42 U.S.C. § 1397bb — General contents of State child health

Page 4452 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1397n–13 (5) Social impact partnership model The term ‘‘social impact partnership model’’ means a method of financing social services in which— (A) Federal funds are awarded to a State or local government only if a State or local government achieves certain outcomes agreed on by the State or local government and the Secretary; and (B) the State or local government coordi- nates with service providers, investors (if ap- plicable to the project), and (if necessary) an intermediary to identify— (i) an intervention expected to produce the outcome; (ii) a service provider to deliver the intervention to the target population; and (iii) investors to fund the delivery of the intervention. (6) State The term ‘‘State’’ means each State of the United States, the District of Columbia, each commonwealth, territory or possession of the United States, and each federally recognized Indian tribe. (Aug. 14, 1935, ch. 531, title XX, § 2063, as added Pub. L. 115–123, div. E, title VIII, § 50802(2), Feb. 9, 2018, 132 Stat. 282.) § 1397n–13. Funding Out of any money in the Treasury of the United States not otherwise appropriated, there is hereby appropriated $100,000,000 for fiscal year 2018 to carry out this division. (Aug. 14, 1935, ch. 531, title XX, § 2064, as added Pub. L. 115–123, div. E, title VIII, § 50802(2), Feb. 9, 2018, 132 Stat. 282.) SUBCHAPTER XXI—STATE CHILDREN’S HEALTH INSURANCE PROGRAM § 1397aa. Purpose; State child health plans (a) Purpose 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 effec- tive 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 re- quirements of section 1397cc of this title, or (2) providing benefits under the State’s med- icaid plan under subchapter XIX, or a combination of both. (b) State child health plan required A State is not eligible for payment under sec- tion 1397ee of this title unless the State has sub- mitted to the Secretary under section 1397ff of this title 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 chil- dren consistent with the provisions of this subchapter, and (2) has been approved under section 1397ff of this title. (c) State entitlement This subchapter constitutes budget authority in advance of appropriations Acts and represents the obligation of the Federal Government to provide for the payment to States of amounts provided under section 1397dd of this title. (d) Effective date No State is eligible for payments under sec- tion 1397ee of this title for child health assist- ance for coverage provided for periods beginning before October 1, 1997. (Aug. 14, 1935, ch. 531, title XXI, § 2101, as added Pub. L. 105–33, title IV, § 4901(a), Aug. 5, 1997, 111 Stat. 552.) Statutory Notes and Related Subsidiaries REFERENCES TO SCHIP AND STATE CHILDREN’S HEALTH INSURANCE PROGRAM Pub. L. 106–113, div. B, § 1000(a)(6) [title VII, § 704], Nov. 29, 1999, 113 Stat. 1536, 1501A–402, which provided that, in official communications concerning this sub- chapter, the terms ‘‘SCHIP’’ and ‘‘State children’s health insurance program’’ were to be used instead of ‘‘CHIP’’ and ‘‘children’s health insurance program’’, re- spectively, was repealed by Pub. L. 111–3, title VI, § 612, Feb. 4, 2009, 123 Stat. 101. § 1397bb. General contents of State child health plan; eligibility; outreach (a) General background and description A State child health plan shall include a de- scription, consistent with the requirements of this subchapter, of— (1) the extent to which, and manner in which, children in the State, including tar- geted low-income children and other classes of children classified by income and other rel- evant factors, currently have creditable health coverage (as defined in section 1397jj(c)(2) of this title); (2) current State efforts to provide or obtain creditable health coverage for uncovered chil- dren, including the steps the State is taking to identify and enroll all uncovered children who are eligible to participate in public health in- surance programs and health insurance pro- grams that involve public-private partner- ships; (3) how the plan is designed to be coordi- nated with such efforts to increase coverage of children under creditable health coverage; (4) the child health assistance provided under the plan for targeted low-income chil- dren, including the proposed methods of deliv- ery, and utilization control systems; (5) eligibility standards consistent with sub- section (b); (6) outreach activities consistent with sub- section (c); and (7) methods (including monitoring) used— (A) to assure the quality and appropriate- ness of care, particularly with respect to well-baby care, well-child care, and immuni- zations provided under the plan; (B) to assure access to covered services, in- cluding emergency services and services de- scribed in paragraphs (5) and (6) of section 1397cc(c) of this title; and Page 4453 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1397bb 1 See References in Text note below. (C) to ensure that the State agency in- volved is in compliance with subparagraphs (A), (B), and (C) of section 1320a–7n(b)(2) of