Through CHIP, states provide health insurance coverage for children in families whose household incomes are too high to qualify for Medicaid. CHIP is funded jointly by the federal government and states. States administer CHIP under federal standards, and the state programs may vary, for example, in the services covered, costs to individuals and families, and eligibility standards. Specifically, CHIP income eligibility standards vary across states, with most states’ upper income eligibility levels between 200 and 300 percent of the federal poverty level and the highest eligibility level being 400 percent of the federal poverty level. PPACA requires states to maintain their current eligibility levels for children in CHIP and Medicaid through fiscal year 2019. Thus, under current law, some states could choose to eliminate or scale back coverage for children in their CHIP and Medicaid programs beginning in fiscal year 2020, even if federal funds for these programs are available. PPACA required the establishment of exchanges by January 1, 2014, to allow consumers to compare individual health insurance options available in each state and enroll in coverage. As of June 2015, 17 states had established state-based exchanges and 34 states had FFEs. The exchanges include certified QHPs offered in the states by the participating issuers of coverage. QHPs are required to meet certain benefit design, consumer protection, and other standards. Issuers may offer multiple QHPs and may also offer other health insurance products outside of the exchange, such as a CHIP managed care plan, Medicare Advantage plan, Medicaid managed care plan, or other commercial insurance products. While the CHIP program was created to address the health care needs of children in low-income families, QHPs offered through the exchanges established by PPACA are intended to target a broader population. Specifically, PPACA contained a number of provisions that were intended to make coverage more available and affordable for individuals seeking coverage in the private individual and small group health insurance markets. Some of these provisions established new rules that limit how much issuers can vary the premiums they charge certain individuals or groups, as well as prohibiting issuers from denying coverage based on an individual’s health status, among other things. With the introduction of QHPs in 2014, researchers have found that issuers have increasingly employed cost-containment tools—such as creating narrow networks that include a smaller group of providers and hospitals—as well as by tiering networks—that is, creating several networks of differing levels of coverage that reflect different arrangements of out-of-pocket costs that may be incurred by an enrollee. The federal government and states each play a role in overseeing CHIP, CHIP plans, exchanges, and QHPs: CHIP. CMS is the federal agency responsible for overseeing states’ implementation and administration of their CHIP programs, including establishing federal standards for these programs and ensuring that states take steps to adequately oversee issuers’ compliance with these standards. At the state level, state agencies such as the Medicaid agencies or departments of health or social services are responsible for administering CHIP programs and overseeing CHIP plans. For CHIP programs operated through the use of managed care, the relevant state agencies contract with managed care organizations to provide services to CHIP enrollees. State departments of insurance may also play a role in overseeing CHIP plans, to the extent these plans are subject to state insurance rules. QHPs. Regardless of the exchange type, CMS has direct oversight responsibilities for the PPACA exchanges, as CMS is responsible for certifying state exchanges for operation and directly operating the FFE. In addition, CMS is responsible for establishing minimum QHP certification requirements that all QHPs must meet in order to participate in an exchange. In the FFE states, CMS oversees compliance with these requirements; in the states with state-based exchanges, the states are responsible for ensuring the plans comply. Federal regulations require that all exchanges have procedures to annually certify QHPs to ensure they are in compliance with exchange requirements. While we and others have reported on CHIP enrollees’ experiences with access to health care compared to those with private insurance or without insurance and comparisons of other aspects of CHIP and QHPs, little is known about whether the provider networks used by QHPs are adequate to address the health care needs of children or how CHIP networks compare with those of QHPs. Specifically, we reported in November 2013 that survey data indicated that CHIP enrollees reported comparably positive responses regarding their ability to obtain care when compared with responses for enrollees with private insurance, but that approximately 18 percent of CHIP enrollees reported difficulties seeing a specialist. We also reported in February 2015 that coverage of services by selected CHIP plans in five selected states was generally comparable to that of the selected QHPs, with the notable exceptions of pediatric dental and certain enabling services such as translation and transportation services, which were covered more frequently by the CHIP plans. However, as noted by MACPAC in its March 2015 report, little has been reported on the provider network differences among CHIP, Medicaid, and QHPs. HHS’ Assistant