42:4.0.1.2.15.1 | SUBPART A
| Subpart A - Introduction; State Plans for Child Health Insurance Programs and Outreach Strategies | |
42:4.0.1.2.15.1.175.1 | SECTION 457.1
| 457.1 Program description. | |
42:4.0.1.2.15.1.175.2 | SECTION 457.2
| 457.2 Basis and scope of subchapter D. | |
42:4.0.1.2.15.1.175.3 | SECTION 457.10
| 457.10 Definitions and use of terms. | |
42:4.0.1.2.15.1.175.4 | SECTION 457.30
| 457.30 Basis, scope, and applicability of subpart A. | |
42:4.0.1.2.15.1.175.5 | SECTION 457.40
| 457.40 State program administration. | |
42:4.0.1.2.15.1.175.6 | SECTION 457.50
| 457.50 State plan. | |
42:4.0.1.2.15.1.175.7 | SECTION 457.60
| 457.60 Amendments. | |
42:4.0.1.2.15.1.175.8 | SECTION 457.65
| 457.65 Effective date and duration of State plans and plan amendments. | |
42:4.0.1.2.15.1.175.9 | SECTION 457.70
| 457.70 Program options. | |
42:4.0.1.2.15.1.175.10 | SECTION 457.80
| 457.80 Current State child health insurance coverage and coordination. | |
42:4.0.1.2.15.1.175.11 | SECTION 457.90
| 457.90 Outreach. | |
42:4.0.1.2.15.1.175.12 | SECTION 457.110
| 457.110 Enrollment assistance and information requirements. | |
42:4.0.1.2.15.1.175.13 | SECTION 457.120
| 457.120 Public involvement in program development. | |
42:4.0.1.2.15.1.175.14 | SECTION 457.125
| 457.125 Provision of child health assistance to American Indian and Alaska Native children. | |
42:4.0.1.2.15.1.175.15 | SECTION 457.130
| 457.130 Civil rights assurance. | |
42:4.0.1.2.15.1.175.16 | SECTION 457.135
| 457.135 Assurance of compliance with other provisions. | |
42:4.0.1.2.15.1.175.17 | SECTION 457.140
| 457.140 Budget. | |
42:4.0.1.2.15.1.175.18 | SECTION 457.150
| 457.150 CMS review of State plan material. | |
42:4.0.1.2.15.1.175.19 | SECTION 457.160
| 457.160 Notice and timing of CMS action on State plan material. | |
42:4.0.1.2.15.1.175.20 | SECTION 457.170
| 457.170 Withdrawal process. | |
42:4.0.1.2.15.2 | SUBPART B
| Subpart B - General Administration - Reviews and Audits; Withholding for Failure to Comply; Deferral and Disallowance of Claims; Reduction of Federal Medical Payments | |
42:4.0.1.2.15.2.175.1 | SECTION 457.200
| 457.200 Program reviews. | |
42:4.0.1.2.15.2.175.2 | SECTION 457.202
| 457.202 Audits. | |
42:4.0.1.2.15.2.175.3 | SECTION 457.203
| 457.203 Administrative and judicial review of action on State plan material. | |
42:4.0.1.2.15.2.175.4 | SECTION 457.204
| 457.204 Withholding of payment for failure to comply with Federal requirements. | |
42:4.0.1.2.15.2.175.5 | SECTION 457.206
| 457.206 Administrative appeals under CHIP. | |
42:4.0.1.2.15.2.175.6 | SECTION 457.208
| 457.208 Judicial review. | |
42:4.0.1.2.15.2.175.7 | SECTION 457.216
| 457.216 Treatment of uncashed or canceled (voided) CHIP checks. | |
42:4.0.1.2.15.2.175.8 | SECTION 457.220
| 457.220 Funds from units of government as the State share of financial participation. | |
42:4.0.1.2.15.2.175.9 | SECTION 457.222
| 457.222 FFP for equipment. | |
42:4.0.1.2.15.2.175.10 | SECTION 457.224
| 457.224 FFP: Conditions relating to cost sharing. | |
42:4.0.1.2.15.2.175.11 | SECTION 457.226
| 457.226 Fiscal policies and accountability. | |
42:4.0.1.2.15.2.175.12 | SECTION 457.228
| 457.228 Cost allocation. | |
42:4.0.1.2.15.2.175.13 | SECTION 457.230
| 457.230 FFP for State ADP expenditures. | |
42:4.0.1.2.15.2.175.14 | SECTION 457.232
| 457.232 Refunding of Federal Share of CHIP overpayments to providers and referral of allegations of waste, fraud or abuse to the Office of Inspector General. | |
