Children's Health Insurance: Coverage of Services and Costs to Consumers in Selected CHIP and Private Health Plans in Five States
Published: 2015-02-25T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Federal funds appropriated to states for CHIP—the jointly financed health insurance program for certain low-income children—are expected to be exhausted soon after the end of fiscal year 2015 unless Congress acts to appropriate new funds. 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. If ineligible, children may be enrolled into a private qualified health plan—or QHP—that has been certified by the Secretary of Health and Human Services (HHS) as comparable to CHIP, if such a QHP is available.
GAO was asked to examine coverage and costs to consumers in selected CHIP plans and private QHPs in selected states. GAO reviewed (1) coverage and (2) costs to consumers for one CHIP plan, one QHP, and, where applicable, one SADP in each of five states—Colorado, Illinois, Kansas, New York, and Utah. State selection was based on variation in location, program size, and design; CHIP plan selection was based on high enrollment; and QHP selection was based on low plan premiums. GAO obtained CHIP and QHP premium data from state officials and federal and state websites. GAO also obtained documents from and spoke to federal officials, including from HHS's Assistant Secretary for Planning and Evaluation, state officials, including from CHIP and insurance departments, and issuers of QHPs.
HHS provided technical comments on a draft of this report, which GAO incorporated as appropriate.
section_title: What GAO Found
paragraphs: In five selected states, GAO determined that coverage of services in the selected State Children's Health Insurance Program (CHIP) plans was generally comparable to that of the selected private qualified health plans (QHP), with some differences. In particular, the plans were generally comparable in that most covered the services GAO reviewed 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. For example, only the selected QHP in New York covered pediatric dental services; the QHPs in the other four states did not include pediatric dental services, although some officials indicated this would change for 2015 offerings. In those four states, stand-alone dental plans (SADP) could be purchased separately. Selected CHIP plans and QHPs were also similar in terms of the services on which they imposed day, visit, or dollar limits, although the five selected CHIP plans generally imposed fewer limits than the selected QHPs. For services where coverage limits were sometimes imposed on QHPs and CHIP plans, GAO's review found that the limits on CHIP plans were at times less restrictive. For example, the selected QHP in Utah limited home- and community-based health care services to 60 visits per year while the selected CHIP plan did not impose any limits. In addition, for pediatric dental services, coverage limits in the selected SADPs were generally similar to those in the selected CHIP plan; however, when there were differences, CHIP was generally more generous.
Consumers' costs for these services—defined as deductibles, copayments, coinsurance, and premiums—were almost always less in the five states' selected CHIP plans when compared to their respective QHPs, despite the application of subsidies authorized under the Patient Protection and Affordable Care Act (PPACA) that reduce these costs in the QHPs. Specifically, when cost-sharing applied, the amount was typically less for CHIP plans, even considering PPACA provisions aimed at reducing cost-sharing amounts for certain low income consumers who purchased QHPs. For example, an office visit to a specialist in Colorado would cost a CHIP enrollee a $2 to $10 copayment per visit, depending on their income, compared to the lowest available copayment of $25 per visit in the selected Colorado QHP. GAO's review of premium data further suggests that selected CHIP premiums were always lower than selected QHP premiums, even when considering the application of PPACA subsidies that help to defray the cost to certain consumers. For example, the 2014 annual premium for the selected Illinois CHIP plan for an individual at 150 percent of the federal poverty level (FPL) was $0. By comparison, the 2014 annual premium for the selected Illinois QHP was $1,254, which was reduced to $944 for an individual at 150 percent of the FPL, after considering federal subsidies to offset the cost of coverage. Finally, all selected CHIP plans and QHPs GAO reviewed limited out-of-pocket maximum costs, and these maximum costs were typically less in the CHIP plans.

section_title: Letter
paragraphs: Federal funding appropriated to states to support the State Children’s  Health Insurance Program (CHIP), a joint federal-state program that was  established in 1997 to provide health coverage to certain low-income  children, will end after September 2015 unless Congress acts to  appropriate new funds. CHIP 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, and federal funds are  expected to run out shortly after the end of fiscal year 2015. 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 can compare and select among qualified health plans (QHP)  and stand-alone dental plans (SADP) offered by participating private  issuers—established under the Patient Protection and Affordable Care  Act (PPACA). PPACA also requires that, beginning in October 2015, if a  state’s CHIP funding is insufficient to cover all CHIP-eligible children, the  state must establish procedures to ensure that the children who are not  covered by CHIP are screened for Medicaid eligibility. If found ineligible  for Medicaid, the children may be enrolled into a QHP that has been  certified as comparable to CHIP by the Secretary of Health and Human  Services (HHS), if such a QHP is available.
