Children's Health Insurance: Information on Coverage of Services, Costs to Consumers, and Access to Care in CHIP and Other Sources of Insurance
Released: 2013-12-20T00:00:00

Letter

Background

Consumers may obtain health insurance from a variety of public and private sources, which can help protect them from the costs associated with obtaining medical care. Health insurance typically includes costs to consumers, which may vary for a number of factors, including scope of coverage, cost-sharing provisions, and federal or state requirements. Recent federal laws —specifically, PPACA and the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA)—further define coverage and cost parameters for certain health insurance plans available to consumers now and in 2014, when exchanges are required to be operational, and include provisions to increase children’s access to coverage.

Coverage and Cost Requirements for CHIP

Unlike states that opt to include coverage for eligible children under a CHIP-funded expansion of Medicaid, and therefore, must extend Medicaid covered services to CHIP-eligible individuals, states with separate CHIP programs have flexibility in program design and are at liberty to modify certain aspects of their programs, such as coverage and cost-sharing requirements. For example, federal laws and regulations allow states with separate CHIP programs to offer one of four types of health benefit coverage and, regardless of the benefit coverage option states choose, require states’ separate CHIP programs to include coverage for routine check-ups, immunizations, and emergency services. States typically cover a broad array of services in their separate CHIP programs and, in some states, adopt the Medicaid requirement to cover Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. Effective October 1, 2009, CHIPRA required CHIP plans to cover dental services defined as “necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.” CHIPRA also required states to comply with mental health parity requirements—meaning they must apply any financial requirements or limits on mental health or substance abuse benefits under their separate CHIP plans in the same manner as applied to medical and surgical benefits. States covering EPSDT services under separate CHIP plans were deemed to comply with these requirements.

With respect to costs to consumers, CHIP premiums and cost-sharing may not exceed minimum amounts as defined by law. States may vary CHIP premiums and cost-sharing based on income and family size, as long as cost-sharing for higher-income children is not lower than for lower-income children. Federal laws and regulations also impose additional limits on premiums and cost-sharing for children in families with incomes at or below 150 percent of the federal poverty level (FPL). For example, the range of copayments was $1.15 to $5.70 per service in 2009 for children in families with incomes between 100 and 150 percent of FPL. In all cases, no cost-sharing can be required for preventive services—defined as well-baby and well-child care, including age- appropriate immunizations and pregnancy-related services. In addition, states may not impose premiums and cost-sharing, in the aggregate, that exceed 5 percent of a family’s total income for the length of the child’s eligibility period in CHIP.

Children’s access to affordable health insurance and health care can be affected by many different factors, and CHIPRA and PPACA also contain provisions to facilitate eligible children’s access to CHIP. For example, CHIPRA appropriated funding for state and other organization outreach grants to help increase enrollment of CHIP-eligible children for federal fiscal years 2009 through 2013 and performance bonuses for simplifying CHIP enrollment and retention by applying certain program reforms. PPACA provisions that aim to facilitate eligible children’s access to CHIP include appropriating additional funding for CHIPRA outreach grants through federal fiscal year 2015. PPACA also requires states to maintain CHIP eligibility standards for children through September 2019. In accordance with this requirement, states are prohibited from increasing existing premiums or imposing new premiums except in limited circumstances.

Coverage and Cost Requirements for QHPs

PPACA requires the establishment of exchanges in all states by January 1, 2014, to allow consumers to compare health insurance options available in that state and enroll in coverage. The exchanges will offer QHPs that are certified and are offered by participating issuers of coverage. PPACA further requires QHPs offered through an exchange to comply with applicable private insurance market reforms, including relevant premium rating requirements, the elimination of lifetime and annual dollar limits on essential health benefits, prohibition of cost-sharing for preventive services, mental health parity requirements, and the offering of comprehensive coverage. With respect to comprehensive coverage, PPACA requires QHPs offered through an exchange to cover 10 categories of EHBs, limit cost-sharing associated with this coverage, and provide one of four levels of coverage determined by the plan’s actuarial value.

