CHILDREN S HEALTH INSURANCE

Transcription

1 Unite States Government Aountaility Offie Report to Congressional Requesters Feruary 2015 CHILDREN S HEALTH INSURANCE Coverage of Servies an Costs to Consumers in Selete CHIP an Private Health Plans in Five States GAO

2 Feruary 2015 CHILDREN S HEALTH INSURANCE Coverage of Servies an Costs to Consumers in Selete CHIP an Private Health Plans in Five States Highlights of GAO , a report to ongressional requesters Why GAO Di This Stuy Feeral funs appropriate to states for CHIP the jointly finane health insurane program for ertain lowinome hilren are expete to e exhauste soon after the en of fisal year 2015 unless Congress ats to appropriate new funs. Beginning in Otoer 2015, any state with insuffiient CHIP funing must estalish proeures to ensure that hilren who are not y CHIP are sreene for Meiai eligiility. If ineligile, hilren may e enrolle into a private qualifie health plan or QHP that has een ertifie y the Seretary of Health an Human Servies (HHS) as omparale to CHIP, if suh a QHP is availale. GAO was aske to examine overage an osts to onsumers in selete CHIP plans an private QHPs in selete states. GAO reviewe (1) overage an (2) osts to onsumers for one CHIP plan, one QHP, an, where appliale, one SADP in eah of five states Colorao, Illinois, Kansas, New York, an Utah. State seletion was ase on variation in loation, program size, an esign; CHIP plan seletion was ase on high enrollment; an QHP seletion was ase on low plan premiums. GAO otaine CHIP an QHP premium ata from state offiials an feeral an state wesites. GAO also otaine ouments from an spoke to feeral offiials, inluing from HHS s Assistant Seretary for Planning an Evaluation, state offiials, inluing from CHIP an insurane epartments, an issuers of QHPs. HHS provie tehnial omments on a raft of this report, whih GAO inorporate as appropriate. What GAO Foun In five selete states, GAO etermine that overage of servies in the selete State Chilren s Health Insurane Program (CHIP) plans was generally omparale to that of the selete private qualifie health plans (QHP), with some ifferenes. In partiular, the plans were generally omparale in that most the servies GAO reviewe with the notale exeptions of peiatri ental an ertain enaling servies suh as translation an transportation servies, whih were more frequently y the CHIP plans. For example, only the selete QHP in New York peiatri ental servies; the QHPs in the other four states i not inlue peiatri ental servies, although some offiials iniate this woul hange for 2015 offerings. In those four states, stan-alone ental plans (SADP) oul e purhase separately. Selete CHIP plans an QHPs were also similar in terms of the servies on whih they impose ay, visit, or ollar limits, although the five selete CHIP plans generally impose fewer limits than the selete QHPs. For servies where overage limits were sometimes impose on QHPs an CHIP plans, GAO s review foun that the limits on CHIP plans were at times less restritive. For example, the selete QHP in Utah limite home- an ommunity-ase health are servies to 60 visits per year while the selete CHIP plan i not impose any limits. In aition, for peiatri ental servies, overage limits in the selete SADPs were generally similar to those in the selete CHIP plan; however, when there were ifferenes, CHIP was generally more generous. Consumers osts for these servies efine as eutiles, opayments, oinsurane, an premiums were almost always less in the five states selete CHIP plans when ompare to their respetive QHPs, espite the appliation of susiies authorize uner the Patient Protetion an Afforale Care At (PPACA) that reue these osts in the QHPs. Speifially, when ost-sharing applie, the amount was typially less for CHIP plans, even onsiering PPACA provisions aime at reuing ost-sharing amounts for ertain low inome onsumers who purhase QHPs. For example, an offie visit to a speialist in Colorao woul ost a CHIP enrollee a $2 to $10 opayment per visit, epening on their inome, ompare to the lowest availale opayment of $25 per visit in the selete Colorao QHP. GAO s review of premium ata further suggests that selete CHIP premiums were always lower than selete QHP premiums, even when onsiering the appliation of PPACA susiies that help to efray the ost to ertain onsumers. For example, the 2014 annual premium for the selete Illinois CHIP plan for an iniviual at 150 perent of the feeral poverty level (FPL) was $0. By omparison, the 2014 annual premium for the selete Illinois QHP was $1,254, whih was reue to $944 for an iniviual at 150 perent of the FPL, after onsiering feeral susiies to offset the ost of overage. Finally, all selete CHIP plans an QHPs GAO reviewe limite out-of-poket maximum osts, an these maximum osts were typially less in the CHIP plans. View GAO For more information, ontat Katherine Iritani at (202) or iritanik@gao.gov. Unite States Government Aountaility Offie

3 Contents Letter 1 Bakgroun 6 In Five States, Coverage in Selete CHIP Plans an QHPs Was Generally Comparale, Although the CHIP Plans More Commonly Covere Dental an Certain Enaling Servies an Ha Fewer Coverage Limits 11 Costs to Consumers Were Almost Always Less in Selete CHIP Plans Than in Selete QHPs Despite PPACA Provisions That Limit QHP Costs 15 Ageny Comments 19 Appenix I Coverage for Selete Servies in CHIP Plans an Qualifie Health Plans (QHP) GAO Reviewe in Five States 20 Appenix II Coverage Limits for Selete Servies in CHIP Plans an QHPs GAO Reviewe in Five States 22 Appenix III Coverage, Coverage Limits, an Cost-Sharing for Selete Dental Servies in CHIP Plans, QHPs, an SADPs 26 Appenix IV Cost-Sharing for Selete Servies in CHIP Plans an QHPs GAO Reviewe in Five States 40 Appenix V GAO Contat an Staff Aknowlegments 54 Relate GAO Prouts 55 Tales Tale 1: Annual Coverage Limits for Selete Servies in State Chilren s Health Insurane Program (CHIP) Plans GAO Reviewe in Five States, Calenar Year Page i

