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United States Government Accountability Office: 
GAO: 

Report to the Chairman, Subcommittee on Health Care, Committee on 
Finance, U.S. Senate: 

November 2013: 

Children's Health Insurance: 

Information on Coverage of Services, Costs to Consumers, and Access to 
Care in CHIP and Other Sources of Insurance: 

GAO-14-40: 

GAO Highlights: 

Highlights of GAO-14-40, a report to the Chairman, Subcommittee on 
Health Care, Committee on Finance, U.S. Senate. 

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. 

View GAO-14-40. For more information, contact Katherine Iritani at 
(202) 512-7114 or iritanik@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

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 Five States, Costs to Consumers Were Almost Always Less in CHIP 
than in Benchmark Plans; CHIP Costs Are Expected to Remain the Same 
and QHP Costs to Reflect PPACA Limits in 2014: 

National Survey Data Suggest that CHIP Access to Care is Comparable to 
Medicaid and Lower than Private Insurance for Some Services: 

Concluding Observations: 

Agency Comments: 

Appendix I: Scope and Methodology of the Medical Expenditure Panel 
Survey (MEPS) Analysis: 

Appendix II: Coverage for Selected Services in CHIP and Benchmark 
Plans in Five States: 

Appendix III: Copayments, Coinsurance, and Annual Coverage Limits for 
Selected Services in CHIP and Benchmark Plans in Five States: 

Appendix IV: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: Annual Limits on Outpatient Therapies, Pediatric Hearing, and 
Home-and Community-Based Services in the State Children's Health 
Insurance Program (CHIP) and Benchmark Plans of Five States: 

Table 2: Examples of Copayments and Coinsurance for Prescription 
Drugs, Office Visits, and Rehabilitative Outpatient Therapies in the 
State Children's Health Insurance Program (CHIP) and Benchmark Plans 
of Five States: 

Table 3: Out-of-pocket Maximum Cost Amounts for Qualified Health Plan 
Enrollees in 2014 by Federal Poverty Level (FPL): 

Table 4: Maximum Premium Contributions for Qualified Health Plan (QHP) 
Enrollees by Federal Poverty Level (FPL) in 2014: 

Table 5: Percentage of Respondents Who Reported Positive Responses to 
Six Medical Expenditure Panel Survey (MEPS) Questions Related to 
Obtaining Needed Care, by Health Insurance Status, 2007 through 2010: 

Table 6: Percentage of Respondents Who Used Specific Services as 
Reported in Medical Expenditure Panel Survey (MEPS) Data Related to 
Health Care Service Visits within the Past 12 Months, by Health 
Insurance Status, 2007 through 2010: 

Table 7: Description of the 12 Medical Expenditure Panel Survey (MEPS) 
Questions and Survey Items and Related Responses Included in Our 
Analysis of Survey Data from 2007 through 2010: 

Table 8: Cost-Sharing Amounts and Annual Coverage Limits for Selected 
Services in the State Children's Health Insurance Program (CHIP) and 
Benchmark Plans in Colorado: 

Table 9: Cost-Sharing Amounts and Annual Coverage Limits for Selected 
Services in the State Children's Health Insurance Program (CHIP) and 
Benchmark Plans in Illinois: 

Table 10: Cost-Sharing Amounts and Annual Coverage Limits for Selected 
Services in the State Children's Health Insurance Program (CHIP) and 
Benchmark Plans in Kansas: 

Table 11: Cost-Sharing Amounts and Annual Coverage Limits for Selected 
Services in the State Children's Health Insurance Program (CHIP) and 
Benchmark Plans in New York: 

Table 12: Cost-Sharing Amounts and Annual Coverage Limits for Selected 
Services in the State Children's Health Insurance Program (CHIP) and 
Benchmark Plans in Utah: 

Figure: 

Figure 1: Number of State Children's Health Insurance Program (CHIP) 
and Benchmark Plans with Limits on Selected Services in Five States: 

Abbreviations: 

AHRQ: Agency for Healthcare Research and Quality: 

CHIP: State Children's Health Insurance Program: 

CHIPRA: Children's Health Insurance Program Reauthorization Act: 

CMS: Centers for Medicare & Medicaid Services: 

EHB: essential health benefits: 

EPSDT: Early Periodic Screening, Diagnosis, and Treatment: 

FEDVIP: Federal Employees Dental and Vision Insurance Program: 

FEHBP: Federal Employees Health Benefits Program: 

FPL: federal poverty level: 

HHS: Department of Health and Human Services: 

MEPS: Medical Expenditure Panel Survey: 

PPACA: Patient Protection and Affordable Care Act: 

QHP: Qualified Health Plan: 

SADP: stand-alone dental plan: 

[End of section] 

GAO:
United States Government Accountability Office: 
441 G St. N.W. 
Washington, DC 20548: 

November 21, 2013: 

The Honorable John D. Rockefeller IV: 
Chairman: 
Subcommittee on Health Care: 
Committee on Finance: 
United States Senate: 

Dear Mr. Chairman: 

The State Children's Health Insurance Program (CHIP), a joint federal-
state program that was established by law in 1997, finances health 
insurance for over 8 million children whose household incomes are too 
high for Medicaid eligibility, but too low to afford private 
insurance.[Footnote 1] States administer CHIP under broad federal 
requirements, and the programs vary, for example, in the services 
covered, costs to individuals and families, and eligibility 
requirements. The Department of Health and Human Services' (HHS) 
Centers for Medicare & Medicaid Services (CMS) is the federal agency 
responsible for overseeing CHIP, with states managing and 
administering the operations of their individual CHIP programs. States 
can operate CHIP as a separate program or include CHIP-eligible 
children in their Medicaid program.[Footnote 2] Congress has 
appropriated federal CHIP funding at various times since the creation 
of the program. Most recently, the Patient Protection and Affordable 
Care Act (PPACA) appropriated federal CHIP funding through federal 
fiscal year 2015, thus requiring Congress to act again to extend 
funding in the future.[Footnote 3] Among other provisions aimed at 
maintaining and increasing access to affordable health insurance, 
PPACA requires the establishment of health insurance exchanges in each 
state--marketplaces where eligible individuals can compare and select 
among qualified health plans (QHP) offered by participating private 
issuers of health coverage, hereafter referred to as issuers, 
beginning in 2014. PPACA also requires that, if a state's CHIP funding 
is insufficient to cover all CHIP-eligible children, beginning in 
October 2015, the state must establish procedures to ensure that the 
children who are not covered by CHIP are screened for Medicaid 
eligibility, and if ineligible for Medicaid, are enrolled into a QHP 
in an exchange in that state if the QHP has been certified as 
comparable to CHIP by the Secretary of HHS.[Footnote 4] 

To prepare for the offering of QHPs in 2014, HHS asked states to 
select benchmark health plans--plans intended as models for the 
benefits that will be offered through QHPs--by December 26, 2012. The 
most commonly selected base-benchmark plan by the states was the 
largest small group market health insurance plan by enrollment and 
product in the state, which reflected the scope of coverage available 
under a typical employer plan. If a state's base-benchmark plan did 
not meet applicable PPACA requirements--such as coverage of certain 
essential health benefits (EHB) categories--the state (or HHS in the 
case of a federally established default plan) generally was required 
to supplement it by using the relevant benefits in that EHB category 
from another one of the plan options to bridge coverage gaps.[Footnote 
5] To offer coverage starting in 2014, individual market and small 
group market insurance plan issuers must offer QHPs that are 
substantially equal to their state's EHB-benchmark plan (base and 
supplemental, if necessary). In this report, we refer to states' EHB-
benchmark plans as "benchmark plans." 

You asked for baseline information about how health care coverage, 
costs, and access to services in separate CHIP programs compare to 
coverage provided to children and families through benchmark plans, 
and how this may change with QHPs offering coverage through the 
exchanges in 2014. In this report, we describe: 

1. how coverage in separate CHIP plans compares to benchmark plans in 
select states, and how coverage might change in 2014, 

2. how costs to consumers in separate CHIP plans compare to benchmark 
plans in select states and how costs to consumers might change in 
2014, and: 

3. how access to care by children covered by CHIP compares to other 
children. 

To address the first two objectives--how coverage and consumers' costs 
in separate CHIP plans compare to benchmark plans in select states and 
how coverage and costs might change in 2014 when QHP coverage in the 
exchanges begins--we reviewed federal statutes and regulations 
governing CHIP-eligible services and the required EHBs to identify a 
range of health care services for further review. Based on variations 
in CMS region, CHIP program design, and size of enrollment in the 
separate CHIP program, we also selected five states for further 
review: Colorado, Illinois, Kansas, New York, and Utah.[Footnote 6] In 
each of these five states, we contacted state officials to identify 
the plan within their separate CHIP program with the largest 
enrollment from late 2012 through early 2013. We also identified the 
base-benchmark and relevant supplemental plans effective in each of 
these five states as of December 26, 2012.[Footnote 7] We then 
reviewed the Evidences of Coverage from each of the plans identified 
to determine whether the services we identified were covered and 
whether there were any annual limits on those services in terms of 
days, visits, or expenditures.[Footnote 8] Our analysis did not 
include other coverage limits, such as unspecified limits based on 
medical necessity, expected improvement deadlines (e.g., improvement 
must be expected within 2 months), and drug day limits (e.g., 
prescriptions filled 30 days at a time). We also reviewed plan 
Evidences of Coverage to identify cost-sharing amounts, including 
deductibles, copayments, and coinsurance, for each of the services and 
any stated out-of-pocket maximum cost amounts.[Footnote 9] We 
contacted state officials in all five states to obtain historic and 
current CHIP premiums and relied on national survey data on private 
individual market premiums to approximate benchmark plan premiums. 
[Footnote 10] Our coverage and cost comparison was limited to these 
five states. Our results cannot be generalized to other states. 
Coverage and cost information for QHPs was not available at the time 
of our analysis. Therefore, to determine how coverage and costs might 
change in 2014, we reviewed federal statutes and implementing 
regulations, interviewed federal and state officials about their 
expectations regarding the coverage and costs for CHIP and QHPs, and 
reviewed preliminary information available on state QHP premiums. 

To describe how access to care for CHIP children compares to other 
children, we analyzed data from the Medical Expenditure Panel Survey 
(MEPS), a nationally representative survey that collects data from a 
sample of non-institutionalized Americans on their health insurance 
status and service utilization, among other factors. Our analysis 
covered the period of 2007 through 2010, the most recent complete data 
available at the time we did our work. We compared responses to a 
series of questions related to health care access and utilization by 
respondents with children eligible for CHIP to respondents with 
children covered under private insurance, Medicaid, and those who were 
uninsured.[Footnote 11] Although MEPS combines Medicaid-and CHIP-
eligible respondents, we consulted with HHS's Agency for Healthcare 
Research and Quality (AHRQ) to develop an analysis that disaggregated 
these responses. We analyzed responses from respondents who were 
enrolled in the program for at least 8 months. To determine the 
reliability of MEPS data, we reviewed related documentation describing 
how these data are collected and processed, and examined other 
research that has used these data to report on access to health care 
services. We also discussed the data and our analysis with AHRQ 
officials. We determined that the data we used in this report were 
sufficiently reliable for the purposes of our engagement. (See 
appendix I for additional information on our MEPS analyses.) 

We conducted this performance audit from September 2012 to November 
2013 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

Background: 

Consumers may obtain health insurance from a variety of public and 
private sources, which can help protect them from the costs associated 
with obtaining medical care. Health insurance typically includes costs 
to consumers, which may vary for a number of factors, including scope 
of coverage, cost-sharing provisions, and federal or state 
requirements. Recent federal laws --specifically, PPACA and the 
Children's Health Insurance Program Reauthorization Act of 2009 
(CHIPRA)--further define coverage and cost parameters for certain 
health insurance plans available to consumers now and in 2014, when 
exchanges are required to be operational, and include provisions to 
increase children's access to coverage. 

Coverage and Cost Requirements for CHIP: 

Unlike states that opt to include coverage for eligible children under 
a CHIP-funded expansion of Medicaid, and therefore, must extend 
Medicaid covered services to CHIP-eligible individuals, states with 
separate CHIP programs have flexibility in program design and are at 
liberty to modify certain aspects of their programs, such as coverage 
and cost-sharing requirements. For example, federal laws and 
regulations allow states with separate CHIP programs to offer one of 
four types of health benefit coverage and, regardless of the benefit 
coverage option states choose, require states' separate CHIP programs 
to include coverage for routine check-ups, immunizations, and 
emergency services.[Footnote 12] States typically cover a broad array 
of services in their separate CHIP programs and, in some states, adopt 
the Medicaid requirement to cover Early and Periodic Screening, 
Diagnostic and Treatment (EPSDT) services.[Footnote 13] Effective 
October 1, 2009, CHIPRA required CHIP plans to cover dental services 
defined as "necessary to prevent disease and promote oral health, 
restore oral structures to health and function, and treat emergency 
conditions." CHIPRA also required states to comply with mental health 
parity requirements--meaning they must apply any financial 
requirements or limits on mental health or substance abuse benefits 
under their separate CHIP plans in the same manner as applied to 
medical and surgical benefits. States covering EPSDT services under 
separate CHIP plans were deemed to comply with these requirements. 

With respect to costs to consumers, CHIP premiums and cost-sharing may 
not exceed minimum amounts as defined by law. States may vary CHIP 
premiums and cost-sharing based on income and family size, as long as 
cost-sharing for higher-income children is not lower than for lower-
income children. Federal laws and regulations also impose additional 
limits on premiums and cost-sharing for children in families with 
incomes at or below 150 percent of the federal poverty level (FPL). 
For example, the range of copayments was $1.15 to $5.70 per service in 
2009 for children in families with incomes between 100 and 150 percent 
of FPL. In all cases, no cost-sharing can be required for preventive 
services--defined as well-baby and well-child care, including age-
appropriate immunizations and pregnancy-related services. In addition, 
states may not impose premiums and cost-sharing, in the aggregate, 
that exceed 5 percent of a family's total income for the length of the 
child's eligibility period in CHIP.[Footnote 14] 

Children's access to affordable health insurance and health care can 
be affected by many different factors, and CHIPRA and PPACA also 
contain provisions to facilitate eligible children's access to CHIP. 
[Footnote 15] For example, CHIPRA appropriated funding for state and 
other organization outreach grants to help increase enrollment of CHIP-
eligible children for federal fiscal years 2009 through 2013 and 
performance bonuses for simplifying CHIP enrollment and retention by 
applying certain program reforms. PPACA provisions that aim to 
facilitate eligible children's access to CHIP include appropriating 
additional funding for CHIPRA outreach grants through federal fiscal 
year 2015. PPACA also requires states to maintain CHIP eligibility 
standards for children through September 2019. In accordance with this 
requirement, states are prohibited from increasing existing premiums 
or imposing new premiums except in limited circumstances.[Footnote 16] 

Coverage and Cost Requirements for QHPs: 

PPACA requires the establishment of exchanges in all states by January 
1, 2014, to allow consumers to compare health insurance options 
available in that state and enroll in coverage.[Footnote 17] The 
exchanges will offer QHPs that are certified and are offered by 
participating issuers of coverage.[Footnote 18] PPACA further requires 
QHPs offered through an exchange to comply with applicable private 
insurance market reforms, including relevant premium rating 
requirements, the elimination of lifetime and annual dollar limits on 
essential health benefits, prohibition of cost-sharing for preventive 
services, mental health parity requirements, and the offering of 
comprehensive coverage. With respect to comprehensive coverage, PPACA 
requires QHPs offered through an exchange to cover 10 categories of 
EHBs, limit cost-sharing associated with this coverage, and provide 
one of four levels of coverage determined by the plan's actuarial 
value.[Footnote 19] 

By the end of December 2012, states had either selected a base-
benchmark plan or been assigned the default base-benchmark plan by 
HHS. In over 80 percent of states, the largest plan by enrollment in 
the largest product by enrollment in the state's small group market 
was established as the base-benchmark plan. 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. PPACA also allows exchanges in each state the option of 
providing pediatric dental services using a stand-alone dental plan 
(SADP). In exchanges with at least one participating SADP, QHPs will 
have the option of excluding pediatric dental benefits from their 
covered services. 

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. CHIP 
officials in our selected states expected minimal or no changes to 
CHIP coverage in 2014, and that the QHPs offered through the exchanges 
would reflect states' benchmark plans and PPACA requirements. 