By the end of December 2012, states had either selected a base- benchmark plan or been assigned the default base-benchmark plan by HHS. In over 80 percent of states, the largest plan by enrollment in the largest product by enrollment in the state’s small group market was established as the base-benchmark plan. In addition, in states where the base-benchmark plan did not include coverage for pediatric dental or vision services, the state (or HHS, in the case of a federally established default benchmark plan) was required to supplement coverage with the addition of the entire category of pediatric dental or vision benefits from either (i) the Federal Employees Dental and Vision Insurance Program (FEDVIP) dental or vision plan with the largest national enrollment of federal employees, or (ii) the benefits available under the plan in the state’s separate CHIP program with the highest enrollment, if a separate CHIP program existed. PPACA also allows exchanges in each state the option of providing pediatric dental services using a stand-alone dental plan (SADP). In exchanges with at least one participating SADP, QHPs will have the option of excluding pediatric dental benefits from their covered services.

In Five States, Coverage in CHIP and Benchmark Plans Was Generally Comparable; These States Expect Minimal Changes to CHIP and QHPs to Reflect PPACA Requirements in 2014

In our five selected states, CHIP and benchmark plans generally covered the services we reviewed and were similar in terms of the services on which they imposed day, visit, or dollar limits. CHIP officials in our selected states expected minimal or no changes to CHIP coverage in 2014, and that the QHPs offered through the exchanges would reflect states’ benchmark plans and PPACA requirements.

Coverage in CHIP and Benchmark Plans Was Generally Comparable, with Some Variation in Hearing and Outpatient Therapy Services in Five States

We determined that the CHIP and benchmark plans in our five selected states were comparable in that they included some level of coverage for nearly all the services we reviewed. Exceptions were hearing-related services, such as tests or hearing aids, where both were not covered by the benchmark plan in Kansas, and outpatient therapies for habilitation, which were not covered by CHIP plans in Kansas and Utah or by the (See app. II for a benchmark plans in Colorado, Kansas, or New York.detailed list of selected services covered by each state.) The benchmark plan coverage for pediatric dental and vision services was often the same as that in the CHIP plan because the base-benchmark plan, which was typically based on the largest plan by enrollment from each state’s small group market, did not cover these services, and the states often selected CHIP as the supplementary coverage model. In particular, the base- benchmark plan in four states did not cover pediatric dental services and in three states did not cover pediatric vision services. Because pediatric dental and vision services are EHBs, these states were required to select supplemental benchmark plans to bridge the coverage gaps, and often selected CHIP as the supplement. National data from HHS suggests that nearly all states supplemented the base-benchmark plan with pediatric dental and vision plans. According to HHS, 50 and 46 states had to identify supplemental pediatric dental and vision plans, respectively, and more than half of the states selected the FEDVIP plan as the supplement for each service.

The CHIP and benchmark plans we reviewed were also generally similar in terms of the services on which they imposed day, visit, or dollar limits. For example, the plans we reviewed were similar in that they typically did not impose any such limits on ambulatory patient services, emergency care, preventive care, or prescription drugs, but commonly did impose limits on outpatient therapies and pediatric dental, vision, and hearing services. One notable difference between CHIP and benchmark plans we reviewed was the frequency by which they limited home- and community-based health care services. While the benchmark plans in four states imposed day or visit limits on these services, only one state’s CHIP plan did so. (See fig. 1.)

For services where both plan types imposed limits, our review of plan Evidences of Coverage found that, except for dental and vision services, the comparability between plan types in terms of annual limits was less clear, but at times was more generous for CHIP. For example, Utah’s benchmark plan limited home- and community-based health care services to 30 visits per year while the state’s CHIP plan did not impose any limits on this service. Comparability between annual service limits in states’ CHIP and benchmark plans was less clear for outpatient therapy services. For example, the Colorado CHIP plan limited outpatient therapy to 40 visits per diagnosis compared to 20 visits per therapy type in the benchmark plan. Similarly, the New York CHIP plan allowed a maximum of six weeks for physical therapy while the benchmark plan allowed up to 60 visits per condition per lifetime. Limits on dental and vision services were largely comparable, due to the selection of CHIP as the supplemental benchmark for those services in most of the selected states. Table 1 provides examples of annual limits for select services between CHIP and benchmark plans, and app. III lists annual limits for all services we reviewed.