4 Tale 2: Annual Coverage Limits for Selete Servies in Qualifie Health Plans (QHP) GAO Reviewe in Five States, Calenar Year Tale 3: Coverage an Coverage Limits for Selete Dental Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Stan-alone Dental Plan (SADP) GAO Reviewe in Colorao, Calenar Year Tale 4: Coverage an Coverage Limits for Selete Dental Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Stan-alone Dental Plan (SADP) GAO Reviewe in Illinois, Calenar Year Tale 5: Coverage an Coverage Limits for Selete Dental Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Stan-alone Dental Plan (SADP) GAO Reviewe in Kansas, Calenar Year Tale 6: Coverage an Coverage Limits for Selete Dental Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Qualifie Health Plan (QHP) GAO Reviewe in New York, Calenar Year Tale 7: Coverage an Coverage Limits for Selete Dental Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Stan-alone Dental Plan (SADP) GAO Reviewe in Utah, Calenar Year Tale 8: Cost-Sharing Amounts for Selete Dental Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Stan-alone Dental Plan (SADP) GAO Reviewe in Colorao, Calenar Year Tale 9: Cost-Sharing Amounts for Selete Dental Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Stan-alone Dental Plan (SADP) GAO Reviewe in Illinois, Calenar Year Tale 10: Cost-Sharing Amounts for Selete Dental Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Stan-alone Dental Plan (SADP) GAO Reviewe in Kansas, Calenar Year Tale 11: Cost-Sharing Amounts for Selete Dental Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Qualifie Health Plan (QHP) GAO Reviewe in New York, Calenar Year Page ii

5 Tale 12: Cost-Sharing Amounts for Selete Dental Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Stan-alone Dental Plan (SADP) GAO Reviewe in Utah, Calenar Year Tale 13: Cost-Sharing Amounts for Selete Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Qualifie Health Plan (QHP) GAO Reviewe in Colorao, Calenar Year Tale 14: Cost-Sharing Amounts for Selete Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Qualifie Health Plan (QHP) GAO Reviewe in Illinois, Calenar Year Tale 15: Cost-Sharing Amounts for Selete Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Qualifie Health Plan (QHP) GAO Reviewe in Kansas, Calenar Year Tale 16: Cost-Sharing Amounts for Selete Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Qualifie Health Plan (QHP) GAO Reviewe in New York, Calenar Year Tale 17: Cost-Sharing Amounts for Selete Servies in the State Chilren s Health Insurane Program (CHIP) Plan an Qualifie Health Plan (QHP) GAO Reviewe in Utah, Calenar Year Figure Figure 1: Selete Servies with Coverage Limits in State Chilren s Health Insurane Program (CHIP) Plans an Qualifie Health Plans (QHP) GAO Reviewe in Five States, Calenar Year Page iii

6 Areviations ASPE AV CHIP CMS EHB EPSDT FPL HHS MAGI PPACA QHP SADP Assistant Seretary for Planning an Evaluation atuarial value State Chilren s Health Insurane Program Centers for Meiare & Meiai Servies essential health enefits Early an Perioi Sreening, Diagnosti an Treatment feeral poverty level Department of Health an Human Servies Moifie Ajuste Gross Inome Patient Protetion an Afforale Care At qualifie health plan stan-alone ental plan This is a work of the U.S. government an is not sujet to opyright protetion in the Unite States. The pulishe prout may e reproue an istriute in its entirety without further permission from GAO. However, eause this work may ontain opyrighte images or other material, permission from the opyright holer may e neessary if you wish to reproue this material separately. Page iv

7 441 G St. N.W. Washington, DC Feruary 25, 2015 The Honorale Orrin G. Hath Chairman Committee on Finane Unite States Senate The Honorale Fre Upton Chairman Committee on Energy an Commere House of Representatives Feeral funing appropriate to states to support the State Chilren s Health Insurane Program (CHIP), a joint feeral-state program that was estalishe in 1997 to provie health overage to ertain low-inome hilren, will en after Septemer 2015 unless Congress ats to appropriate new funs. CHIP finanes health insurane for over 8 million hilren whose househol inomes are too high for Meiai eligiility ut may e too low to affor private insurane, an feeral funs are expete to run out shortly after the en of fisal year Sine January 2014, feeral susiies have een availale to qualifying iniviuals to offset the ost of private health insurane purhase through health insurane exhanges marketplaes where eligile iniviuals an ompare an selet among qualifie health plans (QHP) an stan-alone ental plans (SADP) offere y partiipating private issuers estalishe uner the Patient Protetion an Afforale Care 1 Meiai is a joint feeral-state program that finanes health insurane overage for ertain ategories of lower-inome iniviuals, inluing hilren. Most states upper inome CHIP eligiility levels are etween 200 an 300 perent of the feeral poverty level (FPL), with the highest eligiility level eing 400 perent of the FPL. Page 1

