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42 U.S.C. § 1397aa — Purpose; State child health plans

Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1397aa — Purpose; State child health plans

**(a) Purpose** Except with respect to the rural health transformation program established in [section 1397ee(h) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397ee/h&num=0&edition=prelim), the purpose of this subchapter is to provide funds to States to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner that is coordinated with other sources of health benefits coverage for children. Such assistance shall be provided primarily for obtaining health benefits coverage through— (1) obtaining coverage that meets the requirements of [section 1397cc of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397cc&num=0&edition=prelim), or (2) providing benefits under the State’s medicaid plan under subchapter XIX, or a combination of both. **(b) State child health plan required** A State is not eligible for payment under subsection (a) or (g) of [section 1397ee of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397ee&num=0&edition=prelim) unless the State has submitted to the Secretary under [section 1397ff of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397ff&num=0&edition=prelim) a plan that— (1) sets forth how the State intends to use the funds provided under this subchapter to provide child health assistance to needy children consistent with the provisions of this subchapter, and (2) has been approved under [section 1397ff of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397ff&num=0&edition=prelim). **(c) State entitlement** This subchapter constitutes budget authority i

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Source file: Laws/federal/codes/united-states-code/title-42/section-1397aa-purpose-state-child-health-plans--ab3bc9607b.md
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Source location: Title 42, Chapter 7, § 1397aa; chapter-007-social-security.md

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1397ee — Payments to States

**(a) Payments** (1) **In general** — Subject to the succeeding provisions of this section, the Secretary shall pay to each State with a plan approved under this subchapter, from its allotment under [section 1397dd of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397dd&num=0&edition=prelim), an amount for each quarter equal to the enhanced FMAP (or, in the case of expenditures described in subparagraph (D)(iv), the higher of 75 percent or the sum of the enhanced FMAP plus 5 percentage points) of expenditures in the quarter— (A) for child health assistance under the plan for targeted low-income children in the form of providing medical assistance for which payment is made on the basis of an enhanced FMAP under the fourth sentence of [section 1396d(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396d/b&num=0&edition=prelim); (B) [reserved] (C) for child health assistance under the plan for targeted low-income children in the form of providing health benefits coverage that meets the requirements of [section 1397cc of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397cc&num=0&edition=prelim); and (D) only to the extent permitted consistent with subsection (c)— (i) for payment for other child health assistance for targeted low-income children; (ii) for expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); (iii) for expenditures for outreach activities as provided in [section 1397bb(c)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397bb/c/1&num=0&edition=pre

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1397ee

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1397ff — Process for submission, approval, and amendment of State child health plans

**(a) Initial plan** (1) **In general** — As a condition of receiving payment under subsection (a) or (g) of [section 1397ee of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397ee&num=0&edition=prelim), a State shall submit to the Secretary a State child health plan that meets the applicable requirements of this subchapter. (2) **Approval** — Except as the Secretary may provide under subsection (e), a State plan submitted under paragraph (1)— (A) shall be approved for purposes of this subchapter, and (B) shall be effective beginning with a calendar quarter that is specified in the plan, but in no case earlier than October 1, 1997. **(b) Plan amendments** (1) **In general** — A State may amend, in whole or in part, its State child health plan at any time through transmittal of a plan amendment. (2) **Approval** — Except as the Secretary may provide under subsection (e), an amendment to a State plan submitted under paragraph (1)— (A) shall be approved for purposes of this subchapter, and (B) shall be effective as provided in paragraph (3). (3) **Effective dates for amendments** (A) *In general* — Subject to the succeeding provisions of this paragraph, an amendment to a State plan shall take effect on one or more effective dates specified in the amendment. (B) *Amendments relating to eligibility or benefits* (i) *Notice requirement* — Any plan amendment that eliminates or restricts eligibility or benefits under the plan may not take effect unless the State certifies that it has provided prior public notice of the change, in a form and manner provided under applicable State law. (ii) *Timely transmittal* — Any plan amendment that eliminates or restricts eligibility or benefits under the plan shall

