Form CMS-10398 #34 CMS-10398 #34 Title XXI State Plan Template

TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT
CHILDREN’S HEALTH INSURANCE PROGRAM
(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:______________________________________________________
(Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR,
457.40(b))_______________________________________________________ (Signature of Governor,
or designee, of State/Territory, Date Signed)
submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees
to administer the program in accordance with the provisions of the approved Child Health Plan, the
requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and
other official issuances of the Department.
The following State officials are responsible for program administration and financial oversight (42 CFR
457.40(c)):
Name: ____________
Name: ____________
Name: ____________

Position/Title: ______________
Position/Title: ______________
Position/Title: ______________

Disclosure Statement This information is being collected pursuant to 42 U.S.C. 1397aa, which requires
states to submit a State Child Health Plan in order to receive federal funding. This mandatory
information collection will be used to demonstrate compliance with all requirements of title XXI of the
Act and implementing regulations at 42 CFR part 457. According to the Paperwork Reduction Act of
1995, no persons are required to respond to a collection of information unless it displays a valid Office
of Management and Budget (OMB) control number. The valid OMB control number for this
information collection is 0938-1148 (CMS-10398 #34). Public burden for all of the collection of
information requirements under this control number is estimated to average 80 hours per response,
including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to CMS,
7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-2605, Baltimore, Maryland 21244-1850.

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Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended
the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program
(CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA)
renewed the program. The Patient Protection and Affordable Care Act, as amended by the Health Care
and Education Reconciliation Act of 2010, further modified the program. The HEALTHY KIDS Act
and The Bipartisan Budget Act of 2018 together resulted in an extension of funding for CHIP through
federal fiscal year 2027.
This template outlines the information that must be included in the state plans and the State plan
amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously
approved SPA templates that accompanied guidance issued to States through State Health Official
(SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your
reference. The CHIP SPA template includes the following changes:
• Combined the instruction document with the CHIP SPA template to have a single document. Any
modifications to previous instructions are for clarification only and do not reflect new policy
guidance.
• Incorporated the previously issued guidance and templates (see the Key following the template for
information on the newly added templates), including:
• Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002)
• Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009)
• Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009)
• Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009)
• Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010)
• Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010)
• Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010)
• Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5.
• Removed crowd-out language that had been added by the August 17 letter that later was repealed.
• Added new provisions related to delivery methods, including managed care, to section 3 (81 FR
27498, issued May 6, 2016)
• Added new assurances related to the coverage of vaccines (Sections 2103(c)(1)(D) and (c)(12));
(Section 11405(b)(1) of the Inflation Reduction Act (IRA)); (SHO # 23-003, issued June 27, 2023)
States are not required to resubmit existing State plans using this current updated template. However,
States must use this updated template when submitting a new State Plan Amendment.
Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A)
In order to be eligible for payment under this statute, each State must submit a Title XXI plan for
approval by the Secretary that details how the State intends to use the funds and fulfill other
requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless
the Secretary notifies the State in writing that the plan is disapproved or that specified additional
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information is needed. Unlike Medicaid SPAs, there is only one 90-day review period, or clock for
CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete
response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.
When submitting a State plan amendment, states should redline the changes that are being made to the
existing State plan and provide a “clean” copy including changes that are being made to the existing
state plan.
The template includes the following sections:
1. General Description and Purpose of the Children’s Health Insurance Plans and the
Requirements- This section should describe how the State has designed their program. It also is
the place in the template that a State updates to insert a short description and the proposed
effective date of the SPA, and the proposed implementation date(s) if different from the effective
date. (Section 2101); (42 CFR, 457.70)
2. General Background and Description of State Approach to Child Health Coverage and
Coordination- This section should provide general information related to the special
characteristics of each state’s program. The information should include the extent and manner to
which children in the State currently have creditable health coverage, current State efforts to
provide or obtain creditable health coverage for uninsured children and how the plan is designed
to be coordinated with current health insurance, public health efforts, or other enrollment
initiatives. This information provides a health insurance baseline in terms of the status of the
children in a given State and the State programs currently in place. (Section 2103); (42 CFR
457.410(A))
3. Methods of Delivery and Utilization Controls- This section requires the State to specify its
proposed method of delivery. If the State proposes to use managed care, the State must describe
and attest to certain requirements of a managed care delivery system, including contracting
standards; enrollee enrollment processes; enrollee notification and grievance processes; and
plans for enrolling providers, among others. (Section 2103); (42 CFR Part 457. Subpart L)
4. Eligibility Standards and Methodology- The plan must include a description of the standards
used to determine the eligibility of targeted low-income children for child health assistance under
the plan. This section includes a list of potential eligibility standards the State can check off and
provide a short description of how those standards will be applied. All eligibility standards must
be consistent with the provisions of Title XXI and may not discriminate on the basis of
diagnosis. In addition, if the standards vary within the state, the State should describe how they
will be applied and under what circumstances they will be applied. In addition, this section
provides information on income eligibility for Medicaid expansion programs (which are exempt
from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and
457.320)
5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach
is defined in law as 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. The purpose
is to inform these families of the availability of, and to assist them in enrolling their children in,
such a program. (Section 2102(c)(1)); (42 CFR 457.90)
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6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of
health insurance coverage in a State plan, the child health assistance provided must consist of
any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage;
benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretaryapproved coverage). In this section States identify the scope of coverage and benefits offered
under the plan including the categories under which that coverage is offered. The amount, scope,
and duration of each offered service should be fully explained, as well as any corresponding
limitations or exclusions. (Section 2103); (42 CFR 457.410(A))
7. Quality and Appropriateness of Care- This section includes a description of the methods
(including monitoring) to be used to assure the quality and appropriateness of care and to assure
access to covered services. A variety of methods are available for State’s use in monitoring and
evaluating the quality and appropriateness of care in its child health assistance program. The
section lists some of the methods which states may consider using. In addition to methods, there
are a variety of tools available for State adaptation and use with this program. The section lists
some of these tools. States also have the option to choose who will conduct these activities. As
an alternative to using staff of the State agency administering the program, states have the option
to contract out with other organizations for this quality-of-care function. (Section 2107); (42
CFR 457.495)
8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan
to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if
any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing
requirements provide protection for lower income children, ban cost sharing for preventive
services, address the limitations on premiums and cost-sharing and address the treatment of preexisting medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E)
9. Strategic Objectives and Performance Goals and Plan Administration- The section
addresses the strategic objectives, the performance goals, and the performance measures the
State has established for providing child health assistance to targeted low-income children under
the plan for maximizing health benefits coverage for other low-income children and children
generally in the state. (Section 2107); (42 CFR 457.710)
10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of
the Children’s Health Insurance Program plan and submit to the Secretary an annual report
which includes the progress made in reducing the number of uninsured low-income children. The
report is due by January 1, following the end of the Federal fiscal year and should cover that
Federal Fiscal Year. In this section, states are asked to assure that they will comply with these
requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750)
11. Program Integrity- In this section, the State assures that services are provided in an effective
and efficient manner through free and open competition or through basing rates on other public
and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart
I)
12. Applicant and Enrollee Protections- This section addresses the review process for eligibility
and enrollment matters, health services matters (i.e., grievances), and for states that use premium
assistance a description of how it will assure that applicants and enrollees are given the
opportunity at initial enrollment and at each redetermination of eligibility to obtain health
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benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR
457.1120)
Program Options. As mentioned above, the law allows States to expand coverage for children through
a separate child health insurance program, through a Medicaid expansion program, or through a
combination of these programs. These options are described further below:
• Option to Create a Separate Program- States may elect to establish a separate child health
program that are in compliance with title XXI and applicable rules. These states must
establish enrollment systems that are coordinated with Medicaid and other sources of health
coverage for children and also must screen children during the application process to
determine if they are eligible for Medicaid and, if they are, enroll these children promptly in
Medicaid.
• Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This
option for states would be available for children who do not qualify for Medicaid under State
rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.
Medicaid Expansion- CHIP SPA Requirements
In order to expedite the SPA process, states choosing to expand coverage only through an expansion
of Medicaid eligibility would be required to complete sections:
• 1 (General Description)
• 2 (General Background)
They will also be required to complete the appropriate program sections, including:
• 4 (Eligibility Standards and Methodology)
• 5 (Outreach)
• 9 (Strategic Objectives and Performance Goals and Plan Administration including the
budget)
• 10 (Annual Reports and Evaluations).
Medicaid Expansion- Medicaid SPA Requirements
States expanding through Medicaid-only will also be required to submit a Medicaid State plan
amendment to modify their Title XIX State plans. These states may complete the first check-off and
indicate that the description of the requirements for these sections are incorporated by reference
through their State Medicaid plans for sections:
• 3 (Methods of Delivery and Utilization Controls)
• 4 (Eligibility Standards and Methodology)
• 6 (Coverage Requirements for Children’s Health Insurance)
• 7 (Quality and Appropriateness of Care)
• 8 (Cost Sharing and Payment)
• 11 (Program Integrity)
• 12 (Applicant and Enrollee Protections)
•

Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program
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and a separate child health program to increase health coverage for children. For example, a State
may cover optional targeted-low-income children in families with incomes of up to 133 percent of
poverty through Medicaid and a targeted group of children above that level through a separate child
health program. For the children the State chooses to cover under an expansion of Medicaid, the
description provided under “Option to Expand Medicaid” would apply. Similarly, for children the
State chooses to cover under a separate program, the provisions outlined above in “Option to Create
a Separate Program” would apply. States wishing to use a combination of approaches will be
required to complete the Title XXI State plan and the necessary State plan amendment under Title
XIX.
Where the state’s assurance is requested in this document for compliance with a particular
requirement of 42 CFR 457 et seq., the state shall place a check mark to affirm that it will be in
compliance no later than the applicable compliance date.
Proposed State plan amendments should be submitted electronically and one signed hard copy to the
Centers for Medicare & Medicaid Services at the following address:
Name of Project Officer
Centers for Medicare & Medicaid Services
7500 Security Blvd
Baltimore, Maryland 21244
Attn: Children and Adults Health Programs Group
Center for Medicaid and CHIP Services
Mail Stop - S2-01-16

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Section 1.

General Description and Purpose of the Children’s Health Insurance Plans and the
Requirements

1.1.

The state will use funds provided under Title XXI primarily for (Check appropriate box)
(Section 2101)(a)(1)); (42 CFR 457.70):
Guidance: Check below if child health assistance shall be provided primarily through the
development of a separate program that meets the requirements of Section 2101, which
details coverage requirements and the other applicable requirements of Title XXI.
1.1.1.

Obtaining coverage that meets the requirements for a separate child health program
(Sections 2101(a)(1) and 2103); OR

Guidance: Check below if child health assistance shall be provided primarily through providing
expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is
selected the State must also submit a corresponding Medicaid SPA to CMS for review
and approval.
1.1.2.
Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section
2101(a)(2)); OR
Guidance: Check below if child health assistance shall be provided through a combination of both
1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with
an expansion in the State’s Medicaid program). Note that if this is selected the state must
also submit a corresponding Medicaid state plan amendment to CMS for review and
approval.
1.1.3.
A combination of both of the above. (Section 2101(a)(2))
1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a
separate CHIP program are eligible for this option. States choosing this option must also
complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template.
(Section 2110(b)(5))

1.2.

Check to provide an assurance that expenditures for child health assistance will not be
claimed prior to the time that the State has legislative authority to operate the State plan
or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3.

Check to provide an assurance that the State complies with all applicable civil rights
requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans
with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age
Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35.
(42CFR 457.130)

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Guidance:
The effective date as specified below is defined as the date on which the State begins to
incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is
defined as the date the State begins to provide services; or, the date on which the State puts into practice
the new policy described in the State plan or amendment. For example, in a State that has increased
eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date
the State begins outreach or accepting applications).
1.4.

Provide the effective (date costs begin to be incurred) and implementation (date services
begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one
effective date, but provisions within the SPA may have different implementation dates
that must be after the effective date.
Original Plan
Effective Date:
Implementation Date:
SPA #
Purpose of SPA:
Proposed effective date:
Proposed implementation date:

1.4- TC

Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that
occurred specifically for the development and submission of this State Plan Amendment,
when it occurred and who was involved.
TN No: Approval Date Effective Date

Section 2.

General Background and Description of Approach to Children’s Health Insurance
Coverage and Coordination

Guidance:

The demographic information requested in 2.1. can be used for State planning and will be
used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS
A BASIS FOR THE ALLOTMENT.
Factors that the State may consider in the provision of this information are age breakouts,
income brackets, definitions of insurability, and geographic location, as well as race and
ethnicity. The State should describe its information sources and the assumptions it uses
for the development of its description.
• Population
• Number of uninsured
• Race demographics
• Age Demographics
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•

Info per region/Geographic information

2.1.

Describe the extent to which, and manner in which, children in the State (including
targeted low-income children and other groups of children specified) identified , by
income level and other relevant factors, such as race, ethnicity and geographic location,
currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent
feasible, distinguish between creditable coverage under public health insurance programs
and public-private partnerships (See Section 10 for annual report requirements). (Section
2102(a)(1)); (42 CFR 457.80(a))

Guidance:

Section 2.2 allows states to request to use the funds available under the 10 percent limit
on administrative expenditures in order to fund services not otherwise allowable. The
health services initiatives must meet the requirements of 42 CFR 457.10.

2.2.

Health Services Initiatives- Describe if the State will use the health services initiative
option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is
proposing to cover with administrative funds, including the cost of each program, and
how it is currently funded (if applicable), also update the budget accordingly. (Section
2105(a)(1)(D)(ii)); (42 CFR 457.10)

2.3-TC

Tribal Consultation Requirements- (Sections 1902(a)(73) and 2107(e)(1)(C)); (ARRA
#2, CHIPRA #3, issued May 28, 2009) Section 1902(a)(73) of the Social Security Act
(the Act) requires a State in which one or more Indian Health Programs or Urban Indian
Organizations furnish health care services to establish a process for the State Medicaid
agency to seek advice on a regular, ongoing basis from designees of Indian health
programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal
organizations under the Indian Self-Determination and Education Assistance Act
(ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement
Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended to apply these
requirements to the Children’s Health Insurance Program (CHIP). Consultation is
required concerning Medicaid and CHIP matters having a direct impact on Indian health
programs and Urban Indian organizations.
Describe the process the State uses to seek advice on a regular, ongoing basis from
federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on
matters related to Medicaid and CHIP programs and for consultation on State Plan
Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals
and proposals for demonstration projects prior to submission to CMS. Include
information about the frequency, inclusiveness and process for seeking such advice.

Section 3.

Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded
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eligibility under the State’s Medicaid plan, and continue on to Section 4 (Eligibility Standards
and Methodology).
Guidance:

In Section 3.1, describe all delivery methods the State will use to provide services to
enrollees, including: (1) contracts with managed care organizations (MCO), prepaid
inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care
case management entities (PCCM entities), and primary care case managers (PCCM); (2)
contracts with indemnity health insurance plans; (3) fee-for-service (FFS) paid by the
State to health care providers; and (4) any other arrangements for health care delivery.
The State should describe any variations based upon geography and by population
(including the conception to birth population). States must submit the managed care
contract(s) to CMS’ Regional Office for review.

3.1.

Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)
3.1.1

Choice of Delivery System
3.1.1.1

Does the State use a managed care delivery system for its CHIP
populations? Managed care entities include MCOs, PIHPs, PAHPs,
PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the
box and answer the questions below that apply to your State.
No, the State does not use a managed care delivery system for any
CHIP populations.
Yes, the State uses a managed care delivery system for all CHIP
populations.
Yes, the State uses a managed care delivery system; however, only
some of the CHIP population is included in the managed care
delivery system and some of the CHIP population is included in a feefor-service system.
If the State uses a managed care delivery system for only some of its CHIP
populations and a fee-for-service system for some of its CHIP populations,
please describe which populations are, and which are not, included in the
State’s managed care delivery system for CHIP. States will be asked to
specify which managed care entities are used by the State in its managed
care delivery system below in Section 3.1.2.

Guidance:

Utilization control systems are those administrative mechanisms that are
designed to ensure that enrollees receiving health care services under the
State plan receive only appropriate and medically necessary health care
consistent with the benefit package.
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Examples of utilization control systems include, but are not limited to:
requirements for referrals to specialty care; requirements that clinicians
use clinical practice guidelines; or demand management systems (e.g., use
of an 800 number for after-hours and urgent care). In addition, the State
should describe its plans for review, coordination, and implementation of
utilization controls, addressing both procedures and State developed
standards for review, in order to assure that necessary care is delivered in a
cost-effective and efficient manner. (42 CFR 457.490(b))
If the State does not use a managed care delivery system for any or some
of its CHIP populations, describe the methods of delivery of the child
health assistance using Title XXI funds to targeted low-income children.
Include a description of:
• The methods for assuring delivery of the insurance products and
delivery of health care services covered by such products to the
enrollees, including any variations. (Section 2102(a)(4); 42 CFR
457.490(a))
• The utilization control systems designed to ensure that enrollees
receiving health care services under the State plan receive only
appropriate and medically necessary health care consistent with the
benefit package described in the approved State plan. (Section
2102(a)(4); 42 CFR 457.490(b))
Guidance:

Only States that use a managed care delivery system for all or some CHIP
populations need to answer the remaining questions under Section 3
(starting with 3.1.1.2). If the State uses a managed care delivery system for
only some of its CHIP population, the State’s responses to the following
questions will only apply to those populations.

3.1.1.2

Do any of your CHIP populations that receive services through a managed
care delivery system receive any services outside of a managed care
delivery system?
No
Yes
If yes, please describe which services are carved out of your managed care
delivery system and how the State provides these services to an enrollee,
such as through fee-for-service. Examples of carved out services may
include transportation and dental, among others.