42:4.0.1.2.15.2.175.15 | SECTION 457.236
| 457.236 Audits. | |
42:4.0.1.2.15.2.175.16 | SECTION 457.238
| 457.238 Documentation of payment rates. | |
42:4.0.1.2.15.3 | SUBPART C
| Subpart C - State Plan Requirements: Eligibility, Screening, Applications, and Enrollment | |
42:4.0.1.2.15.3.175.1 | SECTION 457.300
| 457.300 Basis, scope, and applicability. | |
42:4.0.1.2.15.3.175.2 | SECTION 457.301
| 457.301 Definitions and use of terms. | |
42:4.0.1.2.15.3.175.3 | SECTION 457.305
| 457.305 State plan provisions. | |
42:4.0.1.2.15.3.175.4 | SECTION 457.310
| 457.310 Targeted low-income child. | |
42:4.0.1.2.15.3.175.5 | SECTION 457.315
| 457.315 Application of modified adjusted gross income and household definition. | |
42:4.0.1.2.15.3.175.6 | SECTION 457.320
| 457.320 Other eligibility standards. | |
42:4.0.1.2.15.3.175.7 | SECTION 457.330
| 457.330 Application. | |
42:4.0.1.2.15.3.175.8 | SECTION 457.340
| 457.340 Application for and enrollment in CHIP. | |
42:4.0.1.2.15.3.175.9 | SECTION 457.342
| 457.342 Continuous eligibility for children. | |
42:4.0.1.2.15.3.175.10 | SECTION 457.343
| 457.343 Periodic renewal of CHIP eligibility. | |
42:4.0.1.2.15.3.175.11 | SECTION 457.348
| 457.348 Determinations of Children's Health Insurance Program eligibility by other insurance affordability programs. | |
42:4.0.1.2.15.3.175.12 | SECTION 457.350
| 457.350 Eligibility screening and enrollment in other insurance affordability programs. | |
42:4.0.1.2.15.3.175.13 | SECTION 457.351
| 457.351 Coordination involving appeals entities for different insurance affordability programs. | |
42:4.0.1.2.15.3.175.14 | SECTION 457.353
| 457.353 Monitoring and evaluation of screening process. | |
42:4.0.1.2.15.3.175.15 | SECTION 457.355
| 457.355 Presumptive eligibility for children. | |
42:4.0.1.2.15.3.175.16 | SECTION 457.360
| 457.360 Deemed newborn children. | |
42:4.0.1.2.15.3.175.17 | SECTION 457.370
| 457.370 Alignment with Exchange initial open enrollment period. | |
42:4.0.1.2.15.3.175.18 | SECTION 457.380
| 457.380 Eligibility verification. | |
42:4.0.1.2.15.4 | SUBPART D
| Subpart D - State Plan Requirements: Coverage and Benefits | |
42:4.0.1.2.15.4.175.1 | SECTION 457.401
| 457.401 Basis, scope, and applicability. | |
42:4.0.1.2.15.4.175.2 | SECTION 457.402
| 457.402 Definition of child health assistance. | |
42:4.0.1.2.15.4.175.3 | SECTION 457.410
| 457.410 Health benefits coverage options. | |
42:4.0.1.2.15.4.175.4 | SECTION 457.420
| 457.420 Benchmark health benefits coverage. | |
42:4.0.1.2.15.4.175.5 | SECTION 457.430
| 457.430 Benchmark-equivalent health benefits coverage. | |
42:4.0.1.2.15.4.175.6 | SECTION 457.431
| 457.431 Actuarial report for benchmark-equivalent coverage. | |
42:4.0.1.2.15.4.175.7 | SECTION 457.440
| 457.440 Existing comprehensive State-based coverage. | |
42:4.0.1.2.15.4.175.8 | SECTION 457.450
| 457.450 Secretary-approved coverage. | |
42:4.0.1.2.15.4.175.9 | SECTION 457.470
| 457.470 Prohibited coverage. | |
42:4.0.1.2.15.4.175.10 | SECTION 457.475
| 457.475 Limitations on coverage: Abortions. | |
42:4.0.1.2.15.4.175.11 | SECTION 457.480
| 457.480 Preexisting condition exclusions and relation to other laws. | |
42:4.0.1.2.15.4.175.12 | SECTION 457.490
| 457.490 Delivery and utilization control systems. | |
42:4.0.1.2.15.4.175.13 | SECTION 457.495
| 457.495 State assurance of access to care and procedures to assure quality and appropriateness of care. | |
