Children's Health Insurance Program: Effects on Coverage and Access, and Considerations for Extending Funding
Released: 2015-03-30T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: CHIP is a joint federal-state program that finances health insurance for over 8 million children. Since the program's inception, the percentage of uninsured children nationwide has decreased by half, from 13.9 percent in 1997 to 6.6 percent in the first three months of 2014. This year, Congress will decide whether to extend CHIP funding beyond 2015.

GAO was asked to provide information on the effect of CHIP on children's coverage, and what key issues may be considered in determining the ongoing need for CHIP. In this report, GAO examines (1) what assessments of CHIP suggest about its effect on children's health care coverage and access; and (2) what key issues identified by GAO's work the Congress may wish to consider in determining whether to extend CHIP funding.

For the assessments of CHIP's effect, GAO reviewed reports on CHIP, including a mandated evaluation and annual HHS reports on quality, which publish data that states report on Child Core Set measures, which are quality measures identified by HHS that states can use to monitor health care provided to children in CHIP and Medicaid. GAO also reviewed relevant federal statutes and regulations. To identify key issues that the Congress may wish to consider, GAO reviewed its own relevant reports and testimony; reviewed letters from state governors regarding CHIP; and interviewed CHIP officials in 10 states, which were selected based on variation in location, program size, and design.

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

section_title: What GAO Found
paragraphs: Assessments of national data GAO reviewed identify positive effects of the State Children's Health Insurance Program (CHIP), and the quality measures reported by states help identify areas needing improvement.

A mandated evaluation of CHIP published in 2014 noted that CHIP enrollees (1) had substantially better access to care, service use, and preventive care when compared with uninsured children; and (2) experienced comparable access and service use when compared with privately insured children. These findings are generally consistent with prior GAO work, which used national survey data to compare CHIP enrollees' access and service use with children who were uninsured or privately insured. When comparing CHIP enrollees with privately insured children, the mandated evaluation and prior GAO work differed regarding the utilization of certain services, such as emergency room use and dental services, which may be due to differences in when the data were collected and the particular measures that were used.

The Department of Health and Human Services (HHS) also publishes data on quality measures that states voluntarily report annually. These Child Core Set measures show mixed results regarding service utilization among CHIP and Medicaid enrollees. For example, states reported that nearly all children aged 12 to 24 months enrolled in CHIP or Medicaid had at least one primary care physician visit during fiscal year 2013. However, states reported that far fewer children obtained dental prevention or treatment services, with a mean of 46 percent of children receiving a preventive dental service, and a mean of 25 percent receiving dental treatment services. HHS officials said that they use these data to help identify areas for improvement in the care provided in CHIP and Medicaid.

GAO's prior work has identified important issues related to cost, coverage, and access that Congress may wish to consider when determining the ongoing need for CHIP, many of which were similar to issues raised by officials from the 10 states GAO reviewed.

With regard to cost, GAO's prior work found that costs—defined as deductibles, copayments, coinsurance, and premiums—were almost always less for selected CHIP plans when compared with states' benchmark health plans, which were the models for health plans available in health insurance exchanges established under the Patient Protection and Affordable Care Act. Officials in five states expressed concerns about the higher cost of exchange plans compared with CHIP and the implications for families' finances.

With regard to coverage, GAO previously reported that selected CHIP and state benchmark plans were generally similar in terms of their coverage of selected services and the services on which they imposed limits. However, officials from several of the 10 states pointed out that for many services needed by children with special health care needs, CHIP coverage was more comprehensive than exchange plans.

With regard to access, several states raised concerns about negative implications for children's coverage if CHIP funding is not reauthorized, including concerns that their states would lose gains made in covering children, who would also lose access to providers and dental care.

section_title: Letter
paragraphs: The State Children’s Health Insurance Program (CHIP), a joint federal- state program that was established by Congress in 1997, finances health  insurance for over 8 million children whose household incomes are above  the threshold for Medicaid eligibility. Prior to CHIP, private health  insurance coverage for children had been declining every year since  1987—reaching its lowest level of about 66 percent of children in 1994.  While Medicaid helped to cushion the effect of this decline, many of the  children losing coverage were ineligible for Medicaid coverage. Since the  inception of CHIP, the percentage of uninsured children nationwide has  decreased by half, from 13.9 percent in 1997 to 6.6 percent in the first   3 months of 2014. The Centers for Medicare & Medicaid Services  (CMS), within the Department of Health and Human Services (HHS),  oversees CHIP, with states designing, managing, and administering the  operations of their individual programs. 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.