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 benchmark plans in Colorado, Kansas, or New York.[Footnote 
20] (See appendix II for a detailed list of selected services covered 
by each state.) The benchmark plan coverage for pediatric dental and 
vision services was often the same as that in the CHIP plan because 
the base-benchmark plan, which was typically based on the largest plan 
by enrollment from each state's small group market, did not cover 
these services, and the states often selected CHIP as the 
supplementary coverage model. In particular, the base-benchmark plan 
in four states did not cover pediatric dental services and in three 
states did not cover pediatric vision services.[Footnote 21] Because 
pediatric dental and vision services are EHBs, these states were 
required to select supplemental benchmark plans to bridge the coverage 
gaps, and often selected CHIP as the supplement.[Footnote 22] National 
data from HHS suggests that nearly all states supplemented the base-
benchmark plan with pediatric dental and vision plans. According to 
HHS, 50 and 46 states had to identify supplemental pediatric dental 
and vision plans, respectively, and more than half of the states 
selected the FEDVIP plan as the supplement for each service.[Footnote 
23] 

The CHIP and benchmark plans we reviewed were also generally similar 
in terms of the services on which they imposed day, visit, or dollar 
limits. 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.[Footnote 24] One notable 
difference between CHIP and benchmark plans we reviewed was the 
frequency by which they limited home-and community-based health care 
services. While the benchmark plans in four states imposed day or 
visit limits on these services, only one state's CHIP plan did so. 
(See figure 1.) 

Figure 1: Number of State Children's Health Insurance Program (CHIP) 
and Benchmark Plans with Limits on Selected Services in Five States: 

[Refer to PDF for image: vertical bar graph] 

Number of plans: 

Selected services: Impatient hospital; 
CHIP plans: 1; 
Benchmark plans: 0. 

Selected services: Mental health/substance abuse; 
CHIP plans: 0; 
Benchmark plans: 2. 

Selected services: Durable medical equipment; 
CHIP plans: 1; 
Benchmark plans: 2. 

Selected services: Maternity care; 
CHIP plans: 2; 
Benchmark plans: 2. 

Selected services: Home and community based services; 
CHIP plans: 1; 
Benchmark plans: 4. 

Selected services: Hospice; 
CHIP plans: 2; 
Benchmark plans: 3. 

Selected services: Outpatient therapies; pediatric dental; 
CHIP plans: 4; 
Benchmark plans: 4. 

Selected services: Pediatric vision; pediatric hearing; 
CHIP plans: 4; 
Benchmark plans: 5. 

Source: GAO analysis of CHIP and benchmark plan Evidences of Coverage 
and interviews with state CHIP and benchmark plan officials in 
Colorado, Illinois, Kansas, New York, and Utah. 

Notes: CHIP plan data for Colorado and Utah was effective from July 1, 
2012, through June 30, 2013, and for Illinois, Kansas, and New York, 
it was effective calendar year 2013. Benchmark plan data was effective 
as of December 26, 2012, the deadline for benchmark plan selection. 
There were no limits on the following services in the CHIP and 
benchmark plans we reviewed: ambulatory services, emergency care, 
prescription drugs, and preventive services. 

[End of figure] 

For services where both plan types imposed limits, our review of plan 
Evidences of Coverage found that, except for dental and vision 
services, the comparability between plan types in terms of annual 
limits was less clear, but at times was more generous for CHIP. For 
example, Utah's benchmark plan limited home-and community-based health 
care services to 30 visits per year while the state's CHIP plan did 
not impose any limits on this service. Comparability between annual 
service limits in states' CHIP and benchmark plans was less clear for 
outpatient therapy services. For example, the Colorado CHIP plan 
limited outpatient therapy to 40 visits per diagnosis compared to 20 
visits per therapy type in the benchmark plan. Similarly, the New York 
CHIP plan allowed a maximum of six weeks for physical therapy while 
the benchmark plan allowed up to 60 visits per condition per lifetime. 
Limits on dental and vision services were largely comparable, due to 
the selection of CHIP as the supplemental benchmark for those services 
in most of the selected states. Table 1 provides examples of annual 
limits for select services between CHIP and benchmark plans, and 
appendix III lists annual limits for all services we reviewed. 

Table 1: Annual Limits on Outpatient Therapies, Pediatric Hearing, and 
Home-and Community-Based Services in the State Children's Health 
Insurance Program (CHIP) and Benchmark Plans of Five States: 

Outpatient therapies: 

State: Colorado; 
Rehabilitative: 
CHIP plan: 40 visits[A]; 
Benchmark plan: 20 per therapy type[B];
Habilitative: 
CHIP plan: 40 visits[A]; 
Benchmark plan: Not covered. 

State: Illinois; 
Rehabilitative: 
CHIP plan: None; 
Benchmark plan: None;
Habilitative: 
CHIP plan: None; 
Benchmark plan: None. 

State: Kansas; 
Rehabilitative: 
CHIP plan: None; 
Benchmark plan: 
Physical and occupational: None Speech: max 90 days[C];
Habilitative; 
CHIP plan: Not covered; 
Benchmark plan: Not covered. 

State: New York; 
Rehabilitative: 
CHIP plan: Physical and occupational: 6 weeks; Speech: None; 
Benchmark plan: 60 visits per condition per lifetime.
Habilitative: 
CHIP plan: Physical and occupational: 6 weeks; Speech: None; 
Benchmark plan: Not covered. 

State: Utah; 
Rehabilitative: 
CHIP plan: 20 visits[D]; 
Benchmark plan: 20 visits[D]; 
Habilitative: 
CHIP plan: Not covered; 
Benchmark plan: 20 visits[D]. 

Pediatric hearing: 

State: Colorado; 
Testing: 
CHIP plan: None; 
Benchmark plan: None; 
Hearing aids: 
CHIP plan: 1 every 5 years; 
Benchmark plan: 1 every 5 years. 

State: Illinois; 
Testing: 
CHIP plan: None; 
Benchmark plan: Not covered; 
Hearing aids: 
CHIP plan: None; 
Benchmark plan: Unknown[E]. 

State: Kansas; 
Testing: 
CHIP plan: None; 
Benchmark plan: Not covered; 
Hearing aids: 
CHIP plan: Various[F]; 
Benchmark plan: Not covered. 

State: New York; 
Testing: 
CHIP plan: 1 exam; 
Benchmark plan: None; 
Hearing aids: 
CHIP plan: None; 
Benchmark plan: $1,500 1 every 3 years. 

State: Utah; 
Testing: 
CHIP plan: 1 exam; 
Benchmark plan: None; 
Hearing aids: 
CHIP plan: Not covered; 
Benchmark plan: Not covered. 

Home and community-based services: 

State: Colorado; 
CHIP plan: None; 
Benchmark plan: 28 hours per week[G]. 

State: Illinois; 
CHIP plan: None; 
Benchmark plan: None. 

State: Kansas; 
CHIP plan: None; 
Benchmark plan: 3 visits for home care education. 

State: New York; 
CHIP plan: 40 visits; 
Benchmark plan: 40 visits. 

State: Utah; 
CHIP plan: None; 
Benchmark plan: 30 visits. 

Source: GAO analysis of CHIP and benchmark plan Evidences of Coverage 
and information from CHIP and benchmark plan officials in Colorado, 
Illinois, Kansas, New York, and Utah. 

Notes: CHIP plan data for Colorado and Utah was effective from July 1, 
2012, through June 30, 2013, and for Illinois, Kansas, and New York, 
it was effective calendar year 2013. Benchmark plan data was effective 
as of December 26, 2012, the deadline for benchmark plan selection. 
Outpatient therapies consist of physical, occupational, or speech 
therapy. Rehabilitation is provided to help a person regain, maintain, 
or prevent deterioration of a skill that has been acquired but then 
lost or impaired due to illness, injury, or disabling condition. While 
PPACA and implementing regulations do not define habilitative 
services, habilitation has been defined by several advocacy groups as 
a service that is provided in order for a person to attain, maintain, 
or prevent deterioration of a skill or function never learned or 
acquired due to a disabling condition. 

[A] CHIP outpatient therapy visit limits are per diagnosis, per 
calendar year. Service is unlimited for children under 3 years of age 
and speech therapy is unlimited for those with a cleft palate or lip. 

[B] Benchmark rehabilitative outpatient therapies are covered for 
children 3 to 6 years of age, and under 3 years of age if not 
participating in early intervention services. Service is unlimited for 
children with autism spectrum disorder who are under age 19. 

[C] Speech therapy is limited to one service per day up to a maximum 
benefit of 90 daily services per insured per year. 

[D] The limit is for all therapy types combined. 

[E] The state official said there were no dollar limits but was unable 
to provide additional information on limits. 

[F] Hearing aid batteries are limited to 6 batteries per month for 
monaural aids and 12 per month for binaural aids. Batteries for use 
with cochlear devices are limited to lithium ion (3 per 30 days) or 
zinc air (6 per 30 days). Batteries for cochlear devices are covered 
for CHIP-eligible beneficiaries only. Only one type of battery is 
allowed every 30 days. 

[G] Home-and community-based services must not exceed 8 hours per day. 
Additional time up to 35 hours a week may be approved by the health 
plan on a case-by-case basis. Those in the Special Services Program 
(individuals with a terminal illness with a life-expectancy of 1 year 
or less who are not yet receiving hospice care or benefits) are 
limited to 15 home health visits per lifetime. 

[End of table] 

Selected States Expect CHIP Coverage Will Not Change and QHP Coverage 
Will Reflect PPACA Requirements in 2014: 

CHIP officials in all five states said that they expect the services 
we reviewed that were covered by their respective CHIP plans and any 
relevant limits on these services to remain largely unchanged in 2014. 
With respect to QHP coverage, state officials in all five states 
expect 2014 coverage to reflect PPACA and its implementing 
requirements, including being comparable to their respective benchmark 
plans. For example, QHPs must offer EHB services at levels that are 
substantially equal to their respective state's benchmark plans. With 
state approval, QHPs may substitute services that are actuarially 
equivalent and from the same EHB category as the service being 
replaced. The actuarial equivalence requirement also applies to dental 
benefits provided by SADPs, which are expected to be available in all 
five selected states, according to state officials.[Footnote 25] 
Exchange officials in three of the selected states--Colorado, 
Illinois, and Kansas--commented on the advantages and disadvantages of 
SADPs. While their availability could benefit consumers in terms of a 
broader set of options for dental services, their availability could 
also create confusion among consumers. For example, because QHPs are 
not required to include pediatric dental coverage in their plans if an 
SADP is available in their state's exchange, some officials expressed 
concern that a consumer who needs the pediatric dental benefit may 
mistakenly purchase a plan in the exchange without such coverage or, 
conversely, could have duplicate coverage if they purchased an SADP in 
addition to a QHP that may include pediatric dental coverage. 

State officials said that they also expect QHPs to reflect additional 
PPACA requirements. For example, PPACA requires QHPs to include 
coverage for the categories of rehabilitative and habilitative 
services and devices. For benchmark plans that do not cover 
habilitative services, HHS's implementing regulations provide three 
options to comply with the requirement. States can opt to (1) require 
QHPs to cover habilitative services in parity with rehabilitative 
services; (2) select specific services that would qualify as 
habilitative or, if the state neglects to choose either of these 
choices, (3) allow the QHP issuer to determine which services qualify 
as habilitative. Each of the three selected states that did not cover 
outpatient therapies for habilitation--Colorado, Kansas, and New York--
has opted to require QHPs to cover these services in parity with 
rehabilitative services. According to HHS, nationwide data show that 
in addition to these three states, 19 other states had benchmark plans 
that did not cover habilitation, and the majority chose to allow the 
issuers to determine which services would qualify as habilitative. 
[Footnote 26] 

PPACA also eliminates the use of annual and lifetime dollar limits on 
any EHB services. The elimination of lifetime dollar limits was 
effective in September 2010 and the elimination of annual limits takes 
effect in January 2014.[Footnote 27] Among our five selected states, 
four states had benchmark plans that imposed an annual dollar limit on 
at least one of the service categories we reviewed; with limited 
exception, none of these dollar limits were imposed on EHB services. 
For example, Kansas' benchmark plan limited hospice services to $5000 
per insured person per lifetime. In general, state officials indicated 
that for these services, they expected that QHP issuers would 
eliminate the dollar limits. 

PPACA also extends the mental health parity requirements, which 
require that any lifetime limits placed on mental health or substance 
abuse services be the same as those placed on physical health care 
services.[Footnote 28] The benchmark plans in two selected states--New 
York and Utah--included such limits on mental health and substance 
abuse services. For example, both states' benchmark plans limited 
inpatient mental health service to 30 days a year, where similar 
limits did not exist for inpatient physical health services. Officials 
in both states said that they expected that QHP issuers would 
eliminate such limits. 

In Five States, Costs to Consumers Were Almost Always Less in CHIP 
than in Benchmark Plans; CHIP Costs Are Expected to Remain the Same 
and QHP Costs to Reflect PPACA Limits in 2014: 

In our five selected states, consumers' costs were almost always less 
in CHIP plans when compared to the states' benchmark plans. 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. For example, the CHIP plans in 
four of the five selected states did not include any deductibles, 
which means that enrollees in those states did not need to pay a 
specified amount before the plan began paying for services. Utah is 
the only selected state that imposed a deductible on a portion of its 
CHIP population, which applied to about 60 percent of its CHIP 
enrollees--those with higher incomes.[Footnote 29] In contrast, 
benchmark plans in all five selected states had deductibles, which 
ranged from $500 in Illinois and Kansas to $3,000 in Utah for an 
individual, and $1,000 in Kansas to $6,000 in Utah for a family. 

Our review of plan Evidences of Coverage and information from state 
and plan officials also found that, for services we reviewed where the 
plan imposed copayments or coinsurance, the amount was almost always 
less in a state's CHIP plan that in its benchmark plan.[Footnote 30] 
For example, the CHIP plan in two of our five states--Kansas and New 
York--did not impose copayments or coinsurance on any of the services 
we reviewed. In two of the remaining three states, the CHIP plan 
imposed copayments or coinsurance on less than half of the services we 
reviewed, and the amounts were usually minimal and based on a sliding 
income scale. For example, for each brand-name prescription drug, the 
Illinois CHIP plan imposed a $4 copayment on enrollees with incomes 
between 134 and 150 percent of the FPL, which was increased to $7 for 
enrollees with incomes between 201 and 300 percent of the FPL. Utah's 
CHIP plan differed from the other states' plans in that it imposed 
either a copayment or coinsurance on all services we reviewed--except 
preventive and routine dental services--which varied by income level. 

In contrast, the benchmark plans in all five states imposed copayments 
or coinsurance on most services we reviewed. Further, the amounts did 
not vary by income level and were consistently higher than the CHIP 
plan in their respective state. 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. In 
states where the benchmark plan charged coinsurance and the CHIP plan 
required a copayment, a direct comparison of cost differences could 
not be made, although data suggest CHIP costs would generally be lower 
in most cases. For example, while higher-income CHIP enrollees in 
Illinois paid $100 per admission for an inpatient hospital stay, state 
benchmark enrollees were responsible for 10 percent coinsurance after 
the deductible was met, an amount that was likely to be higher than 
the $100 given that 10 percent of the average price for an inpatient 
facility stay in 2011 was over $1,500.[Footnote 31] Table 2 provides 
examples of differences in copayments and coinsurance for select 
services between CHIP and benchmark plans. 

Table 2: Examples of Copayments and Coinsurance for Prescription 
Drugs, Office Visits, and Rehabilitative Outpatient Therapies in the 
State Children's Health Insurance Program (CHIP) and Benchmark Plans 
of Five States: 

Prescription drugs[A]: 

State: CO; 
Generic: 
CHIP plan: 
Less than 150% FPL: $1; 
150-200% FPL: $3; 
Benchmark plan: 
More than 200% FPL: $5; 
N/A: $15; 
Brand-name: 
CHIP plan: 
Less than 150% FPL: $1; 
50-200% FPL: $10; 
Benchmark plan: 
More than 200% FPL: $15; 
N/A: 30. 

