42 C.F.R. Subpart A—Introduction; State Plans for Child Health Insurance Programs and Outreach Strategies
Title 42 - Public Health
Source: 66 FR 2670, Jan. 11, 2001, unless otherwise noted.
Title XXI of the Social Security Act, enacted in 1997 by the Balanced Budget Act, authorizes Federal grants to States for provision of child health assistance to uninsured, low-income children. The program is jointly financed by the Federal and State governments and administered by the States. Within broad Federal rules, each State decides eligible groups, types and ranges of services, payment levels for benefit coverage, and administrative and operating procedures. (a) Basis. This subchapter implements title XXI of the Act, which authorizes Federal grants to States for the provision of child health assistance to uninsured, low-income children. (b) Scope. The regulations in subchapter D set forth State plan requirements, standards, procedures, and conditions for obtaining Federal financial participation (FFP) to enable States to provide health benefits coverage to targeted low-income children, as defined at §457.310. For purposes of this part the following definitions apply: American Indian/Alaska Native (AI/AN) means— (1) A member of a Federally recognized Indian tribe, band, or group; (2) An Eskimo or Aleut or other Alaska Native enrolled by the Secretary of the Interior pursuant to the Alaska Native Claims Settlement Act, 43 U.S.C. 1601 et. seq.; or (3) A person who is considered by the Secretary of the Interior to be an Indian for any purpose. Applicant means a child who has filed an application (or who has an application filed on their behalf) for health benefits coverage through the State Children's Health Insurance Program. A child is an applicant until the child receives coverage through SCHIP. Child means an individual under the age of 19 including the period from conception to birth. Child health assistance means payment for part or all of the cost of health benefits coverage provided to targeted low-income children for the services listed at §457.402. Combination program means a program under which a State implements both a Medicaid expansion program and a separate child health program. Cost sharing means premium charges, enrollment fees, deductibles, coinsurance, copayments, or other similar fees that the enrollee has responsibility for paying. Creditable health coverage has the meaning given the term “creditable coverage” at 45 CFR 146.113 and includes coverage that meets the requirements of §457.410 and is provided to a targeted low-income child. Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in— (1) Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of a woman or her unborn child; (2) Serious impairment of bodily function; or (3) Serious dysfunction of any bodily organ or part. Emergency services means health care services that are— (1) Furnished by any provider qualified to furnish such services; and (2) Needed to evaluate, treat, or stabilize an emergency medical condition. Enrollee means a child who receives health benefits coverage through SCHIP. Enrollment cap means a limit, established by the State in its State plan, on the total number of children permitted to enroll in a State's separate child health program. Family income means income as determined by the State for a family as defined by the State. Federal fiscal year starts on the first day of October each year and ends on the last day of the following September. Fee-for-service entity has the meaning assigned in §457.902. Group health insurance coverage has the meaning assigned at 45 CFR 144.103. Group health plan has the meaning assigned at 45 CFR 144.103. Health benefits coverage means an arrangement under which enrolled individuals are protected from some or all liability for the cost of specified health care services. Health care services means any of the services, devices, supplies, therapies, or other items listed in §457.402. Health insurance coverage has the meaning assigned at 45 CFR 144.103. Health insurance issuer has the meaning assigned at 45 CFR 144.103. Health maintenance organization (HMO) plan has the meaning assigned at §457.420. Health services initiatives means activities that protect the public health, protect the health of individuals, improve or promote a State's capacity to deliver public health services, or strengthen the human and material resources necessary to accomplish public health goals relating to improving the health of children (including targeted low-income children and other low-income children). Joint application has the meaning assigned at §457.301. Low-income child means a child whose family income is at or below 200 percent of the poverty line for the size of the family involved. Managed care entity (MCE) means an entity that enters into a contract to provide services in a managed care delivery system, including but not limited to managed care organizations, prepaid health plans, and primary care case managers. Medicaid applicable income level means, with respect to a child, the effective income level (expressed as a percentage of the poverty line) specified under the policies of the State plan under title XIX of the Act (including for these purposes, a section 1115 waiver authorized by