CHIP officials in all five states said that they expect the services we reviewed that were covered by their respective CHIP plans and any relevant limits on these services to remain largely unchanged in 2014. With respect to QHP coverage, state officials in all five states expect 2014 coverage to reflect PPACA and its implementing requirements, including being comparable to their respective benchmark plans. For example, QHPs must offer EHB services at levels that are substantially equal to their respective state’s benchmark plans. With state approval, QHPs may substitute services that are actuarially equivalent and from the same EHB category as the service being replaced. The actuarial equivalence requirement also applies to dental benefits provided by SADPs, which are expected to be available in all five selected states, according to state officials.Illinois, and Kansas—commented on the advantages and disadvantages of SADPs. While their availability could benefit consumers in terms of a broader set of options for dental services, their availability could also create confusion among consumers. For example, because QHPs are not required to include pediatric dental coverage in their plans if an SADP is available in their state’s exchange, some officials expressed concern that a consumer who needs the pediatric dental benefit may mistakenly purchase a plan in the exchange without such coverage or, conversely, could have duplicate coverage if they purchased an SADP in addition to a QHP that may include pediatric dental coverage.

Exchange officials in three of the selected states—Colorado, State officials said that they also expect QHPs to reflect additional PPACA requirements. For example, PPACA requires QHPs to include coverage for the categories of rehabilitative and habilitative services and devices. For benchmark plans that do not cover habilitative services, HHS’s implementing regulations provide three options to comply with the requirement. States can opt to (1) require QHPs to cover habilitative services in parity with rehabilitative services; (2) select specific services that would qualify as habilitative or, if the state neglects to choose either of these choices, (3) allow the QHP issuer to determine which services qualify as habilitative. Each of the three selected states that did not cover outpatient therapies for habilitation—Colorado, Kansas, and New York— has opted to require QHPs to cover these services in parity with rehabilitative services. According to HHS, nationwide data show that in addition to these three states, 19 other states had benchmark plans that did not cover habilitation, and the majority chose to allow the issuers to determine which services would qualify as habilitative.

PPACA also eliminates the use of annual and lifetime dollar limits on any EHB services. The elimination of lifetime dollar limits was effective in September 2010 and the elimination of annual limits takes effect in January 2014. Among our five selected states, four states had benchmark plans that imposed an annual dollar limit on at least one of the service categories we reviewed; with limited exception, none of these dollar limits were imposed on EHB services. For example, Kansas’ benchmark plan limited hospice services to $5000 per insured person per lifetime. In general, state officials indicated that for these services, they expected that QHP issuers would eliminate the dollar limits.

PPACA also extends the mental health parity requirements, which require that any lifetime limits placed on mental health or substance abuse services be the same as those placed on physical health care services.The benchmark plans in two selected states—New York and Utah— included such limits on mental health and substance abuse services. For example, both states’ benchmark plans limited inpatient mental health service to 30 days a year, where similar limits did not exist for inpatient physical health services. Officials in both states said that they expected that QHP issuers would eliminate such limits.

In Five States, Costs to Consumers Were Almost Always Less in CHIP than in Benchmark Plans; CHIP Costs Are Expected to Remain the Same and QHP Costs to Reflect PPACA Limits in 2014

In our five selected states, consumers’ costs were almost always less in CHIP plans when compared to the states’ benchmark plans. While CHIP officials said that they expect CHIP costs to consumers to remain largely unchanged in 2014, the cost of QHPs to consumers is less certain, since benchmarks are not models for QHP cost-sharing. Instead, PPACA includes provisions that will standardize QHP costs and reduce cost- sharing for certain individuals.