State: Illinois; 
Generic: 
CHIP plan: 
Less than 150% FPL: $2; 
150-200% FPL: $3; 
Benchmark plan: 
More than 200% FPL: $3; 
N/A: $15[B]; 
Brand-name: 
CHIP plan: 
Less than 150% FPL: $3.90; 
150-200% FPL: $5; 
Benchmark plan: 
More than 200% FPL: $7; 
N/A: $30[C]. 

State: Kansas; 
Generic: 
CHIP plan: 
Less than 150% FPL: 0; 
150-200% FPL: 0; 
Benchmark plan: 
More than 200% 0; 
N/A: $15[D]; 
Brand-name: 
CHIP plan: 
Less than 150% FPL: 0; 
150-200% FPL: 0; 
Benchmark plan: 
More than 200% FPL: 0; 
N/A: $30[E]. 

State: New York; 
Generic: 
CHIP plan: 
Less than 150% FPL: 0; 
150-200% FPL: 0; 
Benchmark plan: 
More than 200% FPL: 0; 
N/A: $15; 
Brand-name: 
CHIP plan: 
Less than 150% FPL: 0; 
150-200% FPL: 0; 
More than 200% FPL: 0; 
N/A: $35. 

State: Utah; 
Generic: 
CHIP plan: 
Less than 150% FPL: $1-5; 
150-200% FPL: $15; 
Benchmark plan: 
More than 200% FPL: N/A; 
N/A: 50%.
Brand-name; 
CHIP plan: 
Less than 150% FPL: $1-5; 
150-200% FPL: 25%; 
Benchmark plan: 
More than 200% N/A; 
N/A: 50%. 

Office visit: 

State: Colorado; 
PCP: 
CHIP plan: 
Less than 150% FPL: $2; 
150-200% FPL: $5; 
Benchmark plan: 
More than 200% FPL: $10; 
N/A: $30; 
Specialist; 
CHIP plan: 
Less than 150% FPL: $2; 
150-200% FPL: $5; 
Benchmark plan: $10; 
N/A: $50. 

State: Illinois; 
PCP: 
CHIP plan: 
Less than 150% FPL: $3.90; 
150-200% FPL: $5; 
Benchmark plan: 
More than 200% FPL: $10; 
N/A: $20; 
Specialist: 
CHIP plan: 
Less than 150% FPL: $3.90; 
150-200% FPL: $5; 
Benchmark plan: 
More than 200% FPL: $10; 
N/A: $40. 

State: Kansas; 
PCP: 
CHIP plan: 
Less than 150% FPL: 0; 
150-200% FPL: 0; 
Benchmark plan: More than 200% FPL: 0; 
N/A: $25.
Specialist: 
CHIP plan: 
Less than 150% FPL: 0; 
150-200% FPL: : 0; 
Benchmark plan: 
More than 200% FPL: 0; 
N/A: $25. 

State: New York; 
PCP: 
CHIP plan: 
Less than 150% FPL: 0; 
150-200% FPL: 0; 
Benchmark plan: 
More than 200% FPL: 0; 
N/A: $25; 
Specialist: 
CHIP plan: 
Less than 150% FPL: 0; 
150-200% FPL: 0; 
Benchmark plan: 
More than 200% FPL: 0; 
N/A: $50. 

State: Utah; 
PCP: 
CHIP plan: 
Less than 150% FPL: $3-5; 
150-200% FPL: $25; 
Benchmark plan: 
More than 200% FPL: N/A; 
N/A: 30%; 
Specialist: 
CHIP plan: 
Less than 150% FPL: $3-5; 
150-200% FPL: $40; 
Benchmark plan: 
More than 200% FPL: N/A; 
N/A: 30%. 

Rehabilitative outpatient therapy session (physical, occupational, or 
speech): 

State: Colorado; 
CHIP plan: 
Less than 150% FPL: $2; 
150-200% FPL: $5; 
Benchmark plan: 
More than 200% FPL: $10; 
N/A: $30. 

State: Illinois; 
CHIP plan: 
Less than 150% FPL: 0; 
150-200% FPL: 0; 
Benchmark plan: 
More than 200% FPL: 0; 
N/A: 10%. 

State: Kansas; 
CHIP plan: 
Less than 150% FPL: 0; 
150-200% FPL: 0; 
Benchmark plan: 
More than 200% FPL: 0; 
N/A: $25. 

State: New York; 
CHIP plan: 
Less than 150% FPL: 0; 
150-200% FPL: 0; 
Benchmark plan: 
More than 200% FPL: 0; 
N/A: 0%. 

State: Utah; 
CHIP plan: 
Less than 150% FPL: $3-5; 
150-200% FPL: $40; 
Benchmark plan: 
More than 200% FPL: N/A; 
N/A: 30%. 

Legend: FPL = federal poverty level; N/A = not applicable; PCP = 
primary care physician. 

Source: GAO analysis of Colorado, Illinois, Kansas, New York, and Utah 
CHIP and benchmark plan Evidences of Coverage and information from 
state and health plan officials. 

Notes: CHIP plan data for Colorado and Utah was effective from July 1, 
2012 through June 30, 2013 and for Illinois, Kansas, and New York, it 
was effective calendar year 2013. Benchmark plan data was effective as 
of December 26, 2012, the deadline for benchmark plan selection. 

[A] Brand-name drugs include drugs designated by the plan as 
"preferred" or included in their formulary. 

[B] Benchmark enrollees must pay $30 for generic prescription drugs 
obtained through a mail order service. 

[C] Benchmark enrollees must pay $60 for brand-name prescription drugs 
obtained through a mail order service. 

[D] Benchmark enrollees must pay $37.50 or less for generic 
prescription drugs obtained through a mail order service. 

[E] Benchmark enrollees must pay $75 or less for brand-name 
prescription drugs obtained through a mail order service. 

[End of table] 

Our review of CHIP premiums and other sources of premium data suggest 
that CHIP premiums were also likely lower than benchmark plans. For 
example, 2013 CHIP annual premiums for an individual varied by income 
level and ranged from $0 for enrollees under 150, 160, and 100 percent 
of the FPL in Illinois, New York, and Utah, respectively, to $720 for 
higher-income enrollees between 351 and 400 percent of the FPL in New 
York, with most enrollees across the five selected states paying less 
than $200 a year. Benchmark plan premium data were not readily 
available at the time of our study; however, national survey data from 
America's Health Insurance Plans suggest that individuals under 18 
years of age enrolled in the private individual market paid annual 
premiums that averaged $1,350 in 2009.[Footnote 32] 

In addition, both CHIP and benchmark plans in all five states limited 
the total potential costs to consumers by imposing out-of-pocket 
maximum costs. For example, all five states applied the limit a family 
could pay in CHIP plans as established under federal law--including 
deductibles, copayments, coinsurance, and premiums--at 5 percent of a 
family's income during the child's (or children's) eligibility for 
CHIP.[Footnote 33] This maximum applies to all services, irrespective 
of the number of children in the family enrolled. For benchmark plans, 
out-of-pocket maximum costs were established by each plan. For the 
five benchmark plans we reviewed, the annual out-of-pocket maximum 
costs ranged from $1,000 to $6,050 for an individual and $3,000 to 
$12,100 for a family. Additionally, the benchmark plans differed from 
the CHIP plans in that their maximum costs did not include premiums 
and may not have included deductibles or costs associated with all 
services. For example, three of the five benchmark plans had 
deductibles in addition to the out-of-pocket maximum costs. 
Additionally, copayments for office visits did not apply to the out-of-
pocket maximum costs in four of the five states' benchmark plans. 

Some evidence suggests that most families in the five selected states 
and nationally--whether enrolled in CHIP or a benchmark plan--were 
unlikely to incur costs that reached the out-of-pocket maximum costs. 
Our interviews with CHIP officials in selected states and information 
in the states' CHIP annual reports indicated that it was rare for 
families to exceed their 5 percent maximum costs. Utah was the only 
state that said they had more than a few families exceeding the 
maximum costs, with about 140 families reporting doing so in a given 
year, according to state officials. Similarly, existing national data 
on average out-of-pocket costs for individuals with employer-sponsored 
insurance suggested that individuals enrolled in the benchmark plans 
could also generally incur costs that are lower than the maximum costs 
established by their plan. For example, the Health Care Cost 
Institute, an organization that provides information for researchers 
on health care spending and utilization trends, reported that the 
average out-of-pocket amount spent per consumer was $735 in 2011 for 
health care services through employer-sponsored insurance, which was 
lower than the lowest maximum costs established by our selected 
benchmark plans.[Footnote 34] 

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. All 
five states said they currently have no plans to raise premiums or 
change cost-sharing amounts in 2014. 

In contrast, QHP costs to consumers in 2014 may be different than 
those in the benchmark plans as benchmarks are not models for QHP cost-
sharing. Instead, PPACA included provisions applicable to QHPs that 
will limit premium variation, standardize plan values, and limit out-
of-pocket costs. For example, 

* PPACA will limit premium variation in the individual market by 
prohibiting health plans from adjusting QHP premiums based on factors 
such as health status and gender. Instead, plans will only be allowed 
to adjust premiums for family size, geographic area, age, and tobacco 
use.[Footnote 35] 

* PPACA standardizes plan values through QHP coverage level 
requirements. Specifically, QHPs must offer coverage that meets one of 
four metal tier levels, which correspond to actuarial value 
percentages that range from 60 to 90 percent: bronze (an actuarial 
value of 60 percent), silver (an actuarial value of 70 percent), gold 
(an actuarial value of 80 percent), or platinum (an actuarial value of 
90 percent). Actuarial value indicates the proportion of allowable 
charges that a health plan will pay, on average--the higher the 
actuarial value, the lower the cost-sharing expected to be paid by 
consumers. Deductibles, co-pays, and coinsurance amounts can vary 
within these plans, as long as the overall cost-sharing structure 
meets the required actuarial value levels.[Footnote 36] 

* PPACA establishes out-of-pocket maximum costs on cost-sharing that 
apply to all QHPs and vary by income, a change from the non-income-
based out-of-pocket maximum costs found in our selected benchmark 
plans.[Footnote 37] These maximums for individual plans do not include 
premiums or costs associated with non-EHB services, but do include 
deductibles. See table 3. 

Table 3: Out-of-pocket Maximum Cost Amounts for Qualified Health Plan 
Enrollees in 2014 by Federal Poverty Level (FPL): 

Income level (as a percentage of FPL): 250-400%; 
Individual maximum: $6,350; 
Family maximum: $12,700. 

Income level (as a percentage of FPL): 200-250%; 
Individual maximum: $5,200; 
Family maximum: $10,400. 

Income level (as a percentage of FPL): 100-200%; 
Individual maximum: $2,250; 
Family maximum: $4,500. 

Source: GAO analysis of Internal Revenue Service data related to out-
of-pocket maximums for high deductible health plans (Internal Revenue 
Service Revenue Procedure 2013-25) and the Patient Protection and 
Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 
2014. 

[End of table] 

* SADPs have out-of-pocket maximum costs that are in addition to the 
QHP maximums described above and therefore may increase potential 
maximum costs for families who purchase them.[Footnote 38] For 2014, 
the out-of-pocket maximum costs for SADPs offered in federally 
facilitated exchanges and state partnership exchanges are $700 for a 
plan with one child or $1,400 for a plan with two or more children. 
[Footnote 39] For example, a family at 225 percent of the FPL that 
enrolls their two children in an SADP in addition to their QHP would 
be subject to an out-of-pocket maximum cost of $11,800. 

Additionally, PPACA includes provisions aimed at reducing cost-sharing 
amounts for certain low-income consumers and eligible Indians who 
purchase QHPs through an exchange in the individual market. For 
example, PPACA and federal regulations provide cost-sharing subsidies 
to individuals with incomes between 100 and 250 percent of the FPL to 
offset the costs they incur through copayments, coinsurance, and 
deductibles in a silver-level QHP.[Footnote 40] The cost-sharing 
subsidies will not be provided directly to consumers, instead, QHP 
issuers are required to offer three variations of each silver plan 
they market through an exchange in the individual market. These plan 
variations are to reflect the cost-sharing subsidies through lower out-
of-pocket maximum costs, and, if necessary, through lower deductibles, 
copayments, or coinsurance. Once the adjustments are made, the 
actuarial value of the silver plan available to eligible consumers 
will effectively increase from 70 percent to 73, 87, or 94 percent, 
depending on their income levels. However, cost-sharing subsidies are 
not available for pediatric dental costs incurred by a consumer 
enrolled in a QHP and an SADP.[Footnote 41] 

PPACA also provides a premium tax credit to eligible individuals with 
incomes that are at least 100 percent and no more than 400 percent of 
the FPL when purchasing a plan with a premium no more than the second-
lowest cost silver plan in their state.[Footnote 42] Depending on 
their income, this provision limits the amount families must 
contribute to QHP premiums to 2 to 9.5 percent of their annual income; 
in 2014 these premium contributions will range from $471 to $8,949 for 
a family of four.[Footnote 43] Unlike cost-sharing subsidies, which 
generally do not apply to costs incurred for services by a consumer 
enrolled in an SADP, the maximum contribution amount on premiums 
includes premiums for both QHPs and SADPs, if relevant.[Footnote 44] 
See table 4 for maximum premium contribution amounts by federal 
poverty level. 

Table 4: Maximum Premium Contributions for Qualified Health Plan (QHP) 
Enrollees by Federal Poverty Level (FPL) in 2014: 

Income level (percentage of FPL): 400%; 
Maximum premium (percentage of Income): 9.5%; 
Individual maximum premium contribution: $4,366; 
Family of four maximum premium contribution: $8,949. 

Income level (percentage of FPL): 250%; 
Maximum premium (percentage of Income): 8.05%; 
Individual maximum premium contribution: $2,312; 
Family of four maximum premium contribution: $4,739. 

Income level (percentage of FPL): 200%; 
Maximum premium (percentage of Income): 6.30%; 
Individual maximum premium contribution: $1,448; 
Family of four maximum premium contribution: $2,967. 

Income level (percentage of FPL): 150%; 
Maximum premium (percentage of Income): 4.00%; 
Individual maximum premium contribution: $689; 
Family of four maximum premium contribution: $1,413. 

Income level (percentage of FPL): 100%; 
Maximum premium (percentage of Income): 2.00%; 
Individual maximum premium contribution: $230; 
Family of four maximum premium contribution: $471. 

Source: GAO analysis of the Internal Revenue Service Health Insurance 
Premium Tax Credit Final Rule and the Department of Health and Human 
Service 2013 Poverty Guidelines for the 48 Contiguous States and the 
District of Columbia. 

Note: The maximum premium contribution amounts are for the 48 
contiguous states and the District of Columbia. 

[End of table] 

Preliminary information released by some states suggests that this tax 
credit could defray the premium cost for certain lower-income 
individuals. For example, QHP premium data available in California 
indicates that, on average, it may cost a family of four with an 
income above 400 percent of the FPL over $9,700 a year to enroll in 
the most affordable silver-level QHP.[Footnote 45] Additionally, if 
the parents chose to purchase pediatric dental coverage for their 
children, annual SADP premiums could range from about $120 to $360 per 
child depending upon the region and type of plan chosen. If a state 
exchange does not offer the pediatric dental benefit through an 
integrated QHP and only offers it through an SADP, as is expected to 
be the case in California, all exchange enrollees in that state will 
pay a separate premium for pediatric dental coverage. Together, the 
lowest annual premium cost for the family of four with an income above 
400 percent of the FPL would be close to $10,000. However, if the 
family had an income at 150 percent of the FPL, and was therefore 
eligible for the premium tax credit, their annual premium contribution 
for the QHP and SADPs combined would be much lower, no more than the 
PPACA-established annual maximum of $1,413 plus the cost of the SADP. 
Therefore, this family with an income at 150 percent of the FPL could 
have a premium payment over $8,000 less annually than if their income 
was over 400 percent FPL, and they were not eligible for the premium 
tax credit.[Footnote 46] 

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. MEPS includes questions about respondents' ability to 
obtain care, and responses to these questions can provide insight to 
an individual's access to services. In examining questions related to 
having a usual source of care, getting appointments and care when 
needed, and accessing care, tests, or treatment or seeing specialists 
when needed, most respondents with children enrolled in CHIP had 
positive responses to questions for calendar years 2007 through 2010. 
[Footnote 47] Specifically, five of the six MEPS questions we analyzed 
related to respondents' ability to obtain care. At least 88 percent of 
CHIP enrollees responding to these questions reported they had a usual 
source of care and usually or always got the care they needed. When 
compared to respondents with other sources of insurance, the 
proportion of CHIP enrollees' with positive responses to these 
questions were, for most questions, comparable to respondents with 
Medicaid or with private insurance--that is, within 5 percentage 
points. For example, about 89, 91, and 93 percent of CHIP, Medicaid, 
and privately insured respondents, respectively, reported that they 
had a usual source of care. The proportions of CHIP enrollees and 
those who were uninsured reporting positive responses were also within 
5 percentage points on four of the six questions, but the differences 
were larger for the remaining two questions. Specifically, about 56 
percent of those who were uninsured reported having a usual source of 
care compared to about 89 percent of CHIP enrollees, and about 75 
percent of those who were uninsured reported that it was usually or 
always easy to see a specialist compared to about 81 percent of CHIP 
enrollees. The area of greatest dissatisfaction appeared to be related 
to ease in seeing a specialist. Approximately 18 percent of CHIP 
enrollees reported that it was sometimes or never easy to see a 
specialist. (See table 5.) 