States administer their CHIP programs under broad federal requirements,  and programs vary in the services covered and the costs to individuals  and families. For example, states can operate CHIP as a separate  program, include CHIP-eligible children in their Medicaid program, or do  both. HHS’ Centers for Medicare & Medicaid Services (CMS) is the federal agency responsible for overseeing CHIP.
In November 2013, we issued a report that compared coverage of  services and costs to consumers in separate CHIP plans and plans  intended as models for the benefits that would be offered through QHPs,  known as benchmark plans, in five states—Colorado Kansas, Illinois,  New York, and Utah—and described how coverage and costs might  change in 2014. We found that coverage in selected separate CHIP  plans was generally comparable to benchmark plans and consumers’  costs for these services were almost always less in CHIP than in  benchmark plans. We also concluded that uncertainty remained regarding  issuer decisions regarding how to define certain covered services and the  implementation of other PPACA provisions, such as pediatric dental  services, and that further study would be beneficial. At the time, QHPs  were not available for study.
Now that QHPs have been made available on the exchanges, you asked  us to examine the comparability of benefits and costs to consumers  between CHIP plans and QHPs. In this report, we describe (1) how  coverage of services in separate CHIP plans compares to QHPs in  selected states, and (2) how costs to consumers in separate CHIP plans  compare to QHPs in selected states.
To address both objectives, we selected the same health care services  we reviewed in our 2013 report, which were identified by reviewing  federal statutes and regulations governing CHIP-eligible services and the  essential health benefit (EHB) categories, which are those 10 categories  of service that QHPs are required to cover. In addition to these services,  we also identified selected enabling services, which can help individuals  access the medical care they need and are recognized by the Health  Resources and Services Administration’s Maternal and Child Health  Bureau as especially important for low income children and those with  special health care needs, a significant number of whom rely on Medicaid  or CHIP for some or all of their health care coverage. We focused our  review on the five states selected for our November 2013 report:  Colorado, Kansas, Illinois, New York, and Utah, selected on the basis of  variations in CMS region, CHIP program design, and size of enrollment in  the separate CHIP program. For these five states, we contacted state  officials to identify the separate CHIP plan with the largest enrollment in  2014 and obtained plan coverage and cost sharing information from them  for that CHIP plan in each state.
To compare the CHIP plan coverage and costs to that in QHPs, we  identified the lowest cost silver level QHP in the most populous county in  each of the five states in 2014 by reviewing 2010 Census data and  information available on data.healthcare.gov for states with a federally  facilitated exchange and from state officials in states operating their own  exchanges. We also relied on these data sources to identify the lowest  cost SADP in 2014 in each state where the pediatric dental benefit was  not included in our selected QHP. We then reviewed Evidences of  Coverage from each of the QHPs and SADPs identified to determine  whether the services we identified were covered; whether there were any  annual limits on those services in terms of days, visits, age, or  expenditures; and to identify cost-sharing amounts, including deductibles,  copayments, and coinsurance, for each of the services and any stated  out-of-pocket maximum costs. We obtained 2014 CHIP premiums from  state officials and 2014 QHP premiums from data.healthcare.gov, state  websites, and state officials. We also obtained enrollment data for  federally facilitated exchange states from HHS’s Assistant Secretary for  Planning and Evaluation (ASPE).including from CHIP programs and insurance departments in our five  states, officials from an SADP issuer in one of our five states, and  representatives from two large issuer associations whose members  participate in both CHIP and the marketplaces to obtain their input on the  implementation of certain PPACA provisions.
Finally, we interviewed state officials,  Our coverage and cost comparisons were limited to the selected services,  limits, and plans in these five states, and our results cannot be  generalized to other plans or states. To determine the reliability of the  information from data.heathcare.gov, we spoke with researchers who  have used these data to learn about any potential limitations. To  determine the reliability of information from state officials regarding QHP  identification and premiums, we interviewed officials regarding the steps  they took to assess its reliability. To determine the reliability of enrollment  data from ASPE, we interviewed officials regarding the steps they took to  assess its reliability, and performed minimal data checks for obvious  errors. We did not independently verify the accuracy or completeness of  the data beyond these steps. Based on these efforts, we determined that  these data sources were sufficiently reliable for the purposes of this  report.