Costs to Consumers in Five States Were Almost Always Less in CHIP Plans than in Benchmark Plans

Based on the review of plan Evidences of Coverage in our five selected states, costs to consumers were almost always less in the CHIP plans than in the states’ benchmark plans. For example, the CHIP plans in four of the five selected states did not include any deductibles, which means that enrollees in those states did not need to pay a specified amount before the plan began paying for services. Utah is the only selected state that imposed a deductible on a portion of its CHIP population, which applied to about 60 percent of its CHIP enrollees—those with higher incomes. In contrast, benchmark plans in all five selected states had deductibles, which ranged from $500 in Illinois and Kansas to $3,000 in Utah for an individual, and $1,000 in Kansas to $6,000 in Utah for a family.

Our review of plan Evidences of Coverage and information from state and plan officials also found that, for services we reviewed where the plan imposed copayments or coinsurance, the amount was almost always less in a state’s CHIP plan that in its benchmark plan. For example, the CHIP plan in two of our five states—Kansas and New York—did not impose copayments or coinsurance on any of the services we reviewed. In two of the remaining three states, the CHIP plan imposed copayments or coinsurance on less than half of the services we reviewed, and the amounts were usually minimal and based on a sliding income scale. For example, for each brand-name prescription drug, the Illinois CHIP plan imposed a $4 copayment on enrollees with incomes between 134 and 150 percent of the FPL, which was increased to $7 for enrollees with incomes between 201 and 300 percent of the FPL. Utah’s CHIP plan differed from the other states’ plans in that it imposed either a copayment or coinsurance on all services we reviewed—except preventive and routine dental services—which varied by income level.

In contrast, the benchmark plans in all five states imposed copayments or coinsurance on most services we reviewed. Further, the amounts did not vary by income level and were consistently higher than the CHIP plan in their respective state. These cost differences were particularly pronounced for certain services we reviewed, such as primary care and specialty physician office visits, prescription drugs, and outpatient therapies. For example, depending on income, the copayment for primary care and specialist physician visits ranged from $2 to $10 per visit for Colorado CHIP enrollees, but was $30 and $50 per visit, respectively, for benchmark plan enrollees in the state. In states where the benchmark plan charged coinsurance and the CHIP plan required a copayment, a direct comparison of cost differences could not be made, although data suggest CHIP costs would generally be lower in most cases. For example, while higher-income CHIP enrollees in Illinois paid $100 per admission for an inpatient hospital stay, state benchmark enrollees were responsible for 10 percent coinsurance after the deductible was met, an amount that was likely to be higher than the $100 given that 10 percent of the average price for an inpatient facility stay in 2011 was over $1,500.

Table 2 provides examples of differences in copayments and coinsurance for select services between CHIP and benchmark plans.

Our review of CHIP premiums and other sources of premium data suggest that CHIP premiums were also likely lower than benchmark plans. For example, 2013 CHIP annual premiums for an individual varied by income level and ranged from $0 for enrollees under 150, 160, and 100 percent of the FPL in Illinois, New York, and Utah, respectively, to $720 for higher-income enrollees between 351 and 400 percent of the FPL in New York, with most enrollees across the five selected states paying less than $200 a year. Benchmark plan premium data were not readily available at the time of our study; however, national survey data from America’s Health Insurance Plans suggest that individuals under 18 years of age enrolled in the private individual market paid annual premiums that averaged $1,350 in 2009.

In addition, both CHIP and benchmark plans in all five states limited the total potential costs to consumers by imposing out-of-pocket maximum costs. For example, all five states applied the limit a family could pay in CHIP plans as established under federal law—including deductibles, copayments, coinsurance, and premiums—at 5 percent of a family’s income during the child’s (or children’s) eligibility for CHIP.maximum applies to all services, irrespective of the number of children in the family enrolled. For benchmark plans, out-of-pocket maximum costs were established by each plan. For the five benchmark plans we This reviewed, the annual out-of-pocket maximum costs ranged from $1,000 to $6,050 for an individual and $3,000 to $12,100 for a family. Additionally, the benchmark plans differed from the CHIP plans in that their maximum costs did not include premiums and may not have included deductibles or costs associated with all services. For example, three of the five benchmark plans had deductibles in addition to the out-of-pocket maximum costs. Additionally, copayments for office visits did not apply to the out-of-pocket maximum costs in four of the five states’ benchmark plans.