Table 5: Percentage of Respondents Who Reported Positive Responses to 
Six Medical Expenditure Panel Survey (MEPS) Questions Related to 
Obtaining Needed Care, by Health Insurance Status, 2007 through 2010: 

MEPS question: Do you have a usual source of care? 
Insurance status: 
CHIP: 88.6%; 
Private insurance: 92.6%; 
Medicaid: 90.5%; 
Uninsured: 55.9%. 

MEPS question: How difficult was it to reach the usual source of care 
by telephone during office hours? 
Insurance status: 
CHIP: 88.2%; 
Private insurance: 89.9%; 
Medicaid: 86.2%; 
Uninsured: 88.3%. 

MEPS question: Did you usually or always get care as soon as was 
needed? 
Insurance status: 
CHIP: 91.6%; 
Private insurance: 96.6%; 
Medicaid: 92.3%; 
Uninsured: 90.6%. 

MEPS question: Did you usually or always get an appointment for health 
care as soon as was needed? 
Insurance status: 
CHIP: 92.2%; 
Private insurance: 95.0%; 
Medicaid: 92.4%; 
Uninsured: 91.6%. 

MEPS question: Was it usually or always easy to get a person the care, 
tests or treatment that the parent or a doctor believed necessary? 
Insurance status: 
CHIP: 91.5; 
Private insurance: 96.7%; 
Medicaid: 91.9%; 
Uninsured: 89.9%. 

MEPS question: Was it usually or always easy to see a specialist? 
Insurance status: 
CHIP: 81.4%; 
Private insurance: 86.9%; 
Medicaid: 79.0%; 
Uninsured: 74.5%. 

Source: GAO analysis of MEPS data from surveys conducted in 2007 
through 2010. 

Notes: For our analysis, we pooled MEPS data from surveys conducted in 
2007 through 2010. For purposes of our analysis, we considered the 
following responses to be positive: for the question about a usual 
source of care, we considered all "yes" responses to be positive; for 
the question about how difficult it is to reach the usual source of 
care by telephone, we considered the "it was not at all difficult" or 
"was not too difficult" responses as positive; for the remaining four 
questions, which measured perceptions on accessing health care, we 
considered answers of "usually" or "always" to be positive. Questions 
"was it usually or always easy to get a person the care, tests or 
treatment that the parent or a doctor believed necessary" and "was it 
usually or always easy to see a specialist" were added in 2008, 
therefore, we pooled MEPS data from surveys conducted in 2008 through 
2010 for these two questions. 

[End of table] 

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.[Footnote 48] MEPS questions ask about respondents' 
health care visits, including office-based health provider, emergency 
room, and dental visits, in the year prior to the survey. Respondents 
with children in CHIP reported using services at rates generally 
comparable to those with Medicaid and lower--except for emergency room 
visits, which were higher--than those with private health insurance, 
particularly for oral health care. A higher proportion of CHIP 
respondents reported using health care services compared to those who 
were uninsured. For example, about 51 percent of those with private 
insurance reported visiting a dentist in the past 12 months compared 
to about 42 percent of CHIP respondents. Additionally, 69 percent of 
CHIP respondents reported having an office-based provider visit 
compared to about 50 percent of respondents who were uninsured. (See 
table 6.) 

Table 6: Percentage of Respondents Who Used Specific Services as 
Reported in Medical Expenditure Panel Survey (MEPS) Data Related to 
Health Care Service Visits within the Past 12 Months, by Health 
Insurance Status, 2007 through 2010: 

MEPS data related to health care service visits: Had an office-based 
provider visit; 
Insurance status: 
CHIP: 69.1%; 
Private insurance: 76.9%; 
Medicaid: 70.2%; 
Uninsured: 49.9%. 

MEPS data related to health care service visits: Had an outpatient 
department provider visit; 
Insurance status: 
CHIP: 6.8%; 
Private insurance: 7.0%; 
Medicaid: 6.4%; 
Uninsured: 2.8%. 

MEPS data related to health care service visits: Had an emergency room 
visit; 
Insurance status: 
CHIP: 14.1%; 
Private insurance: 10.4%; 
Medicaid: 16.6%; 
Uninsured: 9.0%. 

MEPS data related to health care service visits: Had any dental care 
visit; 
Insurance status: 
CHIP: 45.9%; 
Private insurance: 55.8%; 
Medicaid: 36.8%; 
Uninsured: 21.2%. 

MEPS data related to health care service visits: Had a general dentist 
visit; 
Insurance status: 
CHIP: 42.4%; 
Private insurance: 50.9%; 
Medicaid: 34.1%; 
Uninsured: 18.3%. 

MEPS data related to health care service visits: Had an orthodontist 
visit; 
Insurance status: 
CHIP: 4.9%; 
Private insurance: 11.2%; 
Medicaid: 2.6%; 
Uninsured: 3.9%. 

Source: GAO analysis of MEPS data from surveys conducted in 2007 
through 2010. 

Notes: For our analysis, we pooled MEPS data from surveys conducted in 
2007 through 2010. The "had any dental care visit" variable includes 
visits to a broad group of dental providers, including general 
dentists, dental hygienists, dental technicians, dental surgeons, 
orthodontists, endodontists, and periodontists. The "had a general 
dentist visit" and "had an orthodontist visit" variables are more 
narrowly defined and refer specifically to visits to general dentists 
and orthodontists, respectively. 

[End of table] 

Because factors other than insurance coverage may affect these 
observed differences in responses about obtaining care or utilization 
of health care services, we ran a logistic regression to determine 
whether differences between CHIP respondents and those with other 
sources of insurance coverage were significant after controlling for 
other factors, such as age, race, and income levels. (See appendix I 
for more detailed information on our model and results.) After 
controlling for these factors, we found that differences between CHIP 
and Medicaid responses were not statistically significant for any of 
the 12 questions we reviewed, and that the differences between CHIP 
and privately insured respondents were statistically significant for 4 
questions, which related to respondents' reported use of emergency 
rooms, dentist visits, orthodontist visits, and their reported ease in 
getting needed care, tests, or treatment. CHIP-covered individuals 
were more likely to report emergency room visits and visits to a 
general dentist, and less likely to report orthodontist visits and 
ease in getting needed care than the privately insured. More 
pronounced differences in reported access existed between CHIP 
enrollees and those who were uninsured. When comparing CHIP to the 
uninsured, differences in responses were statistically significant for 
8 of the 12 questions we reviewed.[Footnote 49] 

Concluding Observations: 

Congress, HHS, and the states have important decisions to make 
regarding the future of CHIP. Congress will face decisions concerning 
CHIP funding as current funding has been appropriated only through 
federal fiscal year 2015. The Secretary of HHS will face decisions 
around parameters by which QHPs offered by exchanges can be considered 
to be comparable to CHIP plans. 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. 

Although state officials in the five states we reviewed expect the 
CHIP landscape to remain relatively stable over the next year, 
uncertainty remains regarding issuer decisions and the implementation 
of other PPACA provisions. This uncertainty complicates making a 
definitive determination of what CHIP enrollees would face if they 
were to obtain QHP coverage rather than be enrolled in CHIP. To some 
extent, coverage and costs in QHPs will be determined by individual 
states, issuers, and families' choices. For example, individual 
issuers of QHPs in many states will define the habilitative services 
they cover and the limits on services they cover, including ones that 
are required under PPACA but that they may not have previously 
covered. In many states, families seeking coverage through exchanges 
will be allowed to choose whether to obtain pediatric dental coverage 
by enrolling in a stand-alone dental plan, which will affect upfront 
and other costs they face. Yet, some--or many--families may choose not 
to purchase dental coverage that all CHIP plans must cover. PPACA 
provisions, which seek to standardize QHP costs and reduce cost-
sharing for certain individuals, could narrow the cost gap we 
identified, but will vary by consumers' income level and plan 
selection. Assessing the comparability of CHIP and QHP plans will 
require ongoing monitoring of a complex array of factors. 

Agency Comments: 

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

As agreed with your office, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from its date. At that time, we will send copies to the Secretary of 
Health and Human Services and other interested parties. In addition, 
the report will be available at no charge on the GAO website at 
[hyperlink, http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact Katherine Iritani at (202)512-7114 or iritanik@gao.gov. 
Contact points for our Offices of Congressional Relations and Public 
Affairs may be found on the last page of this report. GAO staff who 
made key contributions to this report are listed in appendix IV. 

Sincerely yours, 

Signed by: 

Katherine M. Iritani: 
Director, Health Care: 

[End of section] 

Appendix I: Scope and Methodology of the Medical Expenditure Panel 
Survey (MEPS) Analysis: 

To describe how access to care for CHIP children compares to other 
children, we analyzed data from the Medical Expenditure Panel Survey 
(MEPS), a nationally representative survey that collects data from a 
sample of non-institutionalized Americans on their health insurance 
status and service utilization, among other factors. MEPS is 
administered by the Department of Health and Human Services' (HHS) 
Agency for Healthcare Research and Quality (AHRQ) and collects 
information from respondents on many topics, including demographic 
characteristics, insurance status, health conditions, and their use of 
specific health services. We analyzed results from the MEPS household 
component, which collects data from a sample of families and 
individuals in selected communities across the United States and is 
drawn from a nationally representative subsample of households that 
participated in the prior year's National Health Interview 
Survey.[Footnote 50] The MEPS household component features five rounds 
of interviews, which occur over two full calendar years. MEPS collects 
information for each person in the household, and information is 
generally provided by an adult member of the household. 

To identify MEPS questions related to health care access, we reviewed 
the MEPS codebook, which lists all of the MEPS variables available for 
data analysis, and reviewed prior analyses that used MEPS data to 
compare access to care in public and private insurance by AHRQ and the 
Urban Institute. Through these efforts, we identified for further 
review 29 MEPS questions related to health care access.[Footnote 51] 
Once we identified the relevant questions, we compared responses of 
MEPS respondents in households with children from ages 0 to 19 years 
who were eligible for the State Children's Health Insurance Program 
(CHIP) to those who were covered under private insurance, Medicaid, 
and who were uninsured.[Footnote 52] Although MEPS combines responses 
from Medicaid and CHIP-eligible individuals, we consulted with AHRQ to 
disaggregate these responses. Specifically, we applied the Medicaid 
and CHIP income eligibility and earnings disregard rules for all 50 
states and the District of Columbia to identify which respondents were 
eligible for CHIP versus Medicaid.[Footnote 53] To ensure we had a 
large enough sample size for our analysis of CHIP-eligible 
respondents, we included respondents who were continuously enrolled in 
CHIP for at least 8 months, and we analyzed responses from respondents 
enrolled in CHIP, Medicaid, or private insurance for at least eight 
months or who were uninsured at least 8 months out of the year. 
[Footnote 54] In addition, we pooled MEPS survey results from 2007 
through 2010, the most recent, complete MEPS data available at the 
time of our analysis, and combined response choices for some of the 
MEPS questions. For example, some questions had several response 
choices, such as "always," "usually," "sometimes," or "never." We 
combined the four response choices into two response choices (e.g., 
"usually or always" and "sometimes or never"). Despite these efforts, 
8 questions that we originally selected for analysis were excluded 
because of an insufficient number of responses. Nine additional 
questions were excluded due to our determination that they were 
redundant of other questions. As a result, our analyses focused on 12 
MEPS questions: 6 questions asked about respondents experiences 
obtaining care and 6 questions asked about their utilization of 
specific services. (See table 7.) 

Table 7: Description of the 12 Medical Expenditure Panel Survey (MEPS) 
Questions and Survey Items and Related Responses Included in Our 
Analysis of Survey Data from 2007 through 2010: 

MEPS questions related to experiences obtaining care: 

Do you have a usual source of care? 

How difficult was it to reach the usual source of care by telephone 
during office hours?[A] 

Did you usually or always get care as soon as was needed?[B]. 

Did you usually or always get an appointment for health care as soon 
as was needed?[B] 

Was it usually or always easy to get a person the care, tests or 
treatment that the parent or a doctor believed necessary?[B] 

Was it usually or always easy to see a specialist?[B] 

MEPS survey items related to service utilization: 

Had an office-based provider visit[C]. 

Had an outpatient department provider visit[D]. 

Had an emergency room visit[E]. 

Had any dental care visit[F]. 

Had a general dentist visit[F]. 

Had an orthodontist visit[F]. 

Source: GAO analysis of MEPS data from 2007-2010. 

Note: Questions are paraphrased from the MEPS survey. 

[A] The answer choices for this question were: "very difficult, 
somewhat difficult, not too difficult, not at all difficult, refused 
and don't know." Certain answer choices were combined as follows: very 
or somewhat difficult were coded as "difficult"; and not too or not at 
all difficult were coded as "not difficult." 

[B] The answer choices for this question were: "never, sometimes, 
usually, always, refused, and don't know." Certain answer choices were 
combined as follows: never or sometimes; usually or always. Also, the 
age range for this question was from age 0 to age 17 years. 

[C] This category of services includes encounters that took place 
primarily in office-based settings and clinics for all survey years 
included in our analysis. This category includes the number of office-
based visits to physicians and non-physician providers, such as 
chiropractors, midwives, nurses and nurse practitioners, optometrists, 
podiatrists, physician's assistants, physical therapists, occupational 
therapists, psychologists, social workers, technicians, receptionists/ 
clerks/secretaries, or other medical providers. 

[D] This category of services includes the reported visits to hospital 
outpatient departments for all survey years included in our analysis. 
It includes the number of outpatient department visits to physicians 
and non-physician providers. 

[E] This variable represents a count of all emergency room visits 
reported for all survey years included in our analysis. 

[F] The "had any dental care" variable includes visits to any person 
or persons for dental care including general dentists, dental 
hygienists, dental technicians, dental surgeons, orthodontists, 
endodontists, and periodontists for all survey years included in our 
analysis. The "had a general dentist visit" and "had an orthodontist 
visit" variables are more narrowly defined and refer specifically to 
visits to general dentists and orthodontists, respectively. 

[End of table] 

Because factors other than insurance coverage--such as income, parent 
education, and family composition, may affect access to care, we also 
ran a multivariate logistic regression analysis of responses to these 
12 questions. Based on the literature and in consultation with experts 
at AHRQ and the Urban Institute, an organization that has conducted 
past research on access to care using MEPS data, we identified a 
number of factors in addition to insurance that could influence access 
to care and constructed logistic regression models to control for the 
effects of these factors on our results. The factors we included were 
age, race, income, total number of parents in the household, parent 
education, family size, health status, mental health status, children 
with special needs, total number of workers in the household, 
metropolitan statistical area, sex, whether the respondent was born in 
the United States, and English versus non-English speakers.[Footnote 
55] We then tested whether there was a statistically significant 
difference in the effect of enrollment in CHIP versus other types of 
insurance coverage on responses to questions about access to care 
after controlling for these factors.[Footnote 56] For 9 of the 12 
questions in our analysis, there were statistically significant 
differences between CHIP and certain comparison groups after 
controlling for other factors. 