Over the course of the program, Congress has enacted legislation at  various times authorizing continued funding for CHIP. Most recently, the  Patient Protection and Affordable Care Act (PPACA) appropriated federal  CHIP funding through fiscal year 2015. PPACA 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. If such  children are determined to be ineligible for Medicaid, the children may be  enrolled in a qualified health plan (QHP)—which are plans offered by  private issuers through health insurance exchanges in that state—that  has been certified as comparable to CHIP by the Secretary of HHS, if  such a QHP is available. Over the longer term, PPACA requires states to  maintain eligibility levels for children in CHIP and Medicaid until fiscal  year 2019. Thus, under current law, some states could choose to  eliminate or scale back their programs beginning in fiscal year 2020, even  if federal funds are available.

Given that the Congress will decide whether to extend CHIP funding  beyond 2015, you asked us to provide information about the effect that  CHIP has had on children’s health care, and what key issues may be  considered in determining the ongoing need for the CHIP program. In this  report, we examine (1) what assessments of CHIP suggest about the  effect of the program on children’s health care coverage and access  across states; and (2) what key issues the Congress may wish to  consider in determining whether to extend CHIP funding.

To examine what assessments of CHIP suggest about the program’s  effect, we synthesized information from HHS reports on CHIP, including a  mandated national evaluation on the evolution of the program (referred to  as the mandated evaluation) and its role in providing health coverage to  low-income children. We also reviewed HHS’s annual CHIP and  Medicaid reports on quality for fiscal years 2011 through 2014, relying  primarily on the 2014 report (referred to as the annual quality report),  which use state-reported data to assess the quality of care provided to  children enrolled in CHIP and Medicaid for the applicable fiscal year, and  a series of issue briefs on state practices to improve the quality of care for  children enrolled in these programs. To obtain information on state CHIP  reporting requirements and states’ efforts to report data for the annual  quality report, we reviewed federal statutes and regulations governing  CHIP; and interviewed CHIP officials from 10 states, which were selected  based on variation in states’ CHIP program design, income eligibility   The 10  level, program enrollment, and states’ rate of uninsured children.selected states were Alaska, Arizona, Indiana, Mississippi, Nevada, New  Hampshire, Pennsylvania, Rhode Island, South Carolina, and Wisconsin.  For the purposes of the annual quality report, states have the option to  report CHIP and Medicaid data separately, but commonly report  combined data for the two programs. We supplemented HHS’s findings  with relevant findings from our own issued reports, when applicable.

To identify key issues that the Congress may wish to consider in  determining whether to extend funding for CHIP, we reviewed relevant  reports and testimony that we issued from February 2009 through  December 2014. In addition, we interviewed CHIP officials in selected  states about considerations for the extension of CHIP funding, and  reviewed letters from state governors regarding their respective programs  and implications for the future of CHIP.

We conducted this performance audit from November 2014 through  February 2015 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: Federal law provides states with flexibility in how they operate their CHIP  programs and how states implement more recent coverage options under  PPACA. For example, states may operate CHIP as a separate program,  include CHIP-eligible children in their Medicaid programs, or use a  combination of the two approaches. States with separate CHIP  programs may modify certain aspects of their programs, such as  coverage and cost-sharing requirements.regulations require states’ separate CHIP programs to include coverage   However, federal laws and  for routine check-ups, immunizations, inpatient and outpatient hospital  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.” In addition, CHIP premiums and cost- sharing may not exceed maximum amounts as defined by law. Similarly,  PPACA provides states with flexibility in how they opt to implement  certain coverage options included in the law. For example, PPACA allows  states to expand eligibility for Medicaid to most non-elderly, non-pregnant  adults who are not eligible for Medicare and whose income is at or below  133 percent of the FPL. As of January 2015, 29 states have  implemented this expansion. PPACA required the establishment of  health insurance exchanges by January 1, 2014, to allow consumers to  compare individual health insurance options available in each state and  enroll in coverage. In states electing not to operate their own exchange,  PPACA required the federal government to establish and operate an  exchange in the state, referred to as a federally facilitated exchange.  States with federally facilitated exchanges may enter into a partnership  with HHS to assist with the operation of certain exchange functions. As  such, a state could establish the exchange (referred to as a state-based  exchange), cede the responsibility entirely to HHS (referred to as a  federally facilitated exchange), or enter into a partnership with HHS  (referred to as a partnership exchange). As of January 2015, 17 states  established state-based exchanges, 27 states were using the federally  facilitated exchange, and 7 states established partnership exchanges.See fig. 1 for information on the variation in children’s uninsured rates,  CHIP characteristics, and coverage approaches under PPACA by state;  and see appendix I for the information in tabular form.