42:4.0.1.2.15.4.175.14 | SECTION 457.496
| 457.496 Parity in mental health and substance use disorder benefits. | |
42:4.0.1.2.15.5 | SUBPART E
| Subpart E - State Plan Requirements: Enrollee Financial Responsibilities | |
42:4.0.1.2.15.5.175.1 | SECTION 457.500
| 457.500 Basis, scope, and applicability. | |
42:4.0.1.2.15.5.175.2 | SECTION 457.505
| 457.505 General State plan requirements. | |
42:4.0.1.2.15.5.175.3 | SECTION 457.510
| 457.510 Premiums, enrollment fees, or similar fees: State plan requirements. | |
42:4.0.1.2.15.5.175.4 | SECTION 457.515
| 457.515 Co-payments, coinsurance, deductibles, or similar cost-sharing charges: State plan requirements. | |
42:4.0.1.2.15.5.175.5 | SECTION 457.520
| 457.520 Cost sharing for well-baby and well-child care services. | |
42:4.0.1.2.15.5.175.6 | SECTION 457.525
| 457.525 Public schedule. | |
42:4.0.1.2.15.5.175.7 | SECTION 457.530
| 457.530 General cost-sharing protection for lower income children. | |
42:4.0.1.2.15.5.175.8 | SECTION 457.535
| 457.535 Cost-sharing protection to ensure enrollment of American Indians and Alaska Natives. | |
42:4.0.1.2.15.5.175.9 | SECTION 457.540
| 457.540 Cost-sharing charges for children in families with incomes at or below 150 percent of the FPL. | |
42:4.0.1.2.15.5.175.10 | SECTION 457.555
| 457.555 Maximum allowable cost-sharing charges on targeted low-income children in families with income from 101 to 150 percent of the FPL. | |
42:4.0.1.2.15.5.175.11 | SECTION 457.560
| 457.560 Cumulative cost-sharing maximum. | |
42:4.0.1.2.15.5.175.12 | SECTION 457.570
| 457.570 Disenrollment protections. | |
42:4.0.1.2.15.6 | SUBPART F
| Subpart F - Payments to States | |
42:4.0.1.2.15.6.175.1 | SECTION 457.600
| 457.600 Purpose and basis of this subpart. | |
42:4.0.1.2.15.6.175.2 | SECTION 457.602
| 457.602 Applicability. | |
42:4.0.1.2.15.6.175.3 | SECTION 457.606
| 457.606 Conditions for State allotments and Federal payments for a fiscal year. | |
42:4.0.1.2.15.6.175.4 | SECTION 457.608
| 457.608 Process and calculation of State allotments prior to FY 2009. | |
42:4.0.1.2.15.6.175.5 | SECTION 457.609
| 457.609 Process and calculation of State allotments for a fiscal year after FY 2008. | |
42:4.0.1.2.15.6.175.6 | SECTION 457.610
| 457.610 Period of availability for State allotments prior to FY 2009. | |
42:4.0.1.2.15.6.175.7 | SECTION 457.611
| 457.611 Period of availability for State allotments for a fiscal year after FY 2008. | |
42:4.0.1.2.15.6.175.8 | SECTION 457.614
| 457.614 General payment process. | |
42:4.0.1.2.15.6.175.9 | SECTION 457.616
| 457.616 Application and tracking of payments against the fiscal year allotments. | |
42:4.0.1.2.15.6.175.10 | SECTION 457.618
| 457.618 Ten percent limit on certain Children's Health Insurance Program expenditures. | |
42:4.0.1.2.15.6.175.11 | SECTION 457.622
| 457.622 Rate of FFP for State expenditures. | |
42:4.0.1.2.15.6.175.12 | SECTION 457.626
| 457.626 Prevention of duplicate payments. | |
42:4.0.1.2.15.6.175.13 | SECTION 457.628
| 457.628 Other applicable Federal regulations. | |
42:4.0.1.2.15.6.175.14 | SECTION 457.630
| 457.630 Grants procedures. | |
42:4.0.1.2.15.7 | SUBPART G
| Subpart G - Strategic Planning, Reporting, and Evaluation | |
42:4.0.1.2.15.7.175.1 | SECTION 457.700
| 457.700 Basis, scope, and applicability. | |
42:4.0.1.2.15.7.175.2 | SECTION 457.710
| 457.710 State plan requirements: Strategic objectives and performance goals. | |
42:4.0.1.2.15.7.175.3 | SECTION 457.720