To determine the reliability of the MEPS data, we reviewed related 
documentation, identified other studies, including our prior reports, 
that used MEPS data to address similar research questions, and 
consulted researchers at AHRQ and the Urban Institute about our 
analysis. We determined that the MEPS data were sufficiently reliable 
for the purposes of our report. However, there were several 
limitations to our analysis. First, to separate CHIP and Medicaid 
respondents, we relied on state CHIP and Medicaid income eligibility 
and income disregard rules reported by Kaiser between 2007 through 
2010, and did not independently verify these data.[Footnote 57] In 
addition, the information available from Kaiser on each state's income 
disregard rules was limited and had not been uniformly updated since 
2008. Therefore, to account for potential gaps in information, we 
applied the income disregard rules from the 2008 Kaiser report to MEPS 
results from 2007 and 2008, and applied unverified 2010 income 
disregard rules from Kaiser to MEPS results from 2009 and 2010. When 
discrepancies between the 2008 and 2010 Kaiser data existed, we 
contacted states for clarification. In the event we could not verify 
the change in income disregard rules, which was the case with two 
states, we applied the 2008 income disregard rules for MEPS survey 
results to all 4 years of our analysis, 2007 through 2010. In 
addition, our analysis did not account for earnings disregards related 
to child care expenses, child support paid, or child support received; 
therefore, the groups we identified as Medicaid-or CHIP-eligible may 
be understated. Further, our analysis also did not account for income-
ineligible respondents. Therefore, there may be some overlap between 
Medicaid and CHIP respondents or under-reporting of CHIP 
respondents.[Footnote 58] Finally, because our analyses reflect an 
eight-month period of enrollment or uninsurance, the responses may not 
precisely align with the respondents' current health insurance status, 
particularly because several MEPS questions refer to respondents' 
experiences and utilization over the prior 12 months. 

[End of section] 

Appendix II: Coverage for Selected Services in CHIP and Benchmark 
Plans in Five States: 

Service: Ambulatory patient services; Provider office visits: 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Ambulatory patient services; Outpatient surgery: 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Emergency care; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan:
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Inpatient hospital: Facility; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Inpatient hospital: Professional; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Inpatient hospital: Ancillary; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Maternity care; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Mental health; Inpatient; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Mental health; Outpatient; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Substance abuse treatment; Inpatient; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: No; 
Utah: Yes. 

Service: Substance abuse treatment; Outpatient; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Prescription drugs; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Therapies; Physical; Rehabilitative; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Therapies; Physical; Habilitative; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: No; 
New York: Yes; 
Utah: No; 
Benchmark plan: 
Colorado: No; 
Illinois: Yes; 
Kansas: No; 
New York: No; 
Utah: Yes. 

Service: Therapies; Speech; Rehabilitative; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Therapies; Speech; Habilitative; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: No; 
New York: Yes; 
Utah: No; 
Benchmark plan: 
Colorado: No; 
Illinois: Yes; 
Kansas: No; 
New York: No; 
Utah: Yes. 

Service: Therapies; Occupational; Rehabilitative; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Therapies; Occupational; Habilitative; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: No; 
New York: Yes; 
Utah: No; 
[Empty]; 
Benchmark plan: 
Colorado: No; 
Illinois: Yes; 
Kansas: No; 
New York: No; 
Utah: Yes. 

Service: Laboratory services; Inpatient; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Laboratory services; Outpatient; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Preventive care; Well-child; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Preventive care; Immunizations; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Preventive care; Chronic disease management; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Pediatric dental; Routine; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes[A]; 
Illinois: Yes[A]; 
Kansas: Yes[A]; 
New York: Yes[A]; 
Utah: Yes. 

Service: Pediatric dental; Emergency; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes[A]; 
Illinois: Yes[A]; 
Kansas: [A]; 
New York: Yes[A]; 
Utah: No. 

Service: Pediatric dental; Other; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes[A]; 
Illinois: Yes[A]; 
Kansas: [A]; 
New York: Yes[A]; 
Utah: No. 

Service: Pediatric vision; Exams; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes[B]; 
Kansas: Yes[C]; 
New York: Yes[C]; 
Utah: Yes. 

Service: Pediatric vision; Corrective lenses; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: No; 
Benchmark plan: 
Colorado: No; 
Illinois: Yes[B]; 
Kansas: Yes[C]; 
New York: Yes[C]; 
Utah: No. 

Service: Pediatric hearing; Testing; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: No; 
Kansas: No; 
New York: Yes; 
Utah: Yes. 

Service: Pediatric hearing; Hearing aids; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: No; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: No; 
New York: Yes; 
Utah: No. 

Service: Durable medical equipment; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Home and community-based health care; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Service: Hospice; 
CHIP plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes; 
Benchmark plan: 
Colorado: Yes; 
Illinois: Yes; 
Kansas: Yes; 
New York: Yes; 
Utah: Yes. 

Source: GAO analysis of data from CHIP and benchmark plan Evidences of 
Coverage and contact with state and health plan officials in Colorado, 
Illinois, Kansas, New York, and Utah. 

Notes: CHIP plan data for Colorado and Utah was effective from July 1, 
2012, through June 30, 2013, and for Illinois, Kansas, and New York, 
it was effective calendar year 2013. Benchmark plan data was effective 
as of December 26, 2012, the deadline for benchmark plan selection. 

Rehabilitation is provided to help a person regain, maintain or 
prevent deterioration of a skill that has been acquired but then lost 
or impaired due to illness, injury, or disabling condition. While 
PPACA and its implementing regulations do not define habilitative 
services, habilitation has been defined by several advocacy groups as 
a service that is provided in order for a person to attain, maintain, 
or prevent deterioration of a skill or function never learned or 
acquired due to a disabling condition. 

[A] State selected CHIP plan as its supplemental dental benchmark plan. 

[B] State selected FEDVIP as its supplemental vision benchmark plan. 

[C] State selected CHIP as its supplemental vision benchmark plan. 

[End of table] 

[End of section] 

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.[Footnote 59] States' CHIP and benchmark plans may also 
include a deductible, which was the case for all five states' 
benchmark plans and one state's CHIP plan. For all five states, cost-
sharing for individuals and families was also subject to an out-of-
pocket maximum cost. For CHIP enrollees, the out-of-pocket maximum 
cost amount was applied by the plans as established by federal 
statute, limited to 5 percent of a family's income, and included all 
consumer costs, including premiums.[Footnote 60] For the benchmark 
plans, the out-of-pocket maximum cost for benchmark plans was 
established by each issuer, did not include premium costs, and was 
sometimes in addition to the deductible. 

Table 8: Cost-Sharing Amounts and Annual Coverage Limits for Selected 
Services in the State Children's Health Insurance Program (CHIP) and 
Benchmark Plans in Colorado: 

Service: Ambulatory patient services: office visits; Primary care 
physician; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: $2; 
151-200%: $5; 
201-250%: $10; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $30; 
Annual coverage limits: None. 

Service: Ambulatory patient services: office visits; Specialty 
physician; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: $2; 
151-200%: $5; 
201-250%: $10; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $50; 
Annual coverage limits: None. 

Service: Emergency care; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: $3; 
151-200%: $30; 
201-250%: $50; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): 20%; 
Annual coverage limits: None. 

Service: Inpatient hospital; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: $2; 
151-200%: $20; 
201-250%: $50; 
Annual coverage limits: 30 days for rehabilitation therapies[A]; 
Benchmark plans: 
Copay ($)/coinsurance (%): 20%; 
Annual coverage limits: 100 days for skilled nursing hospital bed. 

Service: Maternity care; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: 0; 
151-200%: 0; 
201-250%: 0; 
Annual coverage limits: 1 metabolic screening, 1 postpartum 
visit, and 1 prescreening visit; 
Benchmark plans: 
Copay ($)/coinsurance (%): 0; 
Annual coverage limits: None. 

Service: Mental health and substance abuse; Inpatient; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL):
101-150%: 0; 
151-200%: 0; 
201-250%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): 20%; 
Annual coverage limits: None. 

Service: Mental health and substance abuse; Outpatient therapy; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: $2; 
151-200%: $5; 
201-250%: $10; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $15 per group therapy session; $30 per 
individual therapy session; 
Annual coverage limits: None. 

Service: Prescription drugs; Generic; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: $1; 
151-200%: $3; 
201-250%: $5; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $15[B]; 
Annual coverage limits: None. 

Service: Prescription drugs; Brand-name; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: $1; 
151-200%: $10; 
201-250%: $15; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $30[B,C]; 
Annual coverage limits: None. 

Service: Outpatient therapies (occupational, physical, speech); 
Rehabilitative; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: $2; 
151-200%: $5; 
201-250%: $10; 
Annual coverage limits: 40 visits[D]; 
Benchmark plans: 
Copay ($)/coinsurance (%): $30; 
Annual coverage limits: 20 per therapy type[E]. 

Service: Outpatient therapies (occupational, physical, speech); 
Habilitative; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: $2; 
151-200%: $5; 
201-250%: $10; 
Annual coverage limits: 40 visits[D]; 
Benchmark plans: 
Copay ($)/coinsurance (%): Not covered; 
Annual coverage limits: Not covered. 

Service: Preventive care; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: 0; 
151-200%: 0; 
201-250%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $0; 
Annual coverage limits: None. 

Service: Pediatric dental; Routine; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: 0; 
151-200%: 0; 
201-250%: 0; 
Annual coverage limits: $600[F]; 
Benchmark plans: 
Copay ($)/coinsurance (%): Same as CHIP; 
Annual coverage limits: Same as CHIP. 

Service: Pediatric dental; Other[G]; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: 0; 
151-200%: $5; 
201-250%: $10; 
Annual coverage limits: $600[F]; 
Benchmark plans: 
Copay ($)/coinsurance (%): Same as CHIP; 
Annual coverage limits: Same as CHIP. 

Service: Pediatric vision; Optometrist exam; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: 0; 
151-200%: 0; 
201-250%: 0; 
Annual coverage limits: 1; 
Benchmark plans: 
Copay ($)/coinsurance (%): 30; 
Annual coverage limits: None. 

Service: Pediatric vision; Corrective lenses; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: 0; 
151-200%: 0; 
201-250%: 0; 
Annual coverage limits: 150; 
Benchmark plans: 
Copay ($)/coinsurance (%): Not covered; 
Annual coverage limits: Not covered. 

Service: Pediatric hearing; Testing; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: 0; 
151-200%: 0; 
201-250%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $30; 
Annual coverage limits: None. 

Service: Pediatric hearing; Hearing aids; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: 0; 
151-200%: 0; 
201-250%: 0; 

Annual coverage limits: 1 every 5 years; 
Benchmark plans: 
Copay ($)/coinsurance (%): 20%; 
Annual coverage limits: 1 every 5 years. 

Service: Durable medical equipment; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: 0; 
151-200%: 0; 
201-250%: 0; 
Annual coverage limits: $2,000; 
Benchmark plans: 
Copay ($)/coinsurance (%): 20%; 
Annual coverage limits: $2,000. 

Service: Home and community-based health care; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: 0; 
151-200%: 0; 
201-250%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): 20%; 
Annual coverage limits: 28 hours per week[H]. 

Service: Hospice; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
101-150%: 0; 
151-200%: 0; 
201-250%: 0; 
Annual coverage limits: 9 months[I]; 
Benchmark plans: 
Copay ($)/coinsurance (%): 20%; 
Annual coverage limits: None. 

Source: GAO analysis of the Colorado Access HMO+ plan CHIP plan and 
the Kaiser Foundation Health Plan of Colorado HMO 1200D benchmark plan 
Evidences of Coverage and information from state and plan officials. 

Notes: 

The CHIP plan was in effect July 1, 2012, through June 30, 2013. The 
benchmark plan was in effect as of December 26, 2012, the deadline for 
benchmark plan selection, with the Colorado Access HMO+ CHIP plan 
supplementing the pediatric dental benefit. For the benchmark plans, 
the coinsurance amounts (numbers given as percentages) apply once the 
deductible is met and count toward the out-of-pocket maximum cost. 
Copayments (numbers given as dollars) are paid each time a consumer 
receives a service, are not subject to the deductible, and do not 
count toward the out-of-pocket maximum cost. The Colorado CHIP plan 
did not include a deductible while the benchmark plan included a 
deductible, which was $1,200 for an individual and $3,600 for a 
family. The benchmark plan out-of-pocket maximum costs were in 
addition to the deductible and were $2,500 for an individual and 
$5,000 for a family. 

Rehabilitation is provided to help a person regain, maintain or 
prevent deterioration of a skill that has been acquired but then lost 
or impaired due to illness, injury, or disabling condition. While 
PPACA and implementing regulations do not define habilitative 
services, habilitation has been defined by several advocacy groups as 
a service that is provided in order for a person to attain, maintain, 
or prevent deterioration of a skill or function never learned or 
acquired due to a disabling condition. 

[A] Rehabilitation therapies are occupational, physical, and speech 
therapies. 

[B] The Colorado benchmark plan subjects enrollees to a separate $100 
pharmacy deductible. Payments for prescription drugs are applied to 
this deductible and accumulate separately from the plan deductible for 
covered medical services. Each covered family member must meet their 
individual annual pharmacy deductible before any prescription drug 
benefit is paid by the health plan. 

[C] Brand-name drugs include drugs designated by the plan as 
"preferred" or included in their formulary. 

[D] Outpatient therapy visit limits are per diagnosis, per calendar 
year. Service is unlimited to children under 3 years of age and speech 
therapy is unlimited for those with a cleft palate or lip. 

[E] Outpatient rehabilitative therapies are covered for children 3 to 
6 years of age, and under 3 years of age if not participating in early 
intervention services. Service is unlimited for children with autism 
spectrum disorder who are under age 19. 

[F] The CHIP plan imposes a $600 maximum benefit for all dental 
services. Additional limits on routine dental services include: two 
fluoride varnish treatments per calendar year for children ages 0 to 4 
years of age. Full mouth x-ray every 5 years; one panoramic film every 
5 years; one prophylaxis per year; two oral evaluations per year; two 
topical fluoride treatments per year; and one bitewing x-ray per year. 
Additional limits on other dental services include one amalgam or 
resin restoration every 2 years; one prefabricated crown per tooth 
every 2 years. 

[G] Other dental services include such services as root canals and 
fillings. 

[H] Home-and community-based health care must not exceed 8 hours per 
day. An additional 35 hours a week may be approved by the health plan 
on a case-by-case basis. Those in the Special Services Program 
(individuals with a terminal illness with a life-expectancy of 1 year 
or less that are not yet receiving hospice care or benefits) are 
limited to 15 home health visits per lifetime. 

[I] Hospice is available in 3 month increments, which do not have to 
be consecutive. 

[End of table] 

Table 9: Cost-Sharing Amounts and Annual Coverage Limits for Selected 
Services in the State Children's Health Insurance Program (CHIP) and 
Benchmark Plans in Illinois: 

Service: Ambulatory patient services: office visits; Primary care 
physician; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: $3.90; 
151-200%: $5; 
201-300%: $10; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $20; 
Annual coverage limits: None. 

Service: Ambulatory patient services: office visits; Specialty 
physician; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: $3.90; 
151-200%: $5; 
201-300%: $10; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $40; 
Annual coverage limits: None. 

Service: Emergency care; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: 0; 
151-200%: $5; 
201-300%: $30;
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): Hospital: $0; Emergency room: $150[A]; 
Annual coverage limits: None. 

Service: Inpatient hospital; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: $3.90[B]; 
151-200%: $5[B]; 
201-300%: $100; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): 10%; 
Annual coverage limits: None. 

Service: Maternity care; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: 0; 
151-200%: 0; 
201-300%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $20; 
Annual coverage limits: 1 routine inpatient newborn exam and 1 hearing 
screening. 

Service: Mental health and substance abuse; Inpatient; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: $3.90[B]; 
151-200%: $5[B]; 
201-300%: $100; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): 10%; 
Annual coverage limits: None. 

Service: Mental health and substance abuse; Outpatient therapy; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: 0; 
151-200%: 0; 
201-300%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $20; 
Annual coverage limits: None. 

Service: Prescription drugs; Generic; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: $2; 
151-200%: $3; 
201-300%: $3; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $15[C]; 
Annual coverage limits: None. 

Service: Prescription drugs; Brand-name; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: $3.90; 
151-200%: $5; 
201-300%: $7; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $30[D]; 
Annual coverage limits: None. 

Service: Outpatient therapies (occupational, physical, speech); 
Rehabilitative; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: 0; 
151-200%: 0; 
201-300%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): 10%; 
Annual coverage limits: None. 

