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.

§ 457.210 - Deferral of claims for FFP.

§ 457.212 - Disallowance of claims for FFP.

§ 457.216 - Treatment of uncashed or canceled (voided) CHIP checks.

§ 457.218 - Repayment of Federal funds by installments.

§ 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.

§ 457.234 - State plan requirements.

§ 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.

§ 457.344 - xxx

§ 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 - 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.

§ 457.624 - Limitations on certain payments for certain 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 - xxx

§ 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.

§ 457.902 - 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.

§ 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

Quality Measurement and Improvement; External Quality Review

§ 457.1240 - Quality measurement and improvement.

§ 457.1250 - External quality review.

MCO, PIHP, and PAHP Standards

§ 457.1230 - Access standards.

§ 457.1233 - Structure and operation standards.

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).

Sanctions

§ 457.1270 - Sanctions.

§ 457.1280 - Conditions necessary to contract as an MCO, PAHP, or PIHP.

§ 457.1285 - Program integrity safeguards.

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.

Grievance System

§ 457.1260 - Grievance system.

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.