We conducted this performance audit from November 2014 to February  2015 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.
subsections: section_title: Background
subsections: section_title: Coverage and Cost Requirements for CHIP
paragraphs: Unlike states that opt to cover CHIP-eligible children in their Medicaid  programs 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. However,  federal laws and regulations require states’ separate CHIP programs to  include coverage for routine check-ups, immunizations, emergency  services, and dental services defined as “necessary to prevent disease  and promote oral health, restore oral structures to health and function,  and treat emergency conditions.” States typically cover a broad array of  additional 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.must also comply with mental health parity requirements—meaning they  must apply any financial requirements or limits on mental health or  substance abuse benefits in the same manner as applied to medical and  surgical benefits.
With respect to costs to consumers, CHIP premiums and cost-sharing— irrespective of program design—may not exceed amounts as defined by  law. States may vary separate 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). In all cases, no cost-sharing can be required for  preventive services—defined as well-baby and well-child care, including  age-appropriate immunizations and pregnancy-related services. In  addition, states may not impose premiums and cost-sharing that, in the  aggregate, exceed 5 percent of a family’s total income for the length of  the child’s eligibility period in CHIP.
section_title: Coverage and Cost Requirements for QHPs
paragraphs: PPACA includes provisions that seek to standardize coverage and costs  of private health plans in the individual and small group markets. QHPs  offered both on and off the exchanges are required to comply with  applicable private insurance market reforms, including relevant premium  rating requirements, the elimination of lifetime and annual dollar limits on  EHBs, prohibition of cost-sharing for preventive services, mental health  parity requirements, and the offering of comprehensive coverage. PPACA  allows exchanges in each state to offer coverage of pediatric dental  services as an integrated benefit in a QHP or through an SADP, which  consumers can purchase separately. In exchanges with at least one  participating SADP, QHPs are not required to include the pediatric dental  benefit. Some states require children obtaining coverage in their state- based exchanges to enroll in an SADP if their QHP does not include the  pediatric dental benefit; consumers purchasing coverage in the federally  facilitated exchange are not required to do so.
With respect to costs to consumers, QHPs must offer coverage that  meets one of four metal tier levels, which correspond to actuarial value  (AV) percentages that range from 60 to 90 percent: bronze (AV of   60 percent), silver (AV of 70 percent), gold (AV of 80 percent), or platinum  (AV of 90 percent). that a health plan will pay, on average—the higher the AV, the lower the  cost-sharing expected to be paid by consumers. Cost-sharing subsidies  are available 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. The cost-sharing subsidies are not  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 plans 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 from the subsidies are made, the AV of the silver plan  available to eligible consumers will effectively increase from 70 percent to  73, 87, or 94 percent, depending on income. SADPs have different AV  requirements than QHPs. SADPs are categorized as “high” and “low”  level plans, with 85 and 70 percent AV, respectively.subsidies are not available for pediatric dental costs incurred by a  consumer enrolled in an SADP.
Deductibles, co-pays, coinsurance amounts, and out-of-pocket maximum costs can vary  within these plans, as long as the overall cost-sharing structure meets the required AV  levels. Plans are allowed a de minimis variation of +/- 2 percent. Premium costs are not  included in the AV computation. these premium contributions ranged from $471 to $8,949 for a family of  four. The premium tax credit is available to eligible consumers regardless  of which metal tier they choose; however, the credit is calculated based  on the second-lowest cost silver plan in the rating area in which the  consumer resides. 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 relevant.
Finally, PPACA established out-of-pocket maximum costs that apply to  EHBs included in QHPs and SADPs. In 2014, these maximum costs for  QHPs ranged from $2,250 to $6,350 for individuals and $4,500 to  $12,700 for families for households with incomes between 100 and   400 percent of the FPL. Out-of-pocket maximum costs for SADPs are in  addition to the out-of-pocket maximum costs for QHPs and were  established by each exchange in 2014.