Secretary for Planning and Evaluation contracted for studies looking at provider networks in CHIP, Medicaid, and qualified health plans in six urban areas; but, as of November 2015, HHS had not published the studies. At the federal level, broad network adequacy standards apply to CHIP plans and QHPs. At the state level, most of the five states we reviewed required CHIP plans to adhere to network adequacy standards that related specifically to pediatric provider types. The selected states required QHPs to follow fewer pediatric provider-specific standards. Broad federal network adequacy standards apply to CHIP plans and QHPs. States that administer their CHIP programs through managed care plans must adhere to federal requirements governing CHIP managed care organizations, while QHPs in both state-based exchanges and FFEs are also subject to federal requirements for provider network adequacy. Specifically: Federal law requires that CHIP managed care plans provide assurances that, within their service areas, they have the capacity to serve their expected enrollment; that they maintain an adequate number, mix and distribution of providers; and that they offer an appropriate range of services and access to preventive and primary care services for the expected population. Because CHIP managed care plans primarily cover children, these plans are thus required to include a sufficient network of pediatric providers. Federal regulations require QHPs to maintain networks that are sufficient in number and types of providers in order to ensure that all services are accessible to enrollees without unreasonable delay. Regulations also require that QHP networks include “essential community providers” to ensure reasonable and timely access to a broad range of providers for low-income and medically underserved individuals. CMS has established more specific network adequacy criteria applicable to QHPs participating in the FFE, which CMS operates. For example, in its annual certification guidance to QHP issuers in FFE states for benefit years 2015 and 2016, CMS instructed issuers to submit a list of providers and their geographic locations so that CMS could determine whether an issuer met the “reasonable access” standard—that is, that the issuer maintains networks that are sufficient in number and types of providers in order to ensure that all services are accessible to enrollees without unreasonable delay. CMS also noted that it considers a QHP network to meet the essential community provider requirement when: The network includes at least 30 percent of available essential community providers in the QHP’s service area and The network covers at least one provider in each essential community provider category in each county where an essential community provider in that category is available. For QHPs participating in the FFE, CMS specified that essential community provider categories include, but are not limited to: federally qualified health centers, Indian Health providers, and hospitals. None of these specified categories are specific to pediatric providers. CMS is considering changes to CHIP plan and QHP network adequacy requirements. With regard to the CHIP program, CMS issued a proposed rule in June 2015 that, if finalized as proposed, would amend current Medicaid and CHIP managed care regulations to reduce variation in how states evaluate and define network adequacy. With regard to QHPs in FFE states, CMS issued a proposed rule in December 2015 that, if finalized as proposed, would allow states in which an FFE operates to select a quantifiable network adequacy standard—such as a travel time or distance standard for the proximity of network providers’ locations to enrollees’ residences—applicable to QHPs in that state. If the state does not adopt such a standard or does not review QHP network adequacy, a default federal standard imposing specific time and distance requirements would apply to QHPs in the state. CMS indicated that the agency followed proposed changes to the NAIC network adequacy model in considering modifications to the QHP network adequacy standards. The five selected states we examined had one or more specific network adequacy standards for CHIP plans and QHPs. These standards included the following: Provider-to-enrollee ratios or quantitative standards for a minimum number of providers per enrollee or set of enrollees. Two of the selected states—Massachusetts and Washington—required CHIP plan networks to follow specific provider-to-enrollee ratios. For instance, in Massachusetts, managed care plans in which CHIP children are enrolled must include one primary care provider for every 200 enrollees. These same two states also required at least some QHPs to have a minimum provider-to-enrollee ratio for certain provider types, such as primary care providers. These primary care providers may include, but were not exclusive to, pediatric primary care providers. Travel time or distance standards for the proximity of network providers’ locations to all or some proportion of enrollees’ residences; such standards may differ for rural and urban areas. All five states required CHIP plans to adhere to specific and quantitative travel time standards, travel distance standards, or both. For example, Alabama required that, for 90 percent of enrollees, one hospital must be available within 30 miles of enrollees’ homes, and two behavioral health providers must be available within 10 miles of enrollees’ homes in urban areas or 45 miles in rural areas. All five