Title 42, Part 457 — Allotments and Grants to States

Program description.

Basis and scope of subchapter D.

Definitions and use of terms.

Basis, scope, and applicability of subpart A.

State program administration.

State plan.

Amendments.

Effective date and duration of State plans and plan amendments.

Program options.

Current State child health insurance coverage and coordination.

Outreach.

Enrollment assistance and information requirements.

Public involvement in program development.

Provision of child health assistance to American Indian and Alaska Native children.

Civil rights assurance.

Assurance of compliance with other provisions.

Budget.

CMS review of State plan material.

Notice and timing of CMS action on State plan material.

Withdrawal process.

Program reviews.

Audits.

Administrative and judicial review of action on State plan material.

Withholding of payment for failure to comply with Federal requirements.

Administrative appeals under CHIP.

Judicial review.

Treatment of uncashed or canceled (voided) CHIP checks.

Funds from units of government as the State share of financial participation.

FFP for equipment.

FFP: Conditions relating to cost sharing.

Fiscal policies and accountability.

Cost allocation.

FFP for State ADP expenditures.

Refunding of Federal Share of CHIP overpayments to providers and referral of allegations of waste, fraud or abuse to the Office of Inspector General.

Audits.

Documentation of payment rates.

Basis, scope, and applicability.

Definitions and use of terms.

State plan provisions.

Targeted low-income child.

Application of modified adjusted gross income and household definition.

Other eligibility standards.

Application.

Application for and enrollment in CHIP.

Continuous eligibility for children.

Periodic renewal of CHIP eligibility.

Changes in circumstances.

Determinations of Children's Health Insurance Program eligibility by other insurance affordability programs.

Eligibility screening and enrollment in other insurance affordability programs.

Coordination involving appeals entities for different insurance affordability programs.

Monitoring and evaluation of screening process.

Presumptive eligibility for children.

Deemed newborn children.

Alignment with Exchange initial open enrollment period.

Eligibility verification.

Basis, scope, and applicability.

Definition of child health assistance.

Health benefits coverage options.

Benchmark health benefits coverage.

Benchmark-equivalent health benefits coverage.

Actuarial report for benchmark-equivalent coverage.

Existing comprehensive State-based coverage.

Secretary-approved coverage.

Prohibited coverage.

Limitations on coverage: Abortions.

Prohibited coverage limitations, preexisting condition exclusions, and relation to other laws.

Delivery and utilization control systems.

State assurance of access to care and procedures to assure quality and appropriateness of care.

Parity in mental health and substance use disorder benefits.

Basis, scope, and applicability.

General State plan requirements.

Premiums, enrollment fees, or similar fees: State plan requirements.

Co-payments, coinsurance, deductibles, or similar cost-sharing charges: State plan requirements.

Cost sharing for well-baby and well-child care services.

Public schedule.

General cost-sharing protection for lower income children.

Cost-sharing protection to ensure enrollment of American Indians and Alaska Natives.

Cost-sharing charges for children in families with incomes at or below 150 percent of the FPL.

Maximum allowable cost-sharing charges on targeted low-income children in families with income from 101 to 150 percent of the FPL.

Cumulative cost-sharing maximum.

Disenrollment protections.

Purpose and basis of this subpart.

Applicability.

Conditions for State allotments and Federal payments for a fiscal year.

Process and calculation of State allotments prior to FY 2009.

Process and calculation of State allotments for a fiscal year after FY 2008.

Period of availability for State allotments prior to FY 2009.

Period of availability for State allotments for a fiscal year after FY 2008.

General payment process.

Application and tracking of payments against the fiscal year allotments.

Ten percent limit on certain Children's Health Insurance Program expenditures.

Rate of FFP for State expenditures.

Prevention of duplicate payments.

Other applicable Federal regulations.

Grants procedures.

Basis, scope, and applicability.

State plan requirements: Strategic objectives and performance goals.

State plan requirement: State assurance regarding data collection, records, and reports.

Beneficiary access to and exchange of data.

Access to and exchange of health data for providers and payers.

Prior authorization requirements.

State expenditures and statistical reports.

Annual report.

Access to published provider directory information.

Reporting on Health Care Quality Measures.

Basis, scope, and applicability.

State plan requirement: Procedures to address substitution under group health plans.

Premium assistance programs: Required protections against substitution.

Basis, scope and applicability.

State program administration.

Fraud detection and investigation.

Preliminary investigation.

Full investigation, resolution, and reporting requirements.

Sanctions and related penalties.

Procurement standards.

Certification for contracts and proposals.

Contract and payment requirements including certification of payment-related information.

Documentation.

Verification of enrollment and provider services received.

Integrity of professional advice to enrollees.

Provider and supplier screening, oversight, and reporting requirements.

Basis, scope, and applicability.

CMS review of waiver requests.

Cost-effective coverage through a community-based health delivery system.

Purchase of family coverage.

Cost-effectiveness.

Basis, scope and applicability.

Privacy protections.

State plan requirement: Description of review process.

Program specific review process: Matters subject to review.

Program specific review process: Core elements of review.

Program specific review process: Impartial review.

Program specific review process: Time frames.

Program specific review process: Continuation of enrollment.

Program specific review process: Notice.

Application of review procedures when States offer premium assistance for group health plans.

Basis, scope, and applicability.

Standard contract requirements.

Rate development standards and medical loss ratio.

Non-emergency medical transportation PAHPs.

Information requirements.

Provider discrimination prohibited.

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).

Enrollment process.

Disenrollment.

Conflict of interest safeguards.

Continued services to enrollees.

Network adequacy standards.

Enrollee rights.

Provider-enrollee communication.

Marketing activities.

Liability for payment.

Emergency and poststabilization services.

Access standards.

Structure and operation standards.

Quality measurement and improvement.

External quality review.

Grievance system.

Sanctions.

Conditions necessary to contract as an MCO, PAHP, or PIHP.

Program integrity safeguards.