3.1.2

Use of a Managed Care Delivery System for All or Some of the State’s CHIP
Populations

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3.1.2.1

Check each of the types of entities below that the State will contract with
under its managed care delivery system, and select and/or explain the
method(s) of payment that the State will use:
Managed care organization (MCO) (42 CFR 457.10)
Capitation payment
Describe population served:
Prepaid inpatient health plan (PIHP) (42 CFR 457.10)
Capitation payment
Other (please explain)
Describe population served:

Guidance:

If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively
provide non-emergency medical transportation (a NEMT PAHP), the State
should not check the following box for that plan. Instead, complete section
3.1.3 for the NEMT PAHP.
Prepaid ambulatory health plan (PAHP) (42 CFR 457.10)
Capitation payment
Other (please explain)
Describe population served:
Primary care case manager (PCCM) (individual practitioners) (42
CFR 457.10)
Case management fee
Other (please explain)
Primary care case management entity (PCCM Entity) (42 CFR
457.10)
Case management fee
Shared savings, incentive payments, and/or other financial
rewards for improved quality outcomes (see 42 CFR
457.1240(f))
Other (please explain)
If PCCM entity is selected, please indicate which of the following
function(s) the entity will provide (as described in 42 CFR 457.10), in
addition to PCCM services:
Provision of intensive telephonic case management
Provision of face-to-face case management
Operation of a nurse triage advice line
Development of enrollee care plans
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Execution of contracts with fee-for-service (FFS) providers in the
FFS program
Oversight responsibilities for the activities of FFS providers in the
FFS program
Provision of payments to FFS providers on behalf of the State
Provision of enrollee outreach and education activities
Operation of a customer service call center
Review of provider claims, utilization and/or practice patterns to
conduct provider profiling and/or practice improvement
Implementation of quality improvement activities including
administering enrollee satisfaction surveys or collecting data
necessary for performance measurement of providers
Coordination with behavioral health systems/providers
Other (please describe)
3.1.2.2

3.1.3

The State assures that if its contract with an MCO, PAHP, or PIHP allows
the entity to use a physician incentive plan, the contract stipulates that the
entity must comply with the requirements set forth in 42 CFR 422.208 and
422.210. (42 CFR 457.1201(h), cross-referencing to 42 CFR 438.3(i))

Nonemergency Medical Transportation PAHPs

Guidance:

Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide nonemergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the
only managed care entity for CHIP in the State, please continue to Section 4 after
checking the assurance below. If the State uses a PAHP that does not exclusively
provide NEMT and/or uses other managed care entities beyond a NEMT PAHP,
the State will need to complete the remaining sections within Section 3.
The State assures that it complies with all requirements applicable to NEMT
PAHPs, and through its contracts with such entities, requires NEMT PAHPs to
comply with all applicable requirements, including the following (from 42 CFR
457.1206(b)):
• All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR
457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l)
(related to mental health parity).
• The information requirements in 42 CFR 457.1207 (see Section 3.5 below for
more details).
• The provision against provider discrimination in 42 CFR 457.1208.
• The State responsibility provisions in 42 CFR 457.1212 (about disenrollment),
42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR
438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services
to enrollees).
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•
•

•
•
•
3.2.

3.3

The provisions on enrollee rights and protections in 42 CFR 457.1220,
457.1222, 457.1224, and 457.1226.
The PAHP standards in 42 CFR 438.206(b)(1), as cross-referenced by 42 CFR
457.1230(a) (about availability of services), 42 CFR 457.1230(d) (about
coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d)
(about structure and operation standards).
An enrollee's right to a State review under subpart K of 42 CFR 457.
Prohibitions against affiliations with individuals debarred or excluded by
Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR
457.1285.
Requirements relating to contracts involving Indians, Indian Health Care
Providers, and Indian managed care entities in 42 CFR 457.1209.

General Managed Care Contract Provisions
3.2.1

The State assures that it provides for free and open competition, to the maximum
extent practical, in the bidding of all procurement contracts for coverage or other
services, including external quality review organizations, in accordance with the
procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b);
42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e))

3.2.2

The State assures that it will include provisions in all managed care contracts that
define a sound and complete procurement contract, as required by 45 CFR part
75, as applicable. (42 CFR 457.940(c))

3.2.3

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity
complies with any applicable Federal and State laws that pertain to enrollee
rights, and ensures that its employees and contract providers observe and protect
those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These
Federal and State laws include: Title VI of the Civil Rights Act of 1964 (45 CFR
part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of
1973, Title IX of the Education Amendments of 1972, Titles II and III of the
Americans with Disabilities Act, and section 1557 of the Patient Protection and
Affordable Care Act.

3.2.4

The State assures that it operates a Web site that provides the MCO, PIHP, PAHP,
and PCCM entity contracts. (42 CFR 457.1207, cross-referencing to 42 CFR
438.10(c)(3))

Rate Development Standards and Medical Loss Ratio
3.3.1

The State assures that its payment rates are:

14

Based on public or private payment rates for comparable services for
comparable populations; and
Consistent with actuarially sound principles as defined in 42 CFR 457.10.
(42 CFR 457.1203(a))
Guidance:

States that checked both boxes under 3.3.1 above do not need to make the next
assurance. If the state is unable to check both boxes under 3.1.1 above, the state
must check the next assurance.
If the State is unable to meet the requirements under 42 CFR 457.1203(a),
the State attests that it must establish higher rates because such rates are
necessary to ensure sufficient provider participation or provider access or to
enroll providers who demonstrate exceptional efficiency or quality in the
provision of services. (42 CFR 457.1203(b))

3.3.2

The State assures that its rates are designed to reasonably achieve a medical loss
ratio standard equal to at least 85 percent for the rate year and provide for
reasonable administrative costs. (42 CFR 457.1203(c))

3.3.3

The State assures that it will provide to CMS, if requested by CMS, a description
of the manner in which rates were developed in accordance with the requirements
of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d))

3.3.4

The State assures that it annually submits to CMS a summary description of the
reports pertaining to the medical loss ratio received from the MCOs, PIHPs, and
PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a))

3.3.5

Does the State require an MCO, PIHP, or PAHP to pay remittances through the
contract for not meeting the minimum MLR required by the State? (42 CFR
457.1203(e), cross referencing to 42 CFR 438.74(b)(1))
No, the State does not require any MCO, PIHP, or PAHP to pay remittances.
Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances.
Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay
remittances.
If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay
remittances through the contract for not meeting the minimum MLR required by
the State, please describe which types of managed care entities are and are not
required to pay remittances. For example, if a state requires a medical MCO to pay
a remittances but not a dental PAHP, please include this information.
If the answer to the assurance above is yes for any or all managed care entities,
please answer the next assurance:
15

The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP
to the State, the State:
• Reimburses CMS for an amount equal to the Federal share of the
remittance, taking into account applicable differences in the Federal
matching rate; and
• Submits a separate report describing the methodology used to determine
the State and Federal share of the remittance with the annual report
provided to CMS that summarizes the reports received from the MCOs,
PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR
438.74(b))
3.3.6
3.4

The State assures that each MCO, PIHP, and PAHP calculates and reports the
medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f))

Enrollment
The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs, and PCCM
entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity:
• Accepts individuals eligible for enrollment in the order in which they apply without
restriction (unless authorized by CMS), up to the limits set under the contract (42
CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1));
• Will not, on the basis of health status or need for health care services, discriminate
against individuals eligible to enroll (42 CFR 457.1201(d), cross-referencing to 42
CFR 438.3(d)(3)); and
• Will not discriminate against individuals eligible to enroll on the basis of race, color,
national origin, sex, sexual orientation, gender identity, or disability and will not use
any policy or practice that has the effect of discriminating on the basis of race, color,
national origin, sex, sexual orientation, gender identity or disability. (42 CFR
457.1201(d), cross-referencing to 438.3(d)(4))
3.4.1

Enrollment Process
3.4.1.1

The State assures that it provides informational notices to potential
enrollees in an MCO, PIHP, PAHP, PCCM, or PCCM entity that includes
the available managed care entities, explains how to select an entity,
explains the implications of making or not making an active choice of an
entity, explains the length of the enrollment period as well as the
disenrollment policies, and complies with the information requirements in
42 CFR 457.1207 and accessibility standards established under 42 CFR
457.340. (42 CFR 457.1210(c))

3.4.1.2

The State assures that its enrollment system gives beneficiaries already
enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM entity priority to
16

continue that enrollment if the MCO, PIHP, PAHP, PCCM, or PCCM
entity does not have the capacity to accept all those seeking enrollment
under the program. (42 CFR 457.1210(b))
3.4.1.3

Does the State use a default enrollment process to assign beneficiaries to
an MCO, PIHP, PAHP, PCCM, or PCCM entity? (42 CFR 457.1210(a))
Yes
No
If the State uses a default enrollment process, please make the following
assurances:
The State assigns beneficiaries only to qualified MCOs, PIHPs,
PAHPs, PCCMs, and PCCM entities that are not subject to the
intermediate sanction of having suspension of all new enrollment
(including default enrollment) under 42 CFR 438.702 and have
capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i))
The State maximizes continuation of existing provider-beneficiary
relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not
possible, distributes the beneficiaries equitably and does not
arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity
from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR
457.1210(a)(1)(iii))

3.4.2

Disenrollment
3.4.2.1

The State assures that the State will notify enrollees of their right to
disenroll consistent with the requirements of 42 CFR 438.56 at least
annually. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2))

3.4.2.2

The State assures that the effective date of an approved disenrollment,
regardless of the procedure followed to request the disenrollment, will be
no later than the first day of the second month following the month in
which the enrollee requests disenrollment or the MCO, PIHP, PAHP,
PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212,
cross-referencing to 438.56(e)(1))

3.4.2.3

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM
entity, the State assures that the beneficiary is provided the option to enroll
in another plan or receive benefits from an alternative delivery system.
(Section 2103(f)(3) of the Social Security Act, incorporating section
1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State
Health Official Letter #09-008)

17

3.4.2.4

MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for
Disenrollment.
The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs
and PCCM entities describe the reasons for which an MCO, PIHP,
PAHP, PCCM and PCCM entity may request disenrollment of an
enrollee, if any. (42 CFR 457.1212, cross-referencing to 42 CFR
438.56(b))

Guidance:

Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and
PCCM entity must be specified in the contract with the State. Reasons
for disenrollment may not include an adverse change in the enrollee's
health status, or because of the enrollee's utilization of medical services,
diminished mental capacity, or uncooperative or disruptive behavior
resulting from his or her special needs (except when his or her continued
enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously
impairs the entity's ability to furnish services to either this particular
enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42
CFR 438.56(b)(2))

3.4.2.5

Enrollee Requests for Disenrollment.

Guidance:

The State may also choose to limit disenrollment from the MCO, PIHP,
PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any
time; or 2) without cause during the latter of the 90 days after the
beneficiary’s initial enrollment or the State sends the beneficiary notice of
that enrollment, at least once every 12 months, upon reenrollment if the
temporary loss of CHIP eligibility caused the beneficiary to miss the
annual disenrollment opportunity, or when the State imposes the
intermediate sanction specified in 42 CFR 438.702(a)(4). (42 CFR
457.1212, cross-referencing to 42 CFR 438.56(c))

Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and
PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR
438.56(c))
Yes
No
If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP,
PCCM and PCCM entity, please make the following assurances (42 CFR
457.1212, cross-referencing to 42 CFR 438.56(c)):
The State assures that enrollees and their representatives are given written
notice of disenrollment rights at least 60 days before the start of each
18

enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR
438.56(f)(1))
The State assures that beneficiary requests to disenroll for cause will be
permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity.
(42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2))
The State assures that beneficiary requests for disenrollment without cause
will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the
following times:
• During the 90 days following the date of the beneficiary's initial
enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or
during the 90 days following the date the State sends the beneficiary
notice of that enrollment, whichever is later;
• At least once every 12 months thereafter;
• If the State plan provides for automatic reenrollment for an individual
who loses CHIP eligibility for a period of 2 months or less and the
temporary loss of CHIP eligibility has caused the beneficiary to miss the
annual disenrollment opportunity; and
• When the State imposes the intermediate sanction on the MCO, PIHP,
PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42
CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2))
3.4.2.6

3.5

The State assures that the State ensures timely access to a State review for
any enrollee dissatisfied with a State agency determination that there is not
good cause for disenrollment. (42 CFR 457.1212, cross-referencing to 42
CFR 438.56(f)(2))

Information Requirements for Enrollees and Potential Enrollees
3.5.1

The State assures that it provides, or ensures its contracted MCOs, PAHPs,
PIHPs, PCCMs and PCCM entities provide, all enrollment notices, informational
materials, and instructional materials related to enrollees and potential enrollees in
accordance with the terms of 42 CFR 457.1207, cross-referencing to 42 CFR
438.10.

3.5.2

The State assures that all required information provided to enrollees and potential
enrollees are in a manner and format that may be easily understood and is readily
accessible by such enrollees and potential enrollees. (42 CFR 457.1207, crossreferencing to 42 CFR 438.10(c)(1))

3.5.3

The State assures that it operates a Web site that provides the content specified in
42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)-(i) either directly or by
linking to individual MCO, PIHP, PAHP and PCCM entity Web sites.

19

3.5.4

The State assures that it has developed and requires each MCO, PIHP, PAHP and
PCCM entity to use:
• Definitions for the terms specified under 42 CFR 438.10(c)(4)(i), and
• Model enrollee handbooks, and model enrollee notices. (42 CFR 457.1207,
cross-referencing to 42 CFR 438.10(c)(4))

3.5.5

If the State, MCOs, PIHPs, PAHPs, PCCMs or PCCM entities provide the
information required under 42 CFR 457.1207 electronically, check this box to
confirm that the State assures that it meets the requirements under 42 CFR
457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in
an accessible manner. Including that:
• The format is readily accessible;
• The information is placed in a location on the State, MCO's, PIHP's, PAHP's,
or PCCM's, or PCCM entity's Web site that is prominent and readily
accessible;
• The information is provided in an electronic form which can be electronically
retained and printed;
• The information is consistent with the content and language requirements in
42 CFR 438.10; and
• The enrollee is informed that the information is available in paper form
without charge upon request and is provided the information upon request
within 5 business days.

3.5.6

The State assures that it meets the language and format requirements set forth in
42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not
limited to:
• Establishing a methodology that identifies the prevalent non-English
languages spoken by enrollees and potential enrollees throughout the State,
and in each MCO, PIHP, PAHP, or PCCM entity service area;
• Making oral interpretation available in all languages and written translation
available in each prevalent non-English language;
• Requiring each MCO, PIHP, PAHP, and PCCM entity to make its written
materials that are critical to obtaining services available in the prevalent nonEnglish languages in its particular service area;
• Making interpretation services available to each potential enrollee and
requiring each MCO, PIHP, PAHP, and PCCM entity to make those services
available free of charge to each enrollee; and
• Notifying potential enrollees, and requiring each MCO, PIHP, PAHP, and
PCCM entity to notify its enrollees:
o That oral interpretation is available for any language and written
translation is available in prevalent languages;
o That auxiliary aids and services are available upon request and at no cost
20

for enrollees with disabilities; and
o How to access the services in 42 CFR 457.1207, cross-referencing 42 CFR
438.10(d)(5)(i) and (ii).
3.5.7

The State assures that the State or its contracted representative provides the
information specified in 42 CFR 457.1207, cross-referencing to 438.10(e)(2), and
includes the information either in paper or electronic format, to all potential
enrollees at the time the potential enrollee becomes eligible to enroll in a
voluntary managed care program or is first required to enroll in a mandatory
managed care program and within a timeframe that enables the potential enrollee
to use the information to choose among the available MCOs, PIHPs, PAHPs,
PCCMs and PCCM entities:
• Information about the potential enrollee's right to disenroll consistent with the
requirements of 42 CFR 438.56 and which explains clearly the process for
exercising this disenrollment right, as well as the alternatives available to the
potential enrollee based on their specific circumstance;
• The basic features of managed care;
• Which populations are excluded from enrollment in managed care, subject to
mandatory enrollment, or free to enroll voluntarily in the program;
• The service area covered by each MCO, PIHP, PAHP, PCCM, or PCCM
entity;
• Covered benefits including:
o Which benefits are provided by the MCO, PIHP, or PAHP; and which, if
any, benefits are provided directly by the State; and
o For a counseling or referral service that the MCO, PIHP, or PAHP does
not cover because of moral or religious objections, where and how to
obtain the service;
• The provider directory and formulary information required in 42 CFR
457.1207, cross-referencing to 42 CFR 438.10(h) and (i);
• Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP,
PAHP, PCCM, or PCCM entity consistent with those set forth in the State
plan;
• The requirements for each MCO, PIHP or PAHP to provide adequate access
to covered services, including the network adequacy standards established in
42 CFR 457.1218, cross-referencing 42 CFR 438.68;
• The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for
coordination of enrollee care; and
• To the extent available, quality and performance indicators for each MCO,
PIHP, PAHP and PCCM entity, including enrollee satisfaction.

3.5.8

The State assures that it will provide the information specified in 42 CFR
457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs,
21

PIHPs, PAHPs and PCCM entities, including that the State must notify all
enrollees of their right to disenroll consistent with the requirements of 42 CFR
438.56 at least annually.
3.5.9

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide the
information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)
to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that:
• The MCO, PIHP, PAHP and, when appropriate, the PCCM entity, must make
a good faith effort to give written notice of termination of a contracted
provider within the timeframe specified in 42 CFR 438.10(f), and
• The MCO, PIHP, PAHP and, when appropriate, the PCCM entity must make
available, upon request, any physician incentive plans in place as set forth in
42 CFR 438.3(i).

3.5.10

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide
enrollees of that MCO, PIHP, PAHP or PCCM entity an enrollee handbook that
meets the requirements as applicable to the MCO, PIHP, PAHP and PCCM entity,
specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(1)-(2),
within a reasonable time after receiving notice of the beneficiary's enrollment, by
a method consistent with 42 CFR 438.10(g)(3), and including the following items:
Information that enables the enrollee to understand how to effectively
use the managed care program, which, at a minimum, must include:
o Benefits provided by the MCO, PIHP, PAHP or PCCM entity;
o How and where to access any benefits provided by the State,
including any cost sharing, and how transportation is provided; and
o In the case of a counseling or referral service that the MCO, PIHP,
PAHP, or PCCM entity does not cover because of moral or
religious objections, the MCO, PIHP, PAHP, or PCCM entity must
inform enrollees that the service is not covered by the MCO, PIHP,
PAHP, or PCCM entity and how they can obtain information from
the State about how to access these services;
• The amount, duration, and scope of benefits available under the
contract in sufficient detail to ensure that enrollees understand the
benefits to which they are entitled;
• Procedures for obtaining benefits, including any requirements for
service authorizations and/or referrals for specialty care and for other
benefits not furnished by the enrollee's primary care provider;
• The extent to which, and how, after-hours and emergency coverage are
provided, including:
o What constitutes an emergency medical condition and emergency
services;
o The fact that prior authorization is not required for emergency

•

22

•
•
•
•
•
•

•
•
•

services; and
o The fact that, subject to the provisions of this section, the enrollee
has a right to use any hospital or other setting for emergency care;
Any restrictions on the enrollee's freedom of choice among network
providers;
The extent to which, and how, enrollees may obtain benefits, including
family planning services and supplies from out-of-network providers;
Cost sharing, if any is imposed under the State plan;
Enrollee rights and responsibilities, including the elements specified in
42 CFR §438.100;
The process of selecting and changing the enrollee's primary care
provider;
Grievance, appeal, and review procedures and timeframes, consistent
with 42 CFR 457.1260, in a State-developed or State-approved
description, including:
o The right to file grievances and appeals;
o The requirements and timeframes for filing a grievance or appeal;
o The availability of assistance in the filing process; and
o The right to request a State review after the MCO, PIHP or PAHP
has made a determination on an enrollee's appeal which is adverse
to the enrollee;
How to access auxiliary aids and services, including additional
information in alternative formats or languages;
The toll-free telephone number for member services, medical
management, and any other unit providing services directly to
enrollees; and
Information on how to report suspected fraud or abuse.

3.5.11

The State assures that each MCO, PIHP, PAHP and PCCM entity will give each
enrollee notice of any change that the State defines as significant in the
information specified in the enrollee handbook at least 30 days before the
intended effective date of the change. (42 CFR 457.1207, cross-referencing to 42
CFR 438.10(g)(4))

3.5.12

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM
entity, will make available a provider directory for the MCO’s, PIHP’s, PAHP’s
or PCCM entity’s network providers, including for physicians (including
specialists), hospitals, pharmacies, and behavioral health providers, that includes
information as specified in 42 CFR 457.1207, cross-referencing to 42 CFR
438.10(h)(1)-(2) and (4).