8 At (PPACA). 2 PPACA also requires that, eginning in Otoer 2015, if a state s CHIP funing is insuffiient to over all CHIP-eligile hilren, the state must estalish proeures to ensure that the hilren who are not y CHIP are sreene for Meiai eligiility. If foun ineligile for Meiai, the hilren may e enrolle into a QHP that has een ertifie as omparale to CHIP y the Seretary of Health an Human Servies (HHS), if suh a QHP is availale. 3 States aminister their CHIP programs uner roa feeral requirements, an programs vary in the servies an the osts to iniviuals an families. For example, states an operate CHIP as a separate program, inlue CHIP-eligile hilren in their Meiai program, or o oth. 4 HHS Centers for Meiare & Meiai Servies (CMS) is the feeral ageny responsile for overseeing CHIP. 2 Pu. L. No , 124 Stat. 119 (2010). In this report, referenes to PPACA inlue any amenments mae y the Health Care an Euation Reoniliation At of 2010, Pu. L. No , 124 Stat (2010), unless otherwise iniate. PPACA require the estalishment of health insurane exhanges in eah state y January 1, 2014, to allow onsumers to ompare partiipating iniviual health insurane plans, known as QHPs an SADPs, availale in that state an enroll in overage. In states eleting not to operate their own exhange, PPACA requires the feeral government to estalish an operate an exhange in the state, referre to as a feerally failitate exhange. QHPs an SADPs offere in the exhanges must meet ertain minimum requirements, inluing those relating to overage an ost. The Department of Health an Human Servies Centers for Meiare & Meiai Servies (CMS), whih is taske with overseeing the estalishment of exhanges, refers to exhanges as marketplaes. 3 The Seretary is require to report y April 2015 on omparaility of enefits an ost sharing etween CHIP an QHPs. As of January 2015, CMS ha not issue guiane on how omparaility etween QHPs an CHIP will e efine. Given the unertainty regaring the afforaility an aequay of hilren s overage outsie of CHIP, the Meiai an CHIP Payment an Aess Commission reommene that Congress exten feeral CHIP funing for a transition perio of 2 years. CHIP regulations also generally require that, for hilren foun ineligile for CHIP, either at the time of initial appliation or uring a follow-up eligiility etermination, the state must sreen the hil for Meiai eligiility an, if ineligile for Meiai, the state must then sreen for potential eligiility for other insurane afforaility programs, inluing susiize overage in a QHP. 4 As of January 2015, 42 states operate separate CHIP programs (1 state ha a separate CHIP program only an 41 states CHIP hilren through oth a separate CHIP program an Meiai.) The numer of states that over CHIP hilren through oth a separate CHIP program an Meiai inrease in 2014 ue to feeral requirements in PPACA that hilren ages 6 to18 in families earning uner 133 perent FPL must e uner Meiai. Page 2

9 In Novemer 2013, we issue a report that ompare overage of servies an osts to onsumers in separate CHIP plans an plans intene as moels for the enefits that woul e offere through QHPs, known as enhmark plans, in five states Colorao Kansas, Illinois, New York, an Utah an esrie how overage an osts might hange in We foun that overage in selete separate CHIP plans was generally omparale to enhmark plans an onsumers osts for these servies were almost always less in CHIP than in enhmark plans. We also onlue that unertainty remaine regaring issuer eisions regaring how to efine ertain servies an the implementation of other PPACA provisions, suh as peiatri ental servies, an that further stuy woul e enefiial. At the time, QHPs were not availale for stuy. Now that QHPs have een mae availale on the exhanges, you aske us to examine the omparaility of enefits an osts to onsumers etween CHIP plans an QHPs. In this report, we esrie (1) how overage of servies in separate CHIP plans ompares to QHPs in selete states, an (2) how osts to onsumers in separate CHIP plans ompare to QHPs in selete states. To aress oth ojetives, we selete the same health are servies we reviewe in our 2013 report, whih were ientifie y reviewing feeral statutes an regulations governing CHIP-eligile servies an the essential health enefit (EHB) ategories, whih are those 10 ategories 5 To prepare for the offering of QHPs in 2014, HHS aske states to selet enhmark health plans plans intene as moels for the enefits that woul e offere through QHPs. Benhmark plans were not moels for QHP ost-sharing. Instea, PPACA inlues provisions that stanarize QHP osts an reue ost-sharing for ertain iniviuals. GAO, Chilren s Health Insurane: Information on Coverage of Servies, Costs to Consumers, an Aess to Care in CHIP an Other Soures of Insurane, GAO (Washington, D.C.: Novemer 21, 2013). Page 3

10 of servie that QHPs are require to over. 6 In aition to these servies, we also ientifie selete enaling servies, whih an help iniviuals aess the meial are they nee an are reognize y the Health Resoures an Servies Aministration s Maternal an Chil Health Bureau as espeially important for low inome hilren an those with speial health are nees, a signifiant numer of whom rely on Meiai or CHIP for some or all of their health are overage. 7 We fouse our review on the five states selete for our Novemer 2013 report: Colorao, Kansas, Illinois, New York, an Utah, selete on the asis of variations in CMS region, CHIP program esign, an size of enrollment in the separate CHIP program. 8 For these five states, we ontate state offiials to ientify the separate CHIP plan with the largest enrollment in 2014 an otaine plan overage an ost sharing information from them for that CHIP plan in eah state. To ompare the CHIP plan overage an osts to that in QHPs, we ientifie the lowest ost silver level QHP in the most populous ounty in eah of the five states in 2014 y reviewing 2010 Census ata an information availale on ata.healthare.gov for states with a feerally failitate exhange an from state offiials in states operating their own 6 Base on our review of feeral regulation an health plan ouments, we ientifie suategories of servies for further review. We reviewe the following servies: amulatory patient servies (primary are physiian an speialist offie visits an outpatient surgery); emergeny are; inpatient hospital servies (faility, professional, an anillary); maternity are; mental health servies (inpatient an outpatient); sustane ause servies (inpatient an outpatient); presription rugs; preventive are (well-hil are, immunizations, an hroni isease management); outpatient therapies (physial, speeh, an oupational therapies for rehailitation an hailitation); peiatri ental servies (routine, emergeny, an other); peiatri vision servies (exams an orretive lenses); laoratory servies (inpatient an outpatient); peiatri hearing servies (testing an hearing ais); urale meial equipment; hospie; an home- an ommunity-ase health are. 7 We limite our review to the following enaling servies: offie translation servies; nonhospie respite are; routine transportation; an are oorination/ase management. 8 These five states over hilren through separate CHIP programs an Meiai; however, for our review, we only examine their separate CHIP programs. Page 4

