[Code of Federal Regulations] [Title 42, Volume 3] [Revised as of October 1, 2004] From the U.S. Government Printing Office via GPO Access [CITE: 42CFR457.1] [Page 361-363] TITLE 42--PUBLIC HEALTH CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PART 457_ALLOTMENTS AND GRANTS TO STATES--Table of Contents Subpart A_Introduction; State Plans for Child Health Insurance Programs and Outreach Strategies Sec. 457.1 Program description. Subpart A_Introduction; State Plans for Child Health Insurance Programs and Outreach Strategies Sec. 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. 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 SCHIP. 457.208 Judicial review. 457.210 Deferral of claims for FFP. 457.212 Disallowance of claims for FFP. 457.216 Treatment of uncashed or canceled (voided) SCHIP checks. 457.218 Repayment of Federal funds by installments. 457.220 Public funds 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 SCHIP overpayments to providers and referral of allegations of waste, fraud or abuse of the Office of Inspector General. 457.236 Audit of records. 457.238 Documentation of payment rates. 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. 457.320 Other eligibility standards. 457.340 Application for and enrollment in a separate child health program. 457.350 Eligibility screening and facilitation of Medicaid enrollment. 457.353 Monitoring and evaluation of screening process. 457.355 Presumptive eligibility. 457.380 Eligibility verification. 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. 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. [[Page 362]] 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. Subpart F_Payment 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 for a fiscal year. 457.610 Period of availability for State allotments for a fiscal year. 457.614 General payment process. 457.616 Application and tracking of payments against the fiscal year allotments. 457.618 Ten percent limit on certain State 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. 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. Subpart H_Substitution of Coverage 457.800 Basis, scope, and applicability. 457.805 State plan requirements: Procedures to address substitution under group health plans. 457.810 Premium assistance programs: Required protections against substitution. Subpart I_Program Integrity 457.900 Basis, scope, and applicability. 457.902 Definitions. 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. 457.955 Conditions necessary to contract as a managed care entity (MCE). 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. 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. 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. Authority: Section 1102 of the Social Security Act (42 U.S.C. 1302). Source: 65 FR 33622, May 24, 2000, unless otherwise noted. [[Page 363]] Source: 66 FR 2670, Jan. 11, 2001, unless otherwise noted. Title XXI of the Social Security Act, enacted in 1997 by the Balanced Budget Act, authorizes Federal grants to States for provision of child health assistance to uninsured, low-income children. The program is jointly financed by the Federal and State governments and administered by the States. Within broad Federal rules, each State decides eligible groups, types and ranges of services, payment levels for benefit coverage, and administrative and operating procedures.