selected states also had specific quantitative travel time or distance standards for QHPs for certain provider types, such as primary care providers. These primary care providers may include, but were not necessarily exclusive to, pediatric primary care providers. Capacity or availability standards, which may include requirements that a certain number or proportion of providers are accepting new patients or may require specific limits on appointment wait times. Three of the selected states—Massachusetts, Texas, and Washington—required CHIP plan networks to follow provider capacity or availability standards. Washington, for example, required CHIP plans to ensure that non-emergency, routine primary care be available within 10 days. These same three states also required QHPs to take into account the capacity or availability of network providers. While federal network adequacy standards for QHPs do not impose requirements specifically related to pediatric providers, individual states may adopt such requirements. For CHIP plans, most selected states had specific requirements for pediatric provider types, but, for QHPs, only two states had specific requirements for pediatric provider types. (See fig. 1.) Specifically, four of the selected states—Alabama, Massachusetts, Texas, and Washington—required CHIP plans to meet certain pediatric provider standards. This was particularly true for travel time and distance standards, as well as capacity or availability standards. For example, Texas required CHIP plans to include in their networks one age- appropriate primary care provider within 30 miles of enrollees’ homes for 90 percent of enrollees, and Alabama required CHIP plan networks to provide access to two pediatric primary care providers within a 20-mile radius of enrollees’ homes for 90 percent of enrollees. In addition, Texas required CHIP plans to make preventive health service appointments for children available within a timeframe that is in accordance with standards set by a national pediatric provider group. For QHPs, fewer of the selected states had adopted standards related to pediatric provider types than for CHIP plans. Specifically, two of the five selected states—Texas and Washington—had QHP standards containing requirements specific to pediatric provider types. For example, Washington required QHP issuers to demonstrate that 80 percent of the covered children in a given service area have access to a pediatrician within 30 miles of their homes for an urban area or 60 miles for a rural area and to pediatric specialty services within 60 miles of their homes for an urban area and 90 miles for a rural area. In another example, Texas required that QHP issuers provide routine care for children within two months of the request. Eighteen of 19 selected issuers that offered CHIP plans, QHPs, or both, in the most populous counties of the five selected states reported including at least one children’s hospital in their provider networks for their CHIP plans and QHPs. Most of them—16 of the 18—reported including more than one children’s hospital. Representatives from one QHP-only issuer told us they did not include a children’s hospital in their QHP network, but they instead provide access to children’s pediatric services—such as neonatal intensive care and general pediatric surgery—through an agreement with four hospitals that treat children but are not limited to children. All of the selected issuers of CHIP plans and QHPs told us they had a policy to allow for enrollees to obtain case-by- case exceptions when certain services or providers are unavailable in- network. Officials representing some of the children’s hospitals we spoke with, however, raised concerns around not being included in all plan networks and the potential effect on children’s access to specialty care they may need. Representatives from all nine selected children’s hospitals we contacted in the selected states told us that their hospitals are currently included in networks of many—but not all—CHIP plans and QHPs that are offered in the selected counties. Representatives from five of the nine children’s hospitals located in four different states noted concerns about some aspects of network inclusion that could affect access for children who need specialty care through their hospitals. Specifically: Representatives from three of these five children’s hospitals told us that, in some QHPs that have tiered networks, their hospitals are included in tiers that are associated with higher enrollee cost-sharing. Representatives from two of these five children’s hospitals told us they were concerned about their future inclusion in CHIP and QHP networks, explaining that their hospital’s inclusion in networks could vary from year to year. A representative from one of these two children’s hospitals also noted that the fundamental network adequacy issue for the pediatric population is the small percentage of children with complex health care needs, which typically account for a large percentage of pediatric medical costs. Representatives from three of these five children’s hospitals noted that when their hospitals are not in a CHIP or QHP network, treating CHIP or QHP enrollees at their facilities increases the administrative burden placed on the hospitals as they have to arrange case-by-case exceptions with plan issuers. The selected issuers that offered both CHIP plans and QHPs told us they had the same or similar provider networks for their CHIP plans and QHPs. For example, one issuer told