The Children’s Health Insurance Program Reauthorization Act of 2009  (CHIPRA) included provisions aimed at improving the information  available from states on the quality of health care furnished to children in  both CHIP and Medicaid. Specifically, CHIPRA required the Secretary  of HHS to conduct an independent evaluation of CHIP and to submit the  results to Congress. The mandated evaluation, for which the final report  was issued in August 2014, documents what is known about CHIP;  explores the program’s evolution since inception; and examines the role  CHIP has played in covering low-income children. In addition, CHIPRA  required HHS to identify quality measures, known as the Child Core Set  measures, to serve as a tool for states to use to monitor and improve the  quality of health care provided to children enrolled in CHIP and Medicaid.  CHIPRA also required HHS to develop a standardized format for states to  voluntarily report these measures. These measures assess the quality of  care provided through CHIP and Medicaid, and include a range of health  conditions, such as asthma, obesity, attention deficit hyperactivity  disorder, and perinatal care. (See table 1.)

In 2013, as required by CHIPRA, HHS began annually publishing  recommended changes to the Child Core Set measures in an effort to  improve upon the measures and align them with national quality  measurement activities, which can result in changes to the number of  measures. With the use of state reported data on the Child Core Set,  HHS conducts an annual assessment and publishes its findings in its  annual quality report, as required under CHIPRA. States report CHIP  service utilization and other measures through systems developed by  HHS; specifically, the CHIP Annual Reporting Template System  (CARTS), a web-based data submission tool, and through the Form  CMS-416, an annual report submitted by states on the Medicaid Early  and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit  provided for enrolled children. States that use managed care plans to  deliver CHIP benefits are also required to report outcomes and  performance measures from External Quality Review Organizations and  performance improvement projects.

In February 2010, CMS awarded 10 grants—which funded 18 states to implement  projects that include using quality measures to improve child health. CMS also provided  funding to AHRQ to lead a national evaluation of these demonstrations, to be completed  by September 30, 2015. electronic health records, and (5) assessing the utility of other innovative  approaches to enhance quality.

section_title: Assessments of National Data Largely Show Positive Effect of CHIP on Coverage and Access, and Identify Areas for Improvement
paragraphs: Available assessments of national data we reviewed identify positive  effects of CHIP, including a reduction in the rate of uninsured children and  children’s improved access to care, and these findings are often  consistent with our prior work. HHS also has ongoing efforts to enhance  state reporting of the Child Core Set measures and publishes data from  these quality measures to identify areas for improving the care provided  in CHIP.
subsections: section_title: Mandated Evaluation Highlights Reduction in the Rate of Uninsured Children and Improved Access to Health Care
paragraphs: HHS’s mandated evaluation identified several positive effects of CHIP  across states, particularly with regard to children who are uninsured. For  example, based on an analysis of data from the Current Population  Survey Annual Social and Economic Supplement (CPS-ASEC), the  evaluation reported that Medicaid and CHIP contributed to the decline in  the national rate of uninsured children between 1997 and 2012, with  coverage rates improving for all ethnic and income groups.notably, coverage rates for Hispanic children increased dramatically,  rising from 42 percent to 65 percent during this time. Changes to state  CHIP programs also contributed to the decline in the national uninsured  rates among children. For example, many states expanded CHIP  coverage by raising upper income eligibility limits and covering newly  eligible groups, such as immigrant children who have resided legally in  the United States for less than 5 years, which was newly permitted under   Most  federal law. In addition, state outreach and enrollment activities also  reduced the number of children eligible for—but not enrolled in—Medicaid  or CHIP by about 1.2 million from 2008 to 2012.