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1397cc — Coverage requirements for children’s health insurance

**(a) Required scope of health insurance coverage** The child health assistance provided to a targeted low-income child under the plan in the form described in paragraph (1) of [section 1397aa(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397aa/a&num=0&edition=prelim) shall consist, consistent with paragraphs (5), (6), (7), and (8) of subsection (c), of any of the following: (1) **Benchmark coverage** — Health benefits coverage that is at least equivalent to the benefits coverage in a benchmark benefit package described in subsection (b). (2) **Benchmark-equivalent coverage** — Health benefits coverage that meets the following requirements: (A) *Inclusion of basic services* — The coverage includes benefits for items and services within each of the categories of basic services described in subsection (c)(1). (B) *Aggregate actuarial value equivalent to benchmark package* — The coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages. (C) *Substantial actuarial value for additional services included in benchmark package* — With respect to each of the categories of additional services described in subsection (c)(2) for which coverage is provided under the benchmark benefit package used under subparagraph (B), the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the coverage of that category of services in such package. (3) **Existing comprehensive State-based coverage** — Health benefits coverage under an existing comprehensive State-based program, described in subsection (d)(1). (4) **Secretary-approved coverage** — Any other health benefits coverage that the Secretary determines, upon application by

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1397cc

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1397dd — Allotments

**(a) Appropriation; total allotment** For the purpose of providing allotments to States under this section, subject to subsection (d), there is appropriated, out of any money in the Treasury not otherwise appropriated— (1) for fiscal year 1998, $4,295,000,000; (2) for fiscal year 1999, $4,275,000,000; (3) for fiscal year 2000, $4,275,000,000; (4) for fiscal year 2001, $4,275,000,000; (5) for fiscal year 2002, $3,150,000,000; (6) for fiscal year 2003, $3,150,000,000; (7) for fiscal year 2004, $3,150,000,000; (8) for fiscal year 2005, $4,050,000,000; (9) for fiscal year 2006, $4,050,000,000; (10) for fiscal year 2007, $5,000,000,000; (11) for fiscal year 2008, $5,000,000,000.11 So in original. The period probably should be a semicolon. (12) for fiscal year 2009, $10,562,000,000; (13) for fiscal year 2010, $12,520,000,000; (14) for fiscal year 2011, $13,459,000,000; (15) for fiscal year 2012, $14,982,000,000; (16) for fiscal year 2013, $17,406,000,000; (17) for fiscal year 2014, $19,147,000,000; (18) for fiscal year 2015, for purposes of making 2 semi-annual allotments— (A) $2,850,000,000 for the period beginning on October 1, 2014, and ending on March 31, 2015, and (B) $2,850,000,000 for the period beginning on April 1, 2015, and ending on September 30, 2015; (19) for fiscal year 2016, $19,300,000,000; (20) for fiscal year 2017, for purposes of making 2 semi-annual allotments— (A) $2,850,000,000 for the period beginning on October 1, 2016, and ending on March 31, 2017; and (B) $2,850,000,000 for the period beginning on April 1, 2017, and ending on September 30, 2017; (21) for fiscal year 2018, $21,500,000,000; (22) for fiscal year 2019, $22,600,000,000; (23) for fiscal year 2020, $23,700,000,000; (24) for fiscal year 2021, $24,800,000,

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1397dd

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Federal law — U.S. Code and appendices · legal_authorities

