42 C.F.R. Subpart C—State Plan Requirements: Eligibility, Screening, Applications, and Enrollment
Title 42 - Public Health
Source: 66 FR 2675, Jan. 11, 2001, unless otherwise noted.
(a) Statutory basis. This subpart interprets and implements— (1) Section 2102 of the Act, which relates to eligibility standards and methodologies, coordination with other health insurance programs, and outreach and enrollment efforts to identify and enroll children who are eligible to participate in other public health insurance programs; (2) Section 2105(c)(6)(B) of the Act, which relates to the prohibition against expenditures for child health assistance provided to children eligible for coverage under other Federal health care programs other than programs operated or financed by the Indian Health Service; and (3) Section 2110(b) of the Act, which provides a definition of targeted low-income child. (b) Scope. This subpart sets forth the requirements relating to eligibility standards and to screening, application and enrollment procedures. (c) Applicability. The requirements of this subpart apply to child health assistance provided under a separate child health program. Regulations relating to eligibility, screening, applications and enrollment that are applicable to a Medicaid expansion program are found at §431.636, §435.4, §435.229, §435.1102, §436.3, §436.229, and §436.1102 of this chapter. As used in this subpart— Joint application means a form used to apply for the separate child health program that, when transmitted to the Medicaid agency following a screening that shows the child is potentially eligible for Medicaid, may also be used to apply for Medicaid. Period of presumptive eligibility means a period that begins on the date on which a qualified entity determines that a child is presumptively eligible and ends with the earlier of— (1) In the case of a child on whose behalf a separate child health program application has been filed, the day on which a decision is made on that application; or (2) In the case of a child on whose behalf an application for the separate child health program has not been filed, the last day of the month following the month in which the determination of presumptive eligibility was made. Presumptive income standard means the highest income eligibility standard established under the plan that is most likely to be used to establish eligibility of a child of the age involved. Public agency means a State, county, city or other type of municipal agency, including a public school district, transportation district, irrigation district, or any other type of public entity. Qualified entity means an entity that is determined by the State to be capable of making determinations of presumptive eligibility for children, and that— (1) Furnishes health care items and services covered under the approved plan and is eligible to receive payments under the approved plan; (2) Is authorized to determine eligibility of a child to participate in a Head Start program under the Head Start Act; (3) Is authorized to determine eligibility of a child to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990; (4) Is authorized to determine eligibility of an infant or child to receive assistance under the special nutrition program for women, infants, and children (WIC) under section 17 of the Child Nutrition Act of 1966; (5) Is authorized to determine eligibility of a child for medical assistance under the Medicaid State plan, or eligibility of a child for child health assistance under the State Children's Health Insurance Program; (6) Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801); (7) Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs; (8) Is a State or Tribal child support enforcement agency; (9) Is an organization that— (i) Provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act; (ii) Is a State or Tribal office or entity involved in enrollment in the program under this title, Part A of title IV, or title XXI; or (iii) Determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.); and (10) Any other entity the State so deems, as approved by the Secretary. State health benefits plan means a health insurance coverage plan that is offered or organized by the State government on behalf of State employees or other public agency employees within the State. The term does not include a plan in which the State provides no contribution toward the cost of coverage and in which no State employees participate, or a plan that provides coverage only for a specific type of care, such as dental or vision care. [66 FR 2675, Jan. 11, 2001, as amended at 66 FR 33823, June 25, 2001] The State plan must include a description of— (a) The standards, consistent with §§457.310 and 457.320, used to determine the eligibility of children for coverage under the State plan. (b) The State's policies governing enrollment and disenrollment; processes for screening applicant children for and, if eligible, facilitating their enrollment in Medicaid; and processes for implementing waiting lists and enrollment caps (if any). (a) Definition. A targeted low-income child is a child who meets the standards set forth below and the eligibility standards established by the State under §457.320. (b) Standards. A targeted low-income child must meet the following standards: (1) Financial need standard. A targeted low-income child: (i) Has a family income at or below 200 percent of the Federal poverty line for a family of the size involved; (ii) Resides in a State with no Medicaid applicable income level or; (iii) Resides in a State that has a Medicaid applicable income level and has family income that either— (A) Exceeds the Medicaid applicable income level for the age of such child, but not by more than 50 percentage points; or (B) Does not exceed the income level specified for such child to be eligible for medical assistance under policies of the State plan under title XIX on June 1, 1997. (2) No other coverage standard. A targeted low-income child must not be— (i) Found eligible or potentially eligible for Medicaid under policies of the State plan (determined through either the Medicaid application process or the screening process described at §457.350); or (ii) Covered under a group health plan or under health insurance coverage, as