Service: Outpatient therapies (occupational, physical, speech); 
Habilitative; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: 0; 
151-200%: 0; 
201-300%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): 10%; 
Annual coverage limits: None. 

Service: Preventive care; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: 0; 
151-200%: 0; 
201-300%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $0; 
Annual coverage limits: None. 

Service: Pediatric dental; Routine; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: $3.90; 
151-200%: $5; 
201-300%: $10; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $0; 
Annual coverage limits: Same as CHIP. 

Service: Pediatric dental; Other[E]; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: $3.90; 
151-200%: $5; 
201-300%: $10; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $0; 
Annual coverage limits: Same as CHIP. 

Service: Pediatric vision; Optometrist exam; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: 0; 
151-200%: 0; 
201-300%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $0; 
Annual coverage limits: 1. 

Service: Pediatric vision; Corrective lenses; 
CHIP plan: Copay/coinsurance by federal poverty level (FPL): 
134-150%: 0; 
151-200%: 0; 
201-300%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): $0; 
Annual coverage limits: FEDVIP[F]. 

Service: Pediatric hearing; Testing; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: 0; 
151-200%: 0; 
201-300%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): Not covered; 
Annual coverage limits: Not covered[G]. 

Service: Pediatric hearing; Hearing aids; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: 0; 
151-200%: 0; 
201-300%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): Not covered; 
Annual coverage limits: Not covered. 

Service: Durable medical equipment; 
CHIP plan: Copay/coinsurance by federal poverty level (FPL): 
134-150%: 0; 
151-200%: 0; 
201-300%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): 10%; 
Annual coverage limits: None. 

Service: Home and community-based health care; 
CHIP plan: 
Copay/coinsurance by federal poverty level (FPL): 
134-150%: 0; 
151-200%: 0; 
201-300%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): 10%; 
Annual coverage limits: None. 

Service: Hospice; 
CHIP plan: Copay/coinsurance by federal poverty level (FPL): 
134-150%: 0; 
151-200%: 0; 
201-300%: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay ($)/coinsurance (%): 10%; 
Annual coverage limits: None. 

Source: GAO analysis of the Illinois CHIP State plan, Illinois 
Medicaid State plan, and the Blue Cross Blue Shield of Illinois 
BlueAdvantage Entrepreneur PPO benchmark plan Evidence of Coverage and 
information from state and plan officials. 

Notes: 

The CHIP and Medicaid plans were in effect in calendar year 2013. The 
benchmark plan was in effect as of December 26, 2012, the deadline for 
benchmark plan selection, with the Illinois CHIP and Medicaid plans 
supplementing the pediatric dental benefit, and the Blue Cross and 
Blue Shield Association Federal Employee Program Blue Vision-High plan 
supplementing the pediatric vision benefit. For the benchmark plans, 
coinsurance amounts (numbers given as percentages) apply once the 
deductible is met and count toward the out-of-pocket maximum cost. 
Copayments (numbers given as dollars) are paid each time a consumer 
receives a service, are not subject to the deductible, and do not 
count toward the out-of-pocket maximum cost. The Illinois CHIP plan 
did not include a deductible while the benchmark plan included a 
deductible, which was $500 for an individual and $1,500 for a family. 
The benchmark plan out-of-pocket maximum costs were in addition to the 
deductible and were $1,000 for an individual and $3,000 for a family. 

Rehabilitation is provided to help a person regain, maintain or 
prevent deterioration of a skill that has been acquired but then lost 
or impaired due to illness, injury, or disabling condition. While 
PPACA and implementing regulations do not define habilitative 
services, habilitation has been defined by several advocacy groups as 
a service that is provided in order for a person to attain, maintain, 
or prevent deterioration of a skill or function never learned or 
acquired due to a disabling condition. 

[A] The emergency room copayment is waived if consumer is admitted to 
hospital as an inpatient immediately following. 

[B] The copayment amount is charged per day. 

[C] If generic prescription drugs are ordered through the mail, the 
cost per prescription is $30. 

[D] If brand-name prescription drugs are ordered through the mail, the 
cost per prescription is $60. Brand-name drugs include drugs 
designated by the plan as "preferred" or included in their formulary. 

[E] Other dental services include such services as root canals and 
fillings. 

[F] The 2012 Federal Employee Dental and Vision Insurance Program 
annual coverage limits for corrective lenses includes: one pair of 
standard eyeglass lenses or contact lenses; and one frame (or contacts 
in lieu of glasses). The plan pays for non-collection frames up to 
$150 and up to $600 for medically necessary contact lenses. 

[G] Pediatric hearing testing was not covered with the exception of 
one hearing screening for newborns. 

[End of table] 

Table 10: Cost-Sharing Amounts and Annual Coverage Limits for Selected 
Services in the State Children's Health Insurance Program (CHIP) and 
Benchmark Plans in Kansas: 

Service: Ambulatory patient services: office visits; Primary care 
physician; 
CHIP plan: 
Copay/coinsurance: $0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): $25; 
Annual coverage limits: None. 

Service: Ambulatory patient services: office visits; Specialty 
physician; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): $25; 
Annual coverage limits: None. 

Service: Emergency care; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): $100[A]; 
Annual coverage limits: None. 

Service: Inpatient hospital; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): 20%; 
Annual coverage limits: None. 

Service: Maternity care; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): 20%; 
Annual coverage limits: None. 

Service: Mental health and substance abuse; Inpatient; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): 20%; 
Annual coverage limits: None. 

Service: Mental health and substance abuse; Outpatient therapy; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): $25; 
Annual coverage limits: None. 

Service: Prescription drugs; Generic; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): $15[B]; 
Annual coverage limits: None. 

Service: Prescription drugs; Brand-name; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): $30[C]; 
Annual coverage limits: None. 

Service: Outpatient therapies (occupational, physical, speech); 
Rehabilitative; 
CHIP plan: 
Copay/coinsurance: 0; 
CHIP plan: [Empty]; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): $25; 
Annual coverage limits: Physical and occupational: None; Speech: 
90 days[D]. 

Service: Outpatient therapies (occupational, physical, speech); 
Habilitative; 
CHIP plan: 
Copay/coinsurance: Not covered; 
Annual coverage limits: Not covered; 
Benchmark plans: 
Copay($)/coinsurance (%): Not covered; 
Annual coverage limits: Not covered. 

Service: Preventive care; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): $0; 
Annual coverage limits: None. 

Service: Pediatric dental; Routine; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: Various[E]; 
Benchmark plans: 
Copay($)/coinsurance (%): $0; 
Annual coverage limits: Same as CHIP. 

Service: Pediatric dental; Other[F]; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: Various[G]; 
Benchmark plans: 
Copay($)/coinsurance (%): $0; 
Annual coverage limits: Same as CHIP. 

Service: Pediatric vision; Optometrist exam; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): $0; 
Annual coverage limits: Same as CHIP. 

Service: Pediatric vision; Corrective lenses; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: 4 pairs; 
Benchmark plans: 
Copay($)/coinsurance (%): $0; 
Annual coverage limits: Same as CHIP. 

Service: Pediatric hearing; Testing; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): Not covered; 
Annual coverage limits: Not covered. 

Service: Pediatric hearing; Hearing aids; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: Various[H]; 
Benchmark plans: 
Copay($)/coinsurance (%): Not covered; 
Annual coverage limits: Not covered. 

Service: Durable medical equipment; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): 20%; 
Annual coverage limits: None. 

Service: Home and community-based health care; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): $0; 
Annual coverage limits: 3 visits for home care education. 

Service: Hospice; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay($)/coinsurance (%): $0; 
Annual coverage limits: $5,000 per insured per lifetime. 

Source: GAO analysis of the Kansas Sunflower State Health CHIP plan 
and the Blue Cross and Blue Shield of Kansas Comprehensive Major 
Medical Blue Choice PPO GF 500 deductible with Blue Rx card benchmark 
plan Evidence of Coverage and information from state officials. 

Notes: 

The CHIP plan was in effect in calendar year 2013. The benchmark plan 
was in effect as of December 26, 2012, the deadline for benchmark plan 
selection, with the Kansas Sunflower State Health CHIP plan 
supplementing the pediatric dental and vision benefits. For the 
benchmark plans, coinsurance amounts (numbers given as percentages) 
apply after the deductible is met and count toward the out-of-pocket 
maximum cost. Copayments (numbers given as dollars) are paid each time 
a consumer receives a service, are not subject to the deductible, and 
do not count toward the out-of-pocket maximum cost. The Kansas CHIP 
plan did not include a deductible while the benchmark plan included a 
deductible, which was $500 for an individual and $1,000 for a family. 
The benchmark plan out-of-pocket maximum costs were in addition to the 
deductible and were $1,000 for an individual and $2,000 for a family. 

Rehabilitation is provided to help a person regain, maintain or 
prevent deterioration of a skill that has been acquired but then lost 
or impaired due to illness, injury, or disabling condition. While 
PPACA and implementing regulations do not define habilitative 
services, habilitation has been defined by several advocacy groups as 
a service that is provided in order for a person to attain, maintain, 
or prevent deterioration of a skill or function never learned or 
acquired due to a disabling condition. 

[A] The emergency care copayment is paid after the Enhanced Accidental 
Injury Benefit is reached. Under this provision, the consumer pays $0 
for covered services associated with any and all accidental injuries 
incurred up to a maximum of $1,000 per insured per benefit period. 

[B] If generic prescription drugs are ordered through the mail, the 
cost per prescription is $37.50 or less. 

[C] If brand-name prescription drugs are ordered through the mail, the 
cost per prescription is $75 or less. Brand-name drugs include drugs 
designated by the plan as "preferred" or included in their formulary. 

[D] Speech therapy is limited to one service per day up to a maximum 
benefit of 90 daily services per insured per year. 

[E] Routine pediatric dental services include: two exams per year; one 
comprehensive exam per lifetime; one re-evaluation per year; one set 
of full mouth (or panoramic x-rays and bitewings) every 3 years: three 
topical fluoride treatments per year; one sealant per tooth per year; 
one space maintainer-fixed-unilateral per quadrant per year; one space 
maintainer-fixed-bilateral per arch per year; one space maintainer-
removable-bilateral per arch per year. 

[F] Other dental services include such services as root canals and 
fillings. 

[G] Other dental services include one porcelain, resin, or full cast 
base metal crown every 5 years; one prefabricated steel crown every 2 
years; one endodontic therapy and pulpectomy per tooth per lifetime; 
and dentures every 5 years. 

[H] Hearing aid batteries are limited to 6 batteries per month for 
monaural aids and 12 per month for binaural aids. Batteries for use 
with cochlear devices are limited to lithium ion (3 per 30 days) or 
zinc air (6 per 30 days). Batteries for cochlear devices are covered 
for CHIP-eligible beneficiaries only. Only one type of battery is 
allowed every 30 days. 

[End of table] 

Table 11: Cost-Sharing Amounts and Annual Coverage Limits for Selected 
Services in the State Children's Health Insurance Program (CHIP) and 
Benchmark Plans in New York: 

Service: Ambulatory patient services: office visits; Primary care 
physician; 
CHIP plan: 
Copay/coinsurance: $0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: $25; 
Annual coverage limits: None. 

Service: Ambulatory patient services: office visits; Specialty 
physician; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: $50; 
Annual coverage limits: None. 

Service: Emergency care; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: 0%; 
Annual coverage limits: None. 

Service: Inpatient hospital; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: 0%; 
Annual coverage limits: None. 

Service: Maternity care; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: 1 home care visit for early discharge; 
Benchmark plans: 
Copay/coinsurance: 0%[A]; 
Annual coverage limits: 1 home care visit for early discharge. 

Service: Mental health; Inpatient; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: 0%; 
Annual coverage limits: 30 days. 

Service: Mental health; Outpatient therapy; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: 0%; 
Annual coverage limits: 30 days. 

Service: Substance abuse; Inpatient; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: $0; 
Annual coverage limits: 30 days. 

Service: Substance abuse; Outpatient therapy; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: 0%; 
Annual coverage limits: 60 days. 

Service: Prescription drugs; Generic; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: $15[B]; 
Annual coverage limits: None. 

Service: Prescription drugs; Brand-name; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: $35[B,C]; 
Annual coverage limits: None. 

Service: Outpatient therapies (occupational, physical, speech); 
Rehabilitative; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: Physical and occupational: 6 weeks; Speech: 
None; 
Benchmark plans: 
Copay/coinsurance: 0%; 
Annual coverage limits: 60 visits per condition per lifetime. 

Service: Outpatient therapies (occupational, physical, speech); 
Habilitative; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: Physical and occupational: 6 weeks; Speech: 
None; 
Benchmark plans: 
Copay/coinsurance: Not covered; 
Annual coverage limits: Not covered. 

Service: Preventive care; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: $0; 
Annual coverage limits: None. 

Service: Pediatric dental; Routine; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: Various[D]; 
Benchmark plans: 
Copay/coinsurance: Same as CHIP; 
Annual coverage limits: Same as CHIP. 

Service: Pediatric dental; Other[E]; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: Same as CHIP; 
Annual coverage limits: Same as CHIP. 

Service: Pediatric vision; Optometrist exam; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: 1[F]; 
Benchmark plans: 
Copay/coinsurance: Same as CHIP; 
Annual coverage limits: Same as CHIP. 

Service: Pediatric vision; Corrective lenses; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: 1[G]; 
Benchmark plans: 
Copay/coinsurance: Same as CHIP; 
Annual coverage limits: Same as CHIP. 

Service: Pediatric hearing; Testing; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: 1; 
Benchmark plans: 
Copay/coinsurance: $0; 
Annual coverage limits: None. 

Service: Pediatric hearing; Hearing aids; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: 0%; 
Annual coverage limits: $1,500 1 every 3 years. 

Service: Durable medical equipment; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: 0%; 
Annual coverage limits: $1,500[H]. 

Service: Home and community-based health care; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: 40; 
Benchmark plans: 
Copay/coinsurance: 0%; 
Annual coverage limits: 40. 

Service: Hospice; 
CHIP plan: 
Copay/coinsurance: 0; 
Annual coverage limits: None; 
Benchmark plans: 
Copay/coinsurance: 0%; 
Annual coverage limits: 210 days. 

Source: GAO analysis of the Fidelis Care New York CHIP plan and the 
New York Oxford Health Insurance, Inc. Oxford EPO benchmark plan 
Evidence of Coverage and information from state and plan officials. 

Notes: 

The CHIP plan was in effect in calendar year 2013. The benchmark plan 
was in effect as of December 26, 2012, the deadline for benchmark plan 
selection, with the Fidelis Care New York CHIP plan supplementing the 
pediatric dental and vision benefits. For the benchmark plans, 
coinsurance amounts (numbers given as percentages) apply after the 
deductible is met and count toward the out-of-pocket maximum cost. 
Copayments (numbers given as dollars) are paid each time a consumer 
receives a service, are not subject to the deductible, and do not 
count toward the out-of-pocket maximum cost, unless otherwise 
indicated. The New York CHIP plan did not include a deductible while 
the benchmark plan included a deductible, which was $2,850 for an 
individual and $5,700 for a family. The benchmark plan out-of-pocket 
maximum costs included the deductible and were $2,850 for an 
individual and $5,700 for a family. 

Rehabilitation is provided to help a person regain, maintain or 
prevent deterioration of a skill that has been acquired but then lost 
or impaired due to illness, injury, or disabling condition. While 
PPACA and implementing regulations do not define habilitative 
services, habilitation has been defined by several advocacy groups as 
a service that is provided in order for a person to attain, maintain, 
or prevent deterioration of a skill or function never learned or 
acquired due to a disabling condition. 

[A] Maternity care is only subject to the deductible for the initial 
visit. 

[B] Enrollees pay 100 percent of costs for prescription drugs until 
they've reached their deductible, after which they pay the copayment 
amount listed here. 

[C] Brand-name drugs include drugs designated by the plan as 
"preferred" or included in their formulary. 

[D] Routine pediatric dental services include prophylasis every 6 
months; topical fluoride at 6 month intervals where the local water 
supply is not fluoridated; one exam every 6 months; full mouth x-rays 
at 36 month intervals if necessary; bitewing x-rays at 6-to12-month 
intervals or panoramic x-rays at 36 month intervals. 

[E] Other dental services include such services as root canals and 
fillings. 