section_title: CHIP-Eligible Children and Enrollment in QHPs
paragraphs: CHIP-eligible children may enroll in QHPs instead of enrolling in CHIP— either through a child-only plan or through a plan with other family  members—but they are ineligible for premium tax credits and cost- sharing subsidies because of their eligibility for CHIP. However, if a state  experiences a CHIP funding shortfall in the future and is therefore unable  to enroll all CHIP-eligible children into a CHIP plan, such children may  qualify for premium tax credits and cost-sharing subsidies to offset the   In states not experiencing a funding shortfall,  cost of QHP coverage.enrolling CHIP-eligible children in QHPs would generally increase costs  for families. Under CMS regulations, if an individual who is ineligible for  cost-sharing subsidies enrolls in the same policy as another family  member who is eligible for cost-sharing subsidies, nobody covered under  the policy will qualify for cost-sharing subsidies. As a result, enrolling  CHIP-eligible children in QHPs could result in a loss of cost-sharing  subsidies for family members that are eligible for these subsidies. To  maintain cost-sharing subsidies for eligible family members, the CHIP- eligible child would need to be enrolled in a child-only health plan, for  which premium tax credits would be unavailable because of the child’s  eligibility for CHIP.
section_title: In Five States, Coverage in Selected CHIP Plans and QHPs Was Generally Comparable, Although the CHIP Plans More Commonly Covered Dental and Certain Enabling Services and Had Fewer Coverage Limits
paragraphs: We determined that coverage in the selected CHIP plans and QHPs in  our five states was generally comparable in that it included some level of  coverage for nearly all the services we reviewed. Notable exceptions  were certain enabling services and pediatric dental services, which were  more frequently covered by the selected CHIP plans. (See app. I for a  detailed list of selected services covered by the plans we reviewed.) With  respect to certain enabling services, which may be particularly important  for low income children, care coordination or case management was  offered by all selected CHIP plans, but by only one selected QHP.  Similarly, routine transportation to and from medical appointments was  covered by two CHIP plans but by none of the selected QHPs. With  respect to pediatric dental services, the QHP in New York was the only  selected QHP that covered them; the selected QHPs in the other four  states did not integrate pediatric dental services within the medical  coverage they offered. To obtain coverage for pediatric dental services,  consumers who purchased the selected QHP in these states would also  need to purchase an SADP. For consumers who purchased the selected  QHP in New York or the selected SADP in the other four states, we  determined that pediatric dental coverage available was generally  comparable to what was available in their state’s selected CHIP plan, with  the exception of Utah, where the selected CHIP plan was more generous  than the selected SADP.
However, the extent to which consumers obtained coverage that included  pediatric dental services is not clear. Available federal data with  information on QHP enrollment suggest that many children in the United  States with exchange coverage in 2014 may have been without  comprehensive dental coverage. According to our analysis of enrollment  data for 2014 provided by ASPE, 16 percent of children younger than   18 years of age in the 36 states with federally facilitated exchanges were  enrolled in a QHP that included comprehensive dental services that  covered check-ups, basic, and major dental services. children were enrolled in QHPs that either had less than comprehensive  or no dental coverage. Some of these families are likely to have  purchased an SADP for their children, however. According to an ASPE  report issued in May 2014, 18 percent of children younger than 18 years  of age in the 36 states with federally facilitated exchanges who enrolled in  a QHP also enrolled in an SADP, and these were likely among the  families that had no comprehensive dental coverage included in their   According to our analysis of enrollment data for 2014 provided by  QHP.ASPE, virtually no children younger than 18 years of age in the 36 states  with federally facilitated exchanges were enrolled in a QHP that included  comprehensive dental services and an SADP.
According to CMS, a QHP must offer check-ups, basic, and major dental services to be  considered a QHP with embedded dental coverage. According to our analysis of  enrollment data for 2014 provided by ASPE, less than half of the QHPs in a given state  offered any type of dental coverage—checkups, basic, or major dental services—in two  thirds of states with federally facilitated exchanges. did impose limits on outpatient therapies, pediatric vision, and pediatric  hearing. One notable difference between these selected CHIP plans and  QHPs was the frequency by which they limited home-and community- based health care. While the selected QHP in four states imposed day or  visit limits on these services, only one state’s selected CHIP plan did so.  In contrast, no QHPs imposed limits on durable medical equipment, while  one CHIP plan imposed a $2,000 annual limit.
For services where coverage limits were sometimes imposed on QHPs  and CHIP plans, our review found that the limits on CHIP plans were at  times less restrictive. For example, the selected QHP in Utah limited  home- and community-based health care services to 60 visits per year  while the selected CHIP plan in the state did not impose any limits on  these services. Comparability between service limits in states’ selected  CHIP plans and QHPs was less clear for outpatient therapy services. For  example, the selected CHIP plan in New York limited outpatient physical  and occupational therapies to 6 weeks per year, with no limits on  outpatient speech therapy, while the selected QHP in the state limited  outpatient therapies to a combined 60 visits per condition per lifetime.  (See app. II for a detailed list of coverage limits for services we reviewed  in the selected plans.)