defined in section 2791 of the Public Health Service Act, unless the plan or health insurance coverage program has been in operation since before July 1, 1997 and is administered by a State that receives no Federal funds for the program's operation. A child is not considered covered under a group health plan or health insurance coverage if the child does not have reasonable geographic access to care under that plan. (3) For purposes of this section, policies of the State plan under title XIX plan include policies under a Statewide demonstration project under section 1115(a) of the Act other than a demonstration project that covered an expanded group of eligible children but that either— (i) Did not provide inpatient hospital coverage; or (ii) Limited eligibility to children previously enrolled in Medicaid, imposed premiums as a condition of initial or continued enrollment, and did not impose a general time limit on eligibility. (c) Exclusions. Notwithstanding paragraph (a) of this section, the following groups are excluded from the definition of targeted low-income children: (1) Children eligible for certain State health benefits coverage. (i) A targeted low-income child may not be eligible for health benefits coverage under a State health benefits plan in the State on the basis of a family member's employment with a public agency, even if the family declines to accept the coverage. (ii) A child is considered eligible for health benefits coverage under a State health benefits plan if a more than nominal contribution to the cost of health benefits coverage under a State health benefits plan is available from the State or public agency with respect to the child or would have been available from those sources on November 8, 1999. A contribution is considered more than nominal if the State or public agency makes a contribution toward the cost of an employee's dependent(s) that is $10 per family, per month, more than the State or public agency's contribution toward the cost of covering the employee only. (2) Residents of an institution. A child must not be— (i) An inmate of a public institution as defined at §435.1010 of this chapter; or (ii) A patient in an institution for mental diseases, as defined at §435.1010 of this chapter, at the time of initial application or any redetermination of eligibility. [66 FR 2675, Jan. 11, 2001, as amended at 71 FR 39229, July 12, 2006] (a) Eligibility standards. To the extent consistent with title XXI of the Act and except as provided in paragraph (b) of this section, the State plan may adopt eligibility standards for one or more groups of children related to— (1) Geographic area(s) served by the plan; (2) Age (up to, but not including, age 19); (3) Income; (4) Resources; (5) Spenddowns; (6) Disposition of resources; (7) Residency, in accordance with paragraph (d) of this section; (8) Disability status, provided that such standards do not restrict eligibility; (9) Access to, or coverage under, other health coverage; and (10) Duration of eligibility, in accordance with paragraph (e) of this section. (b) Prohibited eligibility standards. In establishing eligibility standards and methodologies, a State may not— (1) Cover children with a higher family income without covering children with a lower family income within any defined group of covered targeted low-income children; (2) Deny eligibility based on a preexisting medical condition; (3) Discriminate on the basis of diagnosis; (4) Require any family member who is not requesting services to provide a social security number (including those family members whose income or resources might be used in making the child's eligibility determination); (5) Exclude American Indian or Alaska Native children based on eligibility for, or access to, medical care funded by the Indian Health Service; (6) Exclude individuals based on citizenship or nationality, to the extent that the children are U.S. citizens, U.S. nationals or qualified aliens, (as defined at section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, as amended by the BBA of 1997, except to the extent that section 403 of PRWORA precludes them from receiving Federal means-tested public benefits); or (7) Violate any other Federal laws or regulations pertaining to eligibility for a separate child health program under title XXI. (c) Self-declaration of citizenship. In establishing eligibility for coverage under a separate child health plan, a State may accept self-declaration of citizenship (including nationals of the U.S.), provided that the State has implemented effective, fair, and nondiscriminatory procedures for ensuring the integrity of its application process. (d) Residency. The State may establish residency requirements, except that a State may not— (1) Impose a durational residency requirement; (2) Preclude the following individuals from declaring residence in a State— (i) A non-institutionalized child who is not a ward of the State, if the child is physically located in that State, including as a result of the parent's or caretaker's employment in that State; (ii) An institutionalized child who is not a ward of a State, if the State is the State of residence of the child's custodial parent's or caretaker at the time of placement; (iii) A child who is a ward of a State, regardless of the child's physical location; or (iv) A child whose custodial parent or caretaker is involved in work of a transient nature, if the State is the parent's or caretaker's home State. (e) Duration of eligibility. (1) The State may not impose a lifetime cap or other time limit on the eligibility of an individual applicant or enrollee, based on the length of time such applicant or enrollee has received benefits under the State's separate child health program. (2) Eligibility must be redetermined at least every 12 months. [66 FR 2675, Jan. 11, 2001, as amended at 66 FR 33823, June 25, 2001] (a) Application assistance. A State must afford families an opportunity to apply for child health assistance without delay, provided that the State has not reached an approved enrollment cap, and offer assistance to families in understanding and completing applications and in obtaining any required documentation. (b) Use of social security number. A State may require a social security number for each