11 exhanges. 9 We also relie on these ata soures to ientify the lowest ost SADP in 2014 in eah state where the peiatri ental enefit was not inlue in our selete QHP. We then reviewe Evienes of Coverage from eah of the QHPs an SADPs ientifie to etermine whether the servies we ientifie were ; whether there were any annual limits on those servies in terms of ays, visits, age, or expenitures; an to ientify ost-sharing amounts, inluing eutiles, opayments, an oinsurane, for eah of the servies an any state out-of-poket maximum osts. 10 We otaine 2014 CHIP premiums from state offiials an 2014 QHP premiums from ata.healthare.gov, state wesites, an state offiials. We also otaine enrollment ata for feerally failitate exhange states from HHS s Assistant Seretary for Planning an Evaluation (ASPE). 11 Finally, we interviewe state offiials, inluing from CHIP programs an insurane epartments in our five states, offiials from an SADP issuer in one of our five states, an representatives from two large issuer assoiations whose memers partiipate in oth CHIP an the marketplaes to otain their input on the implementation of ertain PPACA provisions. Our overage an ost omparisons were limite to the selete servies, limits, an plans in these five states, an our results annot e 9 QHPs must offer overage that meets one of four metal tier levels ronze, silver, gol, an platinum that orrespon to plans atuarial value. We fouse our review on silver level plans eause reue ost-sharing is availale for eligile iniviuals enrolle in these plans. Sixty-five perent of QHP enrollees in the 36 feerally failitate exhange states hose a silver-level plan in 2014, aoring to an Assistant Seretary for Planning an Evaluation (ASPE) enrollment report. See the Department of Health an Human Servies, Health Insurane Marketplae: Summary Enrollment Report for the Initial Annual Open Enrollment Perio, Assistant Seretary for Planning an Evaluation Issue Brief (Washington, D.C.: May 1, 2014). 10 An Eviene of Coverage oument is a omprehensive guie to an enrollee s health are overage. It explains the enefits an ost-sharing; onitions an limitations of overage; an plan rules. Our analysis i not inlue other overage limits, suh as unspeifie limits ase on meial neessity, expete improvement ealines (e.g., improvement must e expete within 2 months), an rug ay limits (e.g., presriptions fille for 30 ays at a time). 11 ASPE provie ata for the following states: Alaama, Alaska, Arizona, Arkansas, Delaware, Floria, Georgia, Iaho, Illinois, Iniana, Iowa, Kansas, Louisiana, Maine, Mihigan, Mississippi, Missouri, Montana, Neraska, New Hampshire, New Mexio, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, West Virginia Wisonsin, an Wyoming. We i not otain similar enrollment ata from states using their own state-ase exhanges. Page 5

12 generalize to other plans or states. To etermine the reliaility of the information from ata.heathare.gov, we spoke with researhers who have use these ata to learn aout any potential limitations. To etermine the reliaility of information from state offiials regaring QHP ientifiation an premiums, we interviewe offiials regaring the steps they took to assess its reliaility. To etermine the reliaility of enrollment ata from ASPE, we interviewe offiials regaring the steps they took to assess its reliaility, an performe minimal ata heks for ovious errors. We i not inepenently verify the auray or ompleteness of the ata eyon these steps. Base on these efforts, we etermine that these ata soures were suffiiently reliale for the purposes of this report. We onute this performane auit from Novemer 2014 to Feruary 2015 in aorane with generally aepte government auiting stanars. Those stanars require that we plan an perform the auit to otain suffiient, appropriate eviene to provie a reasonale asis for our finings an onlusions ase on our auit ojetives. We elieve that the eviene otaine provies a reasonale asis for our finings an onlusions ase on our auit ojetives. Bakgroun Coverage an Cost Requirements for CHIP Unlike states that opt to over CHIP-eligile hilren in their Meiai programs an therefore must exten Meiai servies to CHIPeligile iniviuals, states with separate CHIP programs have flexiility in program esign an are at lierty to moify ertain aspets of their programs, suh as overage an ost-sharing requirements. However, feeral laws an regulations require states separate CHIP programs to inlue overage for routine hek-ups, immunizations, emergeny servies, an ental servies efine as neessary to prevent isease an promote oral health, restore oral strutures to health an funtion, an treat emergeny onitions. States typially over a roa array of aitional servies in their separate CHIP programs an, in some states, aopt the Meiai requirement to over Early an Perioi Sreening, Page 6

13 Diagnosti an Treatment (EPSDT) servies. 12 State CHIP programs must also omply with mental health parity requirements meaning they must apply any finanial requirements or limits on mental health or sustane ause enefits in the same manner as applie to meial an surgial enefits. With respet to osts to onsumers, CHIP premiums an ost-sharing irrespetive of program esign may not exee amounts as efine y law. States may vary separate CHIP premiums an ost-sharing ase on inome an family size, as long as ost-sharing for higher-inome hilren is not lower than for lower-inome hilren. Feeral laws an regulations also impose aitional limits on premiums an ost-sharing for hilren in families with inomes at or elow 150 perent of the feeral poverty level (FPL). In all ases, no ost-sharing an e require for preventive servies efine as well-ay an well-hil are, inluing age-appropriate immunizations an pregnany-relate servies. In aition, states may not impose premiums an ost-sharing that, in the aggregate, exee 5 perent of a family s total inome for the length of 13 the hil s eligiility perio in CHIP. Coverage an Cost Requirements for QHPs PPACA inlues provisions that seek to stanarize overage an osts of private health plans in the iniviual an small group markets. QHPs offere oth on an off the exhanges are require to omply with appliale private insurane market reforms, inluing relevant premium rating requirements, the elimination of lifetime an annual ollar limits on EHBs, prohiition of ost-sharing for preventive servies, mental health parity requirements, an the offering of omprehensive overage. PPACA allows exhanges in eah state to offer overage of peiatri ental servies as an integrate enefit in a QHP or through an SADP, whih onsumers an purhase separately. In exhanges with at least one partiipating SADP, QHPs are not require to inlue the peiatri ental enefit. Some states require hilren otaining overage in their statease exhanges to enroll in an SADP if their QHP oes not inlue the 12 EPSDT servies inlue omprehensive sreenings, preventive health are servies, an other servies neessary to orret illnesses or onitions ientifie y the sreenings. 13 This annual umulative maximum applies to premiums, eutiles an any appliale ost-sharing requirements, inluing opayments an oinsurane, irrespetive of the numer of hilren in the family who are enrolle in CHIP. Page 7

