TITLE XXI-STATE CHILDREN'S HEALTH INSURANCE PROGRAM 1 TABLE OF CONTENTS OF TITLE 2 ec. 2101. Purpose; state child health plans Page 1631 ec. 2102. ec. 2103. General contents of State child health plan; eligibility; outreach 1632 1633 ec. 2104. Allotments 1637 ec. 2105. Payments to States lec. 2106. lec. 2107. Process for submission, approval, and amendment of State child 1646 health plans. 1642 lec. 2108. Strategic objectives and performance goals; plan administration 1647 1649 SEC. 2101. [42 U.S.C. 1397aa] (a) PURPOSE.-The purpose of this title 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 2103, or (2) providing benefits under the State's medicaid plan under title XIX, or a combination of both. (b) STATE CHILD HEALTH PLAN REQUIRED.-A State is not eligible for payment under section 2105 unless the State has submitted to the Secretary under section 2106 a plan that (1) sets forth how the State intends to use the funds provided under this title to provide child health assistance to needy children consistent with the provisions of this title, and (2) has been approved under section 2106. (c) STATE ENTITLEMENT.-This title 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 2104. Title XXI appears in the United States Code as §§1397aa-1397jj, subchapter XXI, chapter 7, Title 42. See Vol. II, P.L. 106–113, Appendix F, Title VII, §704, with respect to references to SCHIP and State Children's Health Insurance Program. See Vol. II, P.L. 106-554, §1(a)(6) [802(c)], with respect to the elimination of the requirement to reduce Title XXI allotment by Medicaid expansion SCHIP costs. 2 This table of contents does not appear in the law. (d) EFFECTIVE DATE.-No State is eligible for payments under section 2105 for child health assistance for coverage provided for periods beginning before October 1, 1997. GENERAL CONTENTS OF STATE CHILD HEALTH PLAN; ELIGIBILITY; OUTREACH SEC. 2102. [42 U.S.C. 1397bb] (a) GENERAL BACKGROUND AND DESCRIPTION.-A State child health plan shall include a description, consistent with the requirements of this title, of (1) the extent to which, and manner in which, children in the State, including targeted low-income children and other classes of children classified by income and other relevant factors, currently have creditable health coverage (as defined in section 2110(c)(2)); (2) current State efforts to provide or obtain creditable health coverage for uncovered children, including the steps the State is taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs and health insurance programs that involve public-private partnerships; (3) how the plan is designed to be coordinated 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 children, including the proposed methods of delivery, and utilization control systems; (5) eligibility standards consistent with subsection (b); (A) to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan, and (B) to assure access to covered services, including emergency services. (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 consistent with this title) 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, disability status (so long as any standard relating 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 covered targeted low-income children, not cover such children with higher family income without covering children with a lower family income, and (ii) may not deny eligibility based on a child having a preexisting medical condition. (2) METHODOLOGY.-The plan shall include a description of methods of establishing and continuing eligibility and enroll ment. (3) ELIGIBILITY SCREENING; COORDINATION WITH OTHER HEALTH COVERAGE PROGRAMS.-The plan shall include a description of procedures to be used to ensure (A) through both intake and followup screening, that only targeted low-income children are furnished child health assistance under the State child health plan; (B) that children found through the screening to be eligible for medical assistance under the State medicaid plan under title 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 4(c) of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c)); and (E) coordination with other public and private programs providing creditable coverage for low-income children. (4) NONENTITLEMENT.-Nothing in this title shall be construed as providing an individual with an entitlement to child health assistance under a State child health plan. (c) OUTREACH AND COORDINATION.-A State child health plan shall include a description of the procedures to be used by the State to accomplish the following: (1) OUTREACH.-Outreach 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 program. (2) COORDINATION WITH OTHER HEALTH INSURANCE PROGRAMS.-Coordination of the administration of the State program under this title with other public and private health insurance programs. COVERAGE REQUIREMENTS FOR CHILDREN'S HEALTH INSURANCE SEC. 2103. [42 U.S.C. 1397cc] (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 2101(a) shall consist, consistent with subsection (c)(5), of any of the following: (1) BENCHMARK COVERAGE.-Health benefits coverage that is 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 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 follows: (1) FEHBP-EQUIVALENT CHILDREN'S HEALTH INSURANCE COVERAGE. The standard Blue Cross/Blue Shield preferred provider option service benefit plan, described in and offered under section 8903(1) of title 5, United States Code. (2) STATE EMPLOYEE COVERAGE.-A health benefits coverage plan that is offered and generally available to State employees in the State involved. (3) COVERAGE OFFERED THROUGH HMO.-The health insurance coverage plan that― (A) is offered by a health maintenance organization (as defined in section 2791(b)(3) of the Public Health Service Act), 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 involved. (c) CATEGORIES OF SERVICES; DETERMINATION OF ACTUARIAL 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 services. (B) Physicians surgical and medical services. (C) Laboratory and x-ray services. (D) Well-baby and well-child care, including age-appropriate immunizations. (2) CATEGORIES OF ADDITIONAL SERVICES.-For purposes of this section, the categories of additional services described in this paragraph are as follows: (A) Coverage of prescription drugs. (B) Mental health services. (C) Vision services. (D) Hearing services. |