Some evidence suggests that most families in the five selected states and nationally—whether enrolled in CHIP or a benchmark plan—were unlikely to incur costs that reached the out-of-pocket maximum costs. Our interviews with CHIP officials in selected states and information in the states’ CHIP annual reports indicated that it was rare for families to exceed their 5 percent maximum costs. Utah was the only state that said they had more than a few families exceeding the maximum costs, with about 140 families reporting doing so in a given year, according to state officials. Similarly, existing national data on average out-of-pocket costs for individuals with employer-sponsored insurance suggested that individuals enrolled in the benchmark plans could also generally incur costs that are lower than the maximum costs established by their plan. For example, the Health Care Cost Institute, an organization that provides information for researchers on health care spending and utilization trends, reported that the average out-of-pocket amount spent per consumer was $735 in 2011 for health care services through employer-sponsored insurance, which was lower than the lowest maximum costs established by our selected benchmark plans.

Five States Expect CHIP Costs to Consumers to Remain the Same; QHP Costs to Consumers Will Be Subject to PPACA Provisions that Limit Consumers’ Costs in 2014

According to state CHIP officials in all five states, CHIP costs to consumers, including premiums, copayments, coinsurance, and deductibles, are expected to remain largely unchanged in 2014. All five states said they currently have no plans to raise premiums or change cost-sharing amounts in 2014.

In contrast, QHP costs to consumers in 2014 may be different than those in the benchmark plans as benchmarks are not models for QHP cost- sharing. Instead, PPACA included provisions applicable to QHPs that will limit premium variation, standardize plan values, and limit out-of-pocket costs. For example,

PPACA will limit premium variation in the individual market by prohibiting health plans from adjusting QHP premiums based on factors such as health status and gender. Instead, plans will only be allowed to adjust premiums for family size, geographic area, age, and tobacco use.

PPACA standardizes plan values through QHP coverage level requirements. Specifically, QHPs must offer coverage that meets one of four metal tier levels, which correspond to actuarial value percentages that range from 60 to 90 percent: bronze (an actuarial value of 60 percent), silver (an actuarial value of 70 percent), gold (an actuarial value of 80 percent), or platinum (an actuarial value of 90 percent). Actuarial value indicates the proportion of allowable charges that a health plan will pay, on average—the higher the actuarial value, the lower the cost-sharing expected to be paid by consumers. Deductibles, co-pays, and coinsurance amounts can vary within these plans, as long as the overall cost-sharing structure meets the required actuarial value levels.

PPACA establishes out-of-pocket maximum costs on cost-sharing that apply to all QHPs and vary by income, a change from the non- income-based out-of-pocket maximum costs found in our selected benchmark plans. These maximums for individual plans do not include premiums or costs associated with non-EHB services, but do include deductibles. See table 3.

SADPs have out-of-pocket maximum costs that are in addition to the QHP maximums described above and therefore may increase potential maximum costs for families who purchase them. For 2014, the out-of-pocket maximum costs for SADPs offered in federally facilitated exchanges and state partnership exchanges are $700 for a plan with one child or $1,400 for a plan with two or more children. For example, a family at 225 percent of the FPL that enrolls their two children in an SADP in addition to their QHP would be subject to an out-of-pocket maximum cost of $11,800.

Additionally, PPACA includes provisions aimed at reducing cost-sharing amounts for certain low-income consumers and eligible Indians who purchase QHPs through an exchange in the individual market. For example, PPACA and federal regulations provide cost-sharing subsidies 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 will not be provided directly to consumers, instead, QHP issuers are required to offer three variations of each silver plan they market through an exchange in the individual market. These plan variations are to reflect the cost-sharing subsidies through lower out-of-pocket maximum costs, and, if necessary, through lower deductibles, copayments, or coinsurance. Once the adjustments are made, the actuarial value of the silver plan available to eligible consumers will effectively increase from 70 percent to 73, 87, or 94 percent, depending on their income levels. However, cost-sharing subsidies are not available for pediatric dental costs incurred by a consumer enrolled in a QHP and an SADP.