| 457.720 State plan requirement: State assurance regarding data collection, records, and reports. | |
42:4.0.1.2.15.7.175.4 | SECTION 457.730
| 457.730 Beneficiary access to and exchange of data. | |
42:4.0.1.2.15.7.175.5 | SECTION 457.740
| 457.740 State expenditures and statistical reports. | |
42:4.0.1.2.15.7.175.6 | SECTION 457.750
| 457.750 Annual report. | |
42:4.0.1.2.15.7.175.7 | SECTION 457.760
| 457.760 Access to published provider directory information. | |
42:4.0.1.2.15.8 | SUBPART H
| Subpart H - Substitution of Coverage | |
42:4.0.1.2.15.8.175.1 | SECTION 457.800
| 457.800 Basis, scope, and applicability. | |
42:4.0.1.2.15.8.175.2 | SECTION 457.805
| 457.805 State plan requirement: Procedures to address substitution under group health plans. | |
42:4.0.1.2.15.8.175.3 | SECTION 457.810
| 457.810 Premium assistance programs: Required protections against substitution. | |
42:4.0.1.2.15.9 | SUBPART I
| Subpart I - Program Integrity | |
42:4.0.1.2.15.9.175.1 | SECTION 457.900
| 457.900 Basis, scope and applicability. | |
42:4.0.1.2.15.9.175.2 | SECTION 457.910
| 457.910 State program administration. | |
42:4.0.1.2.15.9.175.3 | SECTION 457.915
| 457.915 Fraud detection and investigation. | |
42:4.0.1.2.15.9.175.4 | SECTION 457.925
| 457.925 Preliminary investigation. | |
42:4.0.1.2.15.9.175.5 | SECTION 457.930
| 457.930 Full investigation, resolution, and reporting requirements. | |
42:4.0.1.2.15.9.175.6 | SECTION 457.935
| 457.935 Sanctions and related penalties. | |
42:4.0.1.2.15.9.175.7 | SECTION 457.940
| 457.940 Procurement standards. | |
42:4.0.1.2.15.9.175.8 | SECTION 457.945
| 457.945 Certification for contracts and proposals. | |
42:4.0.1.2.15.9.175.9 | SECTION 457.950
| 457.950 Contract and payment requirements including certification of payment-related information. | |
42:4.0.1.2.15.9.175.10 | SECTION 457.960
| 457.960 Reporting changes in eligibility and redetermining eligibility. | |
42:4.0.1.2.15.9.175.11 | SECTION 457.965
| 457.965 Documentation. | |
42:4.0.1.2.15.9.175.12 | SECTION 457.980
| 457.980 Verification of enrollment and provider services received. | |
42:4.0.1.2.15.9.175.13 | SECTION 457.985
| 457.985 Integrity of professional advice to enrollees. | |
42:4.0.1.2.15.9.175.14 | SECTION 457.990
| 457.990 Provider and supplier screening, oversight, and reporting requirements. | |
42:4.0.1.2.15.10 | SUBPART J
| Subpart J - Allowable Waivers: General Provisions | |
42:4.0.1.2.15.10.175.1 | SECTION 457.1000
| 457.1000 Basis, scope, and applicability. | |
42:4.0.1.2.15.10.175.2 | SECTION 457.1003
| 457.1003 CMS review of waiver requests. | |
42:4.0.1.2.15.10.175.3 | SECTION 457.1005
| 457.1005 Cost-effective coverage through a community-based health delivery system. | |
42:4.0.1.2.15.10.175.4 | SECTION 457.1010
| 457.1010 Purchase of family coverage. | |
42:4.0.1.2.15.10.175.5 | SECTION 457.1015
| 457.1015 Cost-effectiveness. | |
42:4.0.1.2.15.11 | SUBPART K
| Subpart K - State Plan Requirements: Applicant and Enrollee Protections | |
42:4.0.1.2.15.11.175.1 | SECTION 457.1100
| 457.1100 Basis, scope and applicability. | |
42:4.0.1.2.15.11.175.2 | SECTION 457.1110
| 457.1110 Privacy protections. | |
42:4.0.1.2.15.11.175.3 | SECTION 457.1120
| 457.1120 State plan requirement: Description of review process. | |
42:4.0.1.2.15.11.175.4 | SECTION 457.1130
| 457.1130 Program specific review process: Matters subject to review. | |
42:4.0.1.2.15.11.175.5 | SECTION 457.1140
| 457.1140 Program specific review process: Core elements of review. | |
