Title 42

Volume 4 CHAPTER IV SUBCHAP D

Subchapter D - State Children's Health Insurance Programs (schips)

42:4.0.1.2.15PART 457
PART 457 - ALLOTMENTS AND GRANTS TO STATES
42:4.0.1.2.15.1SUBPART A
Subpart A - Introduction; State Plans for Child Health Insurance Programs and Outreach Strategies
42:4.0.1.2.15.1.175.1SECTION 457.1
     457.1 Program description.
42:4.0.1.2.15.1.175.2SECTION 457.2
     457.2 Basis and scope of subchapter D.
42:4.0.1.2.15.1.175.3SECTION 457.10
     457.10 Definitions and use of terms.
42:4.0.1.2.15.1.175.4SECTION 457.30
     457.30 Basis, scope, and applicability of subpart A.
42:4.0.1.2.15.1.175.5SECTION 457.40
     457.40 State program administration.
42:4.0.1.2.15.1.175.6SECTION 457.50
     457.50 State plan.
42:4.0.1.2.15.1.175.7SECTION 457.60
     457.60 Amendments.
42:4.0.1.2.15.1.175.8SECTION 457.65
     457.65 Effective date and duration of State plans and plan amendments.
42:4.0.1.2.15.1.175.9SECTION 457.70
     457.70 Program options.
42:4.0.1.2.15.1.175.10SECTION 457.80
     457.80 Current State child health insurance coverage and coordination.
42:4.0.1.2.15.1.175.11SECTION 457.90
     457.90 Outreach.
42:4.0.1.2.15.1.175.12SECTION 457.110
     457.110 Enrollment assistance and information requirements.
42:4.0.1.2.15.1.175.13SECTION 457.120
     457.120 Public involvement in program development.
42:4.0.1.2.15.1.175.14SECTION 457.125
     457.125 Provision of child health assistance to American Indian and Alaska Native children.
42:4.0.1.2.15.1.175.15SECTION 457.130
     457.130 Civil rights assurance.
42:4.0.1.2.15.1.175.16SECTION 457.135
     457.135 Assurance of compliance with other provisions.
42:4.0.1.2.15.1.175.17SECTION 457.140
     457.140 Budget.
42:4.0.1.2.15.1.175.18SECTION 457.150
     457.150 CMS review of State plan material.
42:4.0.1.2.15.1.175.19SECTION 457.160
     457.160 Notice and timing of CMS action on State plan material.
42:4.0.1.2.15.1.175.20SECTION 457.170
     457.170 Withdrawal process.
42:4.0.1.2.15.2SUBPART B
Subpart B - General Administration - Reviews and Audits; Withholding for Failure to Comply; Deferral and Disallowance of Claims; Reduction of Federal Medical Payments
42:4.0.1.2.15.2.175.1SECTION 457.200
     457.200 Program reviews.
42:4.0.1.2.15.2.175.2SECTION 457.202
     457.202 Audits.
42:4.0.1.2.15.2.175.3SECTION 457.203
     457.203 Administrative and judicial review of action on State plan material.
42:4.0.1.2.15.2.175.4SECTION 457.204
     457.204 Withholding of payment for failure to comply with Federal requirements.
42:4.0.1.2.15.2.175.5SECTION 457.206
     457.206 Administrative appeals under CHIP.
42:4.0.1.2.15.2.175.6SECTION 457.208
     457.208 Judicial review.
42:4.0.1.2.15.2.175.7SECTION 457.216
     457.216 Treatment of uncashed or canceled (voided) CHIP checks.
42:4.0.1.2.15.2.175.8SECTION 457.220
     457.220 Funds from units of government as the State share of financial participation.
42:4.0.1.2.15.2.175.9SECTION 457.222
     457.222 FFP for equipment.
42:4.0.1.2.15.2.175.10SECTION 457.224
     457.224 FFP: Conditions relating to cost sharing.
42:4.0.1.2.15.2.175.11SECTION 457.226
     457.226 Fiscal policies and accountability.
42:4.0.1.2.15.2.175.12SECTION 457.228
     457.228 Cost allocation.
42:4.0.1.2.15.2.175.13SECTION 457.230
     457.230 FFP for State ADP expenditures.
42:4.0.1.2.15.2.175.14SECTION 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.