PPACA also provides a premium tax credit to eligible individuals with incomes that are at least 100 percent and no more than 400 percent of the FPL when purchasing a plan with a premium no more than the second-lowest cost silver plan in their state. Depending on their income, this provision limits the amount families must contribute to QHP premiums to 2 to 9.5 percent of their annual income; in 2014 these premium contributions will range from $471 to $8,949 for a family of four.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 Unlike relevant.federal poverty level.

National Survey Data Suggest that CHIP Access to Care is Comparable to Medicaid and Lower than Private Insurance for Some Services

When asked a series of questions about access to care, MEPS respondents with children covered by CHIP reported positive responses to nearly all questions regarding their ability to obtain care and at levels that were generally comparable to those with other types of insurance. MEPS includes questions about respondents’ ability to obtain care, and responses to these questions can provide insight to an individual’s access to services. In examining questions related to having a usual source of care, getting appointments and care when needed, and accessing care, tests, or treatment or seeing specialists when needed, most respondents with children enrolled in CHIP had positive responses to questions for Specifically, five of the six MEPS calendar years 2007 through 2010.questions we analyzed related to respondents’ ability to obtain care. At least 88 percent of CHIP enrollees responding to these questions reported they had a usual source of care and usually or always got the care they needed. When compared to respondents with other sources of insurance, the proportion of CHIP enrollees’ with positive responses to these questions were, for most questions, comparable to respondents with Medicaid or with private insurance—that is, within 5 percentage points. For example, about 89, 91, and 93 percent of CHIP, Medicaid, and privately insured respondents, respectively, reported that they had a usual source of care. The proportions of CHIP enrollees and those who were uninsured reporting positive responses were also within 5 percentage points on four of the six questions, but the differences were larger for the remaining two questions. Specifically, about 56 percent of those who were uninsured reported having a usual source of care compared to about 89 percent of CHIP enrollees, and about 75 percent of those who were uninsured reported that it was usually or always easy to see a specialist compared to about 81 percent of CHIP enrollees. The area of greatest dissatisfaction appeared to be related to ease in seeing a specialist. Approximately 18 percent of CHIP enrollees reported that it was sometimes or never easy to see a specialist. (See table 5.)

Additional MEPS questions related to respondents’ use of certain medical and dental visits also provide insight on respondents’ access to services and suggest that, for most services, access to care for individuals covered by CHIP is comparable to that of those with Medicaid and lower than that of the privately insured, particularly for dental care. MEPS questions ask about respondents’ health care visits, including office- based health provider, emergency room, and dental visits, in the year prior to the survey. Respondents with children in CHIP reported using services at rates generally comparable to those with Medicaid and lower—except for emergency room visits, which were higher—than those with private health insurance, particularly for oral health care. A higher proportion of CHIP respondents reported using health care services compared to those who were uninsured. For example, about 51 percent of those with private insurance reported visiting a dentist in the past 12 months compared to about 42 percent of CHIP respondents. Additionally, 69 percent of CHIP respondents reported having an office- based provider visit compared to about 50 percent of respondents who were uninsured. (See table 6.)

Because factors other than insurance coverage may affect these observed differences in responses about obtaining care or utilization of health care services, we ran a logistic regression to determine whether differences between CHIP respondents and those with other sources of insurance coverage were significant after controlling for other factors, such as age, race, and income levels. (See app. I for more detailed information on our model and results.) After controlling for these factors, we found that differences between CHIP and Medicaid responses were not statistically significant for any of the 12 questions we reviewed, and that the differences between CHIP and privately insured respondents were statistically significant for 4 questions, which related to respondents’ reported use of emergency rooms, dentist visits, orthodontist visits, and their reported ease in getting needed care, tests, or treatment. CHIP- covered individuals were more likely to report emergency room visits and visits to a general dentist, and less likely to report orthodontist visits and ease in getting needed care than the privately insured. More pronounced differences in reported access existed between CHIP enrollees and those who were uninsured. When comparing CHIP to the uninsured, differences in responses were statistically significant for 8 of the 12 questions we reviewed.

