42 USC 1397bb - General contents of State child health plan; eligibility; outreach

(a) General background and description 
A State child health plan shall include a description, consistent with the requirements of this subchapter, 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 1397jj (c)(2) of this title);
(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;

Advertisement
view counter
(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) of this section;
(6) outreach activities consistent with subsection (c) of this section; and
(7) methods (including monitoring) used
(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 subchapter) 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

Advertisement
view counter
(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 enrollment.
(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 subchapter XIX of this chapter 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 1603 (c) of title 25); and
(E) coordination with other public and private programs providing creditable coverage for low-income children.
(4) Nonentitlement 
Nothing in this subchapter 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 subchapter with other public and private health insurance programs.