3.5.13

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM
entity, will update any information included in a paper provider directory at least
23

monthly and in an electronic provider directories as specified in 42 CFR
438.10(h)(3). (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(3))
3.5.14

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM
entity, will make available the MCO’s, PIHP’s, PAHP’s, or PCCM entity’s
formulary that meets the requirements specified in 42 CFR 457.1207, crossreferencing to 42 CFR 438.10(i), including:
• Which medications are covered (both generic and name brand); and
• What tier each medication is on.

3.5.15

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity follows
the requirements for marketing activities under 42 CFR 457.1224, crossreferencing to 42 CFR 438.104 (except 42 CFR 438.104(c)).

Guidance:

Requirements for marketing activities include, but are not limited to, that the
MCO, PIHP, PAHP, PCCM, or PCCM entity does not distribute any marketing
materials without first obtaining State approval; distributes the materials to its
entire service areas as indicated in the contract; does not seek to influence
enrollment in conjunction with the sale or offering of any private insurance; and
does not, directly or indirectly, engage in door-to-door, telephone, email, texting,
or other cold-call marketing activities. (42 CFR 104(b))

Guidance:

Only States with MCOs, PIHPs, or PAHPs need to answer the remaining
assurances in Section 3.5 (3.5.16 through 3.5.18).

3.5.16

The State assures that each MCO, PIHP and PAHP protects communications
between providers and enrollees under 42 CFR 457.1222, cross-referencing to 42
CFR 438.102.

3.5.17

The State assures that MCOs, PIHPs, and PAHPs have arrangements and
procedures that prohibit the MCO, PIHP, and PAHP from conducting any
unsolicited personal contact with a potential enrollee by an employee or agent of
the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll
with the entity. (42 CFR 457.1280(b)(2))

Guidance:

States should also complete Section 3.9, which includes additional provisions
about the notice procedures for grievances and appeals.

3.5.18

The State assures that each contracted MCO, PIHP, and PAHP comply with the
notice requirements specified for grievances and appeals in accordance with the
terms of 42 CFR 438, Subpart F, except that the terms of 42 CFR 438.420 do not
apply and that references to reviews should be read to refer to reviews as
described in 42 CFR 457, Subpart K. (42 CFR 457.1260)
24

3.6

Benefits and Services

Guidance:

The State should also complete Section 3.10 (Program Integrity).

3.6.1

The State assures that MCO, PIHP, PAHP, PCCM entity, and PCCM contracts
involving Indians, Indian health care providers, and Indian managed care entities
comply with the requirements of 42 CFR 438.14. (42 CFR 457.1209)

3.6.2

The State assures that all services covered under the State plan are available and
accessible to enrollees. (42 CFR 457.1230(a), cross-referencing to 42 CFR
438.206)

3.6.3

The State assures that it:
• Publishes the State’s network adequacy standards developed in
accordance with 42 CFR 457.1218, cross-referencing 42 CFR
438.68(b)(1) on the Web site required by 42 CFR 438.10;
• Makes available, upon request, the State’s network adequacy standards
at no cost to enrollees with disabilities in alternate formats or through
the provision of auxiliary aids and services. (42 CFR 457.1218, crossreferencing 42 CFR 438.68(e))

Guidance:

Only States with MCOs, PIHPs, or PAHPs need to complete the remaining
assurances in Section 3.6 (3.6.4 through 3.6.20.

3.6.4

The State assures that each MCO, PAHP and PIHP meet the State’s network
adequacy standards. (42 CFR 457.1218, cross-referencing 42 CFR 438.68; 42
CFR 457.1230(a), cross-referencing to 42 CFR 438.206)

3.6.5

The State assures that each MCO, PIHP, and PAHP includes within its network of
credentialed providers:
• A sufficient number of providers to provide adequate access to all
services covered under the contract for all enrollees, including those
with limited English proficiency or physical or mental disabilities;
• Women’s health specialists to provide direct access to covered care
necessary to provide women’s routine and preventative health care
services for female enrollees; and
• Family planning providers to ensure timely access to covered services.
(42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)

3.6.6

The State assures that each contract under 42 CFR 457.1201 permits an enrollee
to choose his or her network provider. (42 CFR 457.1201(j), cross-referencing 42
CFR 438.3(l))

25

3.6.7

The State assures that each MCO, PIHP, and PAHP provides for a second opinion
from a network provider, or arranges for the enrollee to obtain one outside the
network, at no cost. (42 CFR 457.1230(a), cross-referencing to 42 CFR
438.206(b)(3))

3.6.8

The State assures that each MCO, PIHP, and PAHP ensures that providers, in
furnishing services to enrollees, provide timely access to care and services,
including by:
• Requiring the contract to adequately and timely cover out-of-network
services if the provider network is unable to provide necessary services
covered under the contract to a particular enrollee and at a cost to the
enrollee that is no greater than if the services were furnished within the
network;
• Requiring the MCO, PIHP and PAHP meet and its network providers
to meet State standards for timely access to care and services, taking
into account the urgency of the need for services;
• Ensuring that the hours of operation for a network provider are no less
than the hours of operation offered to commercial enrollees or
comparable to Medicaid or CHIP Fee-For-Service, if the provider
serves only Medicaid or CHIP enrollees;
• Ensuring that the MCO, PIHP and PAHP makes available services
include in the contract on a 24 hours a day, 7 days a week basis when
medically necessary;
• Establishing mechanisms to ensure compliance by network providers;
• Monitoring network providers regularly to determine compliance;
• Taking corrective action if there is a failure to comply by a network
provider. (42 CFR 457.1230(a), cross-referencing to 42 CFR
438.206(b)(4) and (5) and (c))

3.6.9

The State assures that each MCO, PIHP, and PAHP has the capacity to serve the
expected enrollment in its service area in accordance with the State's standards for
access to care. (42 CFR 457.1230(b), cross-referencing to 42 CFR 438.207)

3.6.10

The State assures that each MCO, PIHP, and PAHP will be required to submit
documentation to the State, at the time of entering into a contract with the State,
on an annual basis, and at any time there has been a significant change to the
MCO, PIHP, or PAHP’s operations that would affect the adequacy of capacity
and services, to demonstrate that each MCO, PIHP, and PAHP for the anticipated
number of enrollees for the service area:
• Offers an appropriate range of preventative, primary care and specialty
services; and
• Maintains a provider network that is sufficient in number, mix, and
geographic distribution. (42 CFR 457.1230, cross-referencing to 42
26

CFR 438.207(b))
3.6.11

Except that 42 CFR 438.210(a)(5) does not apply to CHIP, the State assures that
its contracts with each MCO, PIHP, or PAHP comply with the coverage of
services requirements under 42 CFR 438.210, including:
• Identifying, defining, and specifying the amount, duration, and scope of
each service that the MCO, PIHP, or PAHP is required to offer; and
• Permitting an MCO, PIHP, or PAHP to place appropriate limits on a
service. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(a)
except that 438.210(a)(5) does not apply to CHIP contracts)

3.6.12

Except that 438.210(b)(2)(iii) does not apply to CHIP, the State assures that its
contracts with each MCO, PIHP, or PAHP comply with the authorization of
services requirements under 42 CFR 438.210, including that:
• The MCO, PIHP, or PAHP and its subcontractors have in place and
follow written policies and procedures;
• The MCO, PIHP, or PAHP have in place mechanisms to ensure
consistent application of review criteria and consult with the requesting
provider when appropriate; and
• Any decision to deny a service authorization request or to authorize a
service in an amount, duration, or scope that is less than requested be
made by an individual with appropriate expertise in addressing the
enrollee’s medical, or behavioral health needs. (42 CFR 457.1230(d),
cross referencing to 42 CFR 438.210(b), except that 438.210(b)(2)(iii)
does not apply to CHIP contracts)

3.6.13

The State assures that its contracts with each MCO, PIHP, or PAHP require each
MCO, PIHP, or PAHP to notify the requesting provider and given written notice
to the enrollee of any adverse benefit determination to deny a service
authorization request, or to authorize a service in an amount, duration, or scope
that is less than requested. (42 CFR 457.1230(d), cross-referencing to 42 CFR
438.210(c))

3.6.14

The State assures that its contracts with each MCO, PIHP, or PAHP provide that
compensation to individuals or entities that conduct utilization management
activities is not structured so as to provide incentives for the individual or entity to
deny, limit, or discontinue medically necessary services to any enrollee. (42 CFR
457.1230(d), cross-referencing to 42 CFR 438.210(e))

3.6.15

The State assures that it has a transition of care policy that meets the requirements
of 438.62(b)(1) and requires that each contracted MCO, PIHP, and PAHP
implements the policy. (42 CFR 457.1216, cross-referencing to 42 CFR 438.62)

27

3.6.16

The State assures that each MCO, PIHP, and PAHP has implemented procedures
to deliver care to and coordinate services for all enrollees in accordance with 42
CFR 457.1230(c), cross-referencing to 42 CFR 438.208, including:
• Ensure that each enrollee has an ongoing source of care appropriate to
his or her needs;
• Ensure that each enrollee has a person or entity formally designated as
primarily responsible for coordinating the services accessed by the
enrollee;
• Provide the enrollee with information on how to contract their
designated person or entity responsible for the enrollee’s coordination
of services;
• Coordinate the services the MCO, PIHP, or PAHP furnishes to the
enrollee between settings of care; with services from any other MCO,
PIHP, or PAHP; with fee-for-service services; and with the services the
enrollee receives from community and social support providers;
• Make a best effort to conduct an initial screening of each enrollees
needs within 90 days of the effective date of enrollment for all new
enrollees;
• Share with the State or other MCOs, PIHPs, or PAHPs serving the
enrollee the results of any identification and assessment of the
enrollee’s needs;
• Ensure that each provider furnishing services to enrollees maintains and
shares, as appropriate, an enrollee health record in accordance with
professional standards; and
• Ensure that each enrollee’s privacy is protected in the process of
coordinating care is protected with the requirements of 45 CFR parts
160 and 164 subparts A and E. (42 CFR 457.1230(c), cross-referencing
to 42 CFR 438.208(b))

Guidance:

For assurances 3.6.17 through 3.6.20, applicability to PIHPs and PAHPs is based
a determination by the State in relation to the scope of the entity’s services and on
the way the State has organized its delivery of managed care services, whether a
particular PIHP or PAHP is required to implement the mechanisms for
identifying, assessing, and producing a treatment plan for an individual with
special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR
438.208(a)(2))

3.6.17

The State assures that it has implemented mechanisms for identifying to MCOs,
PIHPs, and PAHPs enrollees with special health care needs who are eligible for
assessment and treatment services under 42 CFR 457.1230(c), cross-referencing
to 42 CFR 438.208(c) and included the mechanism in the State’s quality strategy.

28

3.6.18

The State assures that each applicable MCO, PIHP, and PAHP implements the
mechanisms to comprehensively assess each enrollee identified by the state as
having special health care needs. (42 CFR 457.1230(c), cross-referencing to 42
CFR 438.208(c)(2))

3.6.19

The State assures that each MCO, PIHP, and PAHP will produce a treatment or
service plan that meets the following requirements for enrollees identified with
special health care needs:
• Is in accordance with applicable State quality assurance and utilization
review standards;
• Reviewed and revised upon reassessment of functional need, at least every
12 months, or when the enrollee’s circumstances or needs change
significantly. (42 CFR 457.1230(c), cross-referencing to 42 CFR
438.208(c)(3))

3.6.20

The State assures that each MCO, PIHP, and PAHP must have a mechanism in
place to allow enrollees to directly access a specialist as appropriate for the
enrollee's condition and identified needs for enrollees identified with special
health care needs who need a course of treatment or regular care monitoring. (42
CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(4))

3.7

Operations
3.7.1

Guidance:
3.7.2

The State assures that it has established a uniform credentialing and
recredentialing policy that addresses acute, primary, behavioral, and substance use
disorders providers and requires each MCO, PIHP and PAHP to follow those
policies. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(b)(1))
Only States with MCOs, PIHPs, or PAHPs need to answer the remaining
assurances in Section 3.7 (3.7.2 through 3.7.9).
The State assures each contracted MCO, PIHP and PAHP will comply with the
provider selection requirements in 42 CFR 457.1208 and 457.1233(a), crossreferencing 42 CFR 438.12 and 438.214, including that:
Each MCO, PIHP, or PAHP implements written policies and procedures for
selection and retention of network providers (42 CFR 457.1233(a), crossreferencing 42 CFR 438.214(a));
MCO, PIHP, and PAHP network provider selection policies and procedures
do not discriminate against particular providers that serve high-risk
populations or specialize in conditions that require costly treatment (42 CFR
457.1233(a), cross-referencing 42 CFR 438.214(c));
MCOs, PIHPs, and PAHPs do not discriminate in the participation,
reimbursement, or indemnification of any provider who is acting within the
29

scope of his or her license or certification, solely on the basis of that license
or certification (42 CFR 457.1208, cross referencing 42 CFR 438.12(a));
If an MCO, PIHP, or PAHP declines to include individual or groups of
providers in the MCO, PIHP, or PAHP’s provider network, the MCO, PIHP,
and PAHP gives the affected providers written notice of the reason for the
decision (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); and
MCOs, PIHPs, and PAHPs do not employ or contract with providers
excluded from participation in Federal health care programs under either
section 1128 or section 1128A of the Act. (42 CFR 457.1233(a), crossreferencing 42 CFR 438.214(d)).
3.7.3

The State assures that each contracted MCO, PIHP, and PAHP complies with the
subcontractual relationships and delegation requirements in 42 CFR 457.1233(b),
cross-referencing 42 CFR 438.230, including that:
The MCO, PIHP, or PAHP maintains ultimate responsibility for adhering to
and otherwise fully complying with all terms and conditions of its contract
with the State;
All contracts or written arrangements between the MCO, PIHP, or PAHP and
any subcontractor specify that all delegated activities or obligations, and
related reporting responsibilities, are specified in the contract or written
agreement, the subcontractor agrees to perform the delegated activities and
reporting responsibilities specified in compliance with the MCO's, PIHP's, or
PAHP's contract obligations, and the contract or written arrangement must
either provide for revocation of the delegation of activities or obligations, or
specify other remedies in instances where the State or the MCO, PIHP, or
PAHP determine that the subcontractor has not performed satisfactorily;
All contracts or written arrangements between the MCO, PIHP, or PAHP and
any subcontractor must specify that the subcontractor agrees to comply with
all applicable CHIP laws, regulations, including applicable subregulatory
guidance and contract provisions; and
The subcontractor agrees to the audit provisions in 438.230(c)(3).

3.7.4

The State assures that each contracted MCO and, when applicable, each PIHP and
PAHP, adopts and disseminates practice guidelines that are based on valid and
reliable clinical evidence or a consensus of providers in the particular field;
consider the needs of the MCO's, PIHP's, or PAHP's enrollees; are adopted in
consultation with network providers; and are reviewed and updated periodically
as appropriate. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(b) and
(c))

30

3.7.5

The State assures that each contracted MCO and, when applicable, each PIHP and
PAHP makes decisions for utilization management, enrollee education, coverage
of services, and other areas to which the guidelines apply are consistent with the
practice guidelines. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(d))

3.7.6

The State assures that each contracted MCO, PIHP, and PAHP maintains a health
information system that collects, analyzes, integrates, and reports data consistent
with 42 CFR 438.242. The systems must provide information on areas including,
but not limited to, utilization, claims, grievances and appeals, and disenrollments
for other than loss of CHIP eligibility. (42 CFR 457.1233(d), cross referencing 42
CFR 438.242)

3.7.7

The State assures that it reviews and validates the encounter data collected,
maintained, and submitted to the State by the MCO, PIHP, or PAHP to ensure it is
a complete and accurate representation of the services provided to the enrollees
under the contract between the State and the MCO, PIHP, or PAHP and meets the
requirements 42 CFR 438.242 of this section. (42 CFR 457.1233(d), cross
referencing 42 CFR 438.242)

3.7.8

The State assures that it will submit to CMS all encounter data collected,
maintained, submitted to the State by the MCO, PIHP, and PAHP once the State
has reviewed and validated the data based on the requirements of 42 CFR
438.242. (CMS State Medicaid Director Letter #13-004)

3.7.9

The State assures that each contracted MCO, PIHP and PAHP complies with the
privacy protections under 42 CFR 457.1110. (42 CFR 457.1233(e))

3.8

Beneficiary Protections
3.8.1

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity has
written policies regarding the enrollee rights specified in 42 CFR 438.100. (42
CFR 457.1220, cross-referencing to 42 CFR 438.100(a)(1))

3.8.2

The State assures that its contracts with an MCO, PIHP, PAHP, PCCM, or PCCM
entity include a guarantee that the MCO, PIHP, PAHP, PCCM, or PCCM entity
will not avoid costs for services covered in its contract by referring enrollees to
publicly supported health care resources. (42 CFR 457.1201(p))

3.8.3

The State assures that MCOs, PIHPs, and PAHPs do not hold the enrollee liable
for the following:
• The MCO’s, PIHP’s or PAHP’s debts, in the event of the entity’s solvency.
(42 CFR 457.1226, cross-referencing to 42 CFR 438.106(a))
• Covered services provided to the enrollee for which the State does not pay the
MCO, PIHP or PAHP or for which the State, MCO, PIHP, or PAHP does not
31

•

3.9

pay the individual or the health care provider that furnished the services under
a contractual, referral or other arrangement. (42 CFR 457.1226, crossreferencing to 42 CFR 438.106(b))
Payments for covered services furnished under a contract, referral or other
arrangement that are in excess of the amount the enrollee would owe if the
MCO, PIHP or PAHP covered the services directly. (42 CFR 457.1226, crossreferencing to 42 CFR 438.106(c))

Grievances and Appeals
Guidance:

Only States with MCOs, PIHPs, or PAHPs need to complete Section 3.9. States
with PCCMs and/or PCCM entities should be adhering to the State’s review
process for benefits.

3.9.1

The State assures that each MCO, PIHP, and PAHP has a grievance and appeal
system in place that allows enrollees to file a grievance and request an appeal. (42
CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c))

3.9.2

The State assures that each MCO, PIHP, and PAHP has only one level of appeal
for enrollees. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(b))

3.9.3

The State assures that an enrollee may request a State review after receiving
notice that the adverse benefit determination is upheld, or after an MCO, PIHP, or
PAHP fails to adhere to the notice and timing requirements in 42 CFR 438.408.
(42 CFR 457.1260, cross-referencing to 438.402(c))

3.9.4.

Does the state offer and arrange for an external medical review?
Yes
No

Guidance:

Only states that answered yes to assurance 3.9.4 need to complete the next
assurance (3.9.5).

