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.