individual requesting services consistent with the requirements at §435.910(b), (e), (f), and (g) of this chapter. (c) Notice of rights and responsibilities. A State must inform applicants at the time of application, in writing and orally if appropriate, about the application and eligibility requirements, the time frame for determining eligibility, and the right to review of eligibility determinations as described in §457.1130. (d) Timely determinations of eligibility. (1) The agency must promptly determine eligibility and issue a notice of decision within the time standards established, except in circumstances that are beyond the agency's control. (2) A State must establish time standards for determining eligibility. These standards may not exceed forty-five calendar days (excluding days during which the application has been suspended, pursuant to §457.350(f)(1)). (3) In applying the time standards, the State must define “date of application” and must count each calendar day from the date of application to the day the agency mails or otherwise provides notice of its eligibility decision. (e) Notice of decision concerning eligibility. A State must provide each applicant or enrollee a written notice of any decision on the application or other determination concerning eligibility. (1) If eligibility is approved, the notice must include information on the enrollee's rights and responsibilities under the program, including the opportunity for review of matters described in §457.1130. (2) If eligibility is denied, suspended or terminated, the State must provide notice in accordance with §457.1180. In the case of a suspension or termination of eligibility, the State must provide sufficient notice to enable the child's parent or caretaker to take any appropriate actions that may be required to allow coverage to continue without interruption. (f) Effective date of eligibility. A State must specify a method for determining the effective date of eligibility for its separate child health program, which can be determined based on the date of application or through any other reasonable method. [66 FR 2675, Jan. 11, 2001, as amended at 66 FR 33823, June 25, 2001] (a) State plan requirement. The State plan must include a description of— (1) The screening procedures that the State will use, at intake and any follow-up eligibility determination, including any periodic redetermination, to ensure that only targeted low-income children are furnished child health assistance under the plan; and (2) The procedures that the State will use to ensure that the Medicaid application and enrollment process is initiated and that Medicaid enrollment is facilitated for children found, through the screening process, to be potentially eligible for Medicaid. (b) Screening objectives. (1) A State must use screening procedures to identify, at a minimum, any applicant or enrollee who is potentially eligible for Medicaid under one of the poverty-level-related groups described in section 1902(l) of the Act, section 1931 of the Act, or a Medicaid demonstration project approved under section 1115 of the Act, applying whichever standard and corresponding methodology generally results in a higher income eligibility level for the age group of the child being screened. (2) Screening procedures must also identify any applicant or enrollee who would be potentially eligible for Medicaid services based on the eligibility of his or her mother under one of the poverty level groups described in section 1902(l) of the Act, section 1931 of the Act, or a Medicaid demonstration project approved under section 1115 of the Act. (c) Income eligibility test. To identify the children described in paragraph (b) of this section, a State must either initially apply the gross income test described in paragraph (c)(1) of this section and then use an adjusted income test described in paragraph (c)(2) of this section for applicants whose gross income is above the appropriate Medicaid income standard, or use only the adjusted income test. (1) Initial gross income test. Under this test, a State initially screens for Medicaid eligibility by comparing gross family income to the appropriate Medicaid income standard. (2) Adjusted income test. Under this test, a State screens for Medicaid eligibility by comparing adjusted family income to the appropriate Medicaid income standard. The State must apply Medicaid standards and methodologies relating to income for the particular Medicaid eligibility group, including all income exclusions and disregards, except those that apply only in very limited circumstances. (d) Resource eligibility test. (1) If a State applies a resource test for children under the Medicaid eligibility group used for screening purposes as described in paragraph (b) of this section and a child has been determined potentially income eligible for Medicaid, the State must also screen for Medicaid eligibility by comparing family resources to the appropriate Medicaid resource standard. (2) In conducting the screening, the State must apply Medicaid standards and methodologies related to resources for the particular Medicaid eligibility group, including all resource exclusions and disregards, except those that apply only in very limited circumstances. (e) Children found potentially ineligible for Medicaid. If a State uses a screening procedure other than a full determination of Medicaid eligibility under all possible eligibility groups, and the screening process reveals that the child does not appear to be eligible for Medicaid, the State must provide the child's family with the following in writing: (1) A statement that based on a limited review, the child does not appear eligible for Medicaid, but Medicaid eligibility can only be determined based on a full review of a Medicaid application under all Medicaid eligibility groups; (2) Information about Medicaid eligibility and benefits; and (3) Information about how and where to apply for Medicaid under all eligibility groups. (4) The State will determine the written format and timing of the information regarding Medicaid eligibility, benefits, and the application process required under this paragraph (e). (f) Children found potentially eligible for Medicaid. If the screening process reveals that the child is potentially