3.9.5

The State assures that the external medical review is:
• At the enrollee's option and not required before or used as a deterrent to
proceeding to the State review;
• Independent of both the State and MCO, PIHP, or PAHP;
• Offered without any cost to the enrollee; and
• Not extending any of the timeframes specified in 42 CFR 438.408. (42 CFR
457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(1)(i))

32

3.9.6

The State assures that an enrollee may file a grievance with the MCO, PIHP, or
PAHP at any time. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a)
and 438.402(c)(2)(i))

3.9.7

The State assures that an enrollee has 60 calendar days from the date on an
adverse benefit determination notice to file a request for an appeal to the MCO,
PIHP, or PAHP. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and
438.402(c)(2)(ii))

3.9.8

The State assures that an enrollee may file a grievance and request an appeal
either orally or in writing. (42 CFR 457.1260, cross-referencing to 42 CFR
438.402(a) and 438.402(c)(3)(i))

3.9.9

The State assures that each MCO, PIHP, and PAHP gives enrollees timely and
adequate notice of an adverse benefit determination in writing consistent with the
requirements below in Section 3.9.10 and in 42 CFR 438.10.

3.9.10

The State assures that the notice of an adverse benefit determination explains:
• The adverse benefit determination.
• The reasons for the adverse benefit determination, including the right of the
enrollee to be provided upon request and free of charge, reasonable access to
and copies of all documents, records, and other information relevant to the
enrollee's adverse benefit determination. Such information includes medical
necessity criteria, and any processes, strategies, or evidentiary standards used
in setting coverage limits.
• The enrollee's right to request an appeal of the MCO's, PIHP's, or PAHP's
adverse benefit determination, including information on exhausting the
MCO's, PIHP's, or PAHP's one level of appeal and the right to request a State
review.
• The procedures for exercising the rights specified above under this assurance.
• The circumstances under which an appeal process can be expedited and how
to request it. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(b))

3.9.11

The State assures that the notice of an adverse benefit determination is provided
in a timely manner in accordance with 42 CFR 457.1260. (42 CFR 457.1260,
cross-referencing to 42 CFR 438.404(c))

3.9.12

The State assures that MCOs, PIHPs, and PAHPs give enrollees reasonable
assistance in completing forms and taking other procedural steps related to a
grievance or appeal. This includes, but is not limited to, auxiliary aids and
services upon request, such as providing interpreter services and toll-free numbers
that have adequate TTY/TTD and interpreter capability. (42 CFR 457.1260,
cross-referencing to 42 CFR 438.406(a))
33

3.9.13

The state makes the following assurances related to MCO, PIHP, and
PAHP processes for handling enrollee grievances and appeals:
Individuals who make decisions on grievances and appeals were neither
involved in any previous level of review or decision-making nor a
subordinate of any such individual.
Individuals who make decisions on grievances and appeals, if deciding any
of the following, are individuals who have the appropriate clinical expertise
in treating the enrollee's condition or disease:
• An appeal of a denial that is based on lack of medical necessity.
• A grievance regarding denial of expedited resolution of an appeal.
• A grievance or appeal that involves clinical issues.
All comments, documents, records, and other information submitted by the
enrollee or their representative will be taken into account, without regard to
whether such information was submitted or considered in the initial adverse
benefit determination.
Enrollees have a reasonable opportunity, in person and in writing, to present
evidence and testimony and make legal and factual arguments.
Enrollees are provided the enrollee's case file, including medical records,
other documents and records, and any new or additional evidence considered,
relied upon, or generated by the MCO, PIHP or PAHP (or at the direction of
the MCO, PIHP or PAHP) in connection with the appeal of the adverse
benefit determination. This information must be provided free of charge and
sufficiently in advance of the resolution timeframe for appeals.
The enrollee and his or her representative or the legal representative of a
deceased enrollee's estate are included as parties to the appeal. (42 CFR
457.1260, cross-referencing to 42 CFR 438.406(b))

3.9.14

The State assures that standard grievances are resolved (including notice to the
affected parties) within 90 calendar days from the day the MCO, PIHP, or PAHP
receives the grievance. (42 CFR 457.1260, cross-referencing to 42 CFR
438.408(b))

3.9.15

The State assures that standard appeals are resolved (including notice to the
affected parties) within 30 calendar days from the day the MCO, PIHP, or PAHP
receives the appeal. The MCO, PIHP, or PAHP may extend the timeframe by up
to 14 calendar days if the enrollee requests the extension or the MCO, PIHP, or
PAHP shows that there is need for additional information and that the delay is in
the enrollee's interest. (42 CFR 457.1260, cross-referencing to 42 CFR 42 CFR
438.408(b) and (c))

3.9.16

The State assures that each MCO, PIHP, and PAHP establishes and maintains an
expedited review process for appeals that is no longer than 72 hours after the
34

MCO, PIHP, or PAHP receives the appeal. The expedited review process applies
when the MCO, PIHP, or PAHP determines (for a request from the enrollee) or
the provider indicates (in making the request on the enrollee's behalf or
supporting the enrollee's request) that taking the time for a standard resolution
could seriously jeopardize the enrollee's life, physical or mental health, or ability
to attain, maintain, or regain maximum function. (42 CFR 457.1260, crossreferencing to 42 CFR 438.408(b) and (c), and 42 CFR 438.410(a))
3.9.17

The State assures that if an MCO, PIHP, or PAHP denies a request for expedited
resolution of an appeal, it transfers the appeal within the timeframe for standard
resolution in accordance with 42 CFR 438.408(b)(2). (42 CFR 457.1260, crossreferencing to 42 CFR 438.410(c)(1))

3.9.18

The State assures that if the MCO, PIHP, or PAHP extends the timeframes for an
appeal not at the request of the enrollee or it denies a request for an expedited
resolution of an appeal, it completes all of the following:
• Make reasonable efforts to give the enrollee prompt oral notice of the delay.
• Within 2 calendar days give the enrollee written notice of the reason for the
decision to extend the timeframe and inform the enrollee of the right to file a
grievance if he or she disagrees with that decision.
• Resolve the appeal as expeditiously as the enrollee's health condition requires
and no later than the date the extension expires. (42 CFR 457.1260, crossreferencing to 42 CFR 438.408(c) and 42 CFR 438.410(c))

3.9.19

The State assures that if an MCO, PIHP, or PAHP fails to adhere to the notice and
timing requirements in this section, the enrollee is deemed to have exhausted the
MCO's, PIHP's, or PAHP's appeals process and the enrollee may initiate a State
review. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c)(3))

3.9.20

The State assures that has established a method that an MCO, PIHP, and PAHP
will use to notify an enrollee of the resolution of a grievance and ensure that such
methods meet, at a minimum, the standards described at 42 CFR 438.10. (42 CFR
457.1260, cross referencing to 42 CFR 457.408(d)(1))

3.9.21

For all appeals, the State assures that each contracted MCO, PIHP, and PAHP
provides written notice of resolution in a format and language that, at a minimum,
meet the standards described at 42 CFR 438.10. The notice of resolution includes
at least the following items:
• The results of the resolution process and the date it was completed; and
• For appeals not resolved wholly in favor of the enrollees:
o The right to request a State review, and how to do so.
o The right to request and receive benefits while the hearing is pending, and
how to make the request.
35

o That the enrollee may, consistent with State policy, be held liable for the
cost of those benefits if the hearing decision upholds the MCO's, PIHP's,
or PAHP's adverse benefit determination. (42 CFR 457.1260, cross
referencing to 42 CFR 457.408(d)(2)(i) and (e))
3.9.22

For notice of an expedited resolution, the State assures that each contracted MCO,
PIHP, or PAHP makes reasonable efforts to provide oral notice, in addition to the
written notice of resolution. (42 CFR 457.1260, cross referencing to 42 CFR
457.408(d)(2)(ii))

3.9.23

The State assures that if it offers an external medical review:
• The review is at the enrollee's option and is not required before or used as a
deterrent to proceeding to the State review;
• The review is independent of both the State and MCO, PIHP, or PAHP; and
• The review is offered without any cost to the enrollee. (42 CFR 457.1260,
cross-referencing to 42 CFR 438.408(f))

3.9.24

The State assures that MCOs, PIHPs, and PAHPs do not take punitive action
against providers who request an expedited resolution or support an enrollee's
appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(b))

3.9.25

The State assures that MCOs, PIHPs, or PAHPs must provide information
specified in 42 CFR 438.10(g)(2)(xi) about the grievance and appeal system to all
providers and subcontractors at the time they enter into a contract. This includes:
• The right to file grievances and appeals;
• The requirements and timeframes for filing a grievance or appeal;
• The availability of assistance in the filing process;
• The right to request a State review after the MCO, PIHP or PAHP has made a
determination on an enrollee's appeal which is adverse to the enrollee; and
• The fact that, when requested by the enrollee, benefits that the MCO, PIHP, or
PAHP seeks to reduce or terminate will continue if the enrollee files an appeal
or a request for State review within the timeframes specified for filing, and
that the enrollee may, consistent with State policy, be required to pay the cost
of services furnished while the appeal or State review is pending if the final
decision is adverse to the enrollee. (42 CFR 457.1260, cross-referencing to 42
CFR 438.414)

3.9.26

The State assures that it requires MCOs, PIHPs, and PAHPs to maintain records
of grievances and appeals and reviews the information as part of its ongoing
monitoring procedures, as well as for updates and revisions to the State quality
strategy. The record must be accurately maintained in a manner accessible to the
state and available upon request to CMS. (42 CFR 457.1260, cross-referencing to
42 CFR 438.416)
36

3.9.27

The State assures that if the MCO, PIHP, or PAHP, or the State review officer
reverses a decision to deny, limit, or delay services that were not furnished while
the appeal was pending, the MCO, PIHP, or PAHP must authorize or provide the
disputed services promptly and as expeditiously as the enrollee's health condition
requires but no later than 72 hours from the date it receives notice reversing the
determination. (42 CFR 457.1260, cross-referencing to 42 CFR 438.424(a))

3.10

Program Integrity

Guidance:

The State should complete Section 11 (Program Integrity) in addition to Section 3.10.

Guidance:

Only States with MCOs, PIHPs, or PAHPs need to answer the first seven assurances
(3.10.1 through 3.10.7).

3.10.1

The State assures that any entity seeking to contract as an MCO, PIHP, or PAHP
under a separate child health program has administrative and management
arrangements or procedures designed to safeguard against fraud and abuse,
including:
Enforcing MCO, PIHP, and PAHP compliance with all applicable Federal
and State statutes, regulations, and standards;
Prohibiting MCOs, PIHPs, or PAHPs from conducting any unsolicited
personal contact with a potential enrollee by an employee or agent of the
MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll
with the entity; and
Including a mechanism for MCOs, PIHPs, and PAHPs to report to the State,
to CMS, or to the Office of Inspector General (OIG) as appropriate,
information on violations of law by subcontractors, providers, or enrollees
of an MCO, PIHP, or PAHP and other individuals. (42 CFR 457.1280)

3.10.2

The State assures that it has in effect safeguards against conflict of interest on the
part of State and local officers and employees and agents of the State who have
responsibilities relating to the MCO, PIHP, or PAHP contracts or enrollment
processes described in 42 CFR 457.1210(a). (42 CFR 457.1214, cross referencing
42 CFR 438.58)

3.10.3

The State assures that it periodically, but no less frequently than once every 3
years, conducts, or contracts for the conduct of, an independent audit of the
accuracy, truthfulness, and completeness of the encounter and financial data
submitted by, or on behalf of, each MCO, PIHP or PAHP. (42 CFR 457.1285,
cross referencing 42 CFR 438.602(e))

3.10.4

The State assures that it requires MCOs, PIHPs, PAHP, and or subcontractors
(only to the extent that the subcontractor is delegated responsibility by the MCO,
37

PIHP, or PAHP for coverage of services and payment of claims) implement and
maintain arrangements or procedures that are designed to detect and prevent
fraud, waste, and abuse. The arrangements or procedures must include the
following:
• A compliance program that include all of the elements described in 42 CFR
438.608(a)(1);
• Provision for prompt reporting of all overpayments identified or recovered,
specifying the overpayments due to potential fraud, to the State;
• Provision for prompt notification to the State when it receives information
about changes in an enrollee's circumstances that may affect the enrollee's
eligibility;
• Provision for notification to the State when it receives information about a
change in a network provider's circumstances that may affect the network
provider's eligibility to participate in the managed care program, including the
termination of the provider agreement with the MCO, PIHP or PAHP;
• Provision for a method to verify, by sampling or other methods, whether
services that have been represented to have been delivered by network
providers were received by enrollees and the application of such verification
processes on a regular basis;
• In the case of MCOs, PIHPs, or PAHPs that make or receive annual payments
under the contract of at least $5,000,000, provision for written policies for all
employees of the entity, and of any contractor or agent, that provide detailed
information about the False Claims Act and other Federal and State laws
described in section 1902(a)(68) of the Act, including information about rights
of employees to be protected as whistleblowers;
• Provision for the prompt referral of any potential fraud, waste, or abuse that
the MCO, PIHP, or PAHP identifies to the State Medicaid/CHIP program
integrity unit or any potential fraud directly to the State Medicaid Fraud
Control Unit; and
• Provision for the MCO's, PIHP's, or PAHP's suspension of payments to a
network provider for which the State determines there is a credible allegation
of fraud in accordance with 42 CFR 455.23. (42 CFR 457.1285, cross
referencing 42 CFR 438.608(a))
3.10.5

The State assures that each MCO, PIHP, or PAHP requires and has a mechanism
for a network provider to report to the MCO, PIHP or PAHP when it has received
an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60
calendar days after the date on which the overpayment was identified, and to
notify the MCO, PIHP or PAHP in writing of the reason for the overpayment. (42
CFR 457.1285, cross referencing 42 CFR 438.608(d)(2))

38

3.10.6

The State assures that each MCO, PIHP, or PAHP reports annually to the State on
their recoveries of overpayments. (42 CFR 457.1285, cross referencing 42 CFR
438.608(d)(3))

3.10.7

The State assures that it screens and enrolls, and periodically revalidates, all
network providers of MCOs, PIHPs, and PAHPs, in accordance with the
requirements of part 455, subparts B and E. This requirement also extends to
PCCMs and PCCM entities to the extent that the primary care case manager is not
otherwise enrolled with the State to provide services to fee-for-service
beneficiaries. (42 CFR 457.1285, cross referencing 42 CFR 438.602(b)(1) and
438.608(b))

3.10.8

The State assures that it reviews the ownership and control disclosures submitted
by the MCO, PIHP, PAHP, PCCM or PCCM entity, and any subcontractors. (42
CFR 457.1285, cross referencing 42 CFR 438.602(c))

3.10.9

The State assures that it confirms the identity and determines the exclusion status
of the MCO, PIHP, PAHP, PCCM or PCCM entity, any subcontractor, as well as
any person with an ownership or control interest, or who is an agent or managing
employee of the MCO, PIHP, PAHP, PCCM or PCCM entity through routine
checks of Federal databases. If the State finds a party that is excluded, the State
promptly notifies the MCO, PIHP, PAHP, PCCM, or PCCM entity and takes
action consistent with 42 CFR 438.610(c). (42 CFR 457.1285, cross referencing
42 CFR 438.602(d))

3.10.10

The State assures that it receives and investigates information from
whistleblowers relating to the integrity of the MCO, PIHP, PAHP, PCCM, or
PCCM entity, subcontractors, or network providers receiving Federal funds under
this part. (42 CFR 457.1285, cross referencing 42 CFR 438.602(f))

3.10.11

The State assures that MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities with
which the State contracts are not located outside of the United States and that no
claims paid by an MCO, PIHP, or PAHP to a network provider, out-of-network
provider, subcontractor or financial institution located outside of the U.S. are
considered in the development of actuarially sound capitation rates. (42 CFR
457.1285, cross referencing to 42 CFR 438.602(i); Section 1902(a)(80) of the
Social Security Act)

3.10.12

The State assures that MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities submit
to the State the following data, documentation, and information:
Encounter data in the form and manner described in 42 CFR 438.818.
Data on the basis of which the State determines the compliance of the
MCO, PIHP, or PAHP with the medical loss ratio requirement described
in 42 CFR 438.8.
39

Data on the basis of which the State determines that the MCO, PIHP or
PAHP has made adequate provision against the risk of insolvency as
required under 42 CFR 438.116.
Documentation described in 42 CFR 438.207(b) on which the State bases
its certification that the MCO, PIHP or PAHP has complied with the
State's requirements for availability and accessibility of services, including
the adequacy of the provider network, as set forth in 42 CFR 438.206.
Information on ownership and control described in 42 CFR 455.104 of this
chapter from MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and
subcontractors as governed by 42 CFR 438.230.
The annual report of overpayment recoveries as required in 42 CFR
438.608(d)(3). (42 CFR 457.1285, cross referencing 42 CFR 438.604(a))
3.10.13

The State assures that:
It requires that the data, documentation, or information submitted in
accordance with 42 CFR 457.1285, cross referencing 42 CFR 438.604(a),
is certified in a manner that the MCO's, PIHP's, PAHP's, PCCM's, or
PCCM entity's Chief Executive Officer or Chief Financial Officer is
ultimately responsible for the certification. (42 CFR 457.1285, cross
referencing 42 CFR 438.606(a))
It requires that the certification includes an attestation that, based on best
information, knowledge, and belief, the data, documentation, and
information specified in 42 CFR 438.604 are accurate, complete, and
truthful. (42 CFR 457.1285, cross referencing 42 CFR 438.606(b)); and
It requires the MCO, PIHP, PAHP, PCCM, or PCCM entity to submit the
certification concurrently with the submission of the data, documentation,
or information required in 42 CFR 438.604(a) and (b). (42 CFR 457.1285,
cross referencing 42 CFR 438.604(c))

3.10.14

The State assures that each MCO, PIHP, PAHP, PCCM, PCCM entity, and any
subcontractors provides: written disclosure of any prohibited affiliation under 42
CFR 438.610, written disclosure of and information on ownership and control
required under 42 CFR 455.104, and reports to the State within 60 calendar days
when it has identified the capitation payments or other payments in excess of
amounts specified in the contract. (42 CFR 457.1285, cross referencing 42 CFR
438.608(c))

3.10.15

The State assures that services are provided in an effective and efficient manner.
(Section 2101(a))

3.10.16

The State assures that it operates a Web site that provides:
• The documentation on which the State bases its certification that the MCO,
PIHP or PAHP has complied with the State's requirements for availability and
40

•
•

accessibility of services;
Information on ownership and control of MCOs, PIHPs, PAHPs, PCCMs,
PCCM entities, and subcontractors; and
The results of any audits conducted under 42 CFR 438.602(e). (42 CFR
457.1285, cross-referencing to 42 CFR 438.602(g)).

3.11

Sanctions

Guidance:

Only States with MCOs need to answer the next three assurances (3.11.1 through 3.11.3).
Intermediate sanctions are defined at 42 CFR 438.702(a)(4) as: (1) Civil money penalties;
(2) Appointment of temporary management (for an MCO); (3) Granting enrollees the
right to terminate enrollment without cause; (4) Suspension of all new enrollment; and
(5) Suspension of payment for beneficiaries.

3.11.1

The State assures that it has established intermediate sanctions that it may impose
if it makes the determination that an MCO has acted or failed to act in a manner
specified in 438.700(b)-(d). (42 CFR 457.1270, cross referencing 42 CFR
438.700)

3.11.2

The State assures that it will impose temporary management if it finds that an
MCO has repeatedly failed to meet substantive requirements of part 457 subpart
L. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b))

3.11.3

The State assures that if it imposes temporary management on an MCO, the State
allows enrollees the right to terminate enrollment without cause and notifies the
affected enrollees of their right to terminate enrollment. (42 CFR 457.1270, cross
referencing 42 CFR 438.706(b))

Guidance:

Only states with PCCMs, or PCCM entities need to answer the next assurance
(3.11.4).