15 U.S.C. § 657p — Outreach regarding health insurance options available to children

**(a) Definitions** In this section— (1) the terms “Administration” and “Administrator” means the Small Business Administration and the Administrator thereof, respectively; (2) the term “certified development company” means a development company participating in the program under title V of the Small Business Investment Act of 1958 ([15 U.S.C. 695](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title15-section695&num=0&edition=prelim) et seq.); (3) the term “Medicaid program” means the program established under title XIX of the Social Security Act ([42 U.S.C. 1396](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396&num=0&edition=prelim) et seq.); (4) the term “Service Corps of Retired Executives” means the Service Corps of Retired Executives authorized by [section 637(b)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title15-section637/b/1&num=0&edition=prelim); (5) the term “small business concern” has the meaning given that term in [section 632 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title15-section632&num=0&edition=prelim); (6) the term “small business development center” means a small business development center described in [section 648 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title15-section648&num=0&edition=prelim); (7) the term “State” has the meaning given that term for purposes of title XXI of the Social Security Act ([42 U.S.C. 1397aa](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1397aa&num=0&edition=prelim) et seq.); (8) the term “State Children’s Health Insurance Program” means the State Children’s Health Insurance Program established under title XXI of the Social Security A

Source: Supplied U.S. Code snapshot — release unconfirmed · 15 U.S.C. § 657p

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Federal law — U.S. Code and appendices · legal_authorities

29 U.S.C. § 1181 — Increased portability through limitation on preexisting condition exclusions

**(a) Limitation on preexisting condition exclusion period; crediting for periods of previous coverage** Subject to subsection (d), a group health plan, and a health insurance issuer offering group health insurance coverage, may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if— (1) such exclusion relates to a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on the enrollment date; (2) such exclusion extends for a period of not more than 12 months (or 18 months in the case of a late enrollee) after the enrollment date; and (3) the period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage (if any, as defined in subsection (c)(1)) applicable to the participant or beneficiary as of the enrollment date. **(b) Definitions** For purposes of this part— (1) **Preexisting condition exclusion** (A) *In general* — The term “preexisting condition exclusion” means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date. (B) *Treatment of genetic information* — Genetic information shall not be treated as a condition described in subsection (a)(1) in the absence of a diagnosis of the condition related to such information. (2) **Enrollment date** — The term “enrollment date” means, with respect to an individual covered under a group health plan or health insurance coverage, the date of e

Source: Supplied U.S. Code snapshot — release unconfirmed · 29 U.S.C. § 1181

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Federal law — U.S. Code and appendices · legal_authorities

29 U.S.C. § 1185e — Preventing surprise medical bills

**(a) Coverage of emergency services** (1) **In general** — If a group health plan, or a health insurance issuer offering group health insurance coverage, provides or covers any benefits with respect to services in an emergency department of a hospital or with respect to emergency services in an independent freestanding emergency department (as defined in paragraph (3)(D)), the plan or issuer shall cover emergency services (as defined in paragraph (3)(C))— (A) without the need for any prior authorization determination; (B) whether the health care provider furnishing such services is a participating provider or a participating emergency facility, as applicable, with respect to such services; (C) in a manner so that, if such services are provided to a participant or beneficiary by a nonparticipating provider or a nonparticipating emergency facility— (i) such services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from participating providers and participating emergency facilities with respect to such plan or coverage, respectively; (ii) the cost-sharing requirement is not greater than the requirement that would apply if such services were provided by a participating provider or a participating emergency facility; (iii) such cost-sharing requirement is calculated as if the total amount that would have been charged for such services by such participating provider or participating emergency facility were equal to the recognized amount (as defined in paragraph (3)(H)) for such services, plan or coverage, and year; (iv) the group health plan or health insurance i

Source: Supplied U.S. Code snapshot — release unconfirmed · 29 U.S.C. § 1185e

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Federal law — U.S. Code and appendices · legal_authorities