eligible for Medicaid, the State must establish procedures in coordination with the Medicaid agency that facilitate enrollment in Medicaid and avoid duplicative requests for information and documentation and must— (1) Except as provided in §457.355, find the child ineligible, provisionally ineligible, or suspend the child's application for the separate child health program unless and until a completed Medicaid application for that child is denied, or the child's circumstances change, and promptly transmit the separate child health application to the Medicaid agency as provided in paragraph (f)(3)(ii) of this section; and (2) If a State uses a joint application for its Medicaid and separate child health programs, promptly transmit the application, or the information obtained through the application, and all relevant documentation to the Medicaid agency; or (3) If a State does not use a joint application for its Medicaid and separate child health programs: (i) Promptly inform the child's parent or caretaker in writing and, if appropriate, orally that the child has been found likely to be eligible for Medicaid; provide the family with a Medicaid application and offer information about what, if any, further information, documentation, or other steps are needed to complete the Medicaid application process; and offer assistance in completing the application process; (ii) Promptly transmit the separate child health program application; or the information obtained through the application, and all other relevant information and documentation, including the results of the screening process, to the Medicaid agency for a final determination of Medicaid eligibility in accordance with the requirements of §§431.636 and 457.1110 of this chapter; or (4) Establish other effective and efficient procedures, in coordination with the Medicaid agency, as described and approved in the State plan that ensure that children who are screened as potentially eligible for Medicaid are able to apply for Medicaid without delay and, if eligible, are enrolled in Medicaid in a timely manner; and (5) Determine or redetermine eligibility for the separate child health program, if— (i) The State is notified pursuant to §431.636 of this chapter that the child has been found ineligible for Medicaid, consistent with the time standards established pursuant to §457.340(c); or (ii) The State is notified prior to the final Medicaid eligibility determination that the child's circumstances have changed and another screening shows that the child is not likely to be eligible for Medicaid. (g) Informed application decisions. To enable a family to make an informed decision about applying for Medicaid or completing the Medicaid application process, a State must provide the child's family with information, in writing, about— (1) The State's Medicaid program, including the benefits covered, and restrictions on cost sharing; and (2) Eligibility rules that prohibit children who have been screened eligible for Medicaid from being enrolled in a separate child health program, other than provisional temporary enrollment while a final Medicaid eligibility determination is being made. (3) The State will determine the written format and timing of the information regarding Medicaid eligibility, benefits, and the application process required under this paragraph (g). (h) Waiting lists, enrollment caps and closed enrollment. The State must establish procedures to ensure that— (1) The procedures developed in accordance with this section have been followed for each child applying for a separate child health program before placing the child on a waiting list or otherwise deferring action on the child's application for the separate child health program; and (2) Families are informed that a child may be eligible for Medicaid if circumstances change while the child is on a waiting list for separate child health program. [66 FR 2675, Jan. 11, 2001, as amended at 66 FR 33823, June 25, 2001; 67 FR 61974, Oct. 2, 2002] States must monitor and establish a mechanism to evaluate the screen and enroll process described at §457.350 to ensure that children who are screened potentially eligible for Medicaid are enrolled in Medicaid, if eligible, and that children who are found ineligible for Medicaid are enrolled in the separate child health program, if eligible. (a) General rule. Consistent with subpart D of this part, the State may pay costs of coverage under a separate child health program, during a period of presumptive eligibility for children applying for coverage under the separate child health program, pending the screening process and a final determination of eligibility (including applicants found through screening to be potentially eligible for Medicaid) (b) Expenditures for coverage during a period of presumptive eligibility. Expenditures for coverage during a period of presumptive eligibility implemented in accordance with §435.1102 of this chapter may be considered as expenditures for child health assistance under the plan. [66 FR 2675, Jan. 11, 2001, as amended at 66 FR 33823, June 25, 2001] (a) The State must establish procedures to ensure the integrity of the eligibility determination process. (b) A State may establish reasonable eligibility verification mechanisms to promote enrollment of eligible children and may permit applicants and enrollees to demonstrate that they meet eligibility requirements through self-declaration or affirmation except that a State may permit self-declaration of citizenship only if the State has effective, fair and non-discriminatory procedures to ensure the integrity of the application process in accordance with §457.320(c).
Title 42: Public Health
PART 457—ALLOTMENTS AND GRANTS TO STATES
Subpart C—State Plan Requirements: Eligibility, Screening, Applications, and Enrollment
§ 457.300 Basis, scope, and applicability.
§ 457.301 Definitions and use of terms.
§ 457.305 State plan provisions.
§ 457.310 Targeted low-income child.
§ 457.320 Other eligibility standards.
§ 457.340 Application for and enrollment in a separate child health program.
§ 457.350 Eligibility screening and facilitation of Medicaid enrollment.
§ 457.353 Monitoring and evaluation of screening process.
§ 457.355 Presumptive eligibility.
§ 457.380 Eligibility verification.