In addition, for pediatric dental services, coverage limits in the selected  QHP and SADPs were generally similar to those in the selected CHIP  plan; however, when there were differences, CHIP was generally more  generous. For example, the selected CHIP plan in Kansas allowed one  sealant per tooth per year; in contrast, the selected high and low SADP in  the state allowed one sealant per tooth every three years. Similarly, the  selected CHIP plan in Utah did not have any coverage limits on x-rays  while the selected high and low SADPs in the state did. (See app. III for a  detailed list of selected dental limits we reviewed in selected plans.)
section_title: Costs to Consumers Were Almost Always Less in Selected CHIP Plans Than in Selected QHPs Despite PPACA Provisions That Limit QHP Costs
paragraphs: We determined that costs to consumers were almost always less in the  selected CHIP plans than in the selected QHPs. Even considering  PPACA provisions aimed at reducing cost-sharing amounts for certain  low-income consumers who purchased QHPs, the differences remained,  though were smaller. For example, the selected CHIP plans in four of the  five states did not include any deductible, which means that enrollees in  those states did not need to pay a specified amount before the plan  began paying for services. In contrast, QHPs we reviewed typically  imposed annual deductibles, which were as high as $500 for an individual  and $1,500 for a family in the plan variation that offered the lowest  available deductibles for QHP enrollees. In addition, consumers who  purchase selected SADPs may face separate deductible costs. For  example, whereas dental services were subject to the plan deductible in  the New York QHP, SADPs in Colorado, Illinois, and Kansas had  separate dental deductibles that ranged from $25 to $50 for individuals  enrolled in selected high plans to $45 to $50 for individuals enrolled in  selected low plans. (See app. III for a detailed list of selected dental cost- sharing we reviewed in the selected plans.)
For services we reviewed where the plans imposed copayments or  coinsurance, the amount was typically less in a state’s selected CHIP  plan compared to its selected QHP, even considering PPACA provisions  aimed at reducing cost-sharing amounts for certain low income  consumers who purchased QHPs. For example, the selected 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 selected CHIP plan imposed copayments  or coinsurance on less than half of the services we reviewed, and the  amounts were usually minimal and on a sliding income scale. For  example, for each brand-name prescription drug, the Illinois CHIP plan  imposed a $3.90 copayment on enrollees with incomes greater than 142  and up to 157 percent of the FPL, which was increased to $7 for enrollees  with incomes greater than 209 and up to 313 percent of the FPL. In  contrast, selected QHPs in all five states imposed copayments or  coinsurance on most covered services we reviewed, and the amounts  were consistently higher than the CHIP plan in the same state. For  example, depending on income, the copayment for primary care and  specialist physician visits in Colorado ranged from $2 to $10 per visit for  enrollees in the selected CHIP plan, but was $25 and $35 per visit,  respectively, for all enrollees in the selected QHP. Cost-sharing for dental  services was also higher in a state’s selected SADP than in its selected  CHIP plan a majority of the time. In addition, in states where the selected  QHP charged coinsurance and the selected CHIP plan required a  copayment, a direct comparison of cost differences could not be made,  although data suggest CHIP costs would generally be lower. For  example, for an inpatient hospital admission, higher-income enrollees in  the selected CHIP plan in Colorado paid $50, while all enrollees in the  selected QHP in the state were responsible for 20 percent coinsurance  after the deductible was met, an amount that was likely to be higher given  that 20 percent of the average price for an inpatient facility stay in 2011  was over $3,000.services we reviewed in selected plans.)   (See app. IV for a detailed list of cost-sharing for  Our review of premiums for selected CHIP plans and QHPs also suggests  that premiums were always less in the CHIP plans than in the QHPs we  reviewed, even with the application of the premium tax credit to defray the  cost of QHP premiums. For example, according to CHIP officials, annual  CHIP premiums in 2014 for an individual varied by income level and  ranged from $0 for the lowest income CHIP enrollees in Colorado,   Illinois, Kansas, and New York, to $720 for enrollees between 351 and  400 percent of the FPL in New York, with most enrollees across the five  selected states paying less than $200 per year.annual premiums for a single child only enrolled in selected QHPs ranged  from $1,111 to $1,776 in our five states before the application of the  premium tax credit. With the premium tax credit, the annual premium  amount for selected QHPs was often significantly lower, but was still  higher than the selected CHIP plan in all five states. For example, in  Illinois, the premium for the selected CHIP plan for an individual with an  income at 150 percent of the FPL was $0 and was $1,254 for the selected  QHP, which was reduced to $944 after the premium tax credit was  applied.
