42 C.F.R. PART 457--ALLOTMENTS AND GRANTS TO STATES
TITLE 42--Public Health
CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER D--STATE CHILDREN'S HEALTH INSURANCE PROGRAMS (SCHIPs)
PART 457--ALLOTMENTS AND GRANTS TO STATES
Subpart A--INTRODUCTION; STATE PLANS FOR CHILD HEALTH INSURANCE PROGRAMS AND OUTREACH STRATEGIES
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| Basis and scope of subchapter D.
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| Definitions and use of terms.
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| Basis, scope, and applicability of subpart A.
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| State program administration.
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| Effective date and duration of State plans and plan amendments.
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| Current State child health insurance coverage and coordination.
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| Enrollment assistance and information requirements.
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| Public involvement in program development.
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| Provision of child health assistance to American Indian and Alaska Native children.
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| Assurance of compliance with other provisions.
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| CMS review of State plan material.
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| Notice and timing of CMS action on State plan material.
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Subpart B--GENERAL ADMINISTRATION--REVIEWS AND AUDITS; WITHHOLDING FOR FAILURE TO COMPLY; DEFERRAL AND DISALLOWANCE OF CLAIMS; REDUCTION OF FEDERAL MEDICAL PAYMENTS
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| Administrative and judicial review of action on State plan material.
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| Withholding of payment for failure to comply with Federal requirements.
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| Administrative appeals under SCHIP.
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| Deferral of claims for FFP.
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| Disallowance of claims for FFP.
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| Treatment of uncashed or canceled (voided) SCHIP checks.
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| Repayment of Federal funds by installments.
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| Public funds as the State share of financial participation.
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| FFP: Conditions relating to cost sharing.
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| Fiscal policies and accountability.
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| FFP for State ADP expenditures.
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| Refunding of Federal Share of SCHIP overpayments to providers and referral of allegations of waste, fraud or abuse to the Office of Inspector General.
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| Documentation of payment rates.
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Subpart C--STATE PLAN REQUIREMENTS: ELIGIBILITY, SCREENING, APPLICATIONS, AND ENROLLMENT
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| Basis, scope, and applicability.
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| Definitions and use of terms.
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| Targeted low-income child.
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| Other eligibility standards.
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| Application for and enrollment in a separate child health program.
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| Eligibility screening and facilitation of Medicaid enrollment.
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| Monitoring and evaluation of screening process.
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| Eligibility verification.
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Subpart D--STATE PLAN REQUIREMENTS: COVERAGE AND BENEFITS
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| Basis, scope, and applicability.
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| Definition of child health assistance.
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| Health benefits coverage options.
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| Benchmark health benefits coverage.
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| Benchmark-equivalent health benefits coverage.
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| Actuarial report for benchmark-equivalent coverage.
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| Existing comprehensive State-based coverage.
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| Secretary-approved coverage.
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| Limitations on coverage: Abortions.
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| Preexisting condition exclusions and relation to other laws.
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| Delivery and utilization control systems.
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| State assurance of access to care and procedures to assure quality and appropriateness of care.
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Subpart E--STATE PLAN REQUIREMENTS: ENROLLEE FINANCIAL RESPONSIBILITIES
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| Basis, scope, and applicability.
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| General State plan requirements.
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| Premiums, enrollment fees, or similar fees: State plan requirements.
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| Co-payments, coinsurance, deductibles, or similar cost-sharing charges: State plan requirements.
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| Cost sharing for well-baby and well-child care services.
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| General cost-sharing protection for lower income children.
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| Cost-sharing protection to ensure enrollment of American Indians and Alaska Natives.
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| Cost-sharing charges for children in families with incomes at or below 150 percent of the FPL.
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| Maximum allowable cost-sharing charges on targeted low-income children in families with income from 101 to 150 percent of the FPL.
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| Cumulative cost-sharing maximum.
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| Disenrollment protections.
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Subpart F--PAYMENTS TO STATES
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| Purpose and basis of this subpart.
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| Conditions for State allotments and Federal payments for a fiscal year.
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| Process and calculation of State allotments for a fiscal year.
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| Period of availability for State allotments for a fiscal year.
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| Application and tracking of payments against the fiscal year allotments.
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| Ten percent limit on certain State Children's Health Insurance Program expenditures.
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| Rate of FFP for State expenditures.
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| Prevention of duplicate payments.
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| Other applicable Federal regulations.
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Subpart G--STRATEGIC PLANNING, REPORTING, AND EVALUATION
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| Basis, scope, and applicability.
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| State plan requirements: Strategic objectives and performance goals.
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| State plan requirement: State assurance regarding data collection, records, and report.
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| State expenditures and statistical reports.
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Subpart H--SUBSTITUTION OF COVERAGE
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| Basis, scope, and applicability.
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| State plan requirement: Procedures to address substitution under group health plans.
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| Premium assistance programs: Required protections against substitution.
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Subpart I--PROGRAM INTEGRITY
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| Basis, scope and applicability.
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| State program administration.
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| Fraud detection and investigation.
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| Preliminary investigation.
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| Full investigation, resolution, and reporting requirements.
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| Sanctions and related penalties.
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| Certification for contracts and proposals.
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| Contract and payment requirements including certification of payment-related information.
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| Conditions necessary to contract as a managed care entity (MCE).
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| Reporting changes in eligibility and redetermining eligibility.
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| Verification of enrollment and provider services received.
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| Integrity of professional advice to enrollees.
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Subpart J--ALLOWABLE WAIVERS: GENERAL PROVISIONS
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| Basis, scope, and applicability.
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| CMS review of waiver requests.
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| Cost-effective coverage through a community-based health delivery system.
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| Purchase of family coverage.
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Subpart K--STATE PLAN REQUIREMENTS: APPLICANT AND ENROLLEE PROTECTIONS
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| Basis, scope and applicability.
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| State plan requirement: Description of review process.
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| Program specific review process: Matters subject to review.
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| Program specific review process: Core elements of review.
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| Program specific review process: Impartial review.
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| Program specific review process: Time frames.
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| Program specific review process: Continuation of enrollment.
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| Program specific review process: Notice.
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| Application of review procedures when States offer premium assistance for group health plans.
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