To determine whether factors other than insurance coverage may affect differences in  responses about obtaining care or utilization of health care services, the mandated  evaluation controlled for age, sex, race/ethnicity and language groups, more than three  children in the household, highest education of any parent, parents’ employment status,  parent citizenship, and local area or county.

CHIP enrollees were an estimated 38 percentage points more likely   to have a usual source of dental care, and were an estimated   39 percentage points more likely to have had a dental check-up in the  past year;

CHIP enrollees were an estimated 25 percentage points more likely to  have an annual well-child checkup visit, and were more likely to  receive a range of health services, including mental health visits,  specialty care, and prescription drugs;

CHIP enrollees were more likely to receive most preventive care  measures, including flu vaccinations, vision screenings, and height  and weight measurements; and parents of CHIP enrollees were less likely to report having trouble  paying their child’s medical bills, and were substantially more  confident in their ability to get needed health care for their child.

Based on our assessment of HHS’s Medical Expenditure Panel Survey  from 2007 through 2010, we also found that children enrolled in CHIP  have better access to care and service use than children who are  uninsured. In particular, when compared with uninsured children, we  found that CHIP enrollees fared better, and the differences we identified  were statistically significant in most cases. For example, a higher proportion of CHIP respondents reported having a usual source of care; ease in getting a person the care,  tests, or treatment that the parent or a doctor believed necessary; and  ease in seeing a specialist; and using certain health care services, including office-based provider  visits, outpatient department provider visits, and dental care visits.

When the mandated evaluation compared CHIP enrollees with the  privately-insured group, it also found that CHIP enrollees experienced  comparable access and service use for many, but not all, measures, and  that parents of children enrolled in CHIP experienced less financial  burden in paying their children’s medical bills.

CHIP enrollees used a similar level of preventive care and other  health care services; however, CHIP enrollees had higher usage of  prescription medication and lower levels of emergency department  visits and hospital stays.

CHIP enrollees had similar rates of health and development  screenings, but were 9 percentage points less likely to receive a flu  vaccination.

CHIP enrollees had higher rates of dental access and utilization of  certain services. For example, 92 percent of CHIP enrollees reported  having access to dental coverage in 2012, compared with 77 percent  of privately insured children. In terms of utilization, 84 percent of CHIP  enrollees reported having a dental checkup or cleaning in the previous  12 months compared with 79 percent of privately insured children.

Parents of CHIP enrollees reported substantially less trouble paying  their children’s medical bills and had much lower out-of-pocket  spending levels.

For our assessment of the Medical Expenditure Panel Survey, we also  compared CHIP enrollees’ access and service use with children who  were privately-insured, and our findings were consistent with some of the  findings in the mandated evaluation.

When asked about access to care, we found that respondents with  children enrolled in CHIP reported experiences that were generally  comparable with privately insured children for 5 of the 6 measures  reviewed, including having a usual source of care; ability to make  needed appointments; and ease in seeing a specialist.

Respondents’ reported ease in getting needed care was the only measure for which we  identified a statistically significant difference.

CHIP families faced a lower financial burden than families with private  insurance because of the federal requirement that states’ CHIP  programs 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.

However, with regard to the utilization of certain services, our prior work is  less consistent with the findings of HHS’s mandated evaluation. For  example, when asked about their use of certain medical and dental  services, we found that access to care for CHIP enrollees was lower than  that of the privately-insured for several services, and these differences  were often statistically significant. Specifically, we previously reported that a lower proportion of CHIP enrollees reported visiting dentists   (42.4 percent compared with 50.9 percent) and orthodontists   (4.9 percent compared with 11.2 percent) within the past 12 months  than did those who were privately insured; and a higher proportion of CHIP enrollees reported having an emergency  room visit (14.1 percent compared with 10.4 percent).