us that in 2014 its Medicaid and CHIP plan networks were different in that some Medicaid providers did not initially join QHP networks. However, the issuer told us there was an increase in the number of Medicaid providers willing to join QHP networks in 2015. Representatives from another issuer told us they had one provider network for all plans, including CHIP plans and QHPs. All of the 19 selected issuers we contacted indicated that pediatric specialists are included in each of their networks. However, many expressed challenges recruiting certain types of pediatric specialists. Many of the challenges related to location or compensation as well as reflecting provider availability nationwide: Location. Representatives from four issuers—one QHP issuer, two issuers of CHIP plans, and one issuer of both a CHIP plan and QHP—in two states told us that it is difficult to recruit and retain pediatric behavioral health providers. These representatives further noted that this problem is not specific to their county or state, but related to a nationwide shortage of children’s behavioral health providers. In addition, representatives from four issuers of CHIP plans in three states told us that recruiting specialists in metropolitan counties is generally not as difficult as recruiting specialists in rural counties, and difficulties recruiting specialists in rural counties is a problem affecting all of their insurance plan networks, not just CHIP plans. Compensation. Representatives from one issuer of a CHIP plan told us that some specialists generally require significantly higher compensation than CHIP plans typically pay, making it difficult for the issuer to recruit certain pediatric specialists—such as cardiologists, cardiovascular surgeons, neurologists, neurosurgeons, and urologists—to its network. In addition, the issuer noted that these specialists are difficult to contract with due to the limited number of providers practicing in these specialties. States have primary responsibility for administering CHIP and for overseeing CHIP plan compliance with network adequacy standards, and CMS monitors these state oversight activities. CMS officials reported conducting certain monitoring activities for QHPs to assess the adequacy of provider networks in FFE states. Officials from most of the selected states’ CHIP agencies and departments of insurance reported monitoring issuers’ compliance with state CHIP and QHP standards, but states’ frequency of monitoring varied. CMS officials told us that the agency monitors the oversight activities of states, which have primary responsibility for administering CHIP and for overseeing CHIP plan compliance with network adequacy standards, primarily by reviewing state contracts with plan issuers and requiring certain assurances from states and issuers. Federal law requires states to establish standards for access to care under CHIP managed care plans to ensure that covered services are available within reasonable timeframes and in a manner that ensures both continuity of care and adequate primary care and specialized services capacity; states must also provide assurances to CMS that these standards are met. These standards may include, for example, provider-to-enrollee ratios, travel time or distance standards, and capacity or availability standards. CMS monitors states’ CHIP oversight activities in the following ways: Reviews state contracts with issuers of CHIP plans. Since July 1, 2009, CMS has required states to submit for CMS review all new, extended, renewed, or amended CHIP managed care contracts that states enter with managed care organizations to ensure these contracts comply with federal requirements, including those relating to access to care. Requires states to develop and implement plans that include access standards. States must operate their CHIP programs in accordance with a CMS-approved state CHIP plan that must include a description of the methods the states use to ensure the quality and appropriateness of care provided under the plan. Each state that contracts with managed care organizations to provide CHIP benefits also must develop and implement a Quality Assessment and Improvement Strategy, which must include access to care standards that ensure covered services are available within reasonable timeframes and in a manner that ensures continuity of care and adequate primary care and specialized services capacity. CMS is required to monitor the development and implementation of this plan. In addition, each contract that a state enters into with a managed care organizations to provide CHIP benefits must include a requirement for an annual external independent review to ensure the plan’s quality and timeliness of, and access to, covered items and services under the contract. CMS officials told us that they are not aware of any concerns about children enrolled in CHIP not having access to pediatric specialists, and that they think states make a concerted effort in establishing provider networks for their CHIP plans for children to ensure sufficient pediatricians and pediatric specialists. In contrast with its indirect oversight role over CHIP plans, CMS is responsible for directly monitoring QHPs’ compliance with QHP certification standards in FFE states. CMS officials reported using three types of monitoring activities to assess the adequacy of QHPs’ provider networks in FFE states—through the annual QHP certification process, comprehensive issuer compliance reviews, and post-certification reviews, as