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. 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. 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. 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. While the benchmark plans in  four states imposed day or visit limits on these services, only one state’s  CHIP plan did so. 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. 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. Our review of CHIP premiums and other sources of premium data  suggest that CHIP premiums were also likely lower than 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. 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. 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. A higher  proportion of CHIP respondents reported using health care services  compared to those who were uninsured. Congress will face decisions concerning  CHIP funding as current funding has been appropriated only through  federal fiscal year 2015. 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. Agency Comments

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

More than 8 million children were enrolled in CHIP--the federal and state children's health program that finances health care for certain low-income children--in 2012. PPACA appropriated funding for CHIP through federal fiscal year 2015. Beginning in October 2015, any state with insufficient CHIP funding must establish procedures to ensure that children who are not covered by CHIP are screened for Medicaid eligibility, and if ineligible, are enrolled into a QHP that has been certified by the Secretary of Health and Human Services (HHS) as comparable to CHIP. Exchanges are marketplaces for QHP coverage effective in 2014. GAO was asked to review issues related to CHIP. This report provides a baseline comparison of coverage and costs to consumers in separate CHIP plans and benchmark plans in select states; describes how coverage and costs might change in 2014; and describes how access to care by CHIP children compares to other children nationwide.
For the coverage and cost comparison, GAO reviewed Evidences of Coverage from separate CHIP plans and benchmark plans (base and supplemental) from five states--Colorado, Illinois, Kansas, New York, and Utah--selected based on variation in location, program size, and design. GAO reviewed documents and spoke to officials from states' CHIP programs, exchanges, and benchmark plans, and from the Centers for Medicare & Medicaid Services. To describe access to care by children in CHIP compared to others with Medicaid, private insurance or without insurance, GAO analyzed nationwide data from HHS's MEPS from 2007 through 2010.

What GAO Found

In five selected states, GAO determined that the separate State Children's Health Insurance Program (CHIP) plans were generally comparable to the benchmark plans selected by states in 2012 as models for the benefits that will be offered through qualified health plans (QHP) in 2014. The plans were comparable in the services they covered and the services on which they imposed limits, although there was some variation. For example, in coverage of hearing and outpatient therapy services, the benchmark plan in one of the five states--Kansas--did not cover hearing aids nor hearing tests, while the CHIP plans in all states covered at least one of these services. Similarly, two states' CHIP plans and three states' benchmark plans did not cover certain outpatient therapies--known as habilitative services--to help individuals attain or maintain skills they had not learned due to a disability. States' CHIP and benchmark state plans were also similar in terms of the services on which they imposed day, visit, or dollar limits. Plans most commonly imposed limits on outpatient therapies and pediatric dental, vision, and hearing services. Officials in all five states expect that CHIP coverage, including limits on these services, will remain relatively unchanged in 2014, while QHPs offered in the exchanges will be subject to certain Patient Protection and Affordable Care Act (PPACA) requirements, such as the elimination of annual dollar limits on coverage for certain services.
Consumers' costs for these services--defined as deductibles, copayments, coinsurance, and premiums--were almost always less in the five selected states' CHIP plans when compared to their respective benchmark plans. For example, the CHIP plan in the five states typically did not include deductibles while all five states' benchmark plans did. Similarly, when cost-sharing applied, the amount was almost always less for CHIP plans, and the cost difference was particularly pronounced for physician visits, prescription drugs, and outpatient therapies. For example, an office visit to a specialist in Colorado would cost a CHIP enrollee $2 to $10 per visit, depending on their income, compared to $50 per visit for benchmark plan enrollees. GAO's review of premium data further suggests that CHIP premiums are also lower than benchmark plans' premiums. While CHIP officials in five states expect consumer costs to remain largely unchanged in 2014, the cost of QHPs to consumers is less certain. These plans were not yet available at the time of GAO's review. However, PPACA includes provisions that seek to standardize QHP costs or reduce cost-sharing amounts for certain individuals.
When asked about access to care in the national Medical Expenditure Panel Survey (MEPS), CHIP enrollees reported positive responses regarding their ability to obtain care, and the proportion of positive responses was generally comparable to those with Medicaid--the federal and state program for very low-income children and families--or with private insurance. Regarding use of services, the proportion of CHIP enrollees who reported using certain services was generally comparable to Medicaid, but differed from those with private insurance for certain services. Specifically, a higher proportion of CHIP enrollees reported using emergency room services, and a lower proportion of CHIP enrollees reported visiting dentists and orthodontists. HHS provided technical comments on a draft of this report, which GAO incorporated as appropriate.