However, the additional premium cost to families enrolling previously  eligible CHIP children into their QHPs—a possibility if CHIP funding is not  reauthorized—may be minimal or nothing.amount lower income families pay in premiums, families with incomes at  250 percent or less of the FPL—at least 75 percent of the separate CHIP  enrollees in the states we reviewed—would generally pay no additional  premium to add a child to their QHP. For example, in Kansas, the 2014  annual premium for the lowest cost silver level QHP was $4,875 for a  couple age 40 and an additional $1,211 to add a child. However, if the  couple’s income was 200 percent of the FPL, their maximum annual   Because PPACA limits the  premium would be $2,494, and they would incur no additional costs by  adding a child to their plan.
Finally, all selected CHIP plans and QHPs limited the total potential costs  to consumers by imposing out-of-pocket maximum costs, and these  maximum costs were typically less in the CHIP plans we reviewed. 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. This 5 percent cap resulted in  limits that varied based on a family’s income level. This amount ranged  from $584 to $2,334 for individuals, and $1,193 to $4,770 for a family of  four, between 100 and 400 percent of the FPL in 2014. PPACA also  established out-of-pocket maximum costs that apply to QHPs and may  vary by income. premiums, which may be separately reduced through the application of  premium tax credits. QHPs may set out-of-pocket maximum costs that  are lower than those established by PPACA, which was the case for    For example, the selected QHP in  three of the five selected QHPs.Colorado had individual out-of-pocket maximum costs ranging from $750  to $6,300 for individuals between 100 and 400 percent FPL. This amount  was less than out-of-pocket maximum costs established under federal  law, which ranged from $2,250 to $6,350 for individuals between 100 and  400 percent FPL in 2014.
PPACA out-of-pocket maximum costs on EHB for households with incomes between  100 and 400 percent of the FPL in 2014 ranged from $2,250 to $6,350 for individuals and  $4,500 to $12,700 for families. In 2015, out-of-pocket maximum costs on EHB for  households with incomes between 100 and 400 percent of the FPL ranged from $2,250 to  $6,600 for individuals and from $4,500 to $13,200 for families.
Out-of-pocket maximum costs for SADPs are in addition to the out-of- pocket maximum costs for QHPs and may increase potential costs for  families who purchase them. In 2014, each exchange established  maximum out-of-pocket costs for SADPs, which do not include premiums.  Annual out-of-pocket maximum costs for selected SADPs for three of the  four selected SADPs were $700 for one child and $1400 for two or more  children.
section_title: Agency Comments
paragraphs: 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 offices, 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.
If you or your staffs 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 V.
section_title: Appendix I: Coverage for Selected Services in CHIP Plans and Qualified Health Plans (QHP) GAO Reviewed in Five States
paragraphs: Testing (screening  and/or exam)   The Patient Protection and Affordable Care Act (PPACA) allows exchanges in each state to make  available coverage of pediatric dental services as an embedded benefit in a QHP or through a stand- alone dental plan (SADP), which consumers may purchase separately. In exchanges with at least  one participating SADP, QHPs were not required to include the pediatric dental benefit. Consumers in  these five states were not required to purchase SADPs in 2014, even if their QHP did not include the  pediatric dental benefit.
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.  The plan covers bone anchored hearing aids and cochlear implants only. Bone anchored hearing  aids are used when traditional hearing aids are not efficient because of complications such as chronic  infections or blockage. Cochlear implants are for patients with severe hearing loss where traditional  amplification is no longer beneficial.  The plan covers care coordination and case management for children with special health care needs  only. Utah CHIP defines children with special health care needs as enrollees who have or are at  increased risk for chronic physical, developmental, behavioral, or emotional conditions and who also  require health and related services of a type or amount beyond that required by adults and children  generally.  Routine transportation includes transportation to and from medical appointments.  Routine transportation is covered for CHIP children greater than 142 and up to 209 percent of the  federal poverty level only.