42:4.0.1.2.15.2.175.15SECTION 457.236
     457.236 Audits.
42:4.0.1.2.15.2.175.16SECTION 457.238
     457.238 Documentation of payment rates.
42:4.0.1.2.15.3SUBPART C
Subpart C - State Plan Requirements: Eligibility, Screening, Applications, and Enrollment
42:4.0.1.2.15.3.175.1SECTION 457.300
     457.300 Basis, scope, and applicability.
42:4.0.1.2.15.3.175.2SECTION 457.301
     457.301 Definitions and use of terms.
42:4.0.1.2.15.3.175.3SECTION 457.305
     457.305 State plan provisions.
42:4.0.1.2.15.3.175.4SECTION 457.310
     457.310 Targeted low-income child.
42:4.0.1.2.15.3.175.5SECTION 457.315
     457.315 Application of modified adjusted gross income and household definition.
42:4.0.1.2.15.3.175.6SECTION 457.320
     457.320 Other eligibility standards.
42:4.0.1.2.15.3.175.7SECTION 457.330
     457.330 Application.
42:4.0.1.2.15.3.175.8SECTION 457.340
     457.340 Application for and enrollment in CHIP.
42:4.0.1.2.15.3.175.9SECTION 457.342
     457.342 Continuous eligibility for children.
42:4.0.1.2.15.3.175.10SECTION 457.343
     457.343 Periodic renewal of CHIP eligibility.
42:4.0.1.2.15.3.175.11SECTION 457.348
     457.348 Determinations of Children's Health Insurance Program eligibility by other insurance affordability programs.
42:4.0.1.2.15.3.175.12SECTION 457.350
     457.350 Eligibility screening and enrollment in other insurance affordability programs.
42:4.0.1.2.15.3.175.13SECTION 457.351
     457.351 Coordination involving appeals entities for different insurance affordability programs.
42:4.0.1.2.15.3.175.14SECTION 457.353
     457.353 Monitoring and evaluation of screening process.
42:4.0.1.2.15.3.175.15SECTION 457.355
     457.355 Presumptive eligibility for children.
42:4.0.1.2.15.3.175.16SECTION 457.360
     457.360 Deemed newborn children.
42:4.0.1.2.15.3.175.17SECTION 457.370
     457.370 Alignment with Exchange initial open enrollment period.
42:4.0.1.2.15.3.175.18SECTION 457.380
     457.380 Eligibility verification.
42:4.0.1.2.15.4SUBPART D
Subpart D - State Plan Requirements: Coverage and Benefits
42:4.0.1.2.15.4.175.1SECTION 457.401
     457.401 Basis, scope, and applicability.
42:4.0.1.2.15.4.175.2SECTION 457.402
     457.402 Definition of child health assistance.
42:4.0.1.2.15.4.175.3SECTION 457.410
     457.410 Health benefits coverage options.
42:4.0.1.2.15.4.175.4SECTION 457.420
     457.420 Benchmark health benefits coverage.
42:4.0.1.2.15.4.175.5SECTION 457.430
     457.430 Benchmark-equivalent health benefits coverage.
42:4.0.1.2.15.4.175.6SECTION 457.431
     457.431 Actuarial report for benchmark-equivalent coverage.
42:4.0.1.2.15.4.175.7SECTION 457.440
     457.440 Existing comprehensive State-based coverage.
42:4.0.1.2.15.4.175.8SECTION 457.450
     457.450 Secretary-approved coverage.
42:4.0.1.2.15.4.175.9SECTION 457.470
     457.470 Prohibited coverage.
42:4.0.1.2.15.4.175.10SECTION 457.475
     457.475 Limitations on coverage: Abortions.
42:4.0.1.2.15.4.175.11SECTION 457.480
     457.480 Preexisting condition exclusions and relation to other laws.
42:4.0.1.2.15.4.175.12SECTION 457.490
     457.490 Delivery and utilization control systems.
42:4.0.1.2.15.4.175.13SECTION 457.495
     457.495 State assurance of access to care and procedures to assure quality and appropriateness of care.
42:4.0.1.2.15.4.175.14SECTION 457.496
     457.496 Parity in mental health and substance use disorder benefits.
42:4.0.1.2.15.5SUBPART E
Subpart E - State Plan Requirements: Enrollee Financial Responsibilities
42:4.0.1.2.15.5.175.1SECTION 457.500
     457.500 Basis, scope, and applicability.
42:4.0.1.2.15.5.175.2SECTION 457.505
     457.505 General State plan requirements.
42:4.0.1.2.15.5.175.3SECTION 457.510
     457.510 Premiums, enrollment fees, or similar fees: State plan requirements.
42:4.0.1.2.15.5.175.4SECTION 457.515
     457.515 Co-payments, coinsurance, deductibles, or similar cost-sharing charges: State plan requirements.
42:4.0.1.2.15.5.175.5SECTION 457.520
     457.520 Cost sharing for well-baby and well-child care services.
42:4.0.1.2.15.5.175.6SECTION 457.525
     457.525 Public schedule.
42:4.0.1.2.15.5.175.7SECTION 457.530
     457.530 General cost-sharing protection for lower income children.
42:4.0.1.2.15.5.175.8SECTION 457.535
     457.535 Cost-sharing protection to ensure enrollment of American Indians and Alaska Natives.
42:4.0.1.2.15.5.175.9SECTION 457.540
     457.540 Cost-sharing charges for children in families with incomes at or below 150 percent of the FPL.
42:4.0.1.2.15.5.175.10SECTION 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.
42:4.0.1.2.15.5.175.11SECTION 457.560
     457.560 Cumulative cost-sharing maximum.
42:4.0.1.2.15.5.175.12SECTION 457.570
     457.570 Disenrollment protections.
42:4.0.1.2.15.6SUBPART F
Subpart F - Payments to States
42:4.0.1.2.15.6.175.1SECTION 457.600
     457.600 Purpose and basis of this subpart.
42:4.0.1.2.15.6.175.2SECTION 457.602
     457.602 Applicability.
42:4.0.1.2.15.6.175.3SECTION 457.606
     457.606 Conditions for State allotments and Federal payments for a fiscal year.
42:4.0.1.2.15.6.175.4SECTION 457.608
     457.608 Process and calculation of State allotments prior to FY 2009.
42:4.0.1.2.15.6.175.5SECTION 457.609
     457.609 Process and calculation of State allotments for a fiscal year after FY 2008.
42:4.0.1.2.15.6.175.6SECTION 457.610
     457.610 Period of availability for State allotments prior to FY 2009.
42:4.0.1.2.15.6.175.7SECTION 457.611
     457.611 Period of availability for State allotments for a fiscal year after FY 2008.
42:4.0.1.2.15.6.175.8SECTION 457.614
     457.614 General payment process.
42:4.0.1.2.15.6.175.9SECTION 457.616
     457.616 Application and tracking of payments against the fiscal year allotments.
42:4.0.1.2.15.6.175.10SECTION 457.618
     457.618 Ten percent limit on certain Children's Health Insurance Program expenditures.
42:4.0.1.2.15.6.175.11SECTION 457.622
     457.622 Rate of FFP for State expenditures.
42:4.0.1.2.15.6.175.12SECTION 457.626
     457.626 Prevention of duplicate payments.
42:4.0.1.2.15.6.175.13SECTION 457.628
     457.628 Other applicable Federal regulations.
42:4.0.1.2.15.6.175.14SECTION 457.630
     457.630 Grants procedures.
42:4.0.1.2.15.7SUBPART G
Subpart G - Strategic Planning, Reporting, and Evaluation
42:4.0.1.2.15.7.175.1SECTION 457.700
     457.700 Basis, scope, and applicability.
42:4.0.1.2.15.7.175.2SECTION 457.710
     457.710 State plan requirements: Strategic objectives and performance goals.
42:4.0.1.2.15.7.175.3SECTION 457.720
     457.720 State plan requirement: State assurance regarding data collection, records, and reports.
42:4.0.1.2.15.7.175.4SECTION 457.730
     457.730 Beneficiary access to and exchange of data.
42:4.0.1.2.15.7.175.5SECTION 457.740
     457.740 State expenditures and statistical reports.
42:4.0.1.2.15.7.175.6SECTION 457.750
     457.750 Annual report.
42:4.0.1.2.15.7.175.7SECTION 457.760
     457.760 Access to published provider directory information.
42:4.0.1.2.15.8SUBPART H
Subpart H - Substitution of Coverage
42:4.0.1.2.15.8.175.1SECTION 457.800
     457.800 Basis, scope, and applicability.
42:4.0.1.2.15.8.175.2SECTION 457.805
     457.805 State plan requirement: Procedures to address substitution under group health plans.
42:4.0.1.2.15.8.175.3SECTION 457.810
     457.810 Premium assistance programs: Required protections against substitution.
42:4.0.1.2.15.9SUBPART I
Subpart I - Program Integrity
42:4.0.1.2.15.9.175.1SECTION 457.900
     457.900 Basis, scope and applicability.
42:4.0.1.2.15.9.175.2SECTION 457.910
     457.910 State program administration.
42:4.0.1.2.15.9.175.3SECTION 457.915
     457.915 Fraud detection and investigation.
42:4.0.1.2.15.9.175.4SECTION 457.925
     457.925 Preliminary investigation.
42:4.0.1.2.15.9.175.5SECTION 457.930
     457.930 Full investigation, resolution, and reporting requirements.
42:4.0.1.2.15.9.175.6SECTION 457.935
     457.935 Sanctions and related penalties.
42:4.0.1.2.15.9.175.7SECTION 457.940
     457.940 Procurement standards.
42:4.0.1.2.15.9.175.8SECTION 457.945
     457.945 Certification for contracts and proposals.
42:4.0.1.2.15.9.175.9SECTION 457.950
     457.950 Contract and payment requirements including certification of payment-related information.
42:4.0.1.2.15.9.175.10SECTION 457.960
     457.960 Reporting changes in eligibility and redetermining eligibility.
42:4.0.1.2.15.9.175.11SECTION 457.965
     457.965 Documentation.
42:4.0.1.2.15.9.175.12SECTION 457.980
     457.980 Verification of enrollment and provider services received.
42:4.0.1.2.15.9.175.13SECTION 457.985
     457.985 Integrity of professional advice to enrollees.
42:4.0.1.2.15.9.175.14SECTION 457.990
     457.990 Provider and supplier screening, oversight, and reporting requirements.
42:4.0.1.2.15.10SUBPART J
Subpart J - Allowable Waivers: General Provisions
42:4.0.1.2.15.10.175.1SECTION 457.1000
     457.1000 Basis, scope, and applicability.
42:4.0.1.2.15.10.175.2SECTION 457.1003
     457.1003 CMS review of waiver requests.
42:4.0.1.2.15.10.175.3SECTION 457.1005
     457.1005 Cost-effective coverage through a community-based health delivery system.
42:4.0.1.2.15.10.175.4SECTION 457.1010
     457.1010 Purchase of family coverage.
42:4.0.1.2.15.10.175.5SECTION 457.1015
     457.1015 Cost-effectiveness.
42:4.0.1.2.15.11SUBPART K
Subpart K - State Plan Requirements: Applicant and Enrollee Protections
42:4.0.1.2.15.11.175.1SECTION 457.1100
     457.1100 Basis, scope and applicability.
42:4.0.1.2.15.11.175.2SECTION 457.1110
     457.1110 Privacy protections.
42:4.0.1.2.15.11.175.3SECTION 457.1120
     457.1120 State plan requirement: Description of review process.
42:4.0.1.2.15.11.175.4SECTION 457.1130
     457.1130 Program specific review process: Matters subject to review.
42:4.0.1.2.15.11.175.5SECTION 457.1140
     457.1140 Program specific review process: Core elements of review.
42:4.0.1.2.15.11.175.6SECTION 457.1150
     457.1150 Program specific review process: Impartial review.
42:4.0.1.2.15.11.175.7SECTION 457.1160
     457.1160 Program specific review process: Time frames.
42:4.0.1.2.15.11.175.8SECTION 457.1170
     457.1170 Program specific review process: Continuation of enrollment.