14 peiatri ental enefit; onsumers purhasing overage in the feerally failitate exhange are not require to o so. 14 With respet to osts to onsumers, QHPs must offer overage that meets one of four metal tier levels, whih orrespon to atuarial value (AV) perentages that range from 60 to 90 perent: ronze (AV of 60 perent), silver (AV of 70 perent), gol (AV of 80 perent), or platinum (AV of 90 perent). 15 AV iniates the proportion of allowale harges that a health plan will pay, on average the higher the AV, the lower the ost-sharing expete to e pai y onsumers. Cost-sharing susiies are availale to iniviuals with inomes etween 100 an 250 perent of the FPL to offset the osts they inur through opayments, oinsurane, an eutiles in a silver-level QHP. The ost-sharing susiies are not provie iretly to onsumers; instea, QHP issuers are require to offer three variations of eah silver plan they market through an exhange in the iniviual market. These plans are to reflet the ost-sharing susiies through lower out-of-poket maximum osts an, if neessary, through lower eutiles, opayments, or oinsurane. One the ajustments from the susiies are mae, the AV of the silver plan availale to eligile onsumers will effetively inrease from 70 perent to 73, 87, or 94 perent, epening on inome. SADPs have ifferent AV requirements than QHPs. SADPs are ategorize as high an low level plans, with 85 an 70 perent AV, respetively. 16 Cost-sharing susiies are not availale for peiatri ental osts inurre y a onsumer enrolle in an SADP. PPACA also provies a premium tax reit to eligile iniviuals who purhase QHPs through the exhanges an who have inomes that are etween 100 an 400 perent of the FPL. Depening on their inome, this provision limits the amount families must ontriute to QHP premiums to etween 2 an 9.5 perent, inlusive, of their annual inome; in In 2014, Kentuky, Nevaa, an Washington require hilren otaining overage in their state-ase exhanges to enroll in an SADP if their QHP i not inlue the peiatri ental enefit. 15 Deutiles, o-pays, oinsurane amounts, an out-of-poket maximum osts an vary within these plans, as long as the overall ost-sharing struture meets the require AV levels. Plans are allowe a e minimis variation of +/- 2 perent. Premium osts are not inlue in the AV omputation. 16 Plans are allowe a e minimis variation of +/- 1 perent. Page 8

15 these premium ontriutions range from $471 to $8,949 for a family of four. The premium tax reit is availale to eligile onsumers regarless of whih metal tier they hoose; however, the reit is alulate ase on the seon-lowest ost silver plan in the rating area in whih the onsumer resies. 17 Unlike ost-sharing susiies, whih generally o not apply to osts inurre for servies y a onsumer enrolle in an SADP, the maximum ontriution amount on premiums inlues premiums for oth QHPs an SADPs, if relevant. 18 Finally, PPACA estalishe out-of-poket maximum osts that apply to EHBs inlue in QHPs an SADPs. In 2014, these maximum osts for QHPs range from $2,250 to $6,350 for iniviuals an $4,500 to $12,700 for families for househols with inomes etween 100 an 400 perent of the FPL. Out-of-poket maximum osts for SADPs are in aition to the out-of-poket maximum osts for QHPs an were estalishe y eah exhange in CHIP-Eligile Chilren an Enrollment in QHPs CHIP-eligile hilren may enroll in QHPs instea of enrolling in CHIP either through a hil-only plan or through a plan with other family memers ut they are ineligile for premium tax reits an ostsharing susiies eause of their eligiility for CHIP. However, if a state experienes a CHIP funing shortfall in the future an is therefore unale to enroll all CHIP-eligile hilren into a CHIP plan, suh hilren may qualify for premium tax reits an ost-sharing susiies to offset the ost of QHP overage. 19 In states not experiening a funing shortfall, enrolling CHIP-eligile hilren in QHPs woul generally inrease osts for families. Uner CMS regulations, if an iniviual who is ineligile for 17 Eah state an ivie up areas of resiene in the state into loations alle rating areas, an issuers of QHPs may vary premiums ase on rating area. 18 If an iniviual who is eligile for premium tax reits enrolls in a QHP an an SADP, the portion of the SADP that is alloale to the peiatri ental EHB must e onsiere part of the QHP premium to whih the iniviual s premium tax reit applies. However, unless the onsumer purhases a QHP with a premium that is less than the seon lowest ost silver plan, e.g., a ronze plan, the onsumer woul likely pay the full premium for the SADP. 19 This applies only to hilren enrolle in a separate CHIP plan. In the event of a CHIP funing shortfall, hilren enrolle in a CHIP-fune Meiai expansion woul remain eligile for Meiai, at least until fisal year 2019, uring whih time states may not reue Meiai eligiility levels for hilren. Chilren remaining Meiai eligile woul not qualify for premium tax reits or ost-sharing susiies. Page 9

16 ost-sharing susiies enrolls in the same poliy as another family memer who is eligile for ost-sharing susiies, nooy uner the poliy will qualify for ost-sharing susiies. 20 As a result, enrolling CHIP-eligile hilren in QHPs oul result in a loss of ost-sharing susiies for family memers that are eligile for these susiies. To maintain ost-sharing susiies for eligile family memers, the CHIPeligile hil woul nee to e enrolle in a hil-only health plan, for whih premium tax reits woul e unavailale eause of the hil s eligiility for CHIP Fe. Reg , (De. 7, 2012) (oifie at 45 C.F.R (g)(3)). Aoring to CMS, the ageny aopte this rule eause it woul e operationally iffiult for an issuer to estalish separate ost-sharing amounts for ifferent enrollees uner the same poliy. Page 10