follows: Annual QHP certification process. CMS conducts an annual certification process of QHPs in FFE states. CMS officials told us that during this process they assess QHPs’ provider networks using the “reasonable access” standard in order to identify networks that potentially fail to provide access without unreasonable delay, as required by federal regulations. CMS officials told us they do not assess QHP networks for their adequacy of pediatric providers or pediatric specialists because there have not historically been network adequacy concerns with these types of providers. During the certification process, CMS officials told us they analyze issuers’ QHP provider network data on the providers and types of providers in the networks for each service area using a computerized geographic mapping and analytics tool. CMS compares the QHPs’ network data against internal CMS metrics, including time and distance standards for certain provider categories that have historically raised network adequacy concerns—hospitals, mental health, oncology, primary care, and dental. According to CMS officials, 17 QHP issuers were flagged as having potential network adequacy concerns during the certification process for benefit year 2015, resulting in CMS communicating with the issuers through an iterative process to obtain more information. CMS officials reported that these issuers either provided what CMS officials deemed to be a reasonable justification for the lack of providers, such as a lack of available providers in a specialty or patterns of care that reasonably justify the lack of providers, or they provided CMS with data to indicate they included additional providers in their networks since their initial data submission. CMS officials said that, for benefit years 2014 and 2015, all issuers ended up providing adequate information about their networks to be able to attain QHP certification. Comprehensive issuer compliance reviews. CMS officials reported monitoring QHPs’ compliance with provider network standards in FFE states through comprehensive issuer compliance reviews, though network adequacy is only one of many elements in these reviews. During a compliance review, CMS reviews an issuer’s policies and procedures related to CMS’s internally established availability and accessibility standards and also reviews issuers’ compliance with other federal standards, such as QHPs’ rates, benefit design, and marketing. CMS officials reported that for benefit year 2014 they conducted compliance reviews of 21 issuers; for benefit year 2015, CMS reported having conducted such reviews of 30 issuers. Post-certification reviews. CMS officials reported that they also conduct post-certification reviews, which focus on a specific topic and may be conducted for a sample of issuers or for all issuers, depending on the focus of the review. For example, prior to the start of benefit year 2015, officials said they reviewed all certified QHP issuers’ websites to make sure the links to their provider directories were compliant with CMS network adequacy standards—that is, that the links worked and were easily accessible. In addition to these monitoring activities, CMS officials told us they also receive and respond to consumer complaints about QHPs. According to officials, when a complaint of that nature reaches CMS, the agency will follow up with the consumer on an ad hoc basis. While officials reported that they have heard anecdotally of problems with network adequacy from advocacy groups, they were not aware of any complaints specific to pediatric providers. Officials from CHIP agencies in three of the five selected states— Massachusetts, Texas, and Washington—told us they regularly monitor CHIP plan issuers’ compliance with the states’ CHIP network adequacy standards, but the frequency with which they reported doing this varied. Specifically: CHIP officials from these three states told us they require CHIP plan issuers to submit certain provider network information at the time the plan and network are established and then quarterly or annually thereafter. For example, in Washington, issuers must demonstrate the ability to service 80 percent of the eligible CHIP population in a given service area. Washington CHIP officials told us that issuers must submit information at least quarterly on all of their providers in each service area; this information is entered into a computerized geographic access program that assesses the locations of providers in relation to all potential CHIP enrollees in a service area and measures the results against the state’s distance standards. The officials said they specifically focus on an issuer’s network inclusion of 17 provider types, 6 of which they deem to be “critical” for CHIP and Medicaid, including hospitals, pharmacies, primary care providers, pediatric primary care providers, obstetricians, and behavioral health providers. Additionally, issuers must annually report information to the state CHIP agency, such as their provider-to-enrollee ratios and provider utilization ratios. In contrast, CHIP officials in the other two selected states—Alabama and Pennsylvania—told us they assess CHIP plan issuers’ compliance with state network adequacy standards at the time the network is established and then on an ad hoc basis thereafter. For example, officials from Pennsylvania told us they would request network information if they received a complaint about the network or if a provider group or hospital left the network. CHIP officials in all