the Secretary or under the authority of section 1902(r)(2) of the Act) as of March 31, 1997 for the child to be eligible for medical assistance under either section 1902(l)(2) or 1905(n)(2) of the Act. Medicaid expansion program means a program under which a State receives Federal funding to expand Medicaid eligibility to optional targeted low-income children. Optional targeted low-income child has the meaning assigned at §435.4 (for States) and §436.3 (for Territories) of this chapter. Period of presumptive eligibility has the meaning assigned at §457.301. Poverty line/Federal poverty level means the poverty guidelines updated annually in the Preexisting condition exclusion has the meaning assigned at 45 CFR 144.103. Premium assistance program means a component of a separate child health program, approved under the State plan, under which a State pays part or all of the premiums for a SCHIP enrollee or enrollees' group health insurance coverage or coverage under a group health plan. Presumptive income standard has the meaning assigned at §457.301. Public agency has the meaning assigned in §457.301. Qualified entity has the meaning assigned at §457.301. Separate child health program means a program under which a State receives Federal funding from its title XXI allotment to provide child health assistance through obtaining coverage that meets the requirements of section 2103 of the Act and §457.402. State means all States, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa and the Northern Mariana Islands. The Territories are excluded from this definition for purposes of §457.740. State Children's Health Insurance Program (SCHIP) means a program established and administered by a State, jointly funded with the Federal government, to provide child health assistance to uninsured, low-income children through a separate child health program, a Medicaid expansion program, or a combination program. State health benefits plan has the meaning assigned in §457.301. State plan means the title XXI State child health plan. Targeted low-income child has the meaning assigned in §457.310. Uncovered or uninsured child means a child who does not have creditable health coverage. Well-baby and well-child care services means regular or preventive diagnostic and treatment services necessary to ensure the health of babies, children and adolescents as defined by the State. For purposes of cost sharing, the term has the meaning assigned at §457.520. [66 FR 2670, Jan. 11, 2001, as amended at 67 FR 61974, Oct. 2, 2002] (a) Statutory basis. This subpart implements the following sections of the Act: (1) Section 2101(b), which requires that the State submit a State plan. (2) Section 2102(a), which sets forth requirements regarding the contents of the State plan. (3) Section 2102(b), which relates to eligibility standards and methodologies. (4) Section 2102(c), which requires that the State plan include a description of the procedures to be used by the State to accomplish outreach and coordination with other health insurance programs. (5) Section 2106, which specifies the process for submission, approval, and amendment of State plans. (6) Section 2107(c), which requires that the State plan include a description of the process used to involve the public in the design and implementation of the plan. (7) Section 2107(d), which requires that the State plan include a description of the budget for the plan. (8) Section 2107(e), which provides that certain provisions of title XIX and title XI of the Act apply under title XXI in the same manner that they apply under title XIX. (b) Scope. This subpart sets forth provisions governing the administration of SCHIP, the general requirements for a State plan, and a description of the process for review of a State plan or plan amendment. (c) Applicability. This subpart applies to all States that request Federal financial participation to provide child health assistance under title XXI. (a) Program operation. The State must implement its program in accordance with the approved State plan, any approved State plan amendments, the requirements of title XXI and title XIX (as appropriate), and the requirements in this chapter. CMS monitors the operation of the approved State plan and plan amendments to ensure compliance with the requirements of title XXI, title XIX (as appropriate) and this chapter. (b) State authority to submit State plan. A State plan or plan amendment must be signed by the State Governor, or signed by an individual who has been delegated authority by the Governor to submit it. (c) State program officials. The State must identify in the State plan or State plan amendment, by position or title, the State officials who are responsible for program administration and financial oversight. (d) State legislative authority. The State plan must include an assurance that the State will not claim expenditures for child health assistance prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. The State plan is a comprehensive written statement, submitted by the State to CMS for approval, that describes the purpose, nature, and scope of the State's SCHIP and gives an assurance that the program is administered in conformity with the specific requirements of title XXI, title XIX (as