|
U.S. Code as of:
01/19/04
Section 1397cc. Coverage requirements for children's health insurance
(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 1397aa(a) of this title shall consist, consistent with
subsection (c)(5) of this section, 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) of this section.
(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) of this section.
(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) of this section 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) of this
section.
(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.
(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
[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.
(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 subchapter, 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 August 5, 1997.
(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 -
(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) of
this section,
evaluated as of the time of the modification.
(e) Cost-sharing
(1) Description; general conditions
(A) Description
A State child health plan shall include a description,
consistent with this subsection, of the amount (if any) of
premiums, deductibles, coinsurance, and other cost sharing
imposed. Any such charges shall be imposed pursuant to a public
schedule.
(B) Protection for lower income children
The State child health plan may only vary premiums,
deductibles, coinsurance, and other cost sharing based on the
family income of targeted low-income children in a manner that
does not favor children from families with higher income over
children from families with lower income.
(2) No cost sharing on benefits for preventive services
The State child health plan may not impose deductibles,
coinsurance, or other cost sharing with respect to benefits for
services within the category of services described in subsection
(c)(1)(D) of this section.
(3) Limitations on premiums and cost-sharing
(A) Children in families with income below 150 percent of
poverty line
In 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
For children not described in subparagraph (A), subject to
paragraphs (1)(B) and (2), any premiums, deductibles, cost
sharing or similar charges imposed under the State child health
plan may be imposed on a sliding scale related to income,
except that the total annual aggregate cost-sharing with
respect to all targeted low-income children in a family under
this subchapter may not exceed 5 percent of such family's
income for the year involved.
(4) Relation to medicaid requirements
Nothing in this subsection shall be construed as affecting the
rules relating to the use of enrollment fees, premiums,
deductions, cost sharing, and similar charges in the case of
targeted low-income children who are provided child health
assistance in the form of coverage under a medicaid program under
section 1397aa(a)(2) of this title.
(f) Application of certain requirements
(1) Restriction on application of preexisting condition
exclusions
(A) In general
Subject to subparagraph (B), the State child health plan
shall not permit the imposition of any preexisting condition
exclusion for covered benefits under the plan.
(B) Group health plans and group health insurance coverage
If the State child health plan provides for benefits through
payment for, or a contract with, a group health plan or group
health insurance coverage, the plan may permit the imposition
of a preexisting condition exclusion but only insofar as it is
permitted under the applicable provisions of part 7 of subtitle
B of title I of the Employee Retirement Income Security Act of
1974 [29 U.S.C. 1181 et seq.] and title XXVII of the Public
Health Service Act [42 U.S.C. 300gg et seq.].
(2) Compliance with other requirements
Coverage offered under this section shall comply with the
requirements of subpart 2 of part A of title XXVII of the Public
Health Service Act [42 U.S.C. 300gg-4 et seq.] insofar as such
requirements apply with respect to a health insurance issuer that
offers group health insurance coverage.
|
|