42 USC 1397 - Coverage requirements for children’s health insurance

View all text of Subchapter XXI [§ 1397aa - § 1397mm]

§ 1397cc. Coverage requirements for children’s health insurance

(a) Required scope of health insurance coverageThe child health assistance provided to a targeted low-income child under the plan in the form described in paragraph (1) of section 1397aa(a) of this title shall consist, consistent with paragraphs (5), (6), (7), and (8) of subsection (c), of any of the following:

(1) Benchmark coverage

(2) Benchmark-equivalent coverageHealth benefits coverage that meets the following requirements:

(A) Inclusion of basic services

(B) Aggregate actuarial value equivalent to benchmark package

(3) Existing comprehensive State-based coverage

(4) Secretary-approved coverage

(b) Benchmark benefit packagesThe benchmark benefit packages are as follows:

(1) FEHBP-equivalent children’s health insurance coverage

(2) State employee coverage

(3) Coverage offered through HMOThe 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 [42 U.S.C. 300gg–91(b)(3)]), 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.

(1) Categories of basic servicesFor 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.

(D) Well-baby and well-child care, including age-appropriate immunizations.

(E) Mental health and substance use disorder services (as defined in paragraph (5)).

(2) Categories of additional servicesFor purposes of this section, the categories of additional services described in this paragraph are as follows:

(A) Coverage of prescription drugs.

(B) Vision services.

(3) Treatment of other categories

(4) Determination of actuarial valueThe 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;

(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) Mental health and substance use disorder servicesRegardless of the type of coverage elected by a State under subsection (a), child health assistance provided under such coverage for targeted low-income children and, in the case that the State elects to provide pregnancy-related assistance under such coverage pursuant to section 1397ll of this title, such pregnancy-related assistance for targeted low-income pregnant women (as defined in section 1397ll(d) of this title) shall—

(A) include coverage of mental health services (including behavioral health treatment) necessary to prevent, diagnose, and treat a broad range of mental health symptoms and disorders, including substance use disorders; and

(B) be delivered in a culturally and linguistically appropriate manner.

(6) Dental benefits

(A) In general

(B) Permitting use of dental benchmark plans by certain States

(i) FEHBP children’s dental coverage

(ii) State employee dependent dental coverage

(iii) Coverage offered through commercial dental plan

(7) Mental health services parity

(A) In general

(B) Deemed compliance

(8) Construction on prohibited coverage

(9) Availability of coverage for items and services furnished through school-based health centers

(10) Certain in vitro diagnostic products for COVID–19 testing

(11) Required coverage of COVID–19 vaccines and treatmentRegardless of the type of coverage elected by a State under subsection (a), the child health assistance provided for a targeted low-income child, and, in the case of a State that elects to provide pregnancy-related assistance pursuant to section 1397ll of this title, the pregnancy-related assistance provided for a targeted low-income pregnant woman (as such terms are defined for purposes of such section), shall include coverage, during the period beginning on March 11, 2021, and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in section 1320b–5(g)(1)(B) of this title, of—

(A) a COVID–19 vaccine (and the administration of the vaccine); and

(B) testing and treatments for COVID–19, including specialized equipment and therapies (including preventive therapies), and, in the case of an individual who is diagnosed with or presumed to have COVID–19, during the period during which such individual has (or is presumed to have) COVID–19, the treatment of a condition that may seriously complicate the treatment of COVID–19, if otherwise covered under the State child health plan (or waiver of such plan).

(12) Required coverage of approved, recommended adult vaccines and their administration.

(d) Description of existing comprehensive State-based coverage

(1) In generalA 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;

(D) was offered as of August 5, 1997.

(2) ModificationsA 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—

(A) the actuarial value of the coverage under the program as of August 5, 1997, or

(B) the actuarial value described in subsection (a)(2)(B),

evaluated as of the time of the modification.

(e) Cost-sharing

(1) Description; general conditions

(A) Description

(B) Protection for lower income children

(2) No cost sharing on benefits for preventive services, COVID–19 testing, a COVID–19 vaccine, COVID–19 treatment, or pregnancy-related assistance

(3) Limitations on premiums and cost-sharing

(A) Children in families with income below 150 percent of poverty lineIn the case of a targeted low-income child whose family income is at or below 150 percent of the poverty line, the State child health plan may not impose—

(i) an enrollment fee, premium, or similar charge that exceeds the maximum monthly charge permitted consistent with standards established to carry out section 1396o(b)(1) of this title (with respect to individuals described in such section); and

(ii) a deductible, cost sharing, or similar charge that exceeds an amount that is nominal (as determined consistent with regulations referred to in section 1396o(a)(3) of this title, with such appropriate adjustment for inflation or other reasons as the Secretary determines to be reasonable).

(B) Other children

(i) shall afford individuals enrolled under the plan a grace period of at least 30 days from the beginning of a new coverage period to make premium payments before the individual’s coverage under the plan may be terminated; and

(ii) shall provide to such an individual, not later than 7 days after the first day of such grace period, notice—(I) that failure to make a premium payment within the grace period will result in termination of coverage under the State child health plan; and(II) of the individual’s right to challenge the proposed termination pursuant to the applicable Federal regulations.

For purposes of clause (i), the term “new coverage period” means the month immediately following the last month for which the premium has been paid.

(4) Relation to medicaid requirements

(f) Application of certain requirements

(1) Restriction on application of preexisting condition exclusions

(A) In general

(B) Group health plans and group health insurance coverage

(2) Compliance with other requirements

(3) Compliance with managed care requirements

(Aug. 14, 1935, ch. 531, title XXI, § 2103, as added Pub. L. 105–33, title IV, § 4901(a), Aug. 5, 1997, 111 Stat. 554; amended Pub. L. 111–3, title I, § 111(b)(1), title IV, § 403(a), title V, §§ 501(a)(1), 502, 504(a), 505(a), Feb. 4, 2009, 123 Stat. 28, 84, 89, 90; Pub. L. 115–271, title V, § 5022(a)–(b)(2)(A), (d), Oct. 24, 2018, 132 Stat. 3964, 3965; Pub. L. 116–127, div. F, § 6004(b)(1), (3), Mar. 18, 2020, 134 Stat. 206; Pub. L. 116–260, div. BB, title II, § 203(a)(4)(C), Dec. 27, 2020, 134 Stat. 2917; Pub. L. 117–2, title IX, § 9821(a), Mar. 11, 2021, 135 Stat. 219; Pub. L. 117–169, title I, § 11405(b), Aug. 16, 2022, 136 Stat. 1901.)