this title. (b) General description of eligibility standards and methodology (1) Eligibility standards (A) In general The plan shall include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. Such standards may include (to the extent con- sistent with this subchapter) those relating to the geographic areas to be served by the plan, age, income and resources (including any standards relating to spenddowns and disposition of resources), residency, dis- ability status (so long as any standard relat- ing to such status does not restrict eligi- bility), access to or coverage under other health coverage, and duration of eligibility. Such standards may not discriminate on the basis of diagnosis. (B) Limitations on eligibility standards Such eligibility standards— (i) shall, within any defined group of cov- ered targeted low-income children, not cover such children with higher family in- come without covering children with a lower family income; (ii) may not deny eligibility based on a child having a preexisting medical condi- tion; (iii) may not apply a waiting period (in- cluding a waiting period to carry out para- graph (3)(C)) in the case of a targeted low- income pregnant woman provided preg- nancy-related assistance under section 1397ll of this title; (iv) at State option, may not apply a waiting period in the case of a child pro- vided dental-only supplemental coverage under section 1397jj(b)(5) of this title; and (v) shall, beginning January 1, 2014, use modified adjusted gross income and house- hold income (as defined in section 36B(d)(2) of the Internal Revenue Code of 1986) to de- termine eligibility for child health assist- ance under the State child health plan or under any waiver of such plan and for any other purpose applicable under the plan or waiver for which a determination of in- come is required, including with respect to the imposition of premiums and cost-shar- ing, consistent with section 1396a(e)(14) of this title. (2) Methodology The plan shall include a description of meth- ods of establishing and continuing eligibility and enrollment. (3) Eligibility screening; coordination with other health coverage programs The plan shall include a description of proce- dures to be used to ensure— (A) through both intake and followup screening, that only targeted low-income children are furnished child health assist- ance under the State child health plan; (B) that children found through the screen- ing to be eligible for medical assistance under the State medicaid plan under sub- chapter XIX are enrolled for such assistance under such plan; (C) that the insurance provided under the State child health plan does not substitute for coverage under group health plans; (D) the provision of child health assistance to targeted low-income children in the State who are Indians (as defined in section 1603(c) 1 of title 25); and (E) coordination with other public and pri- vate programs providing creditable coverage for low-income children. (4) Reduction of administrative barriers to en- rollment (A) In general Subject to subparagraph (B), the plan shall include a description of the procedures used to reduce administrative barriers to the en- rollment of children and pregnant women who are eligible for medical assistance under subchapter XIX or for child health assist- ance or health benefits coverage under this subchapter. Such procedures shall be estab- lished and revised as often as the State de- termines appropriate to take into account the most recent information available to the State identifying such barriers. (B) Deemed compliance if joint application and renewal process that permits appli- cation other than in person A State shall be deemed to comply with subparagraph (A) if the State’s application and renewal forms and supplemental forms (if any) and information verification process is the same for purposes of establishing and renewing eligibility for children and preg- nant women for medical assistance under subchapter XIX and child health assistance under this subchapter, and such process does not require an application to be made in per- son or a face-to-face interview. (5) Nonentitlement Nothing in this subchapter shall be con- strued as providing an individual with an enti- tlement to child health assistance under a State child health plan. (c) Outreach and coordination A State child health plan shall include a de- scription of the procedures to be used by the State to accomplish the following: (1) Outreach Outreach (through community health work- ers and others) to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs to inform these families of the availability of, and to assist them in enrolling their children in, such a pro- gram. (2) Coordination with other health insurance programs Coordination of the administration of the State program under this subchapter with Page 4454 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1397bb other public and private health insurance pro- grams. (3) Premium assistance subsidies In the case of a State that provides for pre- mium assistance subsidies under the State child health plan in accordance with para- graph (2)(B), (3), or (10) of section 1397ee(c) of this title, or a waiver approved under section 1315 of this title, outreach, education, and en- rollment assistance for families of children likely to be eligible for such subsidies, to in- form such families of the availability of, and to assist them in enrolling their children in, such subsidies, and for employers likely to provide coverage that is eligible for such sub- sidies, including the specific, significant re- sources the State intends to apply to educate employers about the availability of premium assistance subsidies under the State child health plan. (d) Treatment of children who are inmates of a public institution (1) In general The State child health plan shall provide that— (A) the State shall not terminate eligi- bility for child health or pregnancy-related assistance under the State child health plan for a targeted low-income child or targeted low-income pregnant woman because the child or pregnant woman is an inmate of a public institution, but may suspend cov- erage during the period the child or preg- nant woman is such an inmate; (B) in the case of a targeted low-income child who was determined eligible for child health assistance under the State child health plan (or waiver of such plan) imme- diately before becoming an inmate of a pub- lic institution, the State shall, prior to the child’s release from such public institution, conduct a redetermination of eligibility for such child with respect to such child health assistance (without requiring a new applica- tion from the child) and, if the State deter- mines pursuant to such redetermination that the child continues to meet the eligi- bility requirements for such child health as- sistance, the State shall restore coverage for such child health assistance to such child upon the child’s release from such public in- stitution; and (C) in the case of a targeted low-income child who is determined eligible for child health assistance while an inmate of a pub- lic institution (subject to the exception to the exclusion of children who are inmates of a public institution described in section 1397jj(b)(7) of this title), the State shall proc- ess any application for child health assist- ance submitted by, or on behalf of, the child such that the State makes a determination of eligibility for the child with respect to child health assistance upon release of the child from the public institution. (2) Required coverage of screenings, diagnostic services, referrals, and case management for certain inmates pre-release A State child health plan shall provide that, in the case of a targeted low-income child who is within 30 days of the date on which such child is scheduled to be released from a public institution following adjudication, the State shall have in place a plan for providing, and shall provide in accordance with such plan, screenings, diagnostic services, referrals, and case management services otherwise covered under the State child health plan (or waiver of such plan) in the same manner as described in section 1396a(a)(84)(D) of this title. (Aug. 14, 1935, ch. 531, title XXI, § 2102, as added Pub. L. 105–33, title IV, § 4901(a), Aug. 5, 1997, 111 Stat. 552; amended Pub. L. 111–3, title I, § 111(b)(2), title II, §§ 201(b)(2)(B)(i), 212, title III, § 302(a), title V, § 501(a)(2), (b)(2), Feb. 4, 2009, 123 Stat. 28, 39, 55, 63, 85, 86; Pub. L. 111–148, title II, § 2101(d)(1), Mar. 23, 2010, 124 Stat. 287; Pub. L. 111–152, title I, § 1004(b)(2)(A), Mar. 30, 2010, 124 Stat. 1034; Pub. L. 114–198, title VII, § 706(b)(2), July 22, 2016, 130 Stat. 754; Pub. L. 115–271, title V, § 5022(c), Oct. 24, 2018, 132 Stat. 3964; Pub. L. 117–328, div. FF, title V, § 5121(c)(1), Dec. 29, 2022, 136 Stat. 5942; Pub. L. 118–42, div. G, title I, § 205(b)(1), Mar. 9, 2024, 138 Stat. 406.) APPLICABILITY OF AMENDMENT Amendment of section by section 205(b)(1) of title I of div. G of Pub. L. 118–42 applicable be- ginning Jan. 1, 2026. See 2024 Amendment notes below. Editorial Notes REFERENCES IN TEXT The Internal Revenue Code of 1986, referred to in sub- sec. (b)(1)(B)(v), is classified generally to Title 26, Inter- nal Revenue Code. Section 1603(c) of title 25, referred to in subsec. (b)(3)(D), was redesignated section 1603(13) of title 25 by Pub. L. 111–148, title X, § 10221(a), Mar. 23, 2010, 124 Stat. 935. AMENDMENTS 2024—Subsec. (d)(1)(A). Pub. L. 118–42, § 205(b)(1)(B)–(D), inserted ‘‘or targeted low-income pregnant woman’’ after ‘‘targeted low-income child’’, ‘‘or pregnant woman’’ after ‘‘because the child’’, and ‘‘or pregnant woman’’ after ‘‘during the period the child’’. Pub. L. 118–42, § 205(b)(1)(A), which directed insertion of ‘‘or pregnancy-related’’ after ‘‘child health’’, was ex- ecuted by making the insertion before ‘‘assistance under the State child health plan’’ to reflect the prob- able intent of Congress. 2022—Subsec. (d). Pub. L. 117–328 added subsec. (d). 2018—Subsec. (a)(7)(B). Pub. L. 115–271 substituted ‘‘paragraphs (5) and (6) of section 1397cc(c)’’ for ‘‘section 1397cc(c)(5)’’. 2016—Subsec. (a)(7)(C). Pub. L. 114–198 added subpar. (C). 