TITLE XXI-STATE CHILDREN'S HEALTH INSURANCE PROGRAM1 TABLE OF CONTENTS OF TITLE 2 Sec. 2101. Purpose; state child health plans Page 1611 Sec. 2102. Sec. 2103. General contents of State child health plan; eligibility; outreach 1612 1613 Sec. 2106. Process for submission, approval, and amendment of State child 1625 health plans. Sec. 2107. Sec. 2108. Strategic objectives and performance goals; plan administration 1627 Miscellaneous provisions Definitions 1628 1631 1631 PURPOSE; STATE CHILD HEALTH PLANS 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 eligibility), 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. (3) TREATMENT OF OTHER CATEGORIES.-Nothing in this subsection shall be construed as preventing a State child health plan from providing coverage of benefits that are not within a category of services described in paragraph (1) or (2). (4) DETERMINATION OF ACTUARIAL VALUE.-The actuarial value of coverage of benchmark benefit packages, coverage offered under the State child health plan, and coverage of any categories of additional services under benchmark benefit packages and under coverage offered by such a plan, shall be set forth in an actuarial opinion in an actuarial report that has been prepared (A) by an individual who is a member of the American Academy of Actuaries; (B) using generally accepted actuarial principles and methodologies; (C) using a standardized set of utilization and price factors; (D) using a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan; (E) applying the same principles and factors in comparing the value of different coverage (or categories of services); (F) without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used; and (G) taking into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage. The actuary preparing the opinion shall select and specify in the memorandum the standardized set and population to be used under subparagraphs (C) and (D). (5) CONSTRUCTION ON PROHIBITED COVERAGE.-Nothing in this section shall be construed as requiring any health benefits coverage offered under the plan to provide coverage for items or services for which payment is prohibited under this title, notwithstanding that any benchmark benefit package includes coverage for such an item or service. (d) DESCRIPTION OF EXISTING COMPREHENSIVE STATE-BASED COVERAGE. (1) IN GENERAL.-A program described in this paragraph is a child health coverage program that— (A) includes coverage of a range of benefits; (B) is administered or overseen by the State and receives funds from the State; (C) is offered in New York, Florida, or Pennsylvania; and (D) was offered as of the date of the enactment of this title. (2) MODIFICATIONS.-A State may modify a program described in paragraph (1) from time to time so long as it continues to meet the requirement of subparagraph (A) and does not reduce the actuarial value of the coverage under the program below the lower of |