appropriate), and the regulations in this chapter. The State plan contains all information necessary for CMS to determine whether the plan can be approved to serve as a basis for Federal financial participation (FFP) in the State program. A State may seek to amend its approved State plan in whole or in part at any time through the submission of an amendment to CMS. When the State plan amendment has a significant impact on the approved budget, the amendment must include an amended budget that describes the State's planned expenditures for a 1-year period. A State must amend its State plan whenever necessary to reflect— (a) Changes in Federal law, regulations, policy interpretations, or court decisions that affect provisions in the approved State plan; (b) Changes in State law, organization, policy, or operation of the program that affect the following program elements described in the State plan: (1) Eligibility standards, enrollment caps, and disenrollment policies as described in §457.305. (2) Procedures to prevent substitution of private coverage as described in §457.805, and in §457.810 for premium assistance programs. (3) The type of health benefits coverage offered, consistent with the options described in §457.410. (4) Addition or deletion of specific categories of benefits covered under the State plan. (5) Basic delivery system approach as described in §457.490. (6) Cost-sharing as described in §457.505. (7) Screen and enroll procedures, and other Medicaid coordination procedures as described in §457.350. (8) Review procedures as described in §457.1120. (9) Other comparable required program elements. (c) Changes in the source of the State share of funding, except for changes in the type of non-health care related revenues used to generate general revenue. [66 FR 2670, Jan. 11, 2001, as amended at 66 FR 33822, June 25, 2001] (a) Effective date in general. Except as otherwise limited by this section— (1) A State plan or plan amendment takes effect on the day specified in the plan or plan amendment, but no earlier than October 1, 1997. (2) The effective date may be no earlier than the date on which the State begins to incur costs to implement its State plan or plan amendment. (3) A State plan amendment that takes effect prior to submission of the amendment to CMS may remain in effect only until the end of the State fiscal year in which the State makes it effective, or, if later, the end of the 90-day period following the date on which the State makes it effective, unless the State submits the amendment to CMS for approval before the end of that State fiscal year or that 90-day period. (b) Amendments relating to eligibility or benefits. A State plan amendment that eliminates or restricts eligibility or benefits may not be in effect for longer than a 60-day period, unless the amendment is submitted to CMS before the end of that 60-day period. The amendment may not take effect unless— (1) The State certifies that it has provided prior public notice of the proposed change in a form and manner provided under applicable State law; and (2) The public notice was published before the requested effective date of the change. (c) Amendments relating to cost sharing. A State plan amendment that implements cost-sharing charges, increases existing cost-sharing charges, or increases the cumulative cost-sharing maximum as set forth at §457.560 is considered an amendment that restricts benefits and must meet the requirements in paragraph (b) of this section. (d) Amendments relating to enrollment procedures. A State plan amendment that implements a required period of uninsurance, increases the length of existing required periods of uninsurance, or institutes or extends the use of waiting lists, enrollments caps or closed enrollment periods is considered an amendment that restricts eligibility and must meet the requirements in paragraph (b) of this section. (e) Amendments relating to the source of State funding. A State plan amendment that changes the source of the State share of funding can take effect no earlier than the date of submission of the amendment. (f) Continued approval. An approved State plan continues in effect unless— (1) The State adopts a new plan by obtaining approval under §457.60 of an amendment to the State plan; (2) Withdraws its plan in accordance with §457.170(b); or (3) The Secretary finds substantial noncompliance of the plan with the requirements of the statute or regulations. (a) Health benefits coverage options. A State may elect to obtain health benefits coverage under its plan through— (1) A separate child health program; (2) A Medicaid expansion program; or (3) A combination program. (b) State plan requirement. A State must include in the State plan or plan amendment a description of the State's chosen program option. (c) Medicaid expansion program requirements. A State plan under title XXI for a State that elects to obtain health benefits coverage through its Medicaid plan must— (1) Meet the requirements of— (i) Subpart A; (ii) Subpart B (to the extent that the State claims administrative costs under title XXI); (iii) Subpart F (with respect to determination of the allotment for purposes of the enhanced matching rate, determination of the enhanced matching rate, and payment of any claims