five states also told us that they track any consumer complaints received about CHIP plan provider networks. Officials from most of the selected states—Massachusetts, Pennsylvania, Texas, and Washington—told us that they rely primarily on complaints, network changes, and other concerns to prompt the frequency with which they monitor QHPs’ network adequacy. For example: Department of insurance officials from Texas— an FFE state—noted that QHP issuers must re-submit provider network information when there is a material change to the network, and, if the updated network is no longer adequate, the issuer must also submit an access plan and a request for a waiver in order to continue to offer QHPs in that service area. Department of insurance officials from Pennsylvania—another FFE state—told us that if they receive an access complaint about a QHP, staff will investigate and alert CMS to the problem. Department of insurance officials from one FFE state—Alabama—told us that they do not assess or monitor QHP provider networks, nor do they track consumer complaints. Officials from the departments of insurance in Massachusetts, Pennsylvania, and Washington told us that, as of mid-2015, they had received very few or no complaints about QHPs’ provider networks in 2014 and in 2015. We provided a draft of this report to the Secretary of Health and Human Services. HHS provided technical comments that we incorporated as appropriate. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution of it until 30 days from the report date. At that time, we will send copies to the Secretary of Health and Human Services, and other interested parties. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or iritanik@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix II. This appendix describes the methodology we used to select states, issuers, and children’s hospitals to address our objectives to examine: (1) federal and state provider network adequacy standards State Children’s Health Insurance Program (CHIP) plans must meet, particularly for pediatric providers, and how these compare to standards for qualified health plans (QHP); (2) the extent to which selected issuers of CHIP plans and QHPs include children’s hospitals in their networks and otherwise help to ensure access to pediatric specialists; and (3) how the federal government and selected states monitor CHIP plan and QHP compliance with provider network adequacy standards. We selected five states that administered CHIP separate from their Medicaid program for the majority of their CHIP enrollees, and covered children ages 0 to 18 in their separate CHIP programs—Alabama, Massachusetts, Pennsylvania, Texas, and Washington. The five selected states varied in the type of health insurance exchange where QHPs are sold (i.e., federally facilitated exchange or state-based exchange); the size of their child population, the number of children enrolled in their separate CHIP program as of 2013; the estimated number of children enrolled in a QHP for 2015, and the 2014 CHIP upper income eligibility standard. (See table 1.) Within each selected state, we identified the most populous county (based on 2013 U.S. Census data) from which we selected a set of issuers of CHIP plans and QHPs. To do this, we obtained data on 2014 or 2015 enrollment for all CHIP plans and QHPs offered in each selected county, as well as QHP 2014 or 2015 premium data, from officials at the Centers for Medicare & Medicaid Services (CMS) and agencies in each selected state that administer CHIP, departments of insurance, and exchanges (in the two state-based exchange states). From a total of 37 issuers of CHIP plans and QHPs that offered plans in the five selected counties, we selected 19—4 issuers that only offered a CHIP plan, 8 issuers that only offered QHPs, and 7 issuers that offered both a CHIP plan and QHPs. The 19 issuers we selected included issuers of the largest CHIP plan and largest QHP in each selected county, based on enrollment for benefit year 2014 or 2015, in order to obtain information on issuers who cover a large share of CHIP and QHP enrollees. Because QHP issuers offered more than one QHP in a given county, we selected QHP issuers based on total county enrollment in each issuer’s silver plan with the lowest premium for 2014 or 2015. Where possible, within each state we selected at least one issuer that offered: (1) only a CHIP plan, (2) only QHPs, and (3) both a CHIP plan and QHPs. The CHIP plans and lowest- cost silver plans offered by the 19 selected issuers provided coverage to at least 73 percent of enrollment in CHIP managed care plans and at least 84 percent of enrollment in lowest-cost silver QHPs in each selected county. See table 2 for the selected counties and the number of issuers that offered CHIP plans, QHPs, or both in each county. In four of the five states, we selected a set of hospitals in each selected county whose mission was to primarily serve children—referred to as children’s hospitals. In the fifth selected state, the selected county did not have a children’s hospital, so we contacted children’s hospitals in a neighboring county. We contacted a total of nine children’s hospitals—at least one in each selected state—and interviewed or received written information from all of them. In addition to the contact named above, Kim Yamane, Assistant Director; Sandra George; Kate Nast Jones; Laurie Pachter; and Nina Verevkina made key contributions to this report.

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