29 U.S.C. § 1185f — Ending surprise air ambulance bills

**(a) In general** In the case of a participant or beneficiary who is in a group health plan or group health insurance coverage offered by a health insurance issuer and who receives air ambulance services from a nonparticipating provider (as defined in [section 1185e(a)(3)(G) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title29-section1185e/a/3/G&num=0&edition=prelim)) with respect to such plan or coverage, if such services would be covered if provided by a participating provider (as defined in such section) with respect to such plan or coverage— (1) the cost-sharing requirement with respect to such services shall be the same requirement that would apply if such services were provided by such a participating provider, and any coinsurance or deductible shall be based on rates that would apply for such services if they were furnished by such a participating provider; (2) such cost-sharing amounts shall be counted towards the in-network deductible and in-network out-of-pocket maximum amount under the plan or coverage for the plan year (and such in-network deductible shall be applied) with respect to such items and services so furnished in the same manner as if such cost-sharing payments were with respect to items and services furnished by a participating provider; and (3) the group health plan or health insurance issuer, respectively, shall— (A) not later than 30 calendar days after the bill for such services is transmitted by such provider, send to the provider, an initial payment or notice of denial of payment; and (B) pay a total plan or coverage payment, in accordance with, if applicable, subsection (b)(6), directly to such provider furnishing such services to such participant, beneficiary, or enrollee that is, with application o

Source: Supplied U.S. Code snapshot — release unconfirmed · 29 U.S.C. § 1185f

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1320a–7m — Use of predictive modeling and other analytics technologies to identify and prevent waste, fraud, and abuse in the Medicare fee-for-service program

**(a) Use in the Medicare fee-for-service program** The Secretary shall use predictive modeling and other analytics technologies (in this section referred to as “predictive analytics technologies”) to identify improper claims for reimbursement and to prevent the payment of such claims under the Medicare fee-for-service program. **(b) Predictive analytics technologies requirements** The predictive analytics technologies used by the Secretary shall— (1) capture Medicare provider and Medicare beneficiary activities across the Medicare fee-for-service program to provide a comprehensive view across all providers, beneficiaries, and geographies within such program in order to— (A) identify and analyze Medicare provider networks, provider billing patterns, and beneficiary utilization patterns; and (B) identify and detect any such patterns and networks that represent a high risk of fraudulent activity; (2) be integrated into the existing Medicare fee-for-service program claims flow with minimal effort and maximum efficiency; (3) be able to— (A) analyze large data sets for unusual or suspicious patterns or anomalies or contain other factors that are linked to the occurrence of waste, fraud, or abuse; (B) undertake such analysis before payment is made; and (C) prioritize such identified transactions for additional review before payment is made in terms of the likelihood of potential waste, fraud, and abuse to more efficiently utilize investigative resources; (4) capture outcome information on adjudicated claims for reimbursement to allow for refinement and enhancement of the predictive analytics technologies on the basis of such outcome information, including post-payment information about the eventual status of a claim; and (5) prevent the payment of claims

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320a–7m

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1395ii — Agreements with providers of services; enrollment processes

**(a) Filing of agreements; eligibility for payment; charges with respect to items and services** (1) Any provider of services (except a fund designated for purposes of section 1395f(g) and [section 1395n(e) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395n/e&num=0&edition=prelim)) shall be qualified to participate under this subchapter and shall be eligible for payments under this subchapter if it files with the Secretary an agreement— (A) (i) not to charge, except as provided in paragraph (2), any individual or any other person for items or services for which such individual is entitled to have payment made under this subchapter (or for which he would be so entitled if such provider of services had complied with the procedural and other requirements under or pursuant to this subchapter or for which such provider is paid pursuant to the provisions of [section 1395f(e) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395f/e&num=0&edition=prelim)), and (ii) not to impose any charge that is prohibited under [section 1396a(n)(3) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396a/n/3&num=0&edition=prelim), (B) not to charge any individual or any other person for items or services for which such individual is not entitled to have payment made under this subchapter because payment for expenses incurred for such items or services may not be made by reason of the provisions of paragraph (1) or (9) of [section 1395y(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395y/a&num=0&edition=prelim), but only if (i) such individual was without fault in incurring such expenses and (ii) the Secret

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395ii

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