17 In Five States, Coverage in Selete CHIP Plans an QHPs Was Generally Comparale, Although the CHIP Plans More Commonly Covere Dental an Certain Enaling Servies an Ha Fewer Coverage Limits We etermine that overage in the selete CHIP plans an QHPs in our five states was generally omparale in that it inlue some level of overage for nearly all the servies we reviewe. 21 ale exeptions were ertain enaling servies an peiatri ental servies, whih were more frequently y the selete CHIP plans. 22 (See app. I for a etaile list of selete servies y the plans we reviewe.) With respet to ertain enaling servies, whih may e partiularly important for low inome hilren, are oorination or ase management was offere y all selete CHIP plans, ut y only one selete QHP. Similarly, routine transportation to an from meial appointments was y two CHIP plans ut y none of the selete QHPs. 23 With respet to peiatri ental servies, the QHP in New York was the only selete QHP that them; the selete QHPs in the other four states i not integrate peiatri ental servies within the meial overage they offere. 24 To otain overage for peiatri ental servies, onsumers who purhase the selete QHP in these states woul also nee to purhase an SADP. For onsumers who purhase the selete QHP in New York or the selete SADP in the other four states, we etermine that peiatri ental overage availale was generally omparale to what was availale in their state s selete CHIP plan, with 21 Offiials from eah of the selete states reporte that they ha not unertaken efforts to ompare CHIP an QHP overage an osts. 22 Aitionally, hailitative servies were not y the selete CHIP plan in Kansas. 23 Selete CHIP plans an QHPs were similar in that most i not over non-hospie respite are. 24 We refer to peiatri ental servies as those other than non-emergeny ental only. Offiials from two large national issuer assoiations note several fators that may have ontriute to their QHP issuers eisions not to inlue overage for peiatri ental servies in 2014, inluing lak of experiene offering these servies, onerns aout how the aitional ost of proviing these servies oul affet their ompetitiveness, an the option to not provie them if an SADP was availale in the state. QHP offerings may e ifferent in 2015, however. Aoring to Colorao offiials, more QHPs in their state have inlue peiatri ental servies in 2015 than i in 2014 primarily eause of aministrative simplifiation. Aitionally, plan offiials for the Utah SADP tol us the selete SADP woul e isontinue at the en of 2014, as the ental enefits offere woul e emee in the issuer s meial plans in Page 11

18 the exeption of Utah, where the selete CHIP plan was more generous than the selete SADP. 25 However, the extent to whih onsumers otaine overage that inlue peiatri ental servies is not lear. Availale feeral ata with information on QHP enrollment suggest that many hilren in the Unite States with exhange overage in 2014 may have een without omprehensive ental overage. Aoring to our analysis of enrollment ata for 2014 provie y ASPE, 16 perent of hilren younger than 18 years of age in the 36 states with feerally failitate exhanges were enrolle in a QHP that inlue omprehensive ental servies that hek-ups, asi, an major ental servies. 26 The remaining hilren were enrolle in QHPs that either ha less than omprehensive or no ental overage. Some of these families are likely to have purhase an SADP for their hilren, however. Aoring to an ASPE report issue in May 2014, 18 perent of hilren younger than 18 years of age in the 36 states with feerally failitate exhanges who enrolle in a QHP also enrolle in an SADP, an these were likely among the families that ha no omprehensive ental overage inlue in their QHP. 27 Aoring to our analysis of enrollment ata for 2014 provie y ASPE, virtually no hilren younger than 18 years of age in the 36 states with feerally failitate exhanges were enrolle in a QHP that inlue omprehensive ental servies an an SADP. Selete CHIP plans an QHPs were also similar in terms of the servies on whih they impose ay, visit, or ollar limits; however, in the aggregate, CHIP plans impose fewer limits than QHPs. (See fig.1.) The selete CHIP plans an QHPs we reviewe were generally similar in that they typially i not impose ay, visit, or ollar limits on offie visits, emergeny are, presription rugs, an preventive are, ut ommonly 25 Eah state s CHIP was the moel for ental enefits in Colorao, Illinois, Kansas, an New York QHPs an SADPs in Utah s enhmark plan was the moel for ental enefits in Utah s QHPs an SADPs. 26 Aoring to CMS, a QHP must offer hek-ups, asi, an major ental servies to e onsiere a QHP with emee ental overage. Aoring to our analysis of enrollment ata for 2014 provie y ASPE, less than half of the QHPs in a given state offere any type of ental overage hekups, asi, or major ental servies in two thirs of states with feerally failitate exhanges. 27 See Department of Health an Human Servies, Health Insurane Marketplae: Summary Enrollment Report. Page 12

19 i impose limits on outpatient therapies, peiatri vision, an peiatri hearing. One notale ifferene etween these selete CHIP plans an QHPs was the frequeny y whih they limite home-an ommunityase health are. While the selete QHP in four states impose ay or visit limits on these servies, only one state s selete CHIP plan i so. In ontrast, no QHPs impose limits on urale meial equipment, while one CHIP plan impose a $2,000 annual limit. Figure 1: Selete Servies with Coverage Limits in State Chilren s Health Insurane Program (CHIP) Plans an Qualifie Health Plans (QHP) GAO Reviewe in Five States, Calenar Year 2014 e: We i not ientify any limits on the following servies in the selete CHIP plans an QHPs: offie visits, emergeny are, presription rugs, preventive servies, an when, enaling servies. Coverage limits on peiatri ental servies are exlue from this tale eause the selete QHP in four of the five states i not over peiatri ental servies. Page 13

20 For servies where overage limits were sometimes impose on QHPs an CHIP plans, our review foun that the limits on CHIP plans were at times less restritive. For example, the selete QHP in Utah limite home- an ommunity-ase health are servies to 60 visits per year while the selete CHIP plan in the state i not impose any limits on these servies. Comparaility etween servie limits in states selete CHIP plans an QHPs was less lear for outpatient therapy servies. For example, the selete CHIP plan in New York limite outpatient physial an oupational therapies to 6 weeks per year, with no limits on outpatient speeh therapy, while the selete QHP in the state limite outpatient therapies to a omine 60 visits per onition per lifetime. (See app. II for a etaile list of overage limits for servies we reviewe in the selete plans.) In aition, for peiatri ental servies, overage limits in the selete QHP an SADPs were generally similar to those in the selete CHIP plan; however, when there were ifferenes, CHIP was generally more generous. For example, the selete CHIP plan in Kansas allowe one sealant per tooth per year; in ontrast, the selete high an low SADP in the state allowe one sealant per tooth every three years. Similarly, the selete CHIP plan in Utah i not have any overage limits on x-rays while the selete high an low SADPs in the state i. (See app. III for a etaile list of selete ental limits we reviewe in selete plans.) Page 14

