§1397bb General Contents of State Child Health Plan; Eligibility; Outreach

Summary

Require a State child health plan to explain how many children already have good health coverage, what the State is doing to find and enroll children without coverage, and how the plan works with other public and private programs. The plan must describe the child health benefits for targeted low‑income children, how those benefits are delivered, and how the State will watch use of services. It must explain how the State will make sure care is good and appropriate (especially well-baby and well-child visits and immunizations), that children can get covered services including emergency care, and that the State agency follows federal program‑integrity rules. The plan must also describe outreach efforts and how eligibility and enrollment will be done and maintained. Set clear eligibility rules for targeted low‑income children. These rules may cover area, age, income and resources, residency, disability status (but not limit eligibility because of disability), other coverage, and how long eligibility lasts. The rules cannot base eligibility on diagnosis or on a preexisting medical condition. No waiting period may apply for a pregnant woman getting pregnancy-related help, and a State may choose not to use a waiting period for children with dental‑only coverage. Beginning January 1, 2014, the State must use modified adjusted gross income and household income (as defined in section 36B(d)(2) of the Internal Revenue Code) for income tests and for premiums and cost‑sharing, consistent with federal Medicaid rules. The plan must include steps to make sure only eligible targeted low‑income children get help, to enroll children eligible for Medicaid into Medicaid, to avoid replacing group health plan coverage with the program, to serve Indian children, and to coordinate with other programs. The State must try to cut administrative barriers and may use the same forms and verification process for CHIP and Medicaid (without requiring in‑person applications). The plan does not create a guaranteed legal right to benefits. For children who are inmates of public institutions, the State cannot end eligibility because of incarceration (coverage may be suspended), must redetermine and restore benefits when released if still eligible, must process applications made while incarcerated to decide eligibility on release, and must have a plan to provide screenings, diagnostics, referrals, and case management for children within 30 days before release.