[F] Optometrist exams are limited to one per year, unless they are 
required more frequently, and the enrollee has the appropriate 
documentation. 

[G] Enrollees are limited to one frame and one set of lenses per year, 
unless they are required more frequently, and the enrollee has the 
appropriate documentation. 

[H] This limit is on non-essential durable medical equipment. 

[End of table] 

Table 12: Cost-Sharing Amounts and Annual Coverage Limits for Selected 
Services in the State Children's Health Insurance Program (CHIP) and 
Benchmark Plans in Utah: 

Service: Ambulatory patient services: office visits; Primary care 
physician; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $3; 
100-150%: $5; 
151-200%: $25; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): 30%; 
Benchmark plan: [Empty]; 
Annual coverage limits: None. 

Service: Ambulatory patient services: office visits; Specialty 
physician; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $3; 
100-150%: $5; 
151-200%: $40; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): 30%; 
Annual coverage limits: None. 

Service: Emergency care; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $3; 
100-150%: $5; 
151-200%: $300[A]; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): 30%; 
Benchmark plan: [Empty]; 
Annual coverage limits: None. 

Service: Inpatient hospital; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $50; 
100-150%: $150[A]; 
151-200%: 20%; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): 30%; 
Annual coverage limits: None. 

Service: Maternity care; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: 20%; 
100-150%: 20%; 
151-200%: 20%; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): 30%; 
Benchmark plan: [Empty]; 
Annual coverage limits: None. 

Service: Mental health; Inpatient; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $50; 
100-150%: $150[A]; 
151-200%: 20%; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): 30%; 
Benchmark plan: [Empty]; 
Annual coverage limits: 30 days. 

Service: Mental health; Outpatient therapy; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $3[B]; 
100-150%: $5[B]; 
151-200%: $40[B]; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): 30%; 
Annual coverage limits: 8. 

Service: Substance abuse; Inpatient; 
Primary care physician: Specialty 
physician: 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: 20%; 
100-150%: 20%; 
151-200%: 20%; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): 30%; 
Benchmark plan: [Empty]; 
Annual coverage limits: Combined with mental health. 

Service: Substance abuse; Outpatient therapy; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: 20%: 
100-150%: 20%; 
200%: 20%; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): 30%; 
Annual coverage limits: Combined with mental health. 

Service: Prescription drugs; Generic; 
Primary care physician: 
Specialty physician: 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $1; 
100-150%: $5; 
151-200%: $15; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): 50%; 
Annual coverage limits: None. 

Service: Prescription drugs; Brand-name; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $1; 
100-150%: 5%[C]; 
151-200%: 25%[C]; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): 50%[D]; 
Annual coverage limits: None. 

Service: Outpatient therapies (occupational, physical, speech); 
Rehabilitative; 
Primary care physician: Specialty physician: 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $3; 
100-150%: $5; 
151-200%: $40[A]; 
Annual coverage limits: 20 visits (all therapies combined); 
Benchmark plan: 
Coinsurance (%): 30%; 
Annual coverage limits: 20 visits (all therapies combined). 

Service: Outpatient therapies (occupational, physical, speech); 
Habilitative; 
Primary care physician: Specialty physician: 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: Not covered; 
100-150%: Not covered; 
151-200%: Not covered; 
Annual coverage limits: N/A; 
Benchmark plan: 
Coinsurance (%): 30%; 
Annual coverage limits: 20 visits (all therapies combined). 

Service: Preventive care; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $0; 
100-150%: $0; 
151-200%: $0; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): $0; 
Annual coverage limits: None. 

Service: Pediatric dental; Routine; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $0; 
100-150%: $0; 
151-200%: $0; 
Annual coverage limits: 2 cleanings; 
Benchmark plan: 
Coinsurance (%): 30%; 
Annual coverage limits: Various[E]. 

Service: Pediatric dental; Other[F]; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $0; 
100-150%: 5%[C]; 
151-200%: 20%; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): Not covered; 
Annual coverage limits: Not covered. 

Service: Pediatric vision; Optometrist exam; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $3; 
100-150%: $5; 
151-200%: $40; 
Annual coverage limits: 1; 
Benchmark plan: 
Coinsurance (%): 30%; 
Annual coverage limits: 1[G]. 

Service: Pediatric vision; Corrective lenses; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: Not covered; 
100-150%: Not covered; 
151-200%: Not covered; 
Annual coverage limits: Not covered; 
Benchmark plan: 
Coinsurance (%): Not covered; 
Annual coverage limits: Not covered. 

Service: Pediatric hearing; Testing; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $3; 
100-150%: $5; 
151-200%: $40; 
Annual coverage limits: 1; 
Benchmark plan: 
Coinsurance (%): $0; 
Annual coverage limits: Not covered. 

Service: Pediatric hearing; Hearing aids; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: Not covered[H]; 
100-150%: Not covered[H]; 
151-200%: Not covered[H]; 
Annual coverage limits: Not covered; 
Benchmark plan: 
Coinsurance (%): Not covered; 
Annual coverage limits: Not covered. 

Service: Durable medical equipment; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $3; 
100-150%: 5%; 
151-200%: 20%; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): 30%; 
Annual coverage limits: Various[I]. 

Service: Home and community-based health care; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $3; 
100-150%: 5%; 
151-200%: 20%; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): 30%; 
Annual coverage limits: 30 visits. 

Service: Hospice; 
CHIP plan: 
Copay ($)/coinsurance (%) by federal poverty level (FPL): 
Less than 100%: $3; 
100-150%: 5%; 
151-200%: 20%; 
Annual coverage limits: None; 
Benchmark plan: 
Coinsurance (%): 30%; 
Annual coverage limits: Up to 6 months within 3 years. 

Source: GAO analysis of the Utah CHIP Select Health plan and the Utah 
Public Employee's Health Program Utah Basic Plus benchmark plan 
Evidences of Coverage and information from state and plan officials. 

Notes: 

The CHIP plan was in effect in July 2012, through June 30, 2013. The 
benchmark plan was in effect as of December 26, 2012, the deadline for 
benchmark plan selection. Coinsurance amounts (numbers given as 
percentages) apply once the deductible is met unless otherwise 
indicated. Copayments (numbers given as dollars) are paid each time a 
consumer receives a service and are not subject to the deductible, 
unless otherwise indicated. The Utah CHIP plan did not include any 
deductibles for enrollees at or below100 percent of the FPL; had a $40 
deductible for individuals and families for enrollees from 101 to150 
percent of the FPL, with no dental deductible; and a $500 individual 
deductible and $1,500 family deductible for enrollees between 151 and 
200 percent of the FPL, with a $50 and $150 dental deductible for a 
child and family, respectively. The Utah benchmark plan deductible 
were $3,000 for an individual and $6,000 for a family. The benchmark 
plan out-of-pocket maximum costs included the deductible and were 
$6,050 for an individual and $12,100 for a family. 

Rehabilitation is provided to help a person regain, maintain or 
prevent deterioration of a skill that has been acquired but then lost 
or impaired due to illness, injury, or disabling condition. While 
PPACA and implementing regulations do not define habilitative 
services, habilitation has been defined by several advocacy groups as 
a service that is provided in order for a person to attain, maintain, 
or prevent deterioration of a skill or function never learned or 
acquired due to a disabling condition. 

[A] This copayment is paid after the deductible is met. 

[B] This is the copayment for outpatient therapy office visits. 

[C] This coinsurance is not subject to the deductible. 

[D] Brand-name drugs include drugs designated by the plan as 
"preferred" or included in their formulary. 

[E] Routine pediatric dental services include oral exams 2 times a 
year, ages 3 to18; complete mouth x-rays, once a year for members ages 
13 to18 (or panorex once during any 3 year period in lieu); full 
series bitewing x-rays, twice a year; vertical bitewings up to eight 
films; cleaning two times a year; sealants on permanent molars once 
during any 5 year period for eligible dependents through 17 years. 

[F] Other dental services include such services as root canals and 
fillings. 

[G] This annual limit is for children 5 to18 years; one routine vision 
exam per plan year for children between 3 and 5 is covered as a 
preventive service. 

[H] Hearing aids are not covered by CHIP unless following cochlear 
implants. 

[I] Pre-authorization is required for durable medical equipment over 
$750 and rentals that exceed 60 days; one lens after corneal 
transplant surgery; one pair of ear plugs within 60 days following 
surgery; continuous passive motion machines up to 21 days; one 
artificial eye prosthetic every 5 years; one breast prosthetic per 
affected breast every 2 years; one wheelchair every 5 years; one knee 
brace per knee every 3 years. 

[End of table] 

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Katherine M. Iritani, 202-512-7114 or iritanik@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Susan T. Anthony, Assistant 
Director; Carolyn Fitzgerald; Toni Harrison; Laurie Pachter; Teresa 
Tam; and Hemi Tewarson made key contributions to this report. 

[End of section] 

Related GAO Products: 

Children's Mental Health: Concerns Remain about Appropriate Services 
for Children in Medicaid and Foster Care. [hyperlink, 
http://www.gao.gov/products/GAO-13-15]. Washington, D.C.: December 10, 
2012. 

Medicaid: States Made Multiple Program Changes, and Beneficiaries 
Generally Reported Access Comparable to Private Insurance. [hyperlink, 
http://www.gao.gov/products/GAO-13-55]. Washington, D.C.: November 15, 
2012. 

Children's Health Insurance: Opportunities Exist for Improved Access 
to Affordable Insurance. [hyperlink, 
http://www.gao.gov/products/GAO-12-648]. Washington, D.C.: June 22, 
2012. 

Medicaid and CHIP: Most Physicians Serve Covered Children but Have 
Difficulty Referring Them for Specialty Care. [hyperlink, 
http://www.gao.gov/products/GAO-11-624]. Washington, D.C.: June 30, 
2011. 

Medicaid and CHIP: Given the Association between Parent and Child 
Insurance Status, New Expansions May Benefit Families. [hyperlink, 
http://www.gao.gov/products/GAO-11-264]. Washington, D.C.: February 4, 
2011. 

Oral Health: Efforts Under Way to Improve Children's Access to Dental 
Services, but Sustained Attention Needed to Address Ongoing Concerns. 
[hyperlink, http://www.gao.gov/products/GAO-11-96]. Washington, D.C.: 
November 30, 2010. 

Medicaid: State and Federal Actions Have Been Taken to Improve 
Children's Access to Dental Services, but Gaps Remain. [hyperlink, 
http://www.gao.gov/products/GAO-09-723]. Washington, D.C.: September 
30, 2009. 

[End of section] 

Footnotes: 

[1] Medicaid is a joint federal-state program that finances health 
insurance coverage for certain categories of lower-income individuals, 
including children. Most states' CHIP eligibility levels are between 
200 and 300 percent of the federal poverty level (FPL), with the 
highest eligibility level being 400 percent of the FPL. We use FPL to 
refer to federal poverty guidelines issued by HHS each year in the 
Federal Register. These guidelines provide income thresholds that vary 
by family size and for certain states and are updated using the 
Consumer Price Index. 

[2] As of January 14, 2013, 43 states operated separate CHIP programs 
(15 states had a separate CHIP program only and 28 states covered CHIP 
children through a separate program and a Medicaid expansion). 

[3] Pub. L. No. 111-148, §10203, 124 Stat. 119, 927 (2010). In this 
report, references to PPACA include any amendments made by the Health 
Care Education Reconciliation Act of 2010, Pub. L. No. 111-52, 124 
Stat. 1029 (2010), unless otherwise indicated. 

[4] The QHP must be certified by the Secretary of HHS as offering 
benefits and imposing cost-sharing for children in a manner that is at 
least comparable to the covered services and cost-sharing protections 
provided under the state's CHIP plan. As of November 1, 2013, CMS had 
not issued any guidance on how comparability between QHPs and CHIP 
will be defined. 

[5] PPACA does not explicitly define the services included in the EHB 
categories, rather it identifies 10 broad categories of essential 
benefits that QHPs must provide: ambulatory patient services; 
emergency services; hospitalization; maternity and newborn care; 
mental health and substance use disorder services, including 
behavioral health treatment; prescription drugs; rehabilitative and 
habilitative services and devices; laboratory services; preventive and 
wellness and chronic disease management; and pediatric services, 
including oral and vision care. Rehabilitation is provided to help a 
person regain, maintain or prevent deterioration of a skill that has 
been acquired but then lost or impaired due to illness, injury, or 
disabling condition. While PPACA and its implementing regulations do 
not define habilitative services, habilitation has been defined by 
several advocacy groups as a service that is provided in order for a 
person to attain, maintain, or prevent deterioration of a skill or 
function never learned or acquired due to a disabling condition. 

[6] CMS places states into one of 10 geographic regions. In this 
report, the term "state" includes the District of Columbia. Colorado, 
Kansas, and Utah operate separate CHIP programs. Illinois and New York 
operate both a Medicaid expansion and separate CHIP program; however, 
for our review, we only examined their separate CHIP programs. 

[7] States' base-benchmark and supplemental plans were identified in 
the HHS Final Rule, PPACA Standards Related to Essential Health 
Benefits, Actuarial Value, and Accreditation, 78 Fed. Reg. 12834 (Feb. 
25, 2012). HHS directed states to select a benchmark plan from among 
the following options: one of the three largest plans in the state's 
small group health insurance market; one of the three largest health 
plans offered to state employees; one of the three largest national 
plans offered through the Federal Employees Health Benefits Program 
(FEHBP); or the largest commercial non-Medicaid plan offered by a 
health maintenance organization in the state. If a state did not 
select a benchmark plan, the default plan would be the largest plan by 
enrollment in the largest product by enrollment in the state's small 
group market. 

[8] An Evidence of Coverage is a comprehensive guide to an enrollee's 
health care coverage. It explains the benefits, premiums, cost-
sharing, conditions and limitations of coverage, and plan rules. We 
reviewed these plan documents to identify whether the plan covered 
each of the following services: ambulatory patient services (primary 
care physician and specialist office visits and outpatient surgery); 
emergency care; inpatient hospital services (facility, professional, 
and ancillary); maternity care; mental health services (inpatient and 
outpatient); substance abuse services (inpatient and outpatient); 
prescription drugs; preventive care (well-child care, immunizations, 
and chronic disease management); outpatient therapies (physical, 
speech, and occupational for rehabilitation and habilitation); 
pediatric dental services (routine, emergency, and other); pediatric 
vision services(exams and corrective lenses); laboratory services 
(inpatient and outpatient); pediatric hearing services (testing and 
hearing aids); durable medical equipment; hospice; and home and 
community-based health care. 

[9] A deductible is a specified amount that must be paid by the 
consumer before the health plan will begin paying for covered 
services. A copayment is a fixed dollar amount that a consumer must 
pay at the time a covered service is provided, such as a $25 payment 
for a physician visit. Coinsurance is a fixed percentage of the total 
cost of covered services that a consumer must pay. Health plans may 
also have an explicit limit on the maximum out-of-pocket costs a 
consumer could incur. 

[10] At the time of our analysis, premiums for the benchmark plans 
were not readily available and were often not comparable. For example, 
the base-benchmark plan in the five states was a group plan, which 
does not reflect individual market premiums, which historically are 
higher for consumers and are the point of comparison for purposes of 
this report. In addition, while the national data we cite reflects 
individual market premiums, they may also have limited relevance 
because they are several years old and do not reflect coverage of the 
EHBs, which would result in more comprehensive--and likely more 
expensive coverage--than health plans represented in these data. 

[11] We identified MEPS questions related to respondents' experiences 
obtaining care and their utilization of specific services, including 
office and dental visits. 

[12] Federal law defines four types of allowable coverage for separate 
CHIP plans: (1) benchmark health plan coverage, which must be one of 
the following plans: (i) Blue Cross Blue Shield FEHBP, (ii) a health 
benefits plan that is offered and generally available to state 
employees, or (iii) a health plan with the largest commercial 
enrollment in the state; (2) benchmark-equivalent health benefit 
coverage, which is a plan that must have an aggregate actuarial value 
that is at least equivalent to coverage under one of the benchmark 
plans identified above and must include inpatient and outpatient 
hospital services, physician surgical and medical services, laboratory 
and x-ray services, and routine check-ups; (3) comprehensive state-
based coverage, which was offered by Florida, New York, and 
Pennsylvania as of August 5, 1997; and (4) Secretary-approved 
coverage, whereby the Secretary of HHS determines whether the coverage 
proposed by the state is appropriate for CHIP-eligible children. 
Actuarial value refers to the proportion of medical expenses an 
insurance plan is expected to cover. 