21 Costs to Consumers Were Almost Always Less in Selete CHIP Plans Than in Selete QHPs Despite PPACA Provisions That Limit QHP Costs We etermine that osts to onsumers were almost always less in the selete CHIP plans than in the selete QHPs. Even onsiering PPACA provisions aime at reuing ost-sharing amounts for ertain low-inome onsumers who purhase QHPs, the ifferenes remaine, though were smaller. For example, the selete CHIP plans in four of the five states i not inlue any eutile, whih means that enrollees in those states i not nee to pay a speifie amount efore the plan egan paying for servies. 28 In ontrast, QHPs we reviewe typially impose annual eutiles, whih were as high as $500 for an iniviual an $1,500 for a family in the plan variation that offere the lowest availale eutiles for QHP enrollees. 29 In aition, onsumers who purhase selete SADPs may fae separate eutile osts. For example, whereas ental servies were sujet to the plan eutile in the New York QHP, SADPs in Colorao, Illinois, an Kansas ha separate ental eutiles that range from $25 to $50 for iniviuals enrolle in selete high plans to $45 to $50 for iniviuals enrolle in selete low plans. (See app. III for a etaile list of selete ental ostsharing we reviewe in the selete plans.) For servies we reviewe where the plans impose opayments or oinsurane, the amount was typially less in a state s selete CHIP plan ompare to its selete QHP, even onsiering PPACA provisions aime at reuing ost-sharing amounts for ertain low inome 30 onsumers who purhase QHPs. For example, the selete CHIP plan in two of our five states Kansas an New York i not impose opayments or oinsurane on any of the servies we reviewe. In two of the remaining three states, the selete CHIP plan impose opayments or oinsurane on less than half of the servies we reviewe, an the 28 Utah is the only selete state that impose a eutile on its CHIP population. In 2014, CHIP enrollees in Utah with family inomes etween 134 an 150 perent FPL were sujet to a eutile of $40 a year for the family. Those with family inomes etween 151 an 200 perent FPL were sujet to an annual eutile of $500 an $1,500 for a hil an family, respetively. 29 These annual eutile amounts were for the 94 perent AV plan. To qualify for the 94 perent AV plan, enrollees must have family inomes at or elow 150 perent FPL. The eutiles for the lower AV plans (70, 73, an 87 perent) were often onsieraly higher. See appenix IV. 30 A opayment is a fixe ollar amount that a onsumer must pay at the time a servie is provie. Coinsurane is a fixe perentage of the total ost of servies that a onsumer must pay. Page 15

22 amounts were usually minimal an on a sliing inome sale. 31 For example, for eah ran-name presription rug, the Illinois CHIP plan impose a $3.90 opayment on enrollees with inomes greater than 142 an up to 157 perent of the FPL, whih was inrease to $7 for enrollees with inomes greater than 209 an up to 313 perent of the FPL. In ontrast, selete QHPs in all five states impose opayments or oinsurane on most servies we reviewe, an the amounts were onsistently higher than the CHIP plan in the same state. For example, epening on inome, the opayment for primary are an speialist physiian visits in Colorao range from $2 to $10 per visit for enrollees in the selete CHIP plan, ut was $25 an $35 per visit, respetively, for all enrollees in the selete QHP. Cost-sharing for ental servies was also higher in a state s selete SADP than in its selete CHIP plan a majority of the time. In aition, in states where the selete QHP harge oinsurane an the selete CHIP plan require a opayment, a iret omparison of ost ifferenes oul not e mae, although ata suggest CHIP osts woul generally e lower. For example, for an inpatient hospital amission, higher-inome enrollees in the selete CHIP plan in Colorao pai $50, while all enrollees in the selete QHP in the state were responsile for 20 perent oinsurane after the eutile was met, an amount that was likely to e higher given that 20 perent of the average prie for an inpatient faility stay in 2011 was over $3, (See app. IV for a etaile list of ost-sharing for servies we reviewe in selete plans.) Our review of premiums for selete CHIP plans an QHPs also suggests that premiums were always less in the CHIP plans than in the QHPs we reviewe, even with the appliation of the premium tax reit to efray the ost of QHP premiums. For example, aoring to CHIP offiials, annual CHIP premiums in 2014 for an iniviual varie y inome level an range from $0 for the lowest inome CHIP enrollees in Colorao, Illinois, Kansas, an New York, to $720 for enrollees etween 351 an 400 perent of the FPL in New York, with most enrollees aross the five 31 The selete CHIP plan in Utah iffere from the selete CHIP plans in the other four states in that that it impose either a opayment or oinsurane on nearly all servies we reviewe, whih varie y inome level. 32 Aoring to the Health Care Cost Institute, the average prie of an inpatient stay, whih inlues hospital stays, in 2011 was $15,674. See the Health Care Cost Institute, Health Care Cost an Utilization Report: 2011 (Washington, D.C., Health Care Cost Institute, 2012). Page 16