Differences between our findings and those included in the national  evaluation may be related to the timeframes of the data and the  measures used. For example, some of the data used in our analyses  predate the CHIPRA requirement that CHIP programs offer  comprehensive dental benefits coverage beginning in 2009. The  timeframes for both bodies of work also predate the implementation of the  PPACA requirement that most individual and small group market health  plans provide pediatric dental coverage.

Finally, while the mandated evaluation noted that, overall, CHIP programs  were meeting the health care needs of most enrollees, it identified areas  for program improvement. Specifically, many CHIP enrollees did not  receive recommended preventive care or reported an unmet health care  need. For example, slightly less than half of CHIP enrollees received a flu  vaccination, and only about one-third received a developmental screening  for children under age 6. In addition, one in four CHIP enrollees had an  unmet health care need, with the highest unmet need being for dental  care.

section_title: HHS Has Ongoing Efforts to Enhance State Reporting of Quality Measures and Identify Areas for Improvement to Care Provided in CHIP
paragraphs: HHS publishes data that states report on the Child Core Set measures in  its annual quality report. While reporting on the Child Core Set measures  is voluntary for states, the number of states reporting these quality  measures and the median number of measures each state reports has  increased steadily since reporting of the measures began in 2010. For  example, beginning in fiscal year 2012, all 51 states have reported at  least two or more measures, a notable increase from the 43 states that  reported at least one measure for fiscal year 2010. Similarly, the median  number of Child Core Set measures that states report has increased from  about 7 measures in fiscal year 2010 to 16 measures in fiscal year 2013.  HHS attributed the rise in state reporting to increased familiarity with the  Child Core Set measures and the department’s efforts to streamline state  reporting and provide technical assistance and guidance to states. For  example, CMS established a Quality Measures Technical Assistance and  Analytic Support Program in May 2011, which works with states to  support their efforts in collecting, reporting, and using quality measures  for their CHIP and Medicaid programs.

However, states varied considerably in the number of measures they  reported in fiscal year 2013, ranging from 2 measures in Nebraska and  Wisconsin to 25 measures in North Carolina and South Carolina. (See   fig. 2.)

Several factors can affect a state’s ability to report the Child Core Set  measures. Officials from the states we reviewed provided the following  examples of challenges they face reporting the Child Core Set measures.

Mississippi and Pennsylvania officials cited difficulty reporting certain  measures, such as the extent of follow-up care for children prescribed  medication for attention-deficit/hyperactivity disorder, due, in part, to  their not having access to the data required to report the measure.

Arizona, New Hampshire, Nevada, and Wisconsin officials cited the  difficulty and cost of reporting certain measures, in particular those  measures that require medical record reviews as opposed to the  reporting of measures that use only encounter data. For example,  HHS suggests that medical record reviews be used to calculate a  perinatal measure related to the performance of caesarean sections  and none of these states reported this measure in fiscal year 2013.

Rhode Island officials noted that it can be difficult to collect data for  measures that are not nationally endorsed—and as a result, they may  not report them. For example, in fiscal year 2013, Rhode Island did  not report the Child Core Set measure of a developmental screening  in the first 3 years of a child’s life, which had not been endorsed by  the National Committee for Quality Assurance, but developed by a  university in Oregon.

Noting that the state does not have a department dedicated to  measuring quality, Alaska cited a lack of internal expertise needed to  collect and report reliable data for the measures. As such, an official  cited the need to leverage resources and work with other agencies  within the state that have the expertise to analyze measures and set  targets for quality improvement.

In light of difficulties cited by states in reporting on the Child Core Set  measures, HHS reported ongoing efforts to assist states with reporting  the measures. For example, to streamline state reporting, HHS began  calculating three Child Core Set measures on behalf of states in fiscal  year 2012. Specifically, HHS began calculating the preventive dental and  dental treatment measures from the Form CMS-416. At this time, HHS  also began using data available from the Centers for Disease Control and  Prevention to calculate the neonatal central-line associated blood stream  infection measure. In addition, HHS assists states by allowing states to  report Child Core Set measures for the Medicaid population, CHIP  population, or combined Medicaid and CHIP populations.

