|
U.S. Code as of:
01/19/04
Section 1397jj. Definitions
(a) Child health assistance
For purposes of this subchapter, the term "child health
assistance" means payment for part or all of the cost of health
benefits coverage for targeted low-income children that includes
any of the following (and includes, in the case described in
section 1397ee(a)(1)(D)(i) of this title, payment for part or all
of the cost of providing any of the following), as specified under
the State plan:
(1) Inpatient hospital services.
(2) Outpatient hospital services.
(3) Physician services.
(4) Surgical services.
(5) Clinic services (including health center services) and
other ambulatory health care services.
(6) Prescription drugs and biologicals and the administration
of such drugs and biologicals, only if such drugs and biologicals
are not furnished for the purpose of causing, or assisting in
causing, the death, suicide, euthanasia, or mercy killing of a
person.
(7) Over-the-counter medications.
(8) Laboratory and radiological services.
(9) Prenatal care and prepregnancy family planning services and
supplies.
(10) Inpatient mental health services, other than services
described in paragraph (18) but including services furnished in a
State-operated mental hospital and including residential or other
24-hour therapeutically planned structured services.
(11) Outpatient mental health services, other than services
described in paragraph (19) but including services furnished in a
State-operated mental hospital and including community-based
services.
(12) Durable medical equipment and other medically-related or
remedial devices (such as prosthetic devices, implants,
eyeglasses, hearing aids, dental devices, and adaptive devices).
(13) Disposable medical supplies.
(14) Home and community-based health care services and related
supportive services (such as home health nursing services, home
health aide services, personal care, assistance with activities
of daily living, chore services, day care services, respite care
services, training for family members, and minor modifications to
the home).
(15) Nursing care services (such as nurse practitioner
services, nurse midwife services, advanced practice nurse
services, private duty nursing care, pediatric nurse services,
and respiratory care services) in a home, school, or other
setting.
(16) Abortion only if necessary to save the life of the mother
or if the pregnancy is the result of an act of rape or incest.
(17) Dental services.
(18) Inpatient substance abuse treatment services and
residential substance abuse treatment services.
(19) Outpatient substance abuse treatment services.
(20) Case management services.
(21) Care coordination services.
(22) Physical therapy, occupational therapy, and services for
individuals with speech, hearing, and language disorders.
(23) Hospice care.
(24) Any other medical, diagnostic, screening, preventive,
restorative, remedial, therapeutic, or rehabilitative services
(whether in a facility, home, school, or other setting) if
recognized by State law and only if the service is -
(A) prescribed by or furnished by a physician or other
licensed or registered practitioner within the scope of
practice as defined by State law,
(B) performed under the general supervision or at the
direction of a physician, or
(C) furnished by a health care facility that is operated by a
State or local government or is licensed under State law and
operating within the scope of the license.
(25) Premiums for private health care insurance coverage.
(26) Medical transportation.
(27) Enabling services (such as transportation, translation,
and outreach services) only if designed to increase the
accessibility of primary and preventive health care services for
eligible low-income individuals.
(28) Any other health care services or items specified by the
Secretary and not excluded under this section.
(b) "Targeted low-income child" defined
For purposes of this subchapter -
(1) In general
Subject to paragraph (2), the term "targeted low-income child"
means a child -
(A) who has been determined eligible by the State for child
health assistance under the State plan;
(B)(i) who is a low-income child, or
(ii) is a child -
(I) whose family income (as determined under the State
child health plan) exceeds the medicaid applicable income
level (as defined in paragraph (4)), but does not exceed 50
percentage points above the medicaid applicable income level;
(II) whose family income (as so determined) does not exceed
the medicaid applicable income level (as defined in paragraph
(4) but determined as if "June 1, 1997" were substituted for
"March 31, 1997"); or
(III) who resides in a State that does not have a medicaid
applicable income level (as defined in paragraph (4)); and
(C) who is not found to be eligible for medical assistance
under subchapter XIX of this chapter or covered under a group
health plan or under health insurance coverage (as such terms
are defined in section 300gg-91 of this title).
(2) Children excluded
Such term does not include -
(A) a child who is an inmate of a public institution or a
patient in an institution for mental diseases; or
(B) a child who is a member of a family that is eligible for
health benefits coverage under a State health benefits plan on
the basis of a family member's employment with a public agency
in the State.
(3) Special rule
A child shall not be considered to be described in paragraph
(1)(C) notwithstanding that the child is covered under a health
insurance coverage program that has been in operation since
before July 1, 1997, and that is offered by a State which
receives no Federal funds for the program's operation.
(4) Medicaid applicable income level
The term "medicaid applicable income level" means, with respect
to a child, the effective income level (expressed as a percent of
the poverty line) that has been specified under the State plan
under subchapter XIX of this chapter (including under a waiver
authorized by the Secretary or under section 1396a(r)(2) of this
title), as of March 31, 1997, for the child to be eligible for
medical assistance under section 1396a(l)(2) or 1396d(n)(2) of
this title (as selected by a State) for the age of such child.
(c) Additional definitions
For purposes of this subchapter:
(1) Child
The term "child" means an individual under 19 years of age.
(2) Creditable health coverage
The term "creditable health coverage" has the meaning given the
term "creditable coverage" under section 300gg(c) of this title
and includes coverage that meets the requirements of section
1397cc of this title provided to a targeted low-income child
under this subchapter or under a waiver approved under section
1397ee(c)(2)(B) of this title (relating to a direct service
waiver).
(3) Group health plan; health insurance coverage; etc.
The terms "group health plan", "group health insurance
coverage", and "health insurance coverage" have the meanings
given such terms in section 300gg-91 of this title.
(4) Low-income child
The term "low-income child" means a child whose family income
is at or below 200 percent of the poverty line for a family of
the size involved.
(5) Poverty line defined
The term "poverty line" has the meaning given such term in
section 9902(2) of this title, including any revision required by
such section.
(6) Preexisting condition exclusion
The term "preexisting condition exclusion" has the meaning
given such term in section 300gg(b)(1)(A) of this title.
(7) State child health plan; plan
Unless the context otherwise requires, the terms "State child
health plan" and "plan" mean a State child health plan approved
under section 1397ff of this title.
(8) Uncovered child
The term "uncovered child" means a child that does not have
creditable health coverage.
|
|