[13] State Medicaid programs are required to cover EPSDT services for 
children under age 21. EPSDT services include comprehensive 
screenings, preventive health care services, and other services 
necessary to correct illnesses or conditions identified by the 
screenings. 

[14] This annual cumulative cost-sharing maximum applies to all 
services with cost-sharing requirements, irrespective of the number of 
children in the family that are enrolled in CHIP. 

[15] We have previously issued reports related to children's access to 
affordable health insurance and to health care services, including 
reports on the extent uninsured children would be eligible for 
Medicaid, CHIP, or the premium tax credit under PPACA; children's 
access to primary, specialty and dental care by type of coverage; 
providers' willingness to serve children in CHIP and Medicaid, and on 
the association between parent and child insurance coverage. For a 
list of these and other related reports, see the Related GAO Products 
page at the end of this report. 

[16] There are certain circumstances when states may increase CHIP 
premium levels. For example, states can routinely increase CHIP 
premiums if they obtained CMS approval prior to March 23, 2010, states 
can adopt certain types of inflation-related adjustments to CHIP 
premium levels, and states can impose new premiums for CHIP coverage 
offered after March 23, 2010. 

[17] In states electing not to establish and operate their own state-
based exchange, PPACA requires the federal government to establish and 
operate an exchange in the state, referred to as a federally 
facilitated exchange. Pub. L.No.111-148 §§ 1311(b)(1), 1321 (c), 124 
Stat. at 173, 186. 

[18] In order to become certified, the QHPs offered through the 
exchanges are required to meet certain criteria such as benefit 
design, marketing, and other consumer protections, and issuers 
offering plans must meet requirements, such as being licensed in the 
state where the plan is being offered. 

[19] PPACA requires non-grandfathered health plans in the individual 
and small group markets, both inside and outside of the exchanges, to 
comply with these requirements. These requirements do not apply to 
CHIP. In implementing regulations, HHS has also defined EHB to include 
any state-mandates to cover benefits that were enacted on or before 
December 31, 2011, even if the mandated benefit has a later effective 
date. Actuarial value indicates the proportion of allowable charges 
that a health plan will pay, on average. Actuarial values will assist 
consumers in comparing and selecting health plans by allowing a 
potential enrollee to compare the relative payment generosity among 
plans. 

[20] Rehabilitation is provided to help a person regain, maintain or 
prevent deterioration of a skill that has been acquired but then lost 
or impaired due to illness, injury, or disabling condition. While 
PPACA and implementing regulations do not define habilitative 
services, habilitation has been defined by several advocacy groups as 
a service that is provided in order for a person to attain, maintain, 
or prevent deterioration of a skill or function never learned or 
acquired due to a disabling condition. 

[21] Utah's plan was the only base-benchmark that included pediatric 
dental and vision services. The base-benchmark plans in the other four 
states did not include pediatric dental services, and these four 
states selected CHIP as the supplement. Three states--Illinois, 
Kansas, and New York--did not include pediatric vision services. While 
Kansas and New York selected CHIP as their supplemental vision plan, 
Illinois selected FEDVIP as the supplement. 

[22] Benchmark plans must also include relevant state-mandated 
benefits as an EHB. Among our five states, the number of mandated 
benefits ranged from 9 to 49, and these mandated benefits were 
typically included within the services we reviewed. The state-mandated 
benefits that were not included among our services included services 
not associated with children, such as mammography, prostate cancer 
screening, osteoporosis screening, and shingles vaccinations. 

[23] Nationally, for pediatric dental services, 26 states selected 
FEDVIP as the supplement, and 24 states selected CHIP. For pediatric 
vision services, 39 states selected FEDVIP as the supplement, and 7 
states selected CHIP. For the full list of state selections, see 
Centers for Medicare & Medicaid Services, Additional Information on 
Proposed State Essential Health Benefits Benchmark Plans, accessed 
August 12, 2013, [hyperlink, http://www.cms.gov/CCIIO/Resources/Data-
esources/ehb.html]. 

[24] One state's CHIP plan specified limits on rehabilitative services 
received in an inpatient setting, but not the number of days allowed 
for an inpatient admission. 

[25] Data suggest that SADPs will be offered in most states. 
Specifically, on February 11, 2013, CMS reported that an SADP is 
expected to be offered in each of the states in which federally 
facilitated exchanges, including a state partnership exchange, will be 
operating. In a federally facilitated exchange, the state may pursue a 
state partnership exchange, where a state may administer and operate 
exchange activities associated with plan management and/or consumer 
assistance. QHPs are not required to include the pediatric dental 
benefit in their plans if an SADP is available in their state's 
exchanges. In such instances, consumers are not required to purchase 
an SADP if their QHP does not include the pediatric dental benefit. 

[26] Specifically, 12 states chose to allow the issuers to determine 
which services would qualify as habilitative, four states chose to 
cover these services in parity with rehabilitative services, and three 
states chose to define specific services as habilitative. 

[27] Issuers offering QHPs and group health plans, and issuers 
offering group or certain individual plans outside of the exchanges, 
are prohibited from applying lifetime or annual limits on EHBs. 
Issuers may apply annual limits for EHBs prior to 2014 subject to 
certain limitations. 

[28] PPACA requires issuers offering QHPs and individual plans outside 
of the exchanges to comply with requirements established under the 
Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). MHPAEA 
specifies that the financial requirements (such as cost sharing) and 
treatment limitations (such as the number of visits covered) imposed 
on mental health and substance use disorder benefits cannot be more 
restrictive than those that apply to medical and surgical benefits. 

[29] CHIP enrollees in Utah with family incomes at or below 100 FPL 
were not subject to a deductible. Those with family incomes between 
101 and 150 percent FPL--about 40 percent of enrollees--were subject 
to a deductible of $40 a year for the family. Those with family 
incomes between 151 and 200 percent FPL--about 20 percent of 
enrollees--were subject to an annual deductible of $500 and $1,500 for 
a child and family, respectively. 

[30] As consistent with federal requirements, none of the CHIP or 
benchmark plans we reviewed imposed cost-sharing requirements on 
preventive services. In addition, because most of the five states 
selected CHIP dental or vision as a supplemental plan, the cost-
sharing for those services were the same (and often zero) for both 
plan types. 

[31] According to the Health Care Cost Institute, the average price of 
an inpatient stay, which includes hospital stays, in 2011 was $15,674. 
See the Health Care Cost Institute, Health Care Cost and Utilization 
Report: 2011. (Washington, D.C., Health Care Cost Institute, 2012), 9. 

[32] Per HHS's Assistant Secretary for Planning and Evaluation, 
individual market premiums have increased 28.6 percent from 2009 to 
2012 in a sample of states. In contrast, CHIP officials reported lower 
premium increases, if any. From 2009 to 2012, there were no increases 
in CHIP premiums in Colorado and Illinois. The monthly weighted 
average CHIP premium in New York increased approximately 14 percent 
and Kansas premiums increased by 23 percent for those who paid 
premiums. Utah CHIP premiums didn't change for those with incomes up 
to 150 percent FPL and increased by 25 percent for those with incomes 
from 151 to 200 percent FPL. 

[33] This 5 percent cap results in limits that vary based on a 
family's income level and in 2013 ranged from $1,766 for a family of 
four with an income at 150 percent of the FPL to $4,710 for a family 
of four with an income at 400 percent of the FPL. 

[34] The Health Care Cost Institute, Health Care Cost and Utilization 
Report: 2011. (Washington, D.C., 2012), 8. 

[35] States have the authority to determine the geographic rating area 
in their state, which the Secretary of HHS can review to ensure 
adequacy. If inadequate, the Secretary can establish the rating area. 
Additionally, the ratio of rates cannot vary by more than 3 to 1 for 
adults. This does not apply to children under age 21, who will instead 
have a single age rating band. The ratio of rates for tobacco vs. non-
tobacco users cannot vary by more than 1.5 to 1. 

[36] Plans are allowed a de minimis variation of +/-2 percent (e.g., a 
silver level plan can have an actuarial value between 68 and 72 
percent). SADPs will have different actuarial value requirements and 
will be offered as "high" and "low" level plans, with 85 and 70 
percent actuarial value, respectively, and will have the same 
allowable de minimis variation. 

[37] In 2014, the maximum annual limitation on cost-sharing is based 
on the out-of-pocket limits established by the Internal Revenue 
Service that apply to high deductible health plans. In 2015 and 
thereafter, the maximum annual limitation on cost-sharing is based on 
a premium adjustment percentage index to be established by the HHS 
Secretary. 

[38] SADPs must demonstrate they have reasonable annual limitations on 
cost-sharing as determined by their exchange. The annual limit is 
calculated without regard to the EHBs provided by the QHP and out-of-
network services, 

[39] State-based SADP out-of-pocket maximum costs will be determined 
by individual states. 

[40] PPACA directs issuers to reduce cost sharing for EHB for eligible 
individuals enrolled in certain silver level QHP plans with household 
incomes between 100-400% of the FPL by first reducing the maximum 
annual limitation on cost-sharing to achieve certain actuarial value 
levels. As specified in the 2014 payment notice, the maximum annual 
limitation on cost-sharing for individuals with incomes between 250-
400% of FPL for 2014 was not reduced for the 2014 benefit year. 

[41] PPACA provides that, if an individual is enrolled in both a QHP 
and an SADP, cost-sharing reductions do not apply to the portion of 
the cost-sharing reductions related to the pediatric dental EHB. This 
means that if an individual is enrolled in both a QHP and an SADP, 
cost-sharing reductions are not payable with respect to pediatric 
dental benefits offered through the SADP. 

[42] Advance payments of the premium tax credit are made directly to 
the issuer of the QHP in which a taxpayer enrolls. The premium tax 
credit is computed by taking into account only the premiums for QHPs 
and may not be increased for premiums a taxpayer pays for other 
minimum essential coverage. 

[43] These amounts apply in the 48 contiguous states and the District 
of Columbia. 

[44] If an individual who is eligible for premium tax credits enrolls 
in a QHP and an SADP, the portion of the SADP that is allocable to the 
pediatric dental EHB must be considered part of the QHP premium to 
which the individual's premium tax credit applies. However, unless the 
consumer purchases a QHP with a premium that is less than the second 
lowest cost silver plan, e.g., a bronze plan, the consumer would 
likely pay the premium for the SADP. 

[45] The family of four includes two parents age 40 and two children 
under the age of 21. 

[46] Premium data included in a September 2013 Kaiser Family 
Foundation report also suggest that QHP enrollees in other states who 
were eligible for the premium tax credit could also experience a 
significant reduction in their annual premium contribution. For 
example, without the tax credit, the annual QHP premium for the second 
lowest cost silver-level QHP--not including any SADP premium--for a 
family in Denver, Colorado, would be about $9,000, and it would be 
about $13,000 for a family in New York City. However, if these 
families had incomes at 255 percent of the FPL, and were therefore 
eligible for the premium tax credit, their annual maximum premiums 
would be much lower at about $4,900. The Henry J. Kaiser Family 
Foundation, An Early Look at Premiums and Insurer Participation in 
Health Insurance Marketplaces, 2014. (Menlo Park, CA. Henry J. Kaiser 
Family Foundation, 2013), 10, 19. 

[47] For purposes of our analysis, we considered certain responses to 
be positive. For the question about a usual source of care, we 
considered all "yes" responses to be positive. For the question about 
how difficult it is to reach the usual source of care by telephone, we 
considered the "it was not at all difficult" or "was not too 
difficult" responses as positive. For the remaining four questions, 
which measured perceptions on accessing health care, we considered 
answers of "usually" or "always" to be positive. 

[48] The MEPS questions we reviewed included three related to 
respondents' use of various dental services. The MEPS question, which 
asked whether the respondent "had any dental care visit," includes 
visits to a broad group of dental providers, including general 
dentists, dental hygienists, dental technicians, dental surgeons, 
orthodontists, endodontists, and periodontists. The "had a general 
dentist visit" and "had an orthodontist visit" questions are more 
narrowly defined and refer specifically to visits to general dentists 
and orthodontists, respectively. 

[49] We found there was a statistically significant difference between 
CHIP and the uninsured with respect to differences in having a usual 
source of care; the ease of getting a person the care, tests or 
treatment that the parent or a doctor believed necessary; the ease of 
seeing a specialist; or having had an office-based provider visit, 
outpatient department provider visit, emergency room visit, any dental 
care visit, and a visit to a dentist within the past 12 months. 

[50] The National Health Interview Survey is one of the major data 
collection programs of the Centers for Disease Control and 
Prevention's National Center for Health Statistics. It provides a 
cross-sectional household interview survey with participants in each 
state and the District of Columbia and is used to monitor the health 
of the United States population through data collection and analysis 
on a broad range of health topics. 

[51] We did not include questions that focused on the quality of care 
received. 

[52] The six access to care questions reflect an age range of 0 to 18 
years of age. 

[53] An earnings disregard is a portion of earnings from a working 
family's income that states can exempt in determining income 
eligibility for certain children's health coverage programs. We 
obtained information on each state's Medicaid and CHIP income 
disregards and income eligibility rules for years 2007 through 2010 
from Kaiser Family Foundation and state Medicaid and CHIP officials. 
See [hyperlink, http://kff.org/Medicaid/] and [hyperlink, 
http://kff.org/health-reform/] for the Kaiser Family Foundation 
websites where the annual reports on Medicaid and CHIP are posted. We 
did not apply earnings disregards related to child care expenses, 
child support paid, or child support received. 

[54] Our analysis did not include responses from individuals who 
reported more than one source of insurance during a given year. 

[55] The MEPS Survey factor we used to control for children with 
special health care needs applies to children age 0 to 17 years. 

[56] Statistical significance indicates that the difference between 
observations is unlikely due to chance alone. 

[57] Kaiser Commission on Medicaid and the Uninsured, Health Coverage 
for Children and Families in Medicaid and SCHIP: State Efforts Face 
New Hurdles: A 50-State Update on Eligibility Rules, Enrollment and 
Renewal Procedures, and Cost-Sharing Practices in Medicaid and SCHIP 
in 2008 (Washington, D.C.: Kaiser Family Foundation, 2008); Challenges 
of Providing Health Coverage for Children and Parents in a Recession: 
A 50 State Update on Eligibility Rules, Enrollment and Renewal 
Procedures, and Cost-Sharing Practices in Medicaid and SCHIP in 2009 
(Washington, D.C.: Kaiser Family Foundation, 2009); A Foundation for 
Health Reform: Findings of a 50 State Survey of Eligibility Rules, 
Enrollment and Renewal Procedures, and Cost-Sharing Practices in 
Medicaid and CHIP for Children and Parents During 2009 (Washington, 
D.C.: Kaiser Family Foundation, 2009); Holding Steady, Looking Ahead: 
Annual Findings of a 50-State Survey of Eligibility Rules, Enrollment 
and Renewal Procedures, and Cost-Sharing Practices in Medicaid and 
CHIP, 2010-2011 (Washington, D.C.: Kaiser Family Foundation, 2011); 
and Determining Income Eligibility in Children's Health Coverage 
Programs: How States Use Disregards in Children's Medicaid and SCHIP 
(Washington, D.C.: Kaiser Family Foundation, 2008). 

[58] For example, an income-ineligible respondent could be an 
individual who reported being enrolled in Medicaid, but whose income 
exceeded the state's Medicaid income eligibility and earnings 
disregard rules we applied. These individuals would not be included in 
the Medicaid group. Similarly, survey respondents who reported being 
enrolled in CHIP, but whose incomes exceeded the state's CHIP income 
eligibility and the earnings disregard rules we applied, were not 
included in our CHIP group. 

[59] Mental health and substance abuse services had the same cost-
sharing amounts and annual coverage limits in three of the five 
states, and were therefore combined into a single category for all 
states except New York and Utah. 

[60] All CHIP costs (deductibles, cost-sharing amounts, and premiums) 
count toward a 5 percent out-of-pocket maximum cost, which varies by 
income level, and in 2013 ranged from $1,766 for a family of four at 
150 percent of the FPL to $4,710 for a family of four at 400 percent 
of the FPL. 

[End of section] 

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