section_title: Appendix II: Coverage Limits for Selected Services in CHIP Plans and QHPs GAO Reviewed in Five States
paragraphs: Tables 1 and 2 provide information on coverage limits for selected  services in State Children’s Health Insurance Program (CHIP) plans and  qualified health plans (QHP) in each of the five states we reviewed:  Colorado, Illinois, Kansas, New York, and Utah. For coverage limits on  pediatric dental services, see Appendix III.
section_title: Appendix III: Coverage, Coverage Limits, and Cost-Sharing for Selected Dental Services in CHIP Plans, QHPs, and SADPs
paragraphs: Tables 3 through 12 provide information on coverage, coverage limits,  and cost-sharing—deductibles, copayments, and coinsurance—for  selected dental services in State Children’s Health Insurance Program  (CHIP) plans we reviewed in five states: Colorado, Illinois, Kansas, New  York, and Utah; a qualified health plan (QHP) in New York; and stand- alone dental plans (SADP) in Colorado, Illinois, Kansas, and Utah. For  selected CHIP plans and the QHP in New York, we note differences in  cost-sharing amounts by income level. For selected SADPs, we note the  cost-sharing amounts for the “high” and “low” level options, which have  actuarial values of 85 and 70 percent, respectively.
For all five states, cost-sharing amounts were subject to out-of-pocket  maximum costs. For CHIP enrollees in each state, cost-sharing and  premium amounts were subject to a federally established out-of-pocket- maximum cost equal to 5 percent of a family’s income. For QHP  enrollees, issuers established an out-of-pocket maximum cost for each  plan that was equal to or less than the out-of-pocket maximum cost  established under the Patient Protection and Affordable Care Act  (PPACA). PPACA out-of-pocket maximum costs for households with  incomes between 100 and 400 percent of the federal poverty level (FPL)  in 2014 ranged from $2,250 to $6,350 for individuals and $4,500 to  $12,700 for families. In 2014, each exchange established out-of-pocket  maximum costs for SADPs. Annual out-of-pocket maximum costs for the  selected SADPs in Colorado, Illinois, and Kansas were $700 for one child  and $1400 for two or more children. The selected SADP in Utah imposed  an out-of-pocket maximum cost of $40 for the low plan and $20 for the  high plan. In contrast to CHIP, the out-of-pocket maximum costs for  QHPs and SADPs do not include premiums.
section_title: Appendix IV: Cost-Sharing for Selected Services in CHIP Plans and QHPs GAO Reviewed in Five States
paragraphs: Tables 13 through 17 provide information on cost-sharing—deductibles,  copayments, and coinsurance—for selected services in State Children’s  Health Insurance Program (CHIP) plans and qualified health plans (QHP)  we reviewed in five states: Colorado, Illinois, Kansas, New York, and  Utah. For selected CHIP plans and QHPs, we note differences in cost- sharing amounts by income level. For selected QHPs, these variations  reflect the cost-sharing subsidies that are available to certain enrollees.  For all five states, cost-sharing amounts were subject to out-of-pocket  maximum costs. For CHIP enrollees in each state, cost-sharing and  premium amounts were subject to a federally established out-of-pocket  maximum cost equal to 5 percent of a family’s income. For QHP  enrollees, issuers established an out-of-pocket maximum cost for each  plan that was equal to or less than out-of-pocket maximum costs  established under the Patient Protection and Affordable Care Act  (PPACA). PPACA out-of-pocket maximum costs for households with  incomes between 100 and 400 percent of the federal poverty level (FPL)  in 2014 ranged from $2,250 to $6,350 for individuals and $4,500 to  $12,700 for families. These out-of-pocket maximum costs do not include  costs associated with services provided through a SADP and, in contrast  to CHIP, these out-of-pocket maximum costs do not include premiums.
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Susan T. Anthony, Assistant  Director; Sandra George; John Lalomio; Laurie Pachter; and Teresa Tam  made key contributions to this report.
section_title: Related GAO Products
paragraphs: Children’s Health Insurance: Cost, Coverage, and Access Considerations  for Extending Federal Funding. GAO-15-268T. Washington, D.C.:  December 3, 2014.
Children’s Health Insurance: Information on Coverage of Services, Costs  to Consumers, and Access to Care in CHIP and Other Sources of  Insurance. GAO-14-40. Washington, D.C.: November 21, 2013.
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.