Additionally, HHS reported efforts to assist states in improving their  reporting of the Child Core Set measures through the Quality  Demonstration Grant Program. Through this program, HHS awarded   10 grants providing funding to 18 states to implement various projects to  improve the information available on the quality of care provided to  children enrolled in CHIP, including undertaking efforts to improve their  reporting of the Child Core Set measures. For example, in one such  project, Pennsylvania is testing the use of financial rewards to encourage  certain health systems—which include hospitals, primary care practice  sites, and other facilities—to use the Child Core Set measures to drive   Pennsylvania also reported that it is  quality improvement projects.recruiting health systems to determine the extent to which electronic  health records can provide data for the Child Core Set measures for  children.

From the measures submitted by states, HHS reports states’ performance  to assess the quality of care for children enrolled in CHIP and Medicaid,  and the results of this assessment are mixed. HHS calculates mean  rates for most of the Child Core Set measures—which it calls  performance rates—including primary and preventive care, perinatal  health, management of acute and chronic conditions, and dental services,  among the states reporting those measures. Based on this assessment,  HHS determined that states had high performance rates for some  measures, such as young children’s access to primary care. For example,  a mean of 96 percent of children aged 12 to 24 months enrolled in CHIP  or Medicaid had at least one primary care physician visit during fiscal year  2013. In contrast, states had lower performance rates for other  measures. For example, a mean of 46 percent of children received at  least one preventive dental service, and a mean of 25 percent of children   (See table 2.)  received at least one dental treatment in fiscal year 2013.As such, HHS specified that children’s access to oral health care  continues to be a primary focus of improvement efforts in CHIP and  Medicaid.

In addition to HHS’s review of states’ reporting on the Child Core Set  measures, the department’s annual quality report includes the results of  its review of external quality review reports and performance  improvement projects from states that contract with managed care plans  to deliver services for CHIP and Medicaid enrollees. States are required  to annually review their managed care plans to evaluate the quality,  timeliness, and access to services that the plans provide to enrollees, and  HHS must include this information in its annual quality report. For the  most recent annual quality report, 40 of the 42 states that contract with  managed care plans to deliver services to CHIP and Medicaid enrollees   Based on its review of these  submitted external quality review reports.reports, HHS found that the most frequently reported performance  measures from states’ external quality reports—which included well-child  care, primary care access, childhood immunization rates, and  prenatal/postpartum care—mirrored states’ most frequently reported Child  Core Set measures in fiscal year 2013. In terms of HHS’s review of  states’ performance improvement projects, 38 of the 40 states that  submitted external quality review reports included at least one project  targeted to improve the quality of care for children and pregnant women  enrolled in managed care; for example, by implementing projects related  to behavioral health and improving childhood immunization rates for  children, and prenatal and postpartum care for pregnant women.

section_title: Cost, Coverage, and Access to Care Are Key Considerations in Determining the Reauthorization of CHIP Funding
paragraphs: Our prior work has identified important considerations related to cost,  coverage, and access when determining the ongoing need for CHIP,  many of which were echoed by officials from the 10 states we reviewed.  With regard to cost, our prior work comparing CHIP plans to states’  benchmark plans, which were the models for health plans available under  health insurance exchanges established under PPACA, found that  costs—defined as deductibles, copayments, coinsurance, and  premiums—were almost always less for CHIP plans.

CHIP plans we reviewed typically did not require the payment of  deductibles, while all five states’ benchmark plans did.

The cost difference in copayments between CHIP plans and  benchmark plans was considerable 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.

Families could face higher dental costs in states where dental  coverage through the exchange is optional and offered as a stand- alone dental plan (SADP) as opposed to CHIP plans where dental  benefits are included.

Officials from five selected states also expressed concerns about the  higher costs of QHP coverage and the implications this would have for  families.

See GAO-14-40. The five states evaluated in our prior work were Colorado, Illinois,  Kansas, New York, and Utah. These findings were subsequently discussed in a hearing  before the Subcommittee on Health, Committee on Energy and Commerce, House of  Representatives on December 3, 2014. See GAO, Children’s Health Insurance: Cost,  Coverage, and Access Considerations for Extending Federal Funding. GAO-15-268T  (Washington, D.C.: Dec. 3, 2014); We are currently examining how CHIP coverage and  consumer costs compare to selected QHPs that were available on the exchanges in these  five states in 2014.

