Premium costs are not  included in the AV computation. In Five States, Coverage in Selected CHIP Plans and QHPs Was Generally Comparable, Although the CHIP Plans More Commonly Covered Dental and Certain Enabling Services and Had Fewer Coverage Limits

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. 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. For services where coverage limits were sometimes imposed on QHPs  and CHIP plans, our review found that the limits on CHIP plans were at  times less restrictive. For example, the selected QHP in Utah limited  home- and community-based health care services to 60 visits per year  while the selected CHIP plan in the state did not impose any limits on  these services. In addition, for pediatric dental services, coverage limits in the selected  QHP and SADPs were generally similar to those in the selected CHIP  plan; however, when there were differences, CHIP was generally more  generous. For services we reviewed where the plans imposed copayments or  coinsurance, the amount was typically less in a state’s selected CHIP  plan compared to its selected QHP, even considering PPACA provisions  aimed at reducing cost-sharing amounts for certain low income  consumers who purchased QHPs. IV for a detailed list of cost-sharing for  Our review of premiums for selected CHIP plans and QHPs also suggests  that premiums were always less in the CHIP plans than in the QHPs we  reviewed, even with the application of the premium tax credit to defray the  cost of QHP premiums. For example, according to CHIP officials, annual  CHIP premiums in 2014 for an individual varied by income level and  ranged from $0 for the lowest income CHIP enrollees in Colorado,   Illinois, Kansas, and New York, to $720 for enrollees between 351 and  400 percent of the FPL in New York, with most enrollees across the five  selected states paying less than $200 per year.annual premiums for a single child only enrolled in selected QHPs ranged  from $1,111 to $1,776 in our five states before the application of the  premium tax credit. For example, in  Illinois, the premium for the selected CHIP plan for an individual with an  income at 150 percent of the FPL was $0 and was $1,254 for the selected  QHP, which was reduced to $944 after the premium tax credit was  applied. Finally, all selected CHIP plans and QHPs limited the total potential costs  to consumers by imposing out-of-pocket maximum costs, and these  maximum costs were typically less in the CHIP plans we reviewed. Agency Comments

We provided a draft of this report for comment to HHS. HHS officials  provided technical comments, which we incorporated as appropriate. At that time, we will send copies to the Secretary of Health and  Human Services and other interested parties. GAO staff who made key contributions to  this report are listed in appendix V.

Appendix I: Coverage for Selected Services in CHIP Plans and Qualified Health Plans (QHP) GAO Reviewed in Five States

Testing (screening  and/or exam)   The Patient Protection and Affordable Care Act (PPACA) allows exchanges in each state to make  available coverage of pediatric dental services as an embedded benefit in a QHP or through a stand- alone dental plan (SADP), which consumers may purchase separately. Routine transportation is covered for CHIP children greater than 142 and up to 209 percent of the  federal poverty level only. Appendix III: Coverage, Coverage Limits, and Cost-Sharing for Selected Dental Services in CHIP Plans, QHPs, and SADPs

Tables 3 through 12 provide information on coverage, coverage limits,  and cost-sharing—deductibles, copayments, and coinsurance—for  selected dental services in State Children’s Health Insurance Program  (CHIP) plans we reviewed in five states: Colorado, Illinois, Kansas, New  York, and Utah; a qualified health plan (QHP) in New York; and stand- alone dental plans (SADP) in Colorado, Illinois, Kansas, and Utah. For selected QHPs, these variations  reflect the cost-sharing subsidies that are available to certain enrollees. Children’s Health Insurance: Information on Coverage of Services, Costs  to Consumers, and Access to Care in CHIP and Other Sources of  Insurance.
Why GAO Did This Study

Federal funds appropriated to states for CHIP—the jointly financed health insurance program for certain low-income children—are expected to be exhausted soon after the end of fiscal year 2015 unless Congress acts to appropriate new funds. 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. If ineligible, children may be enrolled into a private qualified health plan—or QHP—that has been certified by the Secretary of Health and Human Services (HHS) as comparable to CHIP, if such a QHP is available.
GAO was asked to examine coverage and costs to consumers in selected CHIP plans and private QHPs in selected states. GAO reviewed (1) coverage and (2) costs to consumers for one CHIP plan, one QHP, and, where applicable, one SADP in each of five states—Colorado, Illinois, Kansas, New York, and Utah. State selection was based on variation in location, program size, and design; CHIP plan selection was based on high enrollment; and QHP selection was based on low plan premiums. GAO obtained CHIP and QHP premium data from state officials and federal and state websites. GAO also obtained documents from and spoke to federal officials, including from HHS's Assistant Secretary for Planning and Evaluation, state officials, including from CHIP and insurance departments, and issuers of QHPs.
HHS provided technical comments on a draft of this report, which GAO incorporated as appropriate.

What GAO Found

In five selected states, GAO determined that coverage of services in the selected State Children's Health Insurance Program (CHIP) plans was generally comparable to that of the selected private qualified health plans (QHP), with some differences. In particular, the plans were generally comparable in that most covered the services GAO reviewed 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. For example, only the selected QHP in New York covered pediatric dental services; the QHPs in the other four states did not include pediatric dental services, although some officials indicated this would change for 2015 offerings. In those four states, stand-alone dental plans (SADP) could be purchased separately. Selected CHIP plans and QHPs were also similar in terms of the services on which they imposed day, visit, or dollar limits, although the five selected CHIP plans generally imposed fewer limits than the selected QHPs. For services where coverage limits were sometimes imposed on QHPs and CHIP plans, GAO's review found that the limits on CHIP plans were at times less restrictive. For example, the selected QHP in Utah limited home- and community-based health care services to 60 visits per year while the selected CHIP plan did not impose any limits. In addition, for pediatric dental services, coverage limits in the selected SADPs were generally similar to those in the selected CHIP plan; however, when there were differences, CHIP was generally more generous.
Consumers' costs for these services—defined as deductibles, copayments, coinsurance, and premiums—were almost always less in the five states' selected CHIP plans when compared to their respective QHPs, despite the application of subsidies authorized under the Patient Protection and Affordable Care Act (PPACA) that reduce these costs in the QHPs. Specifically, when cost-sharing applied, the amount was typically less for CHIP plans, even considering PPACA provisions aimed at reducing cost-sharing amounts for certain low income consumers who purchased QHPs. For example, an office visit to a specialist in Colorado would cost a CHIP enrollee a $2 to $10 copayment per visit, depending on their income, compared to the lowest available copayment of $25 per visit in the selected Colorado QHP. GAO's review of premium data further suggests that selected CHIP premiums were always lower than selected QHP premiums, even when considering the application of PPACA subsidies that help to defray the cost to certain consumers. For example, the 2014 annual premium for the selected Illinois CHIP plan for an individual at 150 percent of the federal poverty level (FPL) was $0. By comparison, the 2014 annual premium for the selected Illinois QHP was $1,254, which was reduced to $944 for an individual at 150 percent of the FPL, after considering federal subsidies to offset the cost of coverage. Finally, all selected CHIP plans and QHPs GAO reviewed limited out-of-pocket maximum costs, and these maximum costs were typically less in the CHIP plans.