3.11.4

Does the State establish intermediate sanctions for PCCMs or PCCM entities?
Yes
No

Guidance:

Only states with MCOs and states that answered yes to assurance 3.11.4 need to
complete the next three assurances (3.11.5 through 3.11.7).

3.11.5

The State assures that before it imposes intermediate sanctions, it gives the
affected entity timely written notice. (42 CFR 457.1270, cross referencing 42
CFR 438.710(a))

41

3.11.6

The State assures that if it intends to terminate an MCO, PCCM, or PCCM entity,
it provides a pre-termination hearing and written notice of the decision as
specified in 42 CFR 438.710(b). If the decision to terminate is affirmed, the State
assures that it gives enrollees of the MCO, PCCM or PCCM entity notice of the
termination and information, consistent with 42 CFR 438.10, on their options for
receiving CHIP services following the effective date of termination. (42 CFR
457.1270, cross referencing 42 CFR 438.710(b))

3.11.7

The State assures that it will give CMS written notice that complies with 42 CFR
438.724 whenever it imposes or lifts a sanction for one of the violations listed in
42 CFR 438.700. (42 CFR 457.1270, cross referencing 42 CFR 438.724)

3.12

Quality Measurement and Improvement; External Quality Review

Guidance:

The State should complete Sections 7 (Quality and Appropriateness of Care) and 9
(Strategic Objectives and Performance Goals and Plan Administration) in addition to
Section 3.12.

Guidance:

States with MCO(s), PIHP(s), PAHP(s), or certain PCCM entity/ies (PCCM entities
whose contract with the State provides for shared savings, incentive payments or other
financial reward for improved quality outcomes - see 42 CFR 457.1240(f)) - should
complete the applicable sub-sections for each entity type in this section, regarding 42
CFR 457.1240 and 1250.

3.12.1 Quality Strategy
Guidance:

All states with MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities need to
complete section 3.12.1.

3.12.1.1

The State assures that it will draft and implement a written quality strategy
for assessing and improving the quality of health care and services
furnished CHIP enrollees as described in 42 CFR 438.340(a). The quality
strategy must include the following items:
• The State-defined network adequacy and availability of services
standards for MCOs, PIHPs, and PAHPs required by 42 CFR 438.68
and 438.206 and examples of evidence-based clinical practice
guidelines the State requires in accordance with 42 CFR 438.236;
• A description of:
o The quality metrics and performance targets to be used in
measuring the performance and improvement of each MCO, PIHP,
and PAHP with which the State contracts, including but not limited
to, the performance measures reported in accordance with 42 CFR
438.330(c); and
o The performance improvement projects to be implemented in
42

•
•
•
•
•
•
•

•
•

accordance with 42 CFR 438.330(d), including a description of any
interventions the State proposes to improve access, quality, or
timeliness of care for beneficiaries enrolled in an MCO, PIHP, or
PAHP;
Arrangements for annual, external independent reviews, in accordance
with 42 CFR 438.350, of the quality outcomes and timeliness of, and
access to, the services covered under each contract;
A description of the State's transition of care policy required under 42
CFR 438.62(b)(3);
The State's plan to identify, evaluate, and reduce, to the extent
practicable, health disparities based on age, race, ethnicity, sex, and
primary language;
For MCOs, appropriate use of intermediate sanctions that, at a
minimum, meet the requirements of subpart I of 42 CFR Part 438;
A description of how the State will assess the performance and quality
outcomes achieved by each PCCM entity;
The mechanisms implemented by the State to comply with 42 CFR
438.208(c)(1) (relating to the identification of persons with special
health care needs);
Identification of the external quality review (EQR)-related activities for
which the State has exercised the option under 42 CFR 438.360
(relating to nonduplication of EQR-related activities), and explain the
rationale for the State's determination that the private accreditation
activity is comparable to such EQR-related activities;
Identification of which quality measures and performance outcomes the
State will publish at least annually on the Web site required under 42
CFR 438.10(c)(3); and
The State's definition of a “significant change” for the purposes of
updating the quality strategy under 42 CFR 438.340(c)(3)(ii). (42 CFR
457.1240(e), cross referencing to 42 CFR 438.340(b))

3.12.1.2

The State assures that the goals and objectives for continuous quality
improvement in the quality strategy are measurable and take into
consideration the health status of all populations in the State served by the
MCO, PIHP, and PAHP. (42 CFR 457.1240(e), cross referencing to 42
CFR 438.340(b)(2))

3.12.1.3

The State assures that for purposes of the quality strategy, the State
provides the demographic information for each CHIP enrollee to the
MCO, PIHP or PAHP at the time of enrollment. (42 CFR 457.1240(e),
cross referencing to 42 CFR 438.340(b)(6))

43

3.12.1.4

The State assures that it will review and update the quality strategy as
needed, but no less than once every 3 years. (42 CFR 457.1240(e), cross
referencing to 42 CFR 438.340(c)(2))

3.12.1.5

The State assures that its review and updates to the quality strategy will
include an evaluation of the effectiveness of the quality strategy conducted
within the previous 3 years and the recommendations provided pursuant to
42 CFR 438.364(a)(4). (42 CFR 457.1240(e), cross referencing to 42 CFR
438.340(c)(2)(i) and (iii).

3.12.1.6

The State assures that it will submit to CMS:
• A copy of the initial quality strategy for CMS comment and feedback
prior to adopting it in final; and
• A copy of the revised strategy whenever significant changes are made
to the document, or whenever significant changes occur within the
State's CHIP program, including after the review and update required
every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR
438.340(c)(3))

3.12.1.7

Before submitting the strategy to CMS for review, the State assures that
when it drafts or revises the State’s quality strategy it will:
• Make the strategy available for public comment; and
• If the State enrolls Indians in the MCO, PIHP, or PAHP, consult with
Tribes in accordance with the State's Tribal consultation policy. (42
CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(1))

3.12.1.8

The State assures that it makes the results of the review of the quality
strategy (including the effectiveness evaluation) and the final quality
strategy available on the Web site required under 42 CFR 438.10(c)(3).
(42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(ii) and
(d))

3.12.2 Quality Assessment and Performance Improvement Program
3.12.2.1

Quality Assessment and Performance Improvement Program: Measures
and Projects

Guidance:

Only states with MCOs, PIHPs, or PAHPs need to complete the next two
assurances (3.12.2.1.1 and 3.12.2.1.2).

3.12.2.1.1

The State assures that it requires that each MCO, PIHP, and PAHP
establish and implement an ongoing comprehensive quality
assessment and performance improvement program for the
services it furnishes to its enrollees as provided in 42 CFR
44

438.330, except that the terms of 42 CFR 438.330(d)(4) (related to
dual eligibles) do not apply. The elements of the assessment and
program include at least:
• Standard performance measures specified by the State;
• Any measures and programs required by CMS (42 CFR
438.330(a)(2);
• Performance improvement projects that focus on clinical and
non-clinical areas, as specified in 42 CFR 438.330(d);
• Collection and submission of performance measurement data
in accordance with 42 CFR 438.330(c);
• Mechanisms to detect both underutilization and overutilization
of services; and
• Mechanisms to assess the quality and appropriateness of care
furnished to enrollees with special health care needs, as defined
by the State in the quality strategy under 42 CFR 457.1240(e)
and Section 3.12.1 of this template). (42 CFR 457.1240(b),
cross referencing to 42 CFR 438.330(b) and (c)(1))
Guidance:

A State may request an exemption from including the
performance measures or performance improvement programs
established by CMS under 42 CFR 438.330(a)(2), by submitting a
written request to CMS explaining the basis for such request.

3.12.2.1.2

The State assures that each MCO, PIHP, and PAHP’s performance
improvement projects are designed to achieve significant
improvement, sustained over time, in health outcomes and enrollee
satisfaction. The performance improvement projects include at
least the following elements:
• Measurement of performance using objective quality
indicators;
• Implementation of interventions to achieve improvement in the
access to and quality of care;
• Evaluation of the effectiveness of the interventions based on
the performance measures specified in 42 CFR
438.330(d)(2)(i); and
• Planning and initiation of activities for increasing or sustaining
improvement. (42 CFR 457.1240(b), cross referencing to 42
CFR 438.330(d)(2))

Guidance:

Only states with a PCCM entity whose contract with the State
provides for shared savings, incentive payments or other financial

45

reward for improved quality outcomes need to, complete the next
assurance (3.12.2.1.3).
3.12.2.1.3

3.12.2.2

The State assures that it requires that each PCCM entity establishes
and implements an ongoing comprehensive quality assessment and
performance improvement program for the services it furnishes to
its enrollees as provided in 42 CFR 438.330, except that the terms
of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply.
The assessment and program must include:
• Standard performance measures specified by the State;
• Mechanisms to detect both underutilization and overutilization
of services; and
• Collection and submission of performance measurement data
in accordance with 42 CFR 438.330(c). (42 CFR 457.1240(a)
and (b), cross referencing to 42 CFR 438.330(b)(3) and (c))

Quality Assessment and Performance Improvement Program:
Reporting and Effectiveness

Guidance:

Only states with MCOs, PIHPs, or PAHPs need to complete
Section 3.12.2.2.

3.12.2.2.1

The State assures that each MCO, PIHP, and PAHP reports on the
status and results of each performance improvement project
conducted by the MCO, PIHP, and PAHP to the State as required
by the State, but not less than once per year. (42 CFR 457.1240(b),
cross referencing to 42 CFR 438.330(d)(3))

3.12.2.2.2

The State assures that it annually requires each MCO, PIHP, and
PAHP to:
1) Measure and report to the State on its performance using the
standard measures required by the State;
2) Submit to the State data specified by the State to calculate the
MCO's, PIHP's, or PAHP's performance using the standard
measures identified by the State; or
3) Perform a combination of options (1) and (2) of this assurance.
(42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(c)(2))

3.12.2.2.3

The State assures that the State reviews, at least annually, the
impact and effectiveness of the quality assessment and
performance improvement program of each MCO, PIHP, PAHP
and PCCM entity. The State’s review must include:
• The MCO's, PIHP's, PAHP's, and PCCM entity's performance
on the measures on which it is required to report; and
46

•
3.12.3 Accreditation

The outcomes and trended results of each MCO's, PIHP's, and
PAHP's performance improvement projects. (42 CFR
457.1240(b), cross referencing to 42 CFR 438.330(e)(1))

Guidance:

Only states with MCOs, PIHPs, or PAHPs need to complete Section
3.12.3.

3.12.3.1

The State assures that it requires each MCO, PIHP, and PAHP to inform
the state whether it has been accredited by a private independent
accrediting entity, and, if the MCO, PIHP, or PAHP has received
accreditation by a private independent accrediting agency, that the MCO,
PIHP, and PAHP authorizes the private independent accrediting entity to
provide the State a copy of its recent accreditation review that includes the
MCO, PIHP, and PAHP’s accreditation status, survey type, and level (as
applicable); accreditation results, including recommended actions or
improvements, corrective action plans, and summaries of findings; and
expiration date of the accreditation. (42 CFR 457.1240(c), cross
referencing to 42 CFR 438.332(a) and (b)).

3.12.3.2

The State assures that it will make the accreditation status for each
contracted MCO, PIHP, and PAHP available on the Web site required
under 42 CFR 438.10(c)(3), including whether each MCO, PIHP, and
PAHP has been accredited and, if applicable, the name of the accrediting
entity, accreditation program, and accreditation level; and update this
information at least annually. (42 CFR 457.1240(c), cross referencing to
42 CFR 438.332(c))

3.12.4 Quality Rating
Guidance:

Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.4.

The State assures that it will implement and operate a quality rating system that issues an
annual quality rating for each MCO, PIHP, and PAHP, which the State will prominently
display on the Web site required under 42 CFR 438.10(c)(3), in accordance with the
requirements set forth in 42 CFR 438.334. (42 CFR 457.1240(d))
Guidance:

States will be required to comply with this assurance within 3 years after CMS, in
consultation with States and other Stakeholders and after providing public notice
and opportunity for comment, has identified performance measures and a
methodology for a Medicaid and CHIP managed care quality rating system in the
Federal Register.

3.12.5 Quality Review
47

Guidance:

All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to
complete Sections 3.12.5 and 3.12.5.1.

The State assures that each contract with a MCO, PIHP, PAHP, or PCCM entity requires
that a qualified EQRO performs an annual external quality review (EQR) for each
contracting MCO, PIHP, PAHP or PCCM entity, except as provided in 42 CFR 438.362.
(42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(a))
3.12.5.1

External Quality Review Organization

3.12.5.1.1

The State assures that it contracts with at least one external quality
review organization (EQRO) to conduct either EQR alone or EQR
and other EQR-related activities. (42 CFR 457.1250(a), cross
referencing to 42 CFR 438.356(a))

3.12.5.1.2

The State assures that any EQRO used by the State to comply with
42 CFR 457.1250 must meet the competence and independence
requirements of 42 CFR 438.354 and, if the EQRO uses
subcontractors, that the EQRO is accountable for and oversees all
subcontractor functions. (42 CFR 457.1250(a), cross referencing to
42 CFR 438.354 and 42 CFR 438.356(b) through (d))

3.12.5.2

External Quality Review-Related Activities

Guidance:

Only states with MCOs, PIHPs, or PAHPs need to complete the next three
assurances (3.12.5.2.1 through 3.12.5.2.3). Under 42 CFR 457.1250(a),
the State, or its agent or EQRO, must conduct the EQR-related activity
under 42 CFR 438.358(b)(1)(iv) regarding validation of the MCO, PIHP,
or PAHP’s network adequacy during the preceding 12 months; however,
the State may permit its contracted MCO, PIHP, and PAHPs to use
information from a private accreditation review in lieu of any or all the
EQR-related activities under 42 CFR 438.358(b)(1)(i) through (iii)
(relating to the validation of performance improvement projects,
validation of performance measures, and compliance review).

3.12.5.2.1

The State assures that the mandatory EQR-related activities
described in 42 CFR 438.358(b)(1)(i) through (iv) (relating to the
validation of performance improvement projects, validation of
performance measures, compliance review, and validation of
network adequacy) will be conducted on all MCOs, PIHPs, or
PAHPs. (42 CFR 457.1250(a), cross referencing to 42 CFR
438.358(b)(1))

48

3.12.5.2.2

The State assures that if it elects to use nonduplication for any or
all of the three mandatory EQR-related activities described at 42
CFR 438.358(b)(1)(i) – (iii), the State will document the use of
nonduplication in the State’s quality strategy. (42 CFR
457.1250(a), cross referencing 438.360, 438.358(b)(1)(i) through
(b)(1)(iii), and 438.340)

3.12.5.2.3

The State assures that if the State elects to use nonduplication for
any or all of the three mandatory EQR-related activities described
at 42 CFR 438.358(b)(1)(i) – (iii), the State will ensure that all
information from a Medicare or private accreditation review for an
MCO, PIHP, or PAHP will be furnished to the EQRO for analysis
and inclusion in the EQR technical report described in 42 CFR
438.364. ((42 CFR 457.1250(a), cross referencing to 42 CFR
438.360(b))

Guidance:

Only states with PCCM entities need to complete the next
assurance (3.12.5.2.4).

3.12.5.2.4

The State assures that the mandatory EQR-related activities
described in 42 CFR 438.358(b)(2) (cross-referencing 42 CFR
438.358(b)(1)(ii) and (b)(1)(iii)) will be conducted on all PCCM
entities, which include:
• Validation of PCCM entity performance measures required in
accordance with 42 CFR 438.330(b)(2) or PCCM entity
performance measures calculated by the State during the
preceding 12 months; and
• A review, conducted within the previous 3-year period, to
determine the PCCM entity’s compliance with the standards set
forth in subpart D of 42 CFR part 438 and the quality
assessment and performance improvement requirements
described in 42 CFR 438.330. (42 CFR 457.1250(a), cross
referencing to 438.358(b)(2))

3.12.5.3

External Quality Review Report

Guidance:

All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities
need to complete Sections 3.12.5.3.

3.12.5.3.1

The State assures that data obtained from the mandatory and
optional, if applicable, EQR-related activities in 42 CFR 438.358 is
used for the annual EQR to comply with 42 CFR 438.350 and must
include, at a minimum, the elements in §438.364(a)(2)(i) through
49

(iv). (42 CFR 457.1250(a), cross referencing to 42 CFR
438.358(a)(2))
3.12.5.3.2

The State assures that only a qualified EQRO will produce the
EQR technical report (42 CFR 438.364(c)(1)).

3.12.5.3.3

The State assures that in order for the qualified EQRO to perform
an annual EQR for each contracting MCO, PIHP, PAHP or PCCM
entity under 42 CFR 438.350(a) that the following conditions are
met:
• The EQRO has sufficient information to use in performing the
review;
• The information used to carry out the review must be obtained
from the EQR-related activities described in 42 CFR 438.358
and, if applicable, from a private accreditation review as
described in 42 CFR 438.360;
• For each EQR-related activity (mandatory or optional), the
information gathered for use in the EQR must include the
elements described in 42 CFR 438.364(a)(2)(i) through (iv);
and
• The information provided to the EQRO in accordance with 42
CFR 438.350(b) is obtained through methods consistent with
the protocols established by the Secretary in accordance with
42 CFR 438.352. (42 CFR 457.1250(a), cross referencing to 42
CFR 438.350(b) through (e))

3.12.5.3.4

The State assures that the results of the reviews performed by a
qualified EQRO of each contracting MCO, PIHP, PAHP, and
PCCM entity are made available as specified in 42 CFR 438.364 in
an annual detailed technical report that summarizes findings on
access and quality of care. The report includes at least the
following items:
• A description of the manner in which the data from all
activities conducted in accordance with 42 CFR 438.358 were
aggregated and analyzed, and conclusions were drawn as to the
quality, timeliness, and access to the care furnished by the
MCO, PIHP, PAHP, or PCCM entity (described in 42 CFR
438.310(c)(2));
• For each EQR-related activity (mandatory or optional)
conducted in accordance with 42 CFR 438.358:
o Objectives;
o Technical methods of data collection and analysis;
o Description of data obtained, including validated
50

•

•

•

•

performance measurement data for each activity conducted
in accordance with 42 CFR 438.358(b)(1)(i) and (ii); and
o Conclusions drawn from the data;
An assessment of each MCO's, PIHP's, PAHP's, or PCCM
entity's strengths and weaknesses for the quality, timeliness,
and access to health care services furnished to CHIP
beneficiaries;
Recommendations for improving the quality of health care
services furnished by each MCO, PIHP, PAHP, or PCCM
entity, including how the State can target goals and objectives
in the quality strategy, under 42 CFR 438.340, to better support
improvement in the quality, timeliness, and access to health
care services furnished to CHIP beneficiaries;
Methodologically appropriate, comparative information about
all MCOs, PIHPs, PAHPs, and PCCM entities, consistent with
guidance included in the EQR protocols issued in accordance
with 42 CFR 438.352(e); and
An assessment of the degree to which each MCO, PIHP,
PAHP, or PCCM entity has addressed effectively the
recommendations for quality improvement made by the EQRO
during the previous year's EQR. (42 CFR 457.1250(a), cross
referencing to 42 CFR 438.350(f) and 438.364(a))

3.12.5.3.5

The State assures that it does not substantively revise the content
of the final EQR technical report without evidence of error or
omission. (42 CFR 457.1250(a), cross referencing to 42 CFR
438.364(b))

3.12.5.3.6

The State assures that it finalizes the annual EQR technical report
by April 30th of each year. (42 CFR 457.1250(a), cross referencing
to 42 CFR 438.364(c)(1))

3.12.5.3.7

The State assures that it posts the most recent copy of the annual
EQR technical report on the Web site required under 42 CFR
438.10(c)(3) by April 30th of each year. (42 CFR 457.1250(a),
cross referencing to 42 CFR 438.364(c)(2)(i))

3.12.5.3.8

The State assures that it provides printed or electronic copies of the
information specified in 42 CFR 438.364(a) for the annual EQR
technical report, upon request, to interested parties such as
participating health care providers, enrollees and potential
enrollees of the MCO, PIHP, PAHP, or PCCM, beneficiary
advocacy groups, and members of the general public. (42 CFR
457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(ii))
51

3.12.5.3.9

The State assures that it makes the information specified in 42
CFR 438.364(a) for the annual EQR technical report available in
alternative formats for persons with disabilities, when requested.
(42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(3))

3.12.5.3.10

The State assures that information released under 42 CFR 438.364
for the annual EQR technical report does not disclose the identity
or other protected health information of any patient. (42 CFR
457.1250(a), cross referencing to 42 CFR 438.364(d))

Section 4.