Based on a review of QHPs available on the state’s exchange in  2014, Nevada officials estimated that the average annual premium for  a child in a family with an income of 168 percent of the FPL was more  than two and a half times higher than the $200 premium for coverage  in a CHIP plan. This price difference does not account for differences  in co-pays, which the state does not charge under CHIP. The extent  to which QHPs in the state apply co-pays to covered services could  increase this price differential further. As such, Nevada officials were  concerned that absent CHIP, families would not purchase QHP plans  due to their higher cost.

Due to the additional premiums and cost-sharing associated with  SADPs, New Hampshire officials expressed concern that families will  forego dental care if they must purchase a SADP. The officials noted that cost-sharing particularly affects families with incomes from  185 to 250 percent of the FPL, which is 75 percent of the state’s CHIP  population.

We also previously reported that coverage is a relevant consideration,  and that separate CHIP and benchmark plans were generally similar in  terms of their coverage of selected services and the services on which  they imposed limits, with some variation. For example, the plans we reviewed were similar in that they typically did not impose any limits on  ambulatory patient services, emergency care, preventive care, or  prescription drugs; but commonly imposed limits on outpatient therapies,  and pediatric dental, vision, and hearing services. Officials from several  selected states pointed out that CHIP coverage was more comprehensive  than QHPs for certain services, particularly for services needed by  children with special health care needs.

Alaska and Pennsylvania officials noted that coverage of services— including orthodontics, vision, audiology, outpatient therapies,  language disorders, and durable medical equipment—was more  comprehensive in CHIP when compared with QHPs in their states.

Rhode Island officials highlighted the state’s coverage of  comprehensive pediatric dental services and any medically necessary  services deemed warranted as a result of the EPSDT benefit to which  all CHIP-eligible children in the state are entitled. According to the  state officials, these same services are either unavailable or  unaffordable through QHPs in the state.

Arizona officials specified that coverage of certain enabling services,  such as non-emergency medical transportation, family support  services, and behavioral health services are included in the state’s  CHIP plan, but may not be offered in QHPs.

With regard to access, our work found that CHIP enrollees generally  reported positive responses in their ability to obtain care that was  generally comparable to those with private insurance, with some  exceptions, including lower utilization of dental and orthodontia services.  Some of the states we reviewed also raised concerns related to access to  care if CHIP funding is not reauthorized. For example, Nevada officials  raised concerns about the ability of certain populations—specifically,  children of undocumented parents—to access care if CHIP is no longer  available. Nevada officials stated that these children could lose CHIP  coverage since a significant portion of them have parents who may not  file federal income tax returns that would expose them to tax penalties for  failing to enroll their children in alternative health coverage. In addition, an  Alaska official noted the need for further work on the comparability of  benefits between QHPs and CHIP to ensure that the former could be an  adequate substitute, and that children moving to QHPs would not  experience decreased access to health care. The official noted that  comparability across benefit packages is particularly important for  children in households whose income changes would result in movement  between CHIP and QHPs.

section_title: Agency Comments
paragraphs: We provided a draft of this report to HHS for comment. The department  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. 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  me at (202) 512-7114 or yocomc@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: Uninsured Rates, State Children’s Health Insurance Program (CHIP) Characteristics, and Coverage Approaches
subsections: section_title: Percentage of uninsured children in 2013
paragraphs: Act (PPACA)

section_title: Percentage of uninsured children in 2013
paragraphs: Act (PPACA)

section_title: State Texas
paragraphs: Act (PPACA)

As of February 2015, 42 states operated separate CHIP programs (2 states had a separate CHIP  program only, and 40 states covered CHIP children through both a separate program and an  expansion of their Medicaid program). The other 9 states covered CHIP children through an  expansion of their Medicaid program, which we refer to as a “CHIP Medicaid expansion.”  Minnesota and New Mexico have CHIP income eligibility levels that vary by age group; therefore, we  reported the highest income eligibility level reported for these states—which are ages 0 to 1 year in  Minnesota and ages 0 to 5 years in New Mexico.  These state-based marketplaces use the federally facilitated marketplace’s information technology  platform for applicants to apply and enroll in their respective states.