2010—Subsec. (b)(1)(B)(v). Pub. L. 111–152 substituted ‘‘modified adjusted gross income’’ for ‘‘modified gross income’’. Pub. L. 111–148 added cl. (v). 2009—Subsec. (a)(7)(B). Pub. L. 111–3, § 501(a)(2), in- serted ‘‘and services described in section 1397cc(c)(5) of this title’’ after ‘‘emergency services’’. Subsec. (b)(1)(B)(iii), (iv). Pub. L. 111–3, §§ 111(b)(2), 501(b)(2), added cls. (iii) and (iv). Subsec. (b)(4), (5). Pub. L. 111–3, § 212, added par. (4) and redesignated former par. (4) as (5). Subsec. (c)(1). Pub. L. 111–3, § 201(b)(2)(B)(i), inserted ‘‘(through community health workers and others)’’ after ‘‘Outreach’’. Subsec. (c)(3). Pub. L. 111–3, § 302(a), added par. (3). Page 4455 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1397cc Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 2024 AMENDMENT Pub. L. 118–42, div. G, title I, § 205(b)(2), Mar. 9, 2024, 138 Stat. 406, provided that: ‘‘The amendments made by paragraph (1) [amending this section] shall apply begin- ning January 1, 2026.’’ EFFECTIVE DATE OF 2022 AMENDMENT Amendment by Pub. L. 117–328 applicable beginning on the first day of the first calendar quarter that be- gins on or after the date that is 24 months after Dec. 29, 2022, see section 5121(d) of Pub. L. 117–328, set out as a note under section 1396a of this title. EFFECTIVE DATE OF 2018 AMENDMENT Pub. L. 115–271, title V, § 5022(e), Oct. 24, 2018, 132 Stat. 3965, provided that: ‘‘(1) IN GENERAL.—Subject to paragraph (2), the amendments made by this section [amending this sec- tion and sections 1397cc and 1397jj of this title] shall take effect with respect to child health assistance pro- vided on or after the date that is 1 year after the date of the enactment of this Act [Oct. 24, 2018]. ‘‘(2) EXCEPTION FOR STATE LEGISLATION.—In the case of a State child health plan under title XXI of the So- cial Security Act [42 U.S.C. 1397aa et seq.] (or a waiver of such plan), which the Secretary of Health and Human Services determines requires State legislation in order for the respective plan (or waiver) to meet any requirement imposed by the amendments made by this section, the respective plan (or waiver) shall not be re- garded as failing to comply with the requirements of such title solely on the basis of its failure to meet such an additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of enactment of this section [Oct. 24, 2018]. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of the session shall be considered to be a separate regular session of the State legislature.’’ EFFECTIVE DATE OF 2009 AMENDMENT Amendment by sections 111(b)(2), 201(b)(2)(B)(i), 212, 302(a), and 501(b)(2) of Pub. L. 111–3 effective Apr. 1, 2009, and applicable to child health assistance and med- ical assistance provided on or after that date, with cer- tain exceptions, see section 3 of Pub. L. 111–3, set out as an Effective Date note under section 1396 of this title. Pub. L. 111–3, title V, § 501(a)(3), Feb. 4, 2009, 123 Stat. 85, provided that: ‘‘The amendments made by para- graphs (1) and (2) [amending this section and section 1397cc of this title] shall apply to coverage of items and services furnished on or after October 1, 2009.’’ § 1397cc. Coverage requirements for children’s health insurance (a) Required scope of health insurance coverage The child health assistance provided to a tar- geted low-income child under the plan in the form described in paragraph (1) of section 1397aa(a) of this title 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 bench- mark benefit package described in subsection (b). (2) Benchmark-equivalent coverage Health benefits coverage that meets the fol- lowing 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 actu- arial value that is equal to at least 75 per- cent of the actuarial value of the coverage of that category of services in such package. (3) Existing comprehensive State-based cov- erage 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 a State, provides appropriate coverage for the population of targeted low-income children proposed to be provided such coverage. (b) Benchmark benefit packages The benchmark benefit packages are as fol- lows: (1) FEHBP-equivalent children’s health insur- ance coverage The standard Blue Cross/Blue Shield pre- ferred provider option service benefit plan, de- scribed in and offered under section 8903(1) of title 5. (2) State employee coverage A health benefits coverage plan that is of- fered and generally available to State employ- ees in the State involved. (3) Coverage offered through HMO The health insurance coverage plan that— (A) is offered by a health maintenance or- ganization (as defined in section 2791(b)(3) of the Public Health Service Act [42 U.S.C. 300gg–91(b)(3)]), and (B) has the largest insured commercial, non-medicaid enrollment of covered lives of such coverage plans offered by such a health maintenance organization in the State in- volved. (c) Categories of services; determination of actu- arial value of coverage (1) Categories of basic services For purposes of this section, the categories of basic services described in this paragraph are as follows: (A) Inpatient and outpatient hospital serv- ices. (B) Physicians’ surgical and medical serv- ices.