Eligibility Standards and Methodology

Guidance:

States electing to use funds provided under Title XXI only to provide expanded
eligibility under the State’s Medicaid plan or combination plan should check the
appropriate box and provide the ages and income level for each eligibility group.
If the State is electing to take up the option to expand Medicaid eligibility as allowed
under section 214 of CHIPRA regarding lawfully residing, complete section 4.1-LR as
well as update the budget to reflect the additional costs if the state will claim title XXI
match for these children until and if the time comes that the children are eligible for
Medicaid.

4.0.

Medicaid Expansion
4.0.1.

4.1.

Ages of each eligibility group and the income standard for that group:

Separate Program Check all standards that will apply to the State plan. (42CFR
457.305(a) and 457.320(a))
4.1.0

Describe how the State meets the citizenship verification requirements.
Include whether or not State has opted to use SSA verification option.

4.1.1

Geographic area served by the Plan if less than Statewide:

4.1.2

Ages of each eligibility group, including unborn children and pregnant
women (if applicable) and the income standard for that group:
4.1.2.1-PC

4.1.3

Age:
2002)

through birth (SHO #02-004, issued November 12,

Income of each separate eligibility group (if applicable):

52

4.1.3.1-PC

0% of the FPL (and not eligible for Medicaid) through
of the FPL (SHO #02-004, issued November 12, 2002)
Resources of each separate eligibility group (including any standards
relating to spend downs and disposition of resources):

4.1.4

%

4.1.5

Residency (so long as residency requirement is not based on length of time
in state):

4.1.6

Disability Status (so long as any standard relating to disability status does
not restrict eligibility):

4.1.7

Access to or coverage under other health coverage:

4.1.8

Duration of eligibility, not to exceed 12 months:

4.1.9

Other Standards- Identify and describe other standards for or affecting
eligibility, including those standards in 457.310 and 457.320 that are not
addressed above. For instance:

Guidance:

States may only require the SSN of the child who is applying for coverage.
If SSNs are required and the State covers unborn children, indicate that the
unborn children are exempt from providing a SSN. Other standards
include, but are not limited to presumptive eligibility and deemed
newborns.

4.1.9.1
Guidance:

States should specify whether Social Security Numbers (SSN) are
required.

States should describe their continuous eligibility process and populations
that can be continuously eligible.

4.1.9.2

Continuous eligibility

4.1-PW

Pregnant Women Option (section 2112)- The State includes eligibility for one or more
populations of targeted low-income pregnant women under the plan. Describe the
population of pregnant women that the State proposes to cover in this section. Include all
eligibility criteria, such as those described in the above categories (for instance, income
and resources) that will be applied to this population. Use the same reference number
system for those criteria (for example, 4.1.1-P for a geographic restriction). Please
remember to update sections 8.1.1-PW, 8.1.2-PW, and 9.10 when electing this option.

Guidance:

States have the option to cover groups of “lawfully residing” children and/or pregnant
women. States may elect to cover (1) “lawfully residing” children described at section
53

2107(e)(1)(J) of the Act; (2) “lawfully residing” pregnant women described at section
2107(e)(1)(J) of the Act; or (3) both. A state electing to cover children and/or pregnant
women who are considered lawfully residing in the U.S. must offer coverage to all such
individuals who meet the definition of lawfully residing, and may not cover a subgroup
or only certain groups. In addition, states may not cover these new groups only in CHIP,
but must also extend the coverage option to Medicaid. States will need to update their
budget to reflect the additional costs for coverage of these children. If a State has been
covering these children with State only funds, it is helpful to indicate that so CMS
understands the basis for the enrollment estimates and the projected cost of providing
coverage. Please remember to update section 9.10 when electing this option.
4.1- LR

Lawfully Residing Option (Sections 2107(e)(1)(J) and 1903(v)(4)(A); (CHIPRA # 17,
SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section
214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA)
regarding lawfully residing to provide coverage to the following otherwise eligible
pregnant women and children as specified below who are lawfully residing in the United
States including the following:
A child or pregnant woman shall be considered lawfully present if he or she is:
(1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641);
(2) An alien in nonimmigrant status who has not violated the terms of the
status under which he or she was admitted or to which he or she has
changed after admission;
(3) An alien who has been paroled into the United States pursuant to section
212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C.
§1182(d)(5)) for less than 1 year, except for an alien paroled for
prosecution, for deferred inspection or pending removal proceedings;
(4) An alien who belongs to one of the following classes:
(i) Aliens currently in temporary resident status pursuant to section 210 or
245A of the INA (8 U.S.C. §§1160 or 1255a, respectively);
(ii) Aliens currently under Temporary Protected Status (TPS) pursuant to
section 244 of the INA (8 U.S.C. §1254a), and pending applicants for
TPS who have been granted employment authorization;
(iii) Aliens who have been granted employment authorization under 8
CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24);
(iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101649, as amended;
(v) Aliens currently under Deferred Enforced Departure (DED) pursuant
to a decision made by the President;
(vi) Aliens currently in deferred action status; or
(vii) Aliens whose visa petition has been approved and who have a
pending application for adjustment of status;
(5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C.
§ 1158) or for withholding of removal under section 241(b)(3) of the INA
54

(8 U.S.C. § 1231) or under the Convention Against Torture who has been
granted employment authorization, and such an applicant under the age of
14 who has had an application pending for at least180 days;
(6) An alien who has been granted withholding of removal under the
Convention Against Torture;
(7) A child who has a pending application for Special Immigrant Juvenile
status as described in section 101(a)(27)(J) of the INA (8 U.S.C.
§1101(a)(27)(J));
(8) An alien who is lawfully present in the Commonwealth of the Northern
Mariana Islands under 48 U.S.C. § 1806(e); or
(9) An alien who is lawfully present in American Samoa under the
immigration laws of American Samoa.
Elected for pregnant women.
Elected for children under age
4.1.1-LR

The State provides assurance that for an individual whom it enrolls in
Medicaid under the CHIPRA Lawfully Residing option, it has verified, at
the time of the individual’s initial eligibility determination and at the time
of the eligibility redetermination, that the individual continues to be
lawfully residing in the United States. The State must first attempt to
verify this status using information provided at the time of initial
application. If the State cannot do so from the information readily
available, it must require the individual to provide documentation or
further evidence to verify satisfactory immigration status in the same
manner as it would for anyone else claiming satisfactory immigration
status under section 1137(d) of the Act.

4.1-DS

Supplemental Dental (Section 2103(c)(5) - A child who is eligible to enroll in dentalonly supplemental coverage, effective January 1, 2009. Eligibility is limited to only
targeted low-income children who are otherwise eligible for CHIP but for the fact that
they are enrolled in a group health plan or health insurance offered through an employer.
The State’s CHIP plan income eligibility level is at least the highest income eligibility
standard under its approved State child health plan (or under a waiver) as of January 1,
2009. All who meet the eligibility standards and apply for dental-only supplemental
coverage shall be provided benefits. States choosing this option must report these
children separately in SEDS. Please update sections 1.1-DS, 4.2-DS, and 9.10 when
electing this option.

4.2.

Assurances The State assures by checking the box below that it has made the following
findings with respect to the eligibility standards in its plan: (Section 2102(b)(1)(B) and 42
CFR 457.320(b))
4.2.1.
These standards do not discriminate on the basis of diagnosis.
55

4.2.2.

4.2.3.

Within a defined group of covered targeted low-income children, these
standards do not cover children of higher income families without covering
children with a lower family income. This applies to pregnant women included
in the State plan as well as targeted low-income children.
These standards do not deny eligibility based on a child having a pre-existing
medical condition. This applies to pregnant women as well as targeted lowincome children.

4.2-DS

Supplemental Dental - Please update sections 1.1-DS, 4.1-DS, and 9.10 when electing
this option. For dental-only supplemental coverage, the State assures that it has made the
following findings with standards in its plan: (Section 2102(b)(1)(B) and 42 CFR
457.320(b))
4.2.1-DS
These standards do not discriminate on the basis of diagnosis.
4.2.2-DS
Within a defined group of covered targeted low-income children, these
standards do not cover children of higher income families without covering
children with a lower family income.
4.2.3-DS
These standards do not deny eligibility based on a child having a preexisting medical condition.

4.3.

Methodology. Describe the methods of establishing and continuing eligibility and
enrollment. The description should address the procedures for applying the eligibility
standards, the organization and infrastructure responsible for making and reviewing
eligibility determinations, and the process for enrollment of individuals receiving covered
services, and whether the State uses the same application form for Medicaid and/or other
public benefit programs. (Section 2102)(b)(2)) (42CFR, 457.350)
Guidance:

The box below should be checked as related to children and pregnant women.
Please note: A State providing dental-only supplemental coverage may not have a
waiting list or limit eligibility in any way.

4.3.1. Limitation on Enrollment Describe the processes, if any, that a State will use for
instituting enrollment caps, establishing waiting lists, and deciding which children will be
given priority for enrollment. If this section does not apply to your state, check the box
below. (Section 2102(b)(2)) (42CFR, 457.305(b))
Check here if this section does not apply to your State.
Guidance:

4.3.2.

Note that for purposes of presumptive eligibility, States do not need to verify the
citizenship status of the child. States electing this option should indicate so in the
State plan. (42 CFR 457.355)

Check if the State elects to provide presumptive eligibility for children that meets the
requirements of section 1920A of the Act. (Section 2107(e)(1)(L)); (42 CFR 457.355)
56

Guidance:

Describe how the State intends to implement the Express Lane option. Include
information on the identified Express Lane agency or agencies, and whether the
State will be using the Express Lane eligibility option for the initial eligibility
determinations, redeterminations, or both.

4.3.3-EL Express Lane Eligibility
Check here if the state elects the option to rely on a
finding from an Express Lane agency when determining whether a child satisfies one or
more components of CHIP eligibility. The state agrees to comply with the requirements
of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update
sections 4.4-EL, 5.2-EL, 9.10, and 12.1 when electing this option. This authority may not
apply to eligibility determinations made before February 4, 2009, or after September 30,
2013. (Section 2107(e)(1)(E))
4.3.3.1-EL Also indicate whether the Express Lane option is applied to (1) initial
eligibility determination, (2) redetermination, or (3) both.
4.3.3.2-EL List the public agencies approved by the State as Express Lane
agencies.
4.3.3.3-EL List the components/components of CHIP eligibility that are
determined under the Express Lane. In this section, specify any differences in
budget unit, deeming, income exclusions, income disregards, or other
methodology between CHIP eligibility determinations for such children and the
determination under the Express Lane option.
4.3.3.3-EL List the component/components of CHIP eligibility that are
determined under the Express Lane.
4.3.3.4-EL Describe the option used to satisfy the screen and enrollment
requirements before a child may be enrolled under title XXI.
Guidance:

States should describe the process they use to screen and enroll children required under
section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and
457.80(c). Describe the screening threshold set as a percentage of the Federal poverty
level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a
minimum of 30 percentage points. (NOTE: The State may set this threshold higher than
30 percentage points to account for any differences between the income calculation
methodologies used by an Express Lane agency and those used by the State for its
Medicaid program. The State may set one screening threshold for all children, based on
the highest Medicaid income threshold, or it may set more than one screening threshold,
based on its existing, age-related Medicaid eligibility thresholds.) Include the screening
threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this
was calculated. Describe whether the State is temporarily enrolling children in CHIP,
57

based on the income finding from an Express Lane agency, pending the completion of the
screen and enroll process.
In this section, states should describe their eligibility screening process in a way that
addresses the five assurances specified below. The State should consider including
important definitions, the relationship with affected Federal, State and local agencies, and
other applicable criteria that will describe the State’s ability to make assurances.
(Sections 2102(b)(3)(A) and 2110(b)(2)(B)), (42 CFR 457.310(b)(2), 42CFR
457.350(a)(1) and 457.80(c)(3))
4.4.

Eligibility screening and coordination with other health coverage programs
States must describe how they will assure that:
4.4.1.

only targeted low-income children who are ineligible for Medicaid or not
covered under a group health plan or health insurance (including access to a
State health benefits plan) are furnished child health assistance under the plan.
(Sections 2102(b)(3)(A), 2110(b)(2)(B)) (42 CFR 457.310(b), 42 CFR
457.350(a)(1) and 42 CFR 457.80(c)(3)) Confirm that the State does not apply a
waiting period for pregnant women.

4.4.2.

children found through the screening process to be potentially eligible for
medical assistance under the State Medicaid plan are enrolled for assistance
under such plan; (Section 2102(b)(3)(B)) (42CFR, 457.350(a)(2))

4.4.3.

children found through the screening process to be ineligible for Medicaid are
enrolled in CHIP; (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR
431.636(b)(4))

4.4.4.

the insurance provided under the State child health plan does not substitute for
coverage under group health plans. (Section 2102(b)(3)(C)) (42CFR, 457.805)

4.4.4.1.

4.4.5.

Guidance:

(formerly 4.4.4.4) If the State provides coverage under a premium
assistance program, describe: 1) the minimum period without coverage
under a group health plan. This should include any allowable exceptions
to the waiting period; 2) the expected minimum level of contribution
employers will make; and 3) how cost-effectiveness is determined.
(42CFR 457.810(a)-(c))

Child health assistance is provided to targeted low-income children in the State
who are American Indian and Alaska Native. (Section 2102(b)(3)(D)) (42 CFR
457.125(a))

When the State is using an income finding from an Express Lane agency, the State must
58

still comply with screen and enroll requirements before enrolling children in CHIP. The
State may either continue its current screen and enroll process, or elect one of two new
options to fulfill these requirements.
4.4-EL

The State should designate the option it will be using to carry out screen and enroll
requirements:
The State will continue to use the screen and enroll procedures required under
section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a)
and 42 CFR 457.80(c). Describe this process.
The State is establishing a screening threshold set as a percentage of the Federal
poverty level (FPL) that exceeds the highest Medicaid income threshold
applicable to a child by a minimum of 30 percentage points. (NOTE: The State
may set this threshold higher than 30 percentage points to account for any
differences between the income calculation methodologies used by the Express
Lane agency and those used by the State for its Medicaid program. The State may
set one screening threshold for all children, based on the highest Medicaid income
threshold, or it may set more than one screening threshold, based on its existing,
age-related Medicaid eligibility thresholds.) Include the screening threshold(s)
expressed as a percentage of the FPL, and provide an explanation of how this was
calculated.
The State is temporarily enrolling children in CHIP, based on the income finding
from the Express Lane agency, pending the completion of the screen and enroll
process.

Section 5.

Outreach and Coordination

5.1.

(formerly 2.2) Describe the current State efforts to provide or obtain creditable health
coverage for uninsured children by addressing sections 5.1.1 and 5.1.2. (Section
2102)(a)(2) (42CFR 457.80(b))
Guidance:

The information below may include whether the state elects express lane
eligibility a description of the State’s outreach efforts through Medicaid and stateonly programs.

5.1.1. (formerly 2.2.1.) The steps the State is currently taking to identify and enroll all
uninsured children who are eligible to participate in public health insurance programs
(i.e., Medicaid and state-only child health insurance):
Guidance:

The State may address the coordination between the public-private outreach and
the public health programs that is occurring statewide. This section will provide a
59

historic record of the steps the State is taking to identify and enroll all uninsured
children from the time the State’s plan was initially approved. States do not have
to rewrite his section but may instead update this section as appropriate.
5.1.2. (formerly 2.2.2.) The steps the State is currently taking to identify and enroll all
uninsured children who are eligible to participate in health insurance programs that
involve a public-private partnership:
Guidance:

The State should describe below how it’s Title XXI program will closely coordinate the
enrollment with Medicaid because under Title XXI, children identified as Medicaideligible are required to be enrolled in Medicaid. Specific information related to Medicaid
screen and enroll procedures is requested in Section 4.4. (42CFR 457.80(c))

5.2.

(formerly 2.3) Describe how CHIP coordinates with other public and private health
insurance programs, other sources of health benefits coverage for children, other relevant
child health programs, (such as title V), that provide health care services for low-income
children to increase the number of children with creditable health coverage. (Section
2102(a)(3), 2102(b)(3)(E) and 2102(c)(2)) (42CFR 457.80(c)). This item requires a brief
overview of how Title XXI efforts – particularly new enrollment outreach efforts – will
be coordinated with and improve upon existing State efforts.

5.2-EL

The State should include a description of its election of the Express Lane eligibility
option to provide a simplified eligibility determination process and expedited enrollment
of eligible children into Medicaid or CHIP.

Guidance:

Outreach strategies may include, but are not limited to, community outreach workers,
outstationed eligibility workers, translation and transportation services, assistance with
enrollment forms, case management and other targeting activities to inform families of
low-income children of the availability of the health insurance program under the plan or
other private or public health coverage.
The description should include information on how the State will inform the target of the
availability of the programs, including American Indians and Alaska Natives, and assist
them in enrolling in the appropriate program.

5.3.

Strategies Describe the procedures used by the State to accomplish outreach to families
of children likely to be eligible for child health assistance or other public or private health
coverage to inform them of the availability of the programs, and to assist them in
enrolling their children in such a program. (Section 2102(c)(1)) (42CFR 457.90)

Section 6.

Coverage Requirements for Children’s Health Insurance

Check here if the State elects to use funds provided under Title XXI only to provide expanded
60

eligibility under the State’s Medicaid plan and proceed to Section 7 since children covered under
a Medicaid expansion program will receive all Medicaid covered services including EPSDT.
6.1.

