42 CFR Part 457
PART 457—ALLOTMENTS AND GRANTS TO STATES
- PART 457—ALLOTMENTS AND GRANTS TO STATES
- Chapter IV—Centers for Medicare & Medicaid Services, Department of Health and Human Services › Subchapter D—State Children's Health Insurance Programs (SCHIPs)
- Subpart A—Introduction; State Plans for Child Health Insurance Programs and Outreach Strategies
- § 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 CHIP.
- § 457.208 Judicial review.
- § 457.216 Treatment of uncashed or canceled (voided) CHIP checks.
- § 457.220 Funds from units of government 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 CHIP overpayments to providers and referral of allegations of waste, fraud or abuse to the Office of Inspector General.
- § 457.236 Audits.
- § 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.
- § 457.315 Application of modified adjusted gross income and household definition.
- § 457.320 Other eligibility standards.
- § 457.330 Application.
- § 457.340 Application for and enrollment in CHIP.
- § 457.342 Continuous eligibility for children.
- § 457.343 Periodic renewal of CHIP eligibility.
- § 457.348 Determinations of Children's Health Insurance Program eligibility by other insurance affordability programs.
- § 457.350 Eligibility screening and enrollment in other insurance affordability programs.
- § 457.351 Coordination involving appeals entities for different insurance affordability programs.
- § 457.353 Monitoring and evaluation of screening process.
- § 457.355 Presumptive eligibility for children.
- § 457.360 Deemed newborn children.
- § 457.370 Alignment with Exchange initial open enrollment period.
- § 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 Prohibited coverage limitations, 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.
- § 457.496 Parity in mental health and substance use disorder benefits.
- 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.
- § 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—Payments 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 prior to FY 2009.
- § 457.609 Process and calculation of State allotments for a fiscal year after FY 2008.
- § 457.610 Period of availability for State allotments prior to FY 2009.
- § 457.611 Period of availability for State allotments for a fiscal year after FY 2008.
- § 457.614 General payment process.
- § 457.616 Application and tracking of payments against the fiscal year allotments.
- § 457.618 Ten percent limit on certain 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.
- § 457.730 Beneficiary access to and exchange of data.
- § 457.731 Access to and exchange of health data for providers and payers.
- § 457.732 Prior authorization requirements.
- § 457.740 State expenditures and statistical reports.
- § 457.750 Annual report.
- § 457.760 Access to published provider directory information.
- § 457.770 Reporting on Health Care Quality Measures.
- Subpart H—Substitution of Coverage
- § 457.800 Basis, scope, and applicability.
- § 457.805 State plan requirement: 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.
- § 457.910 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.
- § 457.960 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.
- § 457.990 Provider and supplier screening, oversight, and reporting requirements.
- 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.
- Subpart L—Managed Care
- General Provisions
- § 457.1200 Basis, scope, and applicability.
- § 457.1201 Standard contract requirements.
- § 457.1203 Rate development standards and medical loss ratio.
- § 457.1206 Non-emergency medical transportation PAHPs.
- § 457.1207 Information requirements.
- § 457.1208 Provider discrimination prohibited.
- § 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).
- State Responsibilities
- § 457.1210 Enrollment process.
- § 457.1212 Disenrollment.
- § 457.1214 Conflict of interest safeguards.
- § 457.1216 Continued services to enrollees.
- § 457.1218 Network adequacy standards.
- Enrollee Rights and Protections
- § 457.1220 Enrollee rights.
- § 457.1222 Provider-enrollee communication.
- § 457.1224 Marketing activities.
- § 457.1226 Liability for payment.
- § 457.1228 Emergency and poststabilization services.
- MCO, PIHP, and PAHP Standards
- § 457.1230 Access standards.
- § 457.1233 Structure and operation standards.
- Quality Measurement and Improvement; External Quality Review
- § 457.1240 Quality measurement and improvement.
- § 457.1250 External quality review.
- Grievance System
- § 457.1260 Grievance system.
- Sanctions
- § 457.1270 Sanctions.
- § 457.1280 Conditions necessary to contract as an MCO, PAHP, or PIHP.
- § 457.1285 Program integrity safeguards.
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