Title 42

PART 457

Part 457 - Allotments And Grants To States

PART 457 - ALLOTMENTS AND GRANTS TO STATES Authority:42 U.S.C. 1302. Source:65 FR 33622, May 24, 2000, unless otherwise noted. Editorial Note:Nomenclature changes to part 457 appear at 75 FR 48852, Aug. 11, 2010 and 77 FR 17213, 2013.

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.