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, Susan T. Anthony,   Assistant Director; Sandra George; Seta Hovagimian; Drew Long;   JoAnn Martinez-Shriver; Vikki Porter; Lisa Rogers; Eden Savino;    Laurie F. Thurber; and Kate Tussey made key contributions to this   report.

section_title: Related GAO Products
paragraphs: Health Care Transparency: Actions Needed to Improve Cost and Quality.  GAO-15-11. Washington, D.C.: October 20, 2014.

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.

State Children’s Health Insurance Program: CMS Should Improve Efforts  to Assess whether SCHIP Is Substituting for Private Insurance.   GAO-09-252. Washington, D.C.: February 20, 2009.

Health Insurance For Children: Private Insurance Coverage Continues to  Deteriorate. GAO/HEHS-96-129. Washington, D.C.: June 17, 1996.


Question-summary annotations: questions: question: What are some advantages that CHIP enrollees have over uninsured and privately insured children?
answer: A mandated evaluation of CHIP published in 2014 noted that CHIP enrollees (1) had substantially better access to care, service use, and preventive care when compared with uninsured children; and (2) experienced comparable access and service use when compared with privately insured children.
child_questions: question: How are the findings of the mandated evaluation of CHIP supported by previous studies?
answer: These findings are generally consistent with prior GAO work, which used national survey data to compare CHIP enrollees' access and service use with children who were uninsured or privately insured.

question: How did the findings of the mandated evaluation differ from prior GAO work?
answer: When comparing CHIP enrollees with privately insured children, the mandated evaluation and prior GAO work differed regarding the utilization of certain services, such as emergency room use and dental services, which may be due to differences in when the data were collected and the particular measures that were used.
child_questions: question: What could have caused this difference?
answer: When comparing CHIP enrollees with privately insured children, the mandated evaluation and prior GAO work differed regarding the utilization of certain services, such as emergency room use and dental services, which may be due to differences in when the data were collected and the particular measures that were used.

questions: question: How do the Child Core Set measures reported by states show mixed results regarding service utilization among CHIP and Medicaid enrollees?
answer: These Child Core Set measures show mixed results regarding service utilization among CHIP and Medicaid enrollees. For example, states reported that nearly all children aged 12 to 24 months enrolled in CHIP or Medicaid had at least one primary care physician visit during fiscal year 2013. However, states reported that far fewer children obtained dental prevention or treatment services, with a mean of 46 percent of children receiving a preventive dental service, and a mean of 25 percent receiving dental treatment services.
child_questions: question: What does the HHS use these data for?
answer: HHS officials said that they use these data to help identify areas for improvement in the care provided in CHIP and Medicaid.

question: How did the utilization of dental services by children compare to that of primary care services in the fiscal year 2013?
answer: For example, states reported that nearly all children aged 12 to 24 months enrolled in CHIP or Medicaid had at least one primary care physician visit during fiscal year 2013. However, states reported that far fewer children obtained dental prevention or treatment services, with a mean of 46 percent of children receiving a preventive dental service, and a mean of 25 percent receiving dental treatment services.

questions: question: How did GAO assess the effect of CHIP?
answer: For the assessments of CHIP's effect, GAO reviewed reports on CHIP, including a mandated evaluation and annual HHS reports on quality, which publish data that states report on Child Core Set measures, which are quality measures identified by HHS that states can use to monitor health care provided to children in CHIP and Medicaid.

question: How did GAO identify key issues that the Congress may wish to consider?
answer: To identify key issues that the Congress may wish to consider, GAO reviewed its own relevant reports and testimony; reviewed letters from state governors regarding CHIP; and interviewed CHIP officials in 10 states, which were selected based on variation in location, program size, and design.
child_questions: question: How were the states in which to interview CHIP officials selected?
answer: To identify key issues that the Congress may wish to consider, GAO reviewed its own relevant reports and testimony; reviewed letters from state governors regarding CHIP; and interviewed CHIP officials in 10 states, which were selected based on variation in location, program size, and design.