The State elects to provide the following forms of coverage to children: (Check all that
apply.) (Section 2103(c)); (42CFR 457.410(a))
Guidance:

Benchmark coverage is substantially equal to the benefits coverage in a
benchmark benefit package (FEHBP-equivalent coverage, State employee
coverage, and/or the HMO coverage plan that has the largest insured commercial,
non-Medicaid enrollment in the state). If box below is checked, either 6.1.1.1.,
6.1.1.2., or 6.1.1.3. must also be checked. (Section 2103(a)(1))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420)
Guidance:

Check box below if the benchmark benefit package to be offered by the
State is the standard Blue Cross/Blue Shield preferred provider option
service benefit plan, as described in and offered under Section 8903(1) of
Title 5, United States Code. (Section 2103(b)(1) (42 CFR 457.420(b))

6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1) (42 CFR 457.420(a)) (If
checked, attach copy of the plan.)

Guidance:

Check box below if the benchmark benefit package to be offered by the
State is State employee coverage, meaning a coverage plan that is offered
and generally available to State employees in the state. (Section
2103(b)(2))

6.1.1.2.

State employee coverage; (Section 2103(b)(2)) (If checked, identify the
plan and attach a copy of the benefits description.)

Guidance:

Check box below if the benchmark benefit package to be offered by the
State is offered by a health maintenance organization (as defined in
Section 2791(b)(3) of the Public Health Services Act) and has the largest
insured commercial, non-Medicaid enrollment of covered lives of such
coverage plans offered by an HMO in the state. (Section 2103(b)(3) (42
CFR 457.420(c)))

6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If
checked, identify the plan and attach a copy of the benefits description.)

Guidance:

States choosing Benchmark-equivalent coverage must check the box below and
ensure that the coverage meets the following requirements:
61







the coverage includes benefits for items and services within each of the categories
of basic services described in 42 CFR 457.430:
• dental services
• inpatient and outpatient hospital services,
• physicians’ services,
• surgical and medical services,
• laboratory and x-ray services,
• well-baby and well-child care, including age-appropriate immunizations,
and
• emergency services;
the coverage has an aggregate actuarial value that is at least actuarially equivalent
to one of the benchmark benefit packages (FEHBP-equivalent coverage, State
employee coverage, or coverage offered through an HMO coverage plan that has
the largest insured commercial enrollment in the state); and
the coverage has an actuarial value that is equal to at least 75 percent of the
actuarial value of the additional categories in such package, if offered, as
described in 42 CFR 457.430:
• coverage of prescription drugs,
• mental health services,
• vision services and
• hearing services.
If 6.1.2. is checked, a signed actuarial memorandum must be attached. The
actuary who prepares the opinion must select and specify the standardized set and
population to be used under paragraphs (b)(3) and (b)(4) of 42 CFR 457.431. The
State must provide sufficient detail to explain the basis of the methodologies used
to estimate the actuarial value or, if requested by CMS, to replicate the State
results.
The actuarial report must be prepared by an individual who is a member of the
American Academy of Actuaries. This report must be prepared in accordance
with the principles and standards of the American Academy of Actuaries. In
preparing the report, the actuary must use generally accepted actuarial principles
and methodologies, use a standardized set of utilization and price factors, use 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,
apply the same principles and factors in comparing the value of different
coverage (or categories of services), without taking into account any differences
in coverage based on the method of delivery or means of cost control or
utilization used, and take 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
62

under such coverage. (Section 2103(a)(2))
6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430)
Specify the coverage, including the amount, scope and duration of each service,
as well as any exclusions or limitations. Attach a signed actuarial report that
meets the requirements specified in 42 CFR 457.431.

Guidance:

A State approved under the provision below, may modify its program from time
to time so long as it continues to provide coverage at least equal to the lower of
the actuarial value of the coverage under the program as of August 5, 1997, or one
of the benchmark programs. If “existing comprehensive state-based coverage” is
modified, an actuarial opinion documenting that the actuarial value of the
modification is greater than the value as of August 5, 1997, or one of the
benchmark plans must be attached. Also, the fiscal year 1996 State expenditures
for “existing comprehensive state-based coverage” must be described in the space
provided for all states. (Section 2103(a)(3))

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR
457.440) This option is only applicable to New York, Florida, and Pennsylvania.
Attach a description of the benefits package, administration, and date of
enactment. If existing comprehensive State-based coverage is modified, provide
an actuarial opinion documenting that the actuarial value of the modification is
greater than the value as of August 5, 1997 or one of the benchmark plans.
Describe the fiscal year 1996 State expenditures for existing comprehensive statebased coverage.

Guidance:

Secretary-approved coverage refers to any other health benefits coverage deemed
appropriate and acceptable by the Secretary upon application by a state. (Section
2103(a)(4)) (42 CFR 457.250)

6.1.4.

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)
Guidance:
Section 1905(r) of the Act defines EPSDT to require coverage of (1) any
medically necessary screening, and diagnostic services, including vision,
hearing, and dental screening and diagnostic services, consistent with a
periodicity schedule based on current and reasonable medical practice
standards or the health needs of an individual child to determine if a
suspected condition or illness exists; and (2) all services listed in section
1905(a) of the Act that are necessary to correct or ameliorate any defects
and mental and physical illnesses or conditions discovered by the
screening services, whether or not those services are covered under the
Medicaid state plan. Section 1902(a)(43) of the Act requires that the State
(1) provide and arrange for all necessary services, including supportive
services, such as transportation, needed to receive medical care included
63

within the scope of the EPSDT benefit and (2) inform eligible
beneficiaries about the services available under the EPSDT benefit.
If the coverage provided does not meet all of the statutory requirements
for EPSDT contained in sections 1902(a)(43) and 1905(r) of the Act, do
not check this box.
6.1.4.1.

Coverage of all benefits that are provided to children under the the same
as Medicaid State plan, including Early Periodic Screening Diagnosis and
Treatment (EPSDT)

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115
demonstration waiver

6.1.4.3.

Coverage that the State has extended to the entire Medicaid population

Guidance:

Check below if the coverage offered includes benchmark coverage, as
specified in 457.420, plus additional coverage. Under this option, the
State must clearly demonstrate that the coverage it provides includes the
same coverage as the benchmark package, and also describes the services
that are being added to the benchmark package.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage

6.1.4.5.

Coverage that is the same as defined by existing comprehensive statebased coverage applicable only New York, Pennsylvania, or Florida
(under 457.440)

Guidance:

Check below if the State is purchasing coverage through a group health
plan, and intends to demonstrate that the group health plan is substantially
equivalent to or greater than to coverage under one of the benchmark plans
specified in 457.420, through use of a benefit-by-benefit comparison of
the coverage. Provide a sample of the comparison format that will be used.
Under this option, if coverage for any benefit does not meet or exceed the
coverage for that benefit under the benchmark, the State must provide an
actuarial analysis as described in 457.431 to determine actuarial
equivalence.

6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or
greater than benchmark coverage through a benefit by benefit comparison
(Provide a sample of how the comparison will be done)
64

Guidance:

Guidance:

Check below if the State elects to provide a source of coverage that is not
described above. Describe the coverage that will be offered, including any
benefit limitations or exclusions.

6.1.4.7.

Other (Describe)

All forms of coverage that the State elects to provide to children in its plan must be
checked. The State should also describe the scope, amount and duration of services
covered under its plan, as well as any exclusions or limitations. States that choose to
cover unborn children under the State plan should include a separate section 6.2 that
specifies benefits for the unborn child population. (Section 2110(a)) (42CFR, 457.490)
If the state elects to cover the new option of targeted low income pregnant women, but
chooses to provide a different benefit package for these pregnant women under the CHIP
plan, the state must include a separate section 6.2 describing the benefit package for
pregnant women. (Section 2112)

6.2.

The State elects to provide the following forms of coverage to children: (Check all that apply. If
an item is checked, describe the coverage with respect to the amount, duration and scope of
services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)
6.2.1.

Inpatient services (Section 2110(a)(1))

6.2.2.

Outpatient services (Section 2110(a)(2))

6.2.3.

Physician services (Section 2110(a)(3))

6.2.4.

Surgical services (Section 2110(a)(4))

6.2.5.

Clinic services (including health center services) and other ambulatory health care
services. (Section 2110(a)(5))

6.2.6.

Prescription drugs (Section 2110(a)(6))

6.2.7.

Over-the-counter medications (Section 2110(a)(7))

6.2.8.

Laboratory and radiological services (Section 2110(a)(8))

6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section
2110(a)(9))

6.2.10.

Durable medical equipment and other medically-related or remedial devices (such
as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and
65

adaptive devices) (Section 2110(a)(12))
6.2.11.

Disposable medical supplies (Section 2110(a)(13))

Guidance:

Home and community based services may include 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.

6.2.12.

Home and community-based health care services (Section 2110(a)(14))

Guidance:

Nursing services may include 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.

6.2.13.

Nursing care services (Section 2110(a)(15))

6.2.14.

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 (Section 2110(a)(16)

6.2.15.

Dental services (Section 2110(a)(17)) States updating their dental benefits must
complete 6.2-DC (CHIPRA # 7, SHO # #09-012 issued October 7, 2009)

6.2.16.

Vision screenings and services (Section 2110(a)(24))

6.2.17.

Hearing screenings and services (Section 2110(a)(24))

6.2.18.

Case management services (Section 2110(a)(20))

6.2.19.

Care coordination services (Section 2110(a)(21))

6.2.20.

Physical therapy, occupational therapy, and services for individuals with speech,
hearing, and language disorders (Section 2110(a)(22))

6.2.21.

Hospice care (Section 2110(a)(23))

Guidance:

See guidance for section 6.1.4.1 for a guidance on the statutory requirements for
EPSDT under sections 1905(r) and 1902(a)(43) of the Act. If the benefit being
provided does not meet the EPSDT statutory requirements, do not check this box.

6.2.22.

EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the
Act
66

6.2.22.1
The state assures that any limitations applied to the amount, duration,
and scope of benefits described in Sections 6.2 and 6.3- BH of the CHIP state
plan can be exceeded as medically necessary.
Guidance:

Any other medical, diagnostic, screening, preventive, restorative, remedial,
therapeutic or rehabilitative service may be provided, whether in a facility, home,
school, or other setting, if recognized by State law and only if the service is: 1)
prescribed by or furnished by a physician or other licensed or registered
practitioner within the scope of practice as prescribed by State law; 2) performed
under the general supervision or at the direction of a physician; or 3) 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.

6.2.23.

Any other medical, diagnostic, screening, preventive, restorative, remedial,
therapeutic, or rehabilitative services. (Section 2110(a)(24))

6.2.24.

Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.25.

Medical transportation (Section 2110(a)(26))

Guidance:

Enabling services, such as transportation, translation, and outreach services, may
be offered only if designed to increase the accessibility of primary and preventive
health care services for eligible low-income individuals.

6.2.26.

Enabling services (such as transportation, translation, and outreach services)
(Section 2110(a)(27))

6.2.27.

Any other health care services or items specified by the Secretary and not
included under this Section (Section 2110(a)(28))

6.2-BH Behavioral Health Coverage Section 2103(c)(5) requires that states provide coverage to
prevent, diagnose, and treat a broad range of mental health and substance use disorders in a culturally
and linguistically appropriate manner for all CHIP enrollees, including pregnant women and unborn
children.
Guidance: Please attach a copy of the state’s periodicity schedule. For pregnancy-related
coverage, please describe the recommendations being followed for those services.
6.2.1- BH Periodicity Schedule The state has adopted the following periodicity schedule for
behavioral health screenings and assessments. Please specify any differences between any
covered CHIP populations:
67

State-developed schedule
American Academy of Pediatrics/ Bright Futures
Other Nationally recognized periodicity schedule (please specify:
Other (please describe:
)

)

6.3- BH Covered Benefits Please check off the behavioral health services that are provided to the
state’s CHIP populations, and provide a description of the amount, duration, and scope of each benefit.
For each benefit, please also indicate whether the benefit is available for mental health and/or substance
use disorders. If there are differences in benefits based on the population or type of condition being
treated, please specify those differences.
If EPSDT is provided, as described at Section 6.2.22 and 6.2.22.1, the state should only check off the
applicable benefits. It does not have to provide additional information regarding the amount, duration,
and scope of each covered behavioral health benefit.
Guidance: Please include a description of the services provided in addition to the behavioral
health screenings and assessments described in the assurance below at 6.3.1.1-BH.
6.3.1- BH

Behavioral health screenings and assessments. (Section 2103(c)(6)(A))
6.3.1.1- BH
The state assures that all developmental and behavioral health
recommendations outlined in the AAP Bright Futures periodicity schedule and
United States Public Preventive Services Task Force (USPSTF) recommendations
graded as A and B are covered as a part of the CHIP benefit package, as
appropriate for the covered populations.
Guidance: Examples of facilitation efforts include requiring managed care
organizations and their networks to use such tools in primary care practice,
providing education, training, and technical resources, and covering the costs of
administering or purchasing the tools.
6.3.1.2- BH
The state assures that it will implement a strategy to facilitate the
use of age-appropriate validated behavioral health screening tools in primary care
settings. Please describe how the state will facilitate the use of validated screening
tools.

6.3.2- BH

Outpatient services (Sections 2110(a)(11) and 2110(a)(19))

Guidance: Psychosocial treatment includes services such as psychotherapy, group
therapy, family therapy and other types of counseling services.
68

6.3.2.1- BH
Provided for:

Psychosocial treatment
Mental Health
Substance Use Disorder

6.3.2.2- BH
Provided for:

Tobacco cessation
Substance Use Disorder

Guidance: In order to provide a benefit package consistent with section 2103(c)(5) of the
Act, MAT benefits are required for the treatment of opioid use disorders. However, if the
state provides MAT for other SUD conditions, please include a description of those
benefits below at section 6.3.2.3- BH.
6.3.2.3- BH
Provided for:

Medication Assisted Treatment
Substance Use Disorder

6.3.2.3.1- BH

Opioid Use Disorder

6.3.2.3.2- BH

Alcohol Use Disorder

6.3.2.3.3- BH

Other

6.3.2.4- BH
Provided for:

Peer Support
Mental Health

6.3.2.5- BH
Provided for:

Caregiver Support
Mental Health
Substance Use Disorder

6.3.2.6- BH
Provided for:

Respite Care
Mental Health
69

Substance Use Disorder

Substance Use Disorder

6.3.2.7- BH
Provided for:

Intensive in-home services
Mental Health
Substance Use Disorder

6.3.2.8- BH
Provided for:

Intensive outpatient
Mental Health
Substance Use Disorder

6.3.2.9- BH
Provided for:

Psychosocial rehabilitation
Mental Health
Substance Use Disorder

Guidance: If the state considers day treatment and partial hospitalization to be the same benefit,
please indicate that in the benefit description. If there are differences between these benefits,
such as the staffing or intensity of the setting, please specify those in the description of the
benefit’s amount, duration, and scope.
6.3.3- BH
Day Treatment
Provided for:
Mental Health

6.3.3.1- BH
Provided for:

Substance Use Disorder

Partial Hospitalization
Mental Health
Substance Use Disorder

6.3.4- BH

Inpatient services, including services furnished in a state-operated mental
hospital and including residential or other 24-hour therapeutically planned
structural services (Sections 2110(a)(10) and 2110(a)(18))
Provided for:
Mental Health
Substance Use Disorder

Guidance: If applicable, please clarify any differences within the residential treatment
benefit (e.g. intensity of services, provider types, or settings in which the residential
treatment services are provided).
70

6.3.4.1- BH
Provided for:

Residential Treatment
Mental Health
Substance Use Disorder

6.3.4.2- BH
Provided for:

Detoxification
Substance Use Disorder

Guidance: Crisis intervention and stabilization could include services such as mobile crisis, or
short term residential or other facility based services in order to avoid inpatient hospitalization.
6.3.5- BH
Emergency services
Provided for:
Mental Health

6.3.5.1- BH
Provided for:

Substance Use Disorder

Crisis Intervention and Stabilization
Mental Health
Substance Use Disorder

6.3.6- BH
Continuing care services
Provided for:
Mental Health
Substance Use Disorder

6.3.7- BH
Care Coordination
Mental Health
Provided for:

Substance Use Disorder

6.3.7.1- BH
Provided for:

Intensive wraparound
Mental Health
Substance Use Disorder

6.3.7.2- BH
Provided for:

Care transition services
Mental Health
Substance Use Disorder

6.3.8- BH
Case Management
Provided for:
Mental Health
71

Substance Use Disorder

6.3.9- BH
Other
Provided for:
Mental Health

Substance Use Disorder

6.4- BH Assessment Tools
6.4.1- BH Please specify or describe all of the tool(s) required by the state and/or each managed
care entity:
ASAM Criteria (American Society Addiction Medicine)
Mental Health
Substance Use Disorders
InterQual
Mental Health

Substance Use Disorders

MCG Care Guidelines
Mental Health

Substance Use Disorders

CALOCUS/LOCUS (Child and Adolescent Level of Care Utilization System)
Mental Health
Substance Use Disorders
CASII (Child and Adolescent Service Intensity Instrument)
Mental Health
Substance Use Disorders
CANS (Child and Adolescent Needs and Strengths)
Mental Health
Substance Use Disorders
State-specific criteria (e.g. state law or policies) (please describe)
Mental Health
Substance Use Disorders

Plan-specific criteria (please describe)
Mental Health
Substance Use Disorders

Other (please describe)
Mental Health

Substance Use Disorders
72

No specific criteria or tools are required
Mental Health
Substance Use Disorders
Guidance: Examples of facilitation efforts include requiring managed care organizations and
their networks to use such tools to determine possible treatments or plans of care, providing
education, training, and technical resources, and covering the costs of administering or
purchasing the assessment tools.
6.4.2- BH
Please describe the state’s strategy to facilitate the use of validated assessment
tools for the treatment of behavioral health conditions.
6.2.5- BH Covered Benefits The State assures the following related to the provision of behavioral
health benefits in CHIP:
All behavioral health benefits are provided in a culturally and linguistically appropriate
manner consistent with the requirements of section 2103(c)(6), regardless of delivery system.
The state will provide all behavioral health benefits consistent with 42 CFR 457.495 to
ensure there are procedures in place to access covered services as well as appropriate and timely
treatment and monitoring of children with chronic, complex or serious conditions.
6.2-DC

Dental Coverage (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) The State will
provide dental coverage to children through one of the following. Please update Sections
9.10 and 10.3-DC when electing this option. Dental services provided to children eligible
for dental-only supplemental services must receive the same dental services as provided
to otherwise eligible CHIP children (Section 2103(a)(5)):

6.2.1-DC
1.
2.
3.
4.

State Specific Dental Benefit Package. The State assures dental services
represented by the following categories of common dental terminology (CDT 1)
codes are included in the dental benefits:
Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity
schedule)
Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes:
D1000-D1999) (must follow periodicity schedule)
Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999)
Endodontic (i.e., root canals) (CDT codes: D3000-D3999)

Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

73

5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999)
6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-D6999)
7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures)
(CDT codes: D7000-D7999)
8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999)
9. Emergency Dental Services
6.2.1.1-DC

Periodicity Schedule. The State has adopted the following periodicity
schedule:
State-developed Medicaid-specific
American Academy of Pediatric Dentistry
Other Nationally recognized periodicity schedule
Other (description attached)

6.2.2-DC

Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR
457.420)

6.2.2.1-DC

FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked,
attach copy of the dental supplemental plan benefits description and the
applicable CDT 2 codes. If the State chooses to provide supplemental
services, also attach a description of the services and applicable CDT
codes)

6.2.2.2-DC

State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify
the plan and attach a copy of the benefits description and the applicable
CDT codes. If the State chooses to provide supplemental services, also
attach a description of the services and applicable CDT codes)

6.2.2.3-DC

HMO with largest insured commercial enrollment (Section
2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the
benefits description and the applicable CDT codes. If the State chooses to
provide supplemental services, also attach a description of the services and
applicable CDT codes)

6.2-DS

Supplemental Dental Coverage- The State will provide dental coverage to children
eligible for dental-only supplemental services. Children eligible for this option must
receive the same dental services as provided to otherwise eligible CHIP children (Section
2110(b)(5)(C)(ii)). Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, and 9.10 when
electing this option.

