter. For  example, officials from Pennsylvania told us they would request  network information if they received a complaint about the network or  if a provider group or hospital left the network.
CHIP officials in all five states also told us that they track any  consumer complaints received about CHIP plan provider networks.
section_title: Selected States’ Monitoring of QHP Network Adequacy
paragraphs: Officials from most of the selected states—Massachusetts, Pennsylvania,  Texas, and Washington—told us that they rely primarily on complaints,  network changes, and other concerns to prompt the frequency with which  they monitor QHPs’ network adequacy. For example:
Department of insurance officials from Texas— an FFE state—noted  that QHP issuers must re-submit provider network information when  there is a material change to the network, and, if the updated network  is no longer adequate, the issuer must also submit an access plan  and a request for a waiver in order to continue to offer QHPs in that  service area.
Department of insurance officials from Pennsylvania—another FFE  state—told us that if they receive an access complaint about a QHP,  staff will investigate and alert CMS to the problem.
Department of insurance officials from one FFE state—Alabama—told  us that they do not assess or monitor QHP provider networks, nor do  they track consumer complaints.
Officials from the departments of insurance in Massachusetts,  Pennsylvania, and Washington told us that, as of mid-2015, they had  received very few or no complaints about QHPs’ provider networks in  2014 and in 2015.
section_title: Agency Comments
paragraphs: We provided a draft of this report to the Secretary of Health and Human  Services.  HHS provided technical comments that we incorporated as  appropriate.
As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution of it until 30 days from  the report 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.
If you or your staff have any questions about this report, please contact  me 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 II.
section_title: Appendix I: Selection Criteria for States, Issuers, and Children’s Hospitals
paragraphs: This appendix describes the methodology we used to select states,  issuers, and children’s hospitals to address our objectives to examine: (1)  federal and state provider network adequacy standards State Children’s  Health Insurance Program (CHIP) plans must meet, particularly for  pediatric providers, and how these compare to standards for qualified  health plans (QHP); (2) the extent to which selected issuers of CHIP  plans and QHPs include children’s hospitals in their networks and  otherwise help to ensure access to pediatric specialists; and (3) how the  federal government and selected states monitor CHIP plan and QHP  compliance with provider network adequacy standards.
subsections: section_title: State selection
paragraphs: We selected five states that administered CHIP separate from their  Medicaid program for the majority of their CHIP enrollees, and covered  children ages 0 to 18 in their separate CHIP programs—Alabama,  Massachusetts, Pennsylvania, Texas, and Washington. The five selected  states varied in the type of health insurance exchange where QHPs are  sold (i.e., federally facilitated exchange or state-based exchange); the  size of their child population, the number of children enrolled in their  separate CHIP program as of 2013; the estimated number of children  enrolled in a QHP for 2015, and the 2014 CHIP upper income eligibility  standard. (See table 1.)
Within each selected state, we identified the most populous county  (based on 2013 U.S. Census data) from which we selected a set of  issuers of CHIP plans and QHPs. To do this, we obtained data on 2014  or 2015 enrollment for all CHIP plans and QHPs offered in each selected  county, as well as QHP 2014 or 2015 premium data, from officials at the  Centers for Medicare & Medicaid Services (CMS) and agencies in each  selected state that administer CHIP, departments of insurance, and  exchanges (in the two state-based exchange states). From a total of 37  issuers of CHIP plans and QHPs that offered plans in the five selected  counties, we selected 19—4 issuers that only offered a CHIP plan, 8  issuers that only offered QHPs, and 7 issuers that offered both a CHIP  plan and QHPs.
The 19 issuers we selected included issuers of the largest CHIP plan and  largest QHP in each selected county, based on enrollment for benefit  year 2014 or 2015, in order to obtain information on issuers who cover a  large share of CHIP and QHP enrollees. Because QHP issuers offered  more than one QHP in a given county, we selected QHP issuers based  on total county enrollment in each issuer’s silver plan with the lowest  premium for 2014 or 2015. Where possible, within each state we  selected at least one issuer that offered: (1) only a CHIP plan, (2) only  QHPs, and (3) both a CHIP plan and QHPs. The CHIP plans and lowest- cost silver plans offered by the 19 selected issuers provided coverage to  at least 73 percent of enrollment in CHIP managed care plans and at  least 84 percent of enrollment in lowest-cost silver QHPs in each selected  county. See table 2 for the selected counties and the number of issuers  that offered CHIP plans, QHPs, or both in each county.
In four of the five states, we selected a set of hospitals in each selected  county whose mission was to primarily serve children—referred to as  children’s hospitals. In the fifth selected state, the selected county did not  have a children’s hospital, so we contacted children’s hospitals in a  neighboring county. We contacted a total of nine children’s hospitals—at  least one in each selected state—and interviewed or received written  information from all of them.
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Kim Yamane, Assistant Director;  Sandra George; Kate Nast Jones; Laurie Pachter; and Nina Verevkina  made key contributions to this report.