The  exchanges include certified QHPs offered in the states by the  participating issuers of coverage. 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. CMS is considering changes to CHIP plan and QHP network adequacy  requirements. Selected States Also Had Network Adequacy Standards, but Held CHIP Plans More Often Than QHPs to Pediatric-Specific Standards

			Overall Network Adequacy Standards in Selected States

The five selected states we examined had one or more specific network  adequacy standards for CHIP plans and QHPs. Two of the  selected states—Massachusetts and Washington—required CHIP  plan networks to follow specific provider-to-enrollee ratios. Three of the selected states—Massachusetts, Texas, and  Washington—required CHIP plan networks to follow provider capacity  or availability  standards. 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. Nearly All Selected Issuers Included at Least One Children’s Hospital in Their Networks, but Many Expressed Challenges Recruiting Certain Specialists

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. 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. 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. CMS Monitors State Oversight of Network Adequacy for CHIP Plans and Directly Monitors Adequacy for QHPs in Federally Facilitated Exchanges; Selected States’ Monitoring Varied CMS Monitored State Oversight of CHIP Network Adequacy through Contract and State Plan Reviews, and Directly Monitored Adequacy for QHPs in Federally Facilitated Exchange States

States have primary responsibility for administering CHIP and for  overseeing CHIP plan compliance with network adequacy standards, and  CMS monitors these state oversight activities. These  standards may include, for example, provider-to-enrollee ratios, travel  time or distance standards, and capacity or availability  standards. CMS is  required to monitor the development and implementation of this  plan. CMS conducts an annual  certification process of QHPs in FFE states. Most Selected States Monitored CHIP and QHP Network Adequacy, but the Frequency of Monitoring Varied

			Selected States’ Monitoring of CHIP Network Adequacy

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. Selected States’ Monitoring of QHP Network Adequacy

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. Agency Comments

We provided a draft of this report to the Secretary of Health and Human  Services. HHS provided technical comments that we incorporated as  appropriate. Appendix I: Selection Criteria for States, Issuers, and Children’s Hospitals

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. 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).
Why GAO Did This Study

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.

What GAO Found

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.