Unlike states that opt to cover CHIP-eligible children in their Medicaid programs and therefore must extend Medicaid covered services to CHIP- eligible individuals, states with separate CHIP programs have flexibility in program design and are at liberty to modify certain aspects of their programs, such as coverage and cost-sharing requirements. However, federal laws and regulations require states’ separate CHIP programs to include coverage for routine check-ups, immunizations, emergency services, and dental services defined as “necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.” States typically cover a broad array of additional services in their separate CHIP programs and, in some states, adopt the Medicaid requirement to cover Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services.must also comply with mental health parity requirements—meaning they must apply any financial requirements or limits on mental health or substance abuse benefits in the same manner as applied to medical and surgical benefits. With respect to costs to consumers, CHIP premiums and cost-sharing— irrespective of program design—may not exceed amounts as defined by law. States may vary separate CHIP premiums and cost-sharing based on income and family size, as long as cost-sharing for higher-income children is not lower than for lower-income children. Federal laws and regulations also impose additional limits on premiums and cost-sharing for children in families with incomes at or below 150 percent of the federal poverty level (FPL). In all cases, no cost-sharing can be required for preventive services—defined as well-baby and well-child care, including age-appropriate immunizations and pregnancy-related services. In addition, states may not impose premiums and cost-sharing that, in the aggregate, exceed 5 percent of a family’s total income for the length of the child’s eligibility period in CHIP. PPACA includes provisions that seek to standardize coverage and costs of private health plans in the individual and small group markets. QHPs offered both on and off the exchanges are required to comply with applicable private insurance market reforms, including relevant premium rating requirements, the elimination of lifetime and annual dollar limits on EHBs, prohibition of cost-sharing for preventive services, mental health parity requirements, and the offering of comprehensive coverage. PPACA allows exchanges in each state to offer coverage of pediatric dental services as an integrated benefit in a QHP or through an SADP, which consumers can purchase separately. In exchanges with at least one participating SADP, QHPs are not required to include the pediatric dental benefit. Some states require children obtaining coverage in their state- based exchanges to enroll in an SADP if their QHP does not include the pediatric dental benefit; consumers purchasing coverage in the federally facilitated exchange are not required to do so. With respect to costs to consumers, QHPs must offer coverage that meets one of four metal tier levels, which correspond to actuarial value (AV) percentages that range from 60 to 90 percent: bronze (AV of 60 percent), silver (AV of 70 percent), gold (AV of 80 percent), or platinum (AV of 90 percent). that a health plan will pay, on average—the higher the AV, the lower the cost-sharing expected to be paid by consumers. Cost-sharing subsidies are available to individuals with incomes between 100 and 250 percent of the FPL to offset the costs they incur through copayments, coinsurance, and deductibles in a silver-level QHP. The cost-sharing subsidies are not provided directly to consumers; instead, QHP issuers are required to offer three variations of each silver plan they market through an exchange in the individual market. These plans are to reflect the cost-sharing subsidies through lower out-of-pocket maximum costs and, if necessary, through lower deductibles, copayments, or coinsurance. Once the adjustments from the subsidies are made, the AV of the silver plan available to eligible consumers will effectively increase from 70 percent to 73, 87, or 94 percent, depending on income. SADPs have different AV requirements than QHPs. SADPs are categorized as “high” and “low” level plans, with 85 and 70 percent AV, respectively.subsidies are not available for pediatric dental costs incurred by a consumer enrolled in an SADP. Deductibles, co-pays, coinsurance amounts, and out-of-pocket maximum costs can vary within these plans, as long as the overall cost-sharing structure meets the required AV levels. Plans are allowed a de minimis variation of +/- 2 percent. Premium costs are not included in the AV computation. these premium contributions ranged from $471 to $8,949 for a family of four. The premium tax credit is available to eligible consumers regardless of which metal tier they choose; however, the credit is calculated based on the second-lowest cost silver plan in the rating area in