Title 42

Volume 4 CHAPTER IV SUBCHAP D

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

42:4.0.1.2.15	PART 457	PART 457 - ALLOTMENTS AND GRANTS TO STATES
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.

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