23 selete states paying less than $200 per year. 33 By omparison, 2014 annual premiums for a single hil only enrolle in selete QHPs range from $1,111 to $1,776 in our five states efore the appliation of the premium tax reit. With the premium tax reit, the annual premium amount for selete QHPs was often signifiantly lower, ut was still higher than the selete CHIP plan in all five states. For example, in Illinois, the premium for the selete CHIP plan for an iniviual with an inome at 150 perent of the FPL was $0 an was $1,254 for the selete QHP, whih was reue to $944 after the premium tax reit was applie. However, the aitional premium ost to families enrolling previously eligile CHIP hilren into their QHPs a possiility if CHIP funing is not 34 reauthorize may e minimal or nothing. Beause PPACA limits the amount lower inome families pay in premiums, families with inomes at 250 perent or less of the FPL at least 75 perent of the separate CHIP enrollees in the states we reviewe woul generally pay no aitional premium to a a hil to their QHP. For example, in Kansas, the 2014 annual premium for the lowest ost silver level QHP was $4,875 for a ouple age 40 an an aitional $1,211 to a a hil. However, if the ouple s inome was 200 perent of the FPL, their maximum annual 33 The lowest inome enrollees fall in the lowest FPL range that CHIP overs in eah respetive state. This range was etween 143 an 156 perent for Colorao, greater than 142 an up to 157 perent for Illinois, etween 134 an 166 perent for Kansas, greater than 154 an less than 160 perent for New York, an etween 134 an 150 perent FPL for Utah. 34 In some ases, enrolling previously eligile CHIP hilren into QHPs oul reue premium osts for families. This is eause CHIP plans an QHPs eah have statutory limits on premiums ase on family inome, an the limits applie to eah program o not aount for families that pay premiums to oth programs, known as premium staking. More than 3 million hilren are sujet to CHIP premiums, so many families enrolling in exhanges may e sujet to premium staking if they also purhase CHIP plans. In ontrast, some families with CHIP-eligile hilren may not qualify for premium tax reits an, therefore, enrolling previously eligile CHIP hilren into QHPs oul inrease their premium osts. Speifially, families o not qualify for QHP susiies if a parent is offere afforale employer overage. The law onsiers employer overage afforale if the ost of the employee-only plan without the ost of aitional family memers oes not exee 9.5 perent of househol inome. This is often referre to as the family glith, as the atual premium that a family pays for insurane may e muh higher than 9.5 perent. See GAO, Chilren s Health Insurane: Opportunities Exist for Improve Aess to Afforale Insurane, GAO (Washington, D.C.: June 22, 2012). Page 17

24 premium woul e $2,494, an they woul inur no aitional osts y aing a hil to their plan. 35 Finally, all selete CHIP plans an QHPs limite the total potential osts to onsumers y imposing out-of-poket maximum osts, an these maximum osts were typially less in the CHIP plans we reviewe. For example, all five states applie the limit a family oul pay in CHIP plans as estalishe uner feeral law inluing eutiles, opayments, oinsurane, an premiums at 5 perent of a family s inome uring the hil s (or hilren s) eligiility for CHIP. This 5 perent ap resulte in limits that varie ase on a family s inome level. This amount range from $584 to $2,334 for iniviuals, an $1,193 to $4,770 for a family of four, etween 100 an 400 perent of the FPL in PPACA also estalishe out-of-poket maximum osts that apply to QHPs an may vary y inome. 36 Unlike CHIP, however, QHP maximums o not inlue premiums, whih may e separately reue through the appliation of premium tax reits. QHPs may set out-of-poket maximum osts that are lower than those estalishe y PPACA, whih was the ase for three of the five selete QHPs. 37 For example, the selete QHP in Colorao ha iniviual out-of-poket maximum osts ranging from $750 to $6,300 for iniviuals etween 100 an 400 perent FPL. This amount was less than out-of-poket maximum osts estalishe uner feeral law, whih range from $2,250 to $6,350 for iniviuals etween 100 an 400 perent FPL in If an iniviual who is eligile for premium tax reits enrolls in a QHP an an SADP, the portion of the SADP that is alloale to the peiatri ental EHB must e onsiere part of the QHP premium to whih the iniviual s premium tax reit applies. However, unless the onsumer purhases a QHP with a premium that is less than the seon lowest ost silver plan, e.g., a ronze plan, the onsumer woul likely pay the full premium for the SADP. 36 PPACA out-of-poket maximum osts on EHB for househols with inomes etween 100 an 400 perent of the FPL in 2014 range from $2,250 to $6,350 for iniviuals an $4,500 to $12,700 for families. In 2015, out-of-poket maximum osts on EHB for househols with inomes etween 100 an 400 perent of the FPL range from $2,250 to $6,600 for iniviuals an from $4,500 to $13,200 for families. 37 Similarly, a reent report y Avalere Health foun that 74 perent of silver level QHPs in 2015 have out-of-poket maximum osts that are elow PPACA-estalishe limits. Avalere Health LLC, Consumers Shoul Look at Maximum Out-of-Poket Limits & Deutiles in the Exhanges (Washington, D.C., Avalere Health LLC, 2014). Page 18

25 Out-of-poket maximum osts for SADPs are in aition to the out-ofpoket maximum osts for QHPs an may inrease potential osts for families who purhase them. In 2014, eah exhange estalishe maximum out-of-poket osts for SADPs, whih o not inlue premiums. Annual out-of-poket maximum osts for selete SADPs for three of the four selete SADPs were $700 for one hil an $1400 for two or more hilren. 38 Ageny Comments We provie a raft of this report for omment to HHS. HHS offiials provie tehnial omments, whih we inorporate as appropriate. As agree with your offies, unless you pulily announe the ontents of this report earlier, we plan no further istriution until 30 ays from its ate. At that time, we will sen opies to the Seretary of Health an Human Servies an other intereste parties. In aition, the report will e availale at no harge on the GAO wesite at If you or your staffs have any questions aout this report, please ontat Katherine Iritani at (202) or iritanik@gao.gov. Contat points for our Offies of Congressional Relations an Puli Affairs may e foun on the last page of this report. GAO staff who mae key ontriutions to this report are liste in appenix V. Katherine M. Iritani Diretor, Health Care 38 The selete SADP in Utah iffere from the selete SADPs in the other three states in that it impose an out-of-poket maximum ost of $40 for the low plan an $20 for the high plan. CMS regulations impose uniform out-of-poket maximum osts on SADPs eginning in Uner these regulations, ost-sharing may not exee $350 for one hil an $700 for two or more hilren. Page 19