Concluding Observations

Congress, HHS, and the states have important decisions to make regarding the future of CHIP. Congress will face decisions concerning CHIP funding as current funding has been appropriated only through federal fiscal year 2015. The Secretary of HHS will face decisions around parameters by which QHPs offered by exchanges can be considered to be comparable to CHIP plans. Beginning in October 2015, if CHIP funding is insufficient, states will need to have procedures in place to enroll CHIP-eligible children in Medicaid, if eligible, and, if not, in QHPs as long as the Secretary of HHS has certified the QHPs are comparable to CHIP in covered services and cost-sharing protections.

Although state officials in the five states we reviewed expect the CHIP landscape to remain relatively stable over the next year, uncertainty remains regarding issuer decisions and the implementation of other PPACA provisions. This uncertainty complicates making a definitive determination of what CHIP enrollees would face if they were to obtain QHP coverage rather than be enrolled in CHIP. To some extent, coverage and costs in QHPs will be determined by individual states, issuers, and families’ choices. For example, individual issuers of QHPs in many states will define the habilitative services they cover and the limits on services they cover, including ones that are required under PPACA but that they may not have previously covered. In many states, families seeking coverage through exchanges will be allowed to choose whether to obtain pediatric dental coverage by enrolling in a stand-alone dental plan, which will affect upfront and other costs they face. Yet, some—or many—families may choose not to purchase dental coverage that all CHIP plans must cover. PPACA provisions, which seek to standardize QHP costs and reduce cost-sharing for certain individuals, could narrow the cost gap we identified, but will vary by consumers’ income level and plan selection. Assessing the comparability of CHIP and QHP plans will require ongoing monitoring of a complex array of factors.

Agency Comments

We provided a draft of this report for comment to HHS. HHS officials provided technical comments, which we incorporated as appropriate.

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Appendix I: Scope and Methodology of the Medical Expenditure Panel Survey (MEPS) Analysis

To describe how access to care for CHIP children compares to other children, we analyzed data from the Medical Expenditure Panel Survey (MEPS), a nationally representative survey that collects data from a sample of non-institutionalized Americans on their health insurance status and service utilization, among other factors. MEPS is administered by the Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) and collects information from respondents on many topics, including demographic characteristics, insurance status, health conditions, and their use of specific health services. We analyzed results from the MEPS household component, which collects data from a sample of families and individuals in selected communities across the United States and is drawn from a nationally representative subsample of households that participated in the prior year’s National Health Interview Survey. The MEPS household component features five rounds of interviews, which occur over two full calendar years. MEPS collects information for each person in the household, and information is generally provided by an adult member of the household.

We did not include questions that focused on the quality of care received. identify which respondents were eligible for CHIP versus Medicaid. To ensure we had a large enough sample size for our analysis of CHIP- eligible respondents, we included respondents who were continuously enrolled in CHIP for at least 8 months, and we analyzed responses from respondents enrolled in CHIP, Medicaid, or private insurance for at least eight months or who were uninsured at least 8 months out of the year. In addition, we pooled MEPS survey results from 2007 through 2010, the most recent, complete MEPS data available at the time of our analysis, and combined response choices for some of the MEPS questions. For example, some questions had several response choices, such as “always,” “usually,” “sometimes,” or “never.” We combined the four response choices into two response choices (e.g., “usually or always” and “sometimes or never”). Despite these efforts, 8 questions that we originally selected for analysis were excluded because of an insufficient number of responses. Nine additional questions were excluded due to our determination that they were redundant of other questions. As a result, our analyses focused on 12 MEPS questions: 6 questions asked about respondents experiences obtaining care and 6 questions asked about their utilization of specific services. (See table 7.)