Guidance:

Under Title XXI, pre-existing condition exclusions are not allowed, with the only

Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

74

exception being in relation to another law in existence (HIPAA/ERISA). Indicate that the
plan adheres to this requirement by checking the applicable description.
In the event that the State provides benefits through a group health plan or group health
coverage, or provides family coverage through a group health plan under a waiver (see
Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by
HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits
through group health coverage, describe briefly any limitations on pre-existing
conditions. (Formerly 8.6.)
6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it
provides both medical/surgical benefits and mental health or substance use disorder benefits, a State
child health plan ensures that financial requirements and treatment limitations applicable to mental
health and substance use disorder benefits comply with the mental health parity requirements of section
2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group
health plan. If the state child health plan provides for delivery of services through a managed care
arrangement, this requirement applies to both the state and managed care plans. These requirements are
also applicable to any additional benefits provided voluntarily to the child health plan population by
managed care entities and will be considered as part of CMS’s contract review process at 457.1201(l).
6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered
benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is
consistent with state and federal law and generally recognized independent standards of medical practice
(§457.496(f)(1)(i)).
6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered
benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit.
The most current version of the standard elected must be used. If different standards are used for
the different benefit types, please specify the benefit type(s) to which each standard is applied. If
“Other” is selected, please provide a description of that standard.
International Classification of Disease (ICD)
Diagnostic and Statistical Manual of Mental Disorders (DSM)
State guidelines
Other (Describe:
6.2.1.2- MHPAEA
benefits?

)

Does the State provide mental health and/or substance use disorder

Yes
75

No
Guidance: If the State does not provide any mental health or substance use disorder
benefits, the mental health parity requirements do not apply ((§457.496(f)(1)).
Continue on to Section 6.3.
6.2.2- MHPAEA Section 2103(c)(6)(B) of the Act provides that to the extent a State child health plan
includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined
in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan
shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.
6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State
must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements,
as indicated in section 6.2.26 of the State child health plan in order to answer “yes.”
Yes
No
Guidance: If the State child health plan does not provide EPSDT consistent with
Medicaid statutory requirements at sections 1902(a)(43) and 1905(r) of the Act,
please go to Section 6.2.3- MHPAEA to complete the required parity analysis of
the State child health plan.
If the state does provide EPSDT benefits consistent with Medicaid requirements,
please continue this section to demonstrate compliance with the statutory
requirements of section 2103(c)(6)(B) of the Act and the mental health parity
regulations of §457.496(b) related to deemed compliance.
6.2.2.2- MHPAEA

EPSDT benefits are provided to the following:

All children covered under the State child health plan
A subset of children covered under the State child health plan.
Please describe the different populations (if applicable) covered under the State child
health plan that are provided EPSDT benefits consistent with Medicaid statutory
requirements.

Guidance: If only a subset of children are provided EPSDT benefits under the
State child health plan, §457.496(b)(3) limits deemed compliance to those
76

children only and you must complete Section 6.2.3- MHPAEA to complete the
required parity analysis for the other children.
6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States
must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act
(§457.496(b)(2)). The State assures each of the following for children eligible for EPSDT under
the separate State child health plan:
All screening services, including screenings for mental health and substance use
disorder conditions, are provided at intervals that align with a periodicity schedule that
meets reasonable standards of medical or dental practice as well as when medically
necessary to determine the existence of suspected illness or conditions (Section 1905(r)).
All diagnostic services described in 1905(a) of the Act are provided as needed to
diagnose suspected conditions or illnesses discovered through screening services,
whether or not those services are covered under the Medicaid state plan (Section
1905(r)).
All items and services described in section 1905(a) of the Act are provided when
needed to correct or ameliorate a defect or any physical or mental illnesses and conditions
discovered by the screening services, whether or not such services are covered under the
Medicaid State plan (Section 1905(r)(5)).
Treatment limitations applied to services provided under the EPSDT benefit are not
limited based on a monetary cap or budgetary constraints and may be exceeded as
medically necessary to correct or ameliorate a medical or physical condition or illness
(Section 1905(r)(5)).
Non-quantitative treatment limitations, such as definitions of medical necessity or
criteria for medical necessity, are applied in an individualized manner that does not
preclude coverage of any items or services necessary to correct or ameliorate any medical
or physical condition or illness (Section 1905(r)(5)).
EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis
(Section 1905(r)(5)).

77

The provision of all requested EPSDT screening services, as well as any corrective
treatments needed based on those screening services, are provided or arranged for as
necessary (Section 1902(a)(43)).
All families with children eligible for the EPSDT benefit under the separate State
child health plan are provided information and informed about the full range of services
available to them (Section 1902(a)(43)(A)).
Guidance: For states seeking deemed compliance for their entire State child health
plan population, please continue to Section 6.3. If not all of the covered
populations are offered EPSDT, the State must conduct a parity analysis of the
benefit packages provided to those populations. Please continue to 6.2.3MHPAEA.
Mental Health Parity Analysis Requirements for States Not Providing EPSDT to All Covered
Populations
Guidance: The State must complete a parity analysis for each population under the State child
health plan that is not provided the EPSDT benefit consistent with the requirements §457.496(b).
If the State provides benefits or limitations that vary within the child or pregnant woman
populations, states should perform a parity analysis for each of the benefit packages. For
example, if different financial requirements are applied according to a beneficiary’s income, a
separate parity analysis is needed for the benefit package provided at each income level.
6.2.3- MHPAEA In order to conduct the parity analysis, the State must place all medical/surgical and
mental health and substance use disorder benefits covered under the State child health plan into one of
four classifications: Inpatient, outpatient, emergency care, and prescription drugs (§§457.496(d)(2)(ii);
457.496(d)(3)(ii)(B)).
6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one
of the four classifications.
6.2.3.1.1 MHPAEA The state assures that:
The State has classified all benefits covered under the State plan into one of the
four classifications.

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The same reasonable standards are used for determining the classification for a
mental health or substance use disorder benefit as are used for determining the
classification of medical/surgical benefits.
6.2.3.1.2- MHPAEA Does the state use sub-classifications to distinguish between office
visits and other outpatient services?
Yes
No
6.2.3.1.2.1- MHPAEA If the State uses sub-classifications to distinguish between
outpatient office visits and other outpatient services, the State assures the
following:
The sub-classifications are only used to distinguish office visits from other
outpatient items and services, and are not used to distinguish between similar
services on other bases (ex: generalist vs. specialist visits).
Guidance: For purposes of this section, any reference to
“classification(s)” includes sub-classification(s) in states using subclassifications to distinguish between outpatient office visits from other
outpatient services.
6.2.3.2 MHPAEA The State assures that:
Mental health/ substance use disorder benefits are provided in all classifications in
which medical/surgical benefits are provided under the State child health plan.
Guidance: States are not required to cover mental health or substance use
disorder benefits. However if a state does provide any mental health or
substance use disorders, those mental health or substance use disorder benefits
must be provided in all the same classifications in which medical/surgical
benefits are covered under the State child health plan.
Annual and Aggregate Lifetime Limits
6.2.4- MHPAEA A State that provides both medical/surgical benefits and mental health and/or
substance use disorder benefits must comply with parity requirements related to annual and aggregate
lifetime dollar limits for benefits covered under the State child health plan (§457.496(c)).
79

6.2.4.1- MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit
and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered
under the State child health plan.
Aggregate lifetime dollar limit is applied
Aggregate annual dollar limit is applied
No dollar limit is applied
Guidance: If there are no aggregate lifetime or annual dollar limit on any mental
health or substance use disorder benefits, please go to section 6.2.5- MHPAEA.
6.2.4.2- MHPAEA Are there any medical/surgical benefits covered under the State child
health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes,
please specify what type of limits apply.
Yes (Type(s) of limit:

)

No
Guidance: If no aggregate lifetime dollar limit is applied to medical/ surgical
benefits, the State may not impose an aggregate lifetime dollar limit on any mental
health or substance use disorder benefits. If no aggregate annual dollar limit is
applied to medical/surgical benefits, the State may not impose an aggregate annual
dollar limit on any mental health or substance use disorder benefits (§457.496(c)(1)).
6.2.4.3 – MHPAEA. States applying an aggregate lifetime or annual dollar limit on
medical/surgical benefits and mental health or substance use disorder benefits must determine
whether the portion of the medical/surgical benefits to which the limit applies is less than onethird, at least one-third but less than two-thirds, or at least two-thirds of all medical/surgical
benefits covered under the State plan (457.496(c)).
The portion of medical/surgical benefits subject to the limit is based on the dollar amount
expected to be paid for all medical/surgical benefits under the State plan for the State plan year
or portion of the plan year after a change in benefits that affects the applicability of the aggregate
lifetime or annual dollar limits (457.496(c)(3)).
The State assures that it has developed a reasonable methodology to calculate the
portion of covered medical/surgical benefits which are subject to the aggregate lifetime
and/or annual dollar limit, as applicable.
Guidance: Please include the state’s methodology to calculate the portion of
covered medical/surgical benefits which are subject to the aggregate lifetime and/or
80

annual dollar limit, as applicable, as an attachment to the State child health plan.
6.2.4.3.1- MHPAEA Please indicate the portion of the total costs for medical and
surgical benefits covered under the State plan which are subject to a lifetime dollar limit:
Less than 1/3
At least 1/3 and less than 2/3
At least 2/3
6.2.4.3.2- MHPAEA Please indicate the portion of the total costs for medical and
surgical benefits covered under the State plan which are subject to an annual dollar limit:
Less than 1/3
At least 1/3 and less than 2/3
At least 2/3
Guidance: If an aggregate lifetime limit is applied to less than one-third of all
medical/surgical benefits, the State may not impose an aggregate lifetime
limit on any mental health or substance use disorder benefits. If an annual
dollar limit is applied to less than one-third of all medical surgical benefits,
the State may not impose an annual dollar limit on any mental health or
substance use disorder benefits (§457.496(c)(1)). Skip to section 6.2.5MHPAEA.
If the State applies an aggregate lifetime or annual dollar limit to at least
one-third of all medical/surgical benefits, please continue below to provide
the assurances related to the determination of the portion of total costs for
medical/surgical benefits that are subject to either an annual or lifetime limit.
6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual
dollar limit to at least1/3 and less than 2/3 of all medical/surgical benefits,
the State assures the following (§§457.496(c)(4)(i)(B); 457.496(c)(4)(ii)):
The State applies an aggregate lifetime or annual dollar limit on
mental health or substance use disorder benefits that is no more
restrictive than an average limit calculated for medical/surgical
benefits.

81

Guidance: The state’s methodology for calculating the average
limit for medical/surgical benefits must be consistent with
§§457.496(c)(4)(i)(B) and 457.496(c)(4)(ii). Please include the
state’s methodology as an attachment to the State child health
plan.
6.2.4.3.2.2- MHPAEA If at least 2/3 of all medical/surgical benefits are
subject to an annual or lifetime limit, the State assures either of the
following (§457.496(c)(2)(i); (§457.496(c)(2)(ii)):
The aggregate lifetime or annual dollar limit is applied to both
medical/surgical benefits and mental health and substance use
disorder benefits in a manner that does not distinguish between
medical/surgical benefits and mental health and substance use
disorder benefits; or
The aggregate lifetime or annual dollar limit placed on mental
health and substance use disorder benefits is no more restrictive
than the aggregate lifetime or annual dollar limit on
medical/surgical benefits.
Quantitative Treatment Limitations
6.2.5- MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health
or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of
benefits in which the State applies one or more QTLs on any mental health or substance use disorder
benefits.
Yes (Specify:

)

No
Guidance: If the state does not apply any type of QTLs on any mental health or substance use
disorder benefits in any classification, the state meets parity requirements for QTLs and should
continue to Section 6.2.6 - MHPAEA. If the state does apply financial requirements to any mental
health or substance use disorder benefits, the state must conduct a parity analysis. Please
continue.
6.2.5.1- MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?
Yes

82

No
Guidance: If the State does not apply QTLs on any medical/surgical benefits, the
State may not impose quantitative treatment limitations on mental health or
substance use disorder benefits, please go to Section 6.2.6- MHPAEA related to nonquantitative treatment limitations.
6.2.5.2- MHPAEA Within each classification of benefits in which the State applies a type of
QTL on any mental health or substance use disorder benefits, the State must determine the
proportion of medical and surgical benefits in the class which are subject to the limitation. More
specifically, the State must determine the ratio of (a) the dollar amount of all payments expected
to be paid under the State plan for medical and surgical benefits within a classification which are
subject to the type quantitative treatment limitation for the plan year (or portion of the plan year
after a mid-year change affecting the applicability of a type of quantitative treatment limitation to
any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all
medical and surgical benefits within the classification for the plan year. For purposes of this
paragraph all payments expected to be paid under the State plan includes payments expected to
be made directly by the State and payments which are expected to be made by MCEs contracting
with the State. (§457.496(d)(3)(i)(C))
The State assures it has applied a reasonable methodology to determine the dollar
amounts used in the ratio described above for each classification within which the State
applies QTLs to mental health or substance use disorder benefits. (§457.496(d)(3)(i)(E))
Guidance: Please include the state’s methodology as an attachment to the State
child health plan.
6.2.5.3- MHPAEA For each type of QTL applied to any mental health or substance use
disorder benefits within a given classification, does the State apply the same type of QTL to
“substantially all” (defined as at least two-thirds) of the medical/surgical benefits within the
same classification? (§457.496(d)(3)(i)(A))
Yes
No
Guidance: If the State does not apply a type of QTL to substantially all
medical/surgical benefits in a given classification of benefits, the State may not
impose that type of QTL on mental health or substance use disorder benefits in that
classification. (§457.496(d)(3)(i)(A))
6.2.5.3.1- MHPAEA For each type of QTL applied to mental health or substance use
disorder benefits, the State must determine the predominant level of that type which is
83

applied to medical/surgical benefits in the classification. The “predominant level” of a
type of QTL in a classification is the level (or least restrictive of a combination of levels)
that applies to more than one-half of the medical/surgical benefits in that classification, as
described in §§457.496(d)(3)(i)(B). The portion of medical/surgical benefits in a
classification to which a given level of a QTL type is applied is based on the dollar
amount of payments expected to be paid for medical/surgical benefits subject to that level
as compared to all medical/surgical benefits in the classification, as described in
§457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental
health or substance use disorder benefits, the State assures:
The same reasonable methodology applied in determining the dollar amounts
used to determine whether substantially all medical/surgical benefits within a
classification are subject to a type of quantitative treatment limitation also is
applied in determining the dollar amounts used to determine the predominant
level of a type of quantitative treatment limitation applied to medical/surgical
benefits within a classification. (§457.496(d)(3)(i)(E))
The level of each type of quantitative treatment limitation applied by the State
to mental health or substance use disorder benefits in any classification is no more
restrictive than the predominate level of that type which is applied by the State to
medical/surgical benefits within the same classification. (§457.496(d)(2)(i))
Guidance: If there is no single level of a type of QTL that exceeds the onehalf threshold, the State may combine levels within a type of QTL such that
the combined levels are applied to at least half of all medical/surgical benefits
within a classification; the predominate level is the least restrictive level of
the levels combined to meet the one-half threshold (§457.496(d)(3)(i)(B)(2)).
Non-Quantitative Treatment Limitations
6.2.6- MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental
health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all
the mental health parity requirements (§§457.496(d)(4); 457.496(d)(5)).
6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State
does not impose NQTLs, please go to Section 6.2.7-MHPAEA.
The State assures that the processes, strategies, evidentiary standards or other factors
used in the application of any NQTL to mental health or substance use disorder benefits
are no more stringent than the processes, strategies, evidentiary standards or other factors

84

used in the application of NQTLs to medical/surgical benefits within the same
classification.
Guidance: Examples of NQTLs include medical management standards to limit or
exclude benefits based on medical necessity, restrictions based on geographic
location, provider specialty, or other criteria to limit the scope or duration of
benefits, provider reimbursement rates and provider network design (ex: preferred
providers vs. participating providers). Additional examples of possible NQTLs are
provided in §457.496(d)(4)(ii).
6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if
they provide coverage of medical or surgical benefits furnished by out-of-network providers.
6.2.6.2.1- MHPAEA Does the state or MCE contracting with the State provide
coverage of services provided by out of network providers?
Yes
No
6.2.6.2.2- MHPAEA If yes, please assure the following:
The State attests that when determining access to out-of-network providers
within a benefit classification, the processes, strategies, evidentiary standards, or
other factors used to determine access to those providers for mental health/
substance use disorder benefits are comparable to and applied no more stringently
than the processes, strategies, evidentiary standards or other factors used to
determine access for out- of-network providers for medical/surgical benefits.
Availability of Plan Information
6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with
information related to medical necessity criteria and denials of payment or reimbursement for mental
health or substance use disorder services.
6.2.7.1- MHPAEA Medical necessity criteria determinations must be made available to any
current or potential enrollee or contracting provider, upon request. The state attests that the
following entities provide this information:
State
Managed Care entities
85

Both
6.2.7.2- MHPAEA Reason for any denial for reimbursement or payment for
mental health or substance use disorder benefits must be made available to the
enrollee by the health plan or the State. The state attests that the following
entities provide denial information:
State
Managed Care entities
Both
6.3.
6.3.1.
6.3.2.

The State assures that, with respect to pre-existing medical conditions, one of the
following two statements applies to its plan: (42CFR 457.480)
The State shall not permit the imposition of any pre-existing medical condition
exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR
The State contracts with a group health plan or group health insurance coverage,
or contracts with a group health plan to provide family coverage under a waiver
(see Section 6.6.2. (formerly 6.4.2) of the template). Pre-existing medical
conditions are permitted to the extent allowed by HIPAA/ERISA. (Formerly 8.6.)
(Section 2103(f)) Describe:

Guidance:

States may request two additional purchase options in Title XXI: cost effective coverage
through a community-based health delivery system and for the purchase of family
coverage. (Section 2105(c)(2) and (3)) (457.1005 and 457.1010)

6.4.

Additional Purchase Options- If the State wishes to provide services under the plan
through cost effective alternatives or the purchase of family coverage, it must request the
appropriate option. To be approved, the State must address the following: (Section
2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)
6.4.1.

Cost Effective Coverage- Payment may be made to a State in excess of the 10
percent limitation on use of funds for payments for: 1) other child health
assistance for targeted low-income children; 2) expenditures for health services
initiatives under the plan for improving the health of children (including targeted
low-income children and other low-income children); 3) expenditures for
outreach activities as provided in Section 2102(c)(1) under the plan; and 4) other
reasonