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Title 42 Part 457

Title 42 → Chapter IV → Subchapter D → Part 457

Electronic Code of Federal Regulations e-CFR

Title 42 Part 457

Title 42Chapter IVSubchapter DPart 457


TITLE 42—Public Health

CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED)

SUBCHAPTER D—STATE CHILDREN'S HEALTH INSURANCE PROGRAMS (SCHIPs)

PART 457—ALLOTMENTS AND GRANTS TO STATES

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Subpart A—INTRODUCTION; STATE PLANS FOR CHILD HEALTH INSURANCE PROGRAMS AND OUTREACH STRATEGIES

§457.1
Program description.
§457.2
Basis and scope of subchapter D.
§457.10
Definitions and use of terms.
§457.30
Basis, scope, and applicability of subpart A.
§457.40
State program administration.
§457.50
State plan.
§457.60
Amendments.
§457.65
Effective date and duration of State plans and plan amendments.
§457.70
Program options.
§457.80
Current State child health insurance coverage and coordination.
§457.90
Outreach.
§457.110
Enrollment assistance and information requirements.
§457.120
Public involvement in program development.
§457.125
Provision of child health assistance to American Indian and Alaska Native children.
§457.130
Civil rights assurance.
§457.135
Assurance of compliance with other provisions.
§457.140
Budget.
§457.150
CMS review of State plan material.
§457.160
Notice and timing of CMS action on State plan material.
§457.170
Withdrawal process.
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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

§457.200
Program reviews.
§457.202
Audits.
§457.203
Administrative and judicial review of action on State plan material.
§457.204
Withholding of payment for failure to comply with Federal requirements.
§457.206
Administrative appeals under CHIP.
§457.208
Judicial review.
§457.216
Treatment of uncashed or canceled (voided) CHIP checks.
§457.220
Funds from units of government as the State share of financial participation.
§457.222
FFP for equipment.
§457.224
FFP: Conditions relating to cost sharing.
§457.226
Fiscal policies and accountability.
§457.228
Cost allocation.
§457.230
FFP for State ADP expenditures.
§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.
§457.236
Audits.
§457.238
Documentation of payment rates.
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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.
§457.315
Application of modified adjusted gross income and household definition.
§457.320
Other eligibility standards.
§457.330
Application.
§457.340
Application for and enrollment in CHIP.
§457.342
Continuous eligibility for children.
§457.343
Periodic renewal of CHIP eligibility.
§457.348
Determinations of Children's Health Insurance Program eligibility by other insurance affordability programs.
§457.350
Eligibility screening and enrollment in other insurance affordability programs.
§457.351
Coordination involving appeals entities for different insurance affordability programs.
§457.353
Monitoring and evaluation of screening process.
§457.355
Presumptive eligibility for children.
§457.360
Deemed newborn children.
§457.370
Alignment with Exchange initial open enrollment period.
§457.380
Eligibility verification.
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Subpart D—STATE PLAN REQUIREMENTS: COVERAGE AND BENEFITS

§457.401
Basis, scope, and applicability.
§457.402
Definition of child health assistance.
§457.410
Health benefits coverage options.
§457.420
Benchmark health benefits coverage.
§457.430
Benchmark-equivalent health benefits coverage.
§457.431
Actuarial report for benchmark-equivalent coverage.
§457.440
Existing comprehensive State-based coverage.
§457.450
Secretary-approved coverage.
§457.470
Prohibited coverage.
§457.475
Limitations on coverage: Abortions.
§457.480
Preexisting condition exclusions and relation to other laws.
§457.490
Delivery and utilization control systems.
§457.495
State assurance of access to care and procedures to assure quality and appropriateness of care.
§457.496
Parity in mental health and substance use disorder benefits.
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Subpart E—STATE PLAN REQUIREMENTS: ENROLLEE FINANCIAL RESPONSIBILITIES

§457.500
Basis, scope, and applicability.
§457.505
General State plan requirements.
§457.510
Premiums, enrollment fees, or similar fees: State plan requirements.
§457.515
Co-payments, coinsurance, deductibles, or similar cost-sharing charges: State plan requirements.
§457.520
Cost sharing for well-baby and well-child care services.
§457.525
Public schedule.
§457.530
General cost-sharing protection for lower income children.
§457.535
Cost-sharing protection to ensure enrollment of American Indians and Alaska Natives.
§457.540
Cost-sharing charges for children in families with incomes at or below 150 percent of the FPL.
§457.555
Maximum allowable cost-sharing charges on targeted low-income children in families with income from 101 to 150 percent of the FPL.
§457.560
Cumulative cost-sharing maximum.
§457.570
Disenrollment protections.
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Subpart F—PAYMENTS TO STATES

§457.600
Purpose and basis of this subpart.
§457.602
Applicability.
§457.606
Conditions for State allotments and Federal payments for a fiscal year.
§457.608
Process and calculation of State allotments prior to FY 2009.
§457.609
Process and calculation of State allotments for a fiscal year after FY 2008.
§457.610
Period of availability for State allotments prior to FY 2009.
§457.611
Period of availability for State allotments for a fiscal year after FY 2008.
§457.614
General payment process.
§457.616
Application and tracking of payments against the fiscal year allotments.
§457.618
Ten percent limit on certain Children's Health Insurance Program expenditures.
§457.622
Rate of FFP for State expenditures.
§457.626
Prevention of duplicate payments.
§457.628
Other applicable Federal regulations.
§457.630
Grants procedures.
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Subpart G—STRATEGIC PLANNING, REPORTING, AND EVALUATION

§457.700
Basis, scope, and applicability.
§457.710
State plan requirements: Strategic objectives and performance goals.
§457.720
State plan requirement: State assurance regarding data collection, records, and reports.
§457.740
State expenditures and statistical reports.
§457.750
Annual report.
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Subpart H—SUBSTITUTION OF COVERAGE

§457.800
Basis, scope, and applicability.
§457.805
State plan requirement: Procedures to address substitution under group health plans.
§457.810
Premium assistance programs: Required protections against substitution.
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Subpart I—PROGRAM INTEGRITY

§457.900
Basis, scope and applicability.
§457.910
State program administration.
§457.915
Fraud detection and investigation.
§457.925
Preliminary investigation.
§457.930
Full investigation, resolution, and reporting requirements.
§457.935
Sanctions and related penalties.
§457.940
Procurement standards.
§457.945
Certification for contracts and proposals.
§457.950
Contract and payment requirements including certification of payment-related information.
§457.960
Reporting changes in eligibility and redetermining eligibility.
§457.965
Documentation.
§457.980
Verification of enrollment and provider services received.
§457.985
Integrity of professional advice to enrollees.
§457.990
Provider and supplier screening, oversight, and reporting requirements.
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Subpart J—ALLOWABLE WAIVERS: GENERAL PROVISIONS

§457.1000
Basis, scope, and applicability.
§457.1003
CMS review of waiver requests.
§457.1005
Cost-effective coverage through a community-based health delivery system.
§457.1010
Purchase of family coverage.
§457.1015
Cost-effectiveness.
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Subpart K—STATE PLAN REQUIREMENTS: APPLICANT AND ENROLLEE PROTECTIONS

§457.1100
Basis, scope and applicability.
§457.1110
Privacy protections.
§457.1120
State plan requirement: Description of review process.
§457.1130
Program specific review process: Matters subject to review.
§457.1140
Program specific review process: Core elements of review.
§457.1150
Program specific review process: Impartial review.
§457.1160
Program specific review process: Time frames.
§457.1170
Program specific review process: Continuation of enrollment.
§457.1180
Program specific review process: Notice.
§457.1190
Application of review procedures when States offer premium assistance for group health plans.
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Subpart L—MANAGED CARE

General Provisions

§457.1200
Basis, scope, and applicability.
§457.1201
Standard contract requirements.
§457.1203
Rate development standards and medical loss ratio.
§457.1206
Non-emergency medical transportation PAHPs.
§457.1207
Information requirements.
§457.1208
Provider discrimination prohibited.
§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).

State Responsibilities

§457.1210
Enrollment process.
§457.1212
Disenrollment.
§457.1214
Conflict of interest safeguards.
§457.1216
Continued services to enrollees.
§457.1218
Network adequacy standards.

Enrollee Rights and Protections

§457.1220
Enrollee rights.
§457.1222
Provider-enrollee communication.
§457.1224
Marketing activities.
§457.1226
Liability for payment.
§457.1228
Emergency and poststabilization services.

MCO, PIHP, and PAHP Standards

§457.1230
Access standards.
§457.1233
Structure and operation standards.

Quality Measurement and Improvement; External Quality Review

§457.1240
Quality measurement and improvement.
§457.1250
External quality review.

Grievance System

§457.1260
Grievance system.

Sanctions

§457.1270
Sanctions.
§457.1280
Conditions necessary to contract as an MCO, PAHP, or PIHP.
§457.1285
Program integrity safeguards.

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