Because factors other than insurance coverage—such as income, parent education, and family composition, may affect access to care, we also ran a multivariate logistic regression analysis of responses to these 12 questions. Based on the literature and in consultation with experts at AHRQ and the Urban Institute, an organization that has conducted past research on access to care using MEPS data, we identified a number of factors in addition to insurance that could influence access to care and constructed logistic regression models to control for the effects of these factors on our results. The factors we included were age, race, income, total number of parents in the household, parent education, family size, health status, mental health status, children with special needs, total number of workers in the household, metropolitan statistical area, sex, whether the respondent was born in the United States, and English versus non-English speakers. We then tested whether there was a statistically significant difference in the effect of enrollment in CHIP versus other types of insurance coverage on responses to questions about access to care after controlling for these factors. For 9 of the 12 questions in our analysis, there were statistically significant differences between CHIP and certain comparison groups after controlling for other factors.

To determine the reliability of the MEPS data, we reviewed related documentation, identified other studies, including our prior reports, that used MEPS data to address similar research questions, and consulted researchers at AHRQ and the Urban Institute about our analysis. We determined that the MEPS data were sufficiently reliable for the purposes of our report. However, there were several limitations to our analysis. First, to separate CHIP and Medicaid respondents, we relied on state CHIP and Medicaid income eligibility and income disregard rules reported by Kaiser between 2007 through 2010, and did not independently verify these data. In addition, the information available from Kaiser on each state’s income disregard rules was limited and had not been uniformly updated since 2008. Therefore, to account for potential gaps in information, we applied the income disregard rules from the 2008 Kaiser report to MEPS results from 2007 and 2008, and applied unverified 2010 income disregard rules from Kaiser to MEPS results from 2009 and 2010. When discrepancies between the 2008 and 2010 Kaiser data existed, we contacted states for clarification. In the event we could not verify the change in income disregard rules, which was the case with two states, we applied the 2008 income disregard rules for MEPS survey results to all 4 years of our analysis, 2007 through 2010. In addition, our analysis did not account for earnings disregards related to child care expenses, child support paid, or child support received; therefore, the groups we identified as Medicaid- or CHIP-eligible may be understated. Further, our analysis also did not account for income-ineligible respondents. Therefore, there may be some overlap between Medicaid and CHIP respondents or under- Finally, because our analyses reflect an reporting of CHIP respondents.eight-month period of enrollment or uninsurance, the responses may not precisely align with the respondents’ current health insurance status, particularly because several MEPS questions refer to respondents’ experiences and utilization over the prior 12 months.

Appendix II: Coverage for Selected Services in CHIP and Benchmark Plans in Five States

Legend: = yes;  = no.

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.

State selected CHIP as its supplemental vision benchmark plan.

Appendix III: Copayments, Coinsurance, and Annual Coverage Limits for Selected Services in CHIP and Benchmark Plans in Five States

Tables 8 through 12 provide information on copayments, coinsurance, and annual coverage limits for selected services in the State Children’s Health Insurance Program (CHIP) and benchmark plans in each of the five states we reviewed: Colorado, Illinois, Kansas, New York, and Utah. States’ CHIP and benchmark plans may also include a deductible, which was the case for all five states’ benchmark plans and one state’s CHIP plan. For all five states, cost-sharing for individuals and families was also subject to an out-of-pocket maximum cost. For CHIP enrollees, the out-of- pocket maximum cost amount was applied by the plans as established by federal statute, limited to 5 percent of a family’s income, and included all For the benchmark plans, the out- consumer costs, including premiums.of-pocket maximum cost for benchmark plans was established by each issuer, did not include premium costs, and was sometimes in addition to the deductible.

Appendix IV: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Susan T. Anthony, Assistant Director; Carolyn Fitzgerald; Toni Harrison; Laurie Pachter; Teresa Tam; and Hemi Tewarson made key contributions to this report.

Related GAO Products

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Medicaid: States Made Multiple Program Changes, and Beneficiaries Generally Reported Access Comparable to Private Insurance. GAO-13-55. Washington, D.C.: November 15, 2012.

Children’s Health Insurance: Opportunities Exist for Improved Access to Affordable Insurance. GAO-12-648. Washington, D.C.: June 22, 2012.

Medicaid and CHIP: Most Physicians Serve Covered Children but Have Difficulty Referring Them for Specialty Care. GAO-11-624. Washington, D.C.: June 30, 2011.

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