42:4.0.1.2.15.11.175.6 | SECTION 457.1150
| 457.1150 Program specific review process: Impartial review. | |
42:4.0.1.2.15.11.175.7 | SECTION 457.1160
| 457.1160 Program specific review process: Time frames. | |
42:4.0.1.2.15.11.175.8 | SECTION 457.1170
| 457.1170 Program specific review process: Continuation of enrollment. | |
42:4.0.1.2.15.11.175.9 | SECTION 457.1180
| 457.1180 Program specific review process: Notice. | |
42:4.0.1.2.15.11.175.10 | SECTION 457.1190
| 457.1190 Application of review procedures when States offer premium assistance for group health plans. | |
42:4.0.1.2.15.12 | SUBPART L
| Subpart L - Managed Care | |
42:4.0.1.2.15.12.175 | SUBJGRP 175
| General Provisions | |
42:4.0.1.2.15.12.175.1 | SECTION 457.1200
| 457.1200 Basis, scope, and applicability. | |
42:4.0.1.2.15.12.175.2 | SECTION 457.1201
| 457.1201 Standard contract requirements. | |
42:4.0.1.2.15.12.175.3 | SECTION 457.1203
| 457.1203 Rate development standards and medical loss ratio. | |
42:4.0.1.2.15.12.175.4 | SECTION 457.1206
| 457.1206 Non-emergency medical transportation PAHPs. | |
42:4.0.1.2.15.12.175.5 | SECTION 457.1207
| 457.1207 Information requirements. | |
42:4.0.1.2.15.12.175.6 | SECTION 457.1208
| 457.1208 Provider discrimination prohibited. | |
42:4.0.1.2.15.12.175.7 | SECTION 457.1209
| 457.1209 Requirements that apply to MCO, PIHP, PAHP, PCCM, and PCCM entity contracts involving Indians, Indian health care provider (IHCP), and Indian managed care entities (IMCE). | |
42:4.0.1.2.15.12.176 | SUBJGRP 176
| State Responsibilities | |
42:4.0.1.2.15.12.176.8 | SECTION 457.1210
| 457.1210 Enrollment process. | |
42:4.0.1.2.15.12.176.9 | SECTION 457.1212
| 457.1212 Disenrollment. | |
42:4.0.1.2.15.12.176.10 | SECTION 457.1214
| 457.1214 Conflict of interest safeguards. | |
42:4.0.1.2.15.12.176.11 | SECTION 457.1216
| 457.1216 Continued services to enrollees. | |
42:4.0.1.2.15.12.176.12 | SECTION 457.1218
| 457.1218 Network adequacy standards. | |
42:4.0.1.2.15.12.177 | SUBJGRP 177
| Enrollee Rights and Protections | |
42:4.0.1.2.15.12.177.13 | SECTION 457.1220
| 457.1220 Enrollee rights. | |
42:4.0.1.2.15.12.177.14 | SECTION 457.1222
| 457.1222 Provider-enrollee communication. | |
42:4.0.1.2.15.12.177.15 | SECTION 457.1224
| 457.1224 Marketing activities. | |
42:4.0.1.2.15.12.177.16 | SECTION 457.1226
| 457.1226 Liability for payment. | |
42:4.0.1.2.15.12.177.17 | SECTION 457.1228
| 457.1228 Emergency and poststabilization services. | |
42:4.0.1.2.15.12.178 | SUBJGRP 178
| MCO, PIHP, and PAHP Standards | |
42:4.0.1.2.15.12.178.18 | SECTION 457.1230
| 457.1230 Access standards. | |
42:4.0.1.2.15.12.178.19 | SECTION 457.1233
| 457.1233 Structure and operation standards. | |
42:4.0.1.2.15.12.179 | SUBJGRP 179
| Quality Measurement and Improvement; External Quality Review | |
42:4.0.1.2.15.12.179.20 | SECTION 457.1240
| 457.1240 Quality measurement and improvement. | |
42:4.0.1.2.15.12.179.21 | SECTION 457.1250
| 457.1250 External quality review. | |
42:4.0.1.2.15.12.180 | SUBJGRP 180
| Grievance System | |
42:4.0.1.2.15.12.180.22 | SECTION 457.1260
| 457.1260 Grievance system. | |
42:4.0.1.2.15.12.181 | SUBJGRP 181
| Sanctions | |
42:4.0.1.2.15.12.181.23 | SECTION 457.1270
| 457.1270 Sanctions. | |
42:4.0.1.2.15.12.181.24 | SECTION 457.1280
| 457.1280 Conditions necessary to contract as an MCO, PAHP, or PIHP. | |
42:4.0.1.2.15.12.181.25 | SECTION 457.1285
| 457.1285 Program integrity safeguards. | |