which the consumer resides. Unlike cost-sharing subsidies, which generally do not apply to costs incurred for services by a consumer enrolled in an SADP, the maximum contribution amount on premiums includes premiums for both QHPs and SADPs, if relevant. Finally, PPACA established out-of-pocket maximum costs that apply to EHBs included in QHPs and SADPs. In 2014, these maximum costs for QHPs ranged from $2,250 to $6,350 for individuals and $4,500 to $12,700 for families for households with incomes between 100 and 400 percent of the FPL. Out-of-pocket maximum costs for SADPs are in addition to the out-of-pocket maximum costs for QHPs and were established by each exchange in 2014. CHIP-eligible children may enroll in QHPs instead of enrolling in CHIP— either through a child-only plan or through a plan with other family members—but they are ineligible for premium tax credits and cost- sharing subsidies because of their eligibility for CHIP. However, if a state experiences a CHIP funding shortfall in the future and is therefore unable to enroll all CHIP-eligible children into a CHIP plan, such children may qualify for premium tax credits and cost-sharing subsidies to offset the In states not experiencing a funding shortfall, cost of QHP coverage.enrolling CHIP-eligible children in QHPs would generally increase costs for families. Under CMS regulations, if an individual who is ineligible for cost-sharing subsidies enrolls in the same policy as another family member who is eligible for cost-sharing subsidies, nobody covered under the policy will qualify for cost-sharing subsidies. As a result, enrolling CHIP-eligible children in QHPs could result in a loss of cost-sharing subsidies for family members that are eligible for these subsidies. To maintain cost-sharing subsidies for eligible family members, the CHIP- eligible child would need to be enrolled in a child-only health plan, for which premium tax credits would be unavailable because of the child’s eligibility for CHIP. We determined that coverage in the selected CHIP plans and QHPs in our five states was generally comparable in that it included some level of coverage for nearly all the services we reviewed. Notable exceptions were certain enabling services and pediatric dental services, which were more frequently covered by the selected CHIP plans. (See app. I for a detailed list of selected services covered by the plans we reviewed.) With respect to certain enabling services, which may be particularly important for low income children, care coordination or case management was offered by all selected CHIP plans, but by only one selected QHP. Similarly, routine transportation to and from medical appointments was covered by two CHIP plans but by none of the selected QHPs. With respect to pediatric dental services, the QHP in New York was the only selected QHP that covered them; the selected QHPs in the other four states did not integrate pediatric dental services within the medical coverage they offered. To obtain coverage for pediatric dental services, consumers who purchased the selected QHP in these states would also need to purchase an SADP. For consumers who purchased the selected QHP in New York or the selected SADP in the other four states, we determined that pediatric dental coverage available was generally comparable to what was available in their state’s selected CHIP plan, with the exception of Utah, where the selected CHIP plan was more generous than the selected SADP. However, the extent to which consumers obtained coverage that included pediatric dental services is not clear. Available federal data with information on QHP enrollment suggest that many children in the United States with exchange coverage in 2014 may have been without comprehensive dental coverage. According to our analysis of enrollment data for 2014 provided by ASPE, 16 percent of children younger than 18 years of age in the 36 states with federally facilitated exchanges were enrolled in a QHP that included comprehensive dental services that covered check-ups, basic, and major dental services. children were enrolled in QHPs that either had less than comprehensive or no dental coverage. Some of these families are likely to have purchased an SADP for their children, however. According to an ASPE report issued in May 2014, 18 percent of children younger than 18 years of age in the 36 states with federally facilitated exchanges who enrolled in a QHP also enrolled in an SADP, and these were likely among the families that had no comprehensive dental coverage included in their According to our analysis of enrollment data for 2014 provided by QHP.ASPE, virtually no children younger than 18 years of age in the 36 states with federally facilitated exchanges were enrolled in a QHP that included comprehensive dental services and an SADP. According to CMS, a QHP must offer check-ups, basic, and major dental services to be considered a QHP with embedded dental coverage.