42:4.0.1.2.15.11.175.9SECTION 457.1180
     457.1180 Program specific review process: Notice.
42:4.0.1.2.15.11.175.10SECTION 457.1190
     457.1190 Application of review procedures when States offer premium assistance for group health plans.
42:4.0.1.2.15.12SUBPART L
Subpart L - Managed Care
42:4.0.1.2.15.12.175SUBJGRP 175
  General Provisions
42:4.0.1.2.15.12.175.1SECTION 457.1200
     457.1200 Basis, scope, and applicability.
42:4.0.1.2.15.12.175.2SECTION 457.1201
     457.1201 Standard contract requirements.
42:4.0.1.2.15.12.175.3SECTION 457.1203
     457.1203 Rate development standards and medical loss ratio.
42:4.0.1.2.15.12.175.4SECTION 457.1206
     457.1206 Non-emergency medical transportation PAHPs.
42:4.0.1.2.15.12.175.5SECTION 457.1207
     457.1207 Information requirements.
42:4.0.1.2.15.12.175.6SECTION 457.1208
     457.1208 Provider discrimination prohibited.
42:4.0.1.2.15.12.175.7SECTION 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).
42:4.0.1.2.15.12.176SUBJGRP 176
  State Responsibilities
42:4.0.1.2.15.12.176.8SECTION 457.1210
     457.1210 Enrollment process.
42:4.0.1.2.15.12.176.9SECTION 457.1212
     457.1212 Disenrollment.
42:4.0.1.2.15.12.176.10SECTION 457.1214
     457.1214 Conflict of interest safeguards.
42:4.0.1.2.15.12.176.11SECTION 457.1216
     457.1216 Continued services to enrollees.
42:4.0.1.2.15.12.176.12SECTION 457.1218
     457.1218 Network adequacy standards.
42:4.0.1.2.15.12.177SUBJGRP 177
  Enrollee Rights and Protections
42:4.0.1.2.15.12.177.13SECTION 457.1220
     457.1220 Enrollee rights.
42:4.0.1.2.15.12.177.14SECTION 457.1222
     457.1222 Provider-enrollee communication.
42:4.0.1.2.15.12.177.15SECTION 457.1224
     457.1224 Marketing activities.
42:4.0.1.2.15.12.177.16SECTION 457.1226
     457.1226 Liability for payment.
42:4.0.1.2.15.12.177.17SECTION 457.1228
     457.1228 Emergency and poststabilization services.
42:4.0.1.2.15.12.178SUBJGRP 178
  MCO, PIHP, and PAHP Standards
42:4.0.1.2.15.12.178.18SECTION 457.1230
     457.1230 Access standards.
42:4.0.1.2.15.12.178.19SECTION 457.1233
     457.1233 Structure and operation standards.
42:4.0.1.2.15.12.179SUBJGRP 179
  Quality Measurement and Improvement; External Quality Review
42:4.0.1.2.15.12.179.20SECTION 457.1240
     457.1240 Quality measurement and improvement.
42:4.0.1.2.15.12.179.21SECTION 457.1250
     457.1250 External quality review.
42:4.0.1.2.15.12.180SUBJGRP 180
  Grievance System
42:4.0.1.2.15.12.180.22SECTION 457.1260
     457.1260 Grievance system.
42:4.0.1.2.15.12.181SUBJGRP 181
  Sanctions
42:4.0.1.2.15.12.181.23SECTION 457.1270
     457.1270 Sanctions.
42:4.0.1.2.15.12.181.24SECTION 457.1280
     457.1280 Conditions necessary to contract as an MCO, PAHP, or PIHP.
42:4.0.1.2.15.12.181.25SECTION 457.1285
     457.1285 Program integrity safeguards.