for administrative costs under title XXI only); (iv) Subpart G; and (v) Subpart J (if the State claims administrative costs under title XXI and seeks a waiver of limitations on such claims based on a community based health delivery system). (2) Be consistent with the State's Medicaid State plan, or an approvable amendment to that plan, as required under title XIX. (d) Separate child health program requirements. A State that elects to obtain health benefits coverage under its plan through a separate child health program must meet all the requirements of part 457. (e) Combination program requirements. A State that elects to obtain health benefits coverage through both a separate child health program and a Medicaid expansion program must meet the requirements of paragraphs (c) and (d) of this section. A State plan must include a description of— (a) The extent to which, and manner in which, children in the State, including targeted low-income children and other classes of children, by income level and other relevant factors, currently have creditable health coverage (as defined in §457.10) and, if sufficient information is available, whether the creditable health coverage they have is under public health insurance programs or health insurance programs that involve public-private partnerships; (b) Current State efforts to provide or obtain creditable health coverage for uncovered children, including the steps the State is taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs and health insurance programs that involve public-private partnerships; and (c) Procedures the State uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children. Such procedures include those designed to— (1) Increase the number of children with creditable health coverage; (2) Assist in the enrollment in SCHIP of children determined ineligible for Medicaid; and (3) Ensure that only eligible targeted low-income children are covered under SCHIP, such as those procedures required under §§457.350 and 457.353, as applicable. (a) Procedures required. A State plan must include a description of procedures used to inform families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs of the availability of the programs, and to assist them in enrolling their children in one of the programs. (b) Examples. Outreach strategies may include but are not limited to the following: (1) Education and awareness campaigns, including targeted mailings and information distribution through various organizations. (2) Enrollment simplification, such as simplified or joint application forms. (3) Application assistance, including opportunities to apply for child health assistance under the plan through community-based organizations and in combination with other benefits and services available to children. (a) Information disclosure. The State must make accurate, easily understood, linguistically appropriate information available to families of potential applicants, applicants and enrollees, and provide assistance to these families in making informed decisions about their health plans, professionals, and facilities. (b) Required information. The State must make available to potential applicants and provide applicants and enrollees the following information in a timely manner: (1) Types of benefits, and amount, duration and scope of benefits available under the program. (2) Cost-sharing requirements as described in §457.525. (3) Names and locations of current participating providers. (4) If an enrollment cap is in effect or the State is using a waiting list, a description of the procedures relating to the cap or waiting list, including the process for deciding which children will be given priority for enrollment, how children will be informed of their status on a waiting list and the circumstances under which enrollment will reopen. (5) Information on physician incentive plans as required by §457.985. (6) Review processes available to applicants and enrollees as described in the State plan pursuant to §457.1120. A State plan must include a description of the method the State uses to— (a) Involve the public in both the design and initial implementation of the program; (b) Ensure ongoing public involvement once the State plan has been implemented; and (c) Ensure interaction with Indian Tribes and organizations in the State on the development and implementation of the procedures required at §457.125. (a) Enrollment. A State must include in its State plan a description of procedures used to ensure the provision of child health assistance to American Indian and Alaska Native children. (b) Exemption from cost sharing. The procedures required by paragraph (a) of this section must include an exemption from cost sharing for American Indian and Alaska Native children in accordance with §457.535. The State plan must include an assurance that the State will comply with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. The State plan must include an assurance that the State will comply, under title XXI, with the following provisions of titles XIX and XI of the Social Security Act: (a) Section 1902(a)(4)(C) (relating to conflict of interest standards). (b) Paragraphs (2), (16) and (17) of section 1903(i) (relating to limitations on payment). (c) Section 1903(w) (relating to limitations on provider donations and taxes). (d) Section 1132 (relating to periods within which claims must be filed). The State plan, or plan amendment that has a significant impact on the approved budget, must include a budget that describes the State's planned expenditures for a 1-year period. The budget must describe— (a) Planned use of funds, including— (1) Projected amount to be spent on health services; (2) Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and (3) Assumptions on which the budget is based, including cost per child and expected enrollment; and (b) Projected sources of non-Federal plan expenditures, including any requirements for cost sharing by enrollees. (a) Basis for action. CMS reviews each State plan and plan amendment to determine whether it meets or continues to meet the requirements for approval under relevant Federal statutes, regulations, and guidelines furnished by CMS to assist in the interpretation of these regulations. (b) Action on complete plan. CMS approves or disapproves the State plan or plan amendment only in its entirety. (c) Authority. The CMS Administrator exercises delegated authority to review and then to approve or disapprove the State plan or plan amendment, or to determine that previously approved material no longer meets the requirements for approval. The Administrator does not make a final determination of disapproval without first consulting the Secretary. (d) Initial submission. The Administrator designates an official to receive the initial submission of State plans. (e) Review process. (1) The Administrator designates an individual to coordinate CMS's review for each State that submits a State plan. (2) CMS notifies the State of the identity of the designated individual in the first correspondence relating to that plan, and at any time there is a change in the designated individual. (3) In the temporary absence of the designated individual during regular business hours, an alternate individual will act in place of the designated individual. (a) Notice of final determination. The Administrator provides written notification to the State of the approval or disapproval of a State plan or plan amendment. (b) Timing. (1) A State plan or plan amendment will be considered approved unless CMS, within 90 calendar days after receipt of the State plan or plan amendment in the CMS central office, sends the State— (i) Written notice of disapproval; or (ii) Written notice of additional information it needs in order to make a final determination. (2) A State plan or plan amendment is considered received when the designated official or individual, as determined in §457.150(d) and (e), receives an electronic, fax or paper copy of the complete material. (3) If CMS requests additional information, the 90-day review period for CMS action on the State plan or plan amendment— (i) Stops on the day CMS sends a written request for additional information or the next business day if the request is sent on a Federal holiday or weekend; and (ii) Resumes on the next calendar day after the CMS designated individual receives an electronic, fax, or hard copy from the State of all the requested additional information, unless the information is received after 5 p.m. eastern standard time on a day prior to a non-business day or any time on a non-business day, in which case the review period resumes on the following business day. (4) The 90-day review period cannot stop or end on a non-business day. If the 90th calendar day falls on a non-business day, CMS will consider the 90th day to be the next business day. (5) CMS may send written notice of its need for additional information as many times as necessary to obtain the complete information necessary to review the State plan or plan amendment. (a) Withdrawal of proposed State plans or plan amendments. A State may withdraw a proposed State plan or plan amendment, or any portion of a proposed State plan or plan amendment, at any time during the review process by providing written notice to CMS of the withdrawal. (b) Withdrawal of approved State plans. A State may request withdrawal of an approved State plan by submitting a State plan amendment to CMS in accordance with §457.60.
Title 42: Public Health
PART 457—ALLOTMENTS AND GRANTS TO STATES
Subpart A—Introduction; State Plans for Child Health Insurance Programs and Outreach Strategies
§ 457.1 Program description.
§ 457.2 Basis and scope of subchapter D.
§ 457.10 Definitions and use of terms.
§ 457.30 Basis, scope, and applicability of subpart A.
§ 457.40 State program administration.
§ 457.50 State plan.
§ 457.60 Amendments.
§ 457.65 Effective date and duration of State plans and plan amendments.
§ 457.70 Program options.
§ 457.80 Current State child health insurance coverage and coordination.
§ 457.90 Outreach.
§ 457.110 Enrollment assistance and information requirements.
§ 457.120 Public involvement in program development.
§ 457.125 Provision of child health assistance to American Indian and Alaska Native children.
§ 457.130 Civil rights assurance.
§ 457.135 Assurance of compliance with other provisions.
§ 457.140 Budget.
§ 457.150 CMS review of State plan material.
§ 457.160 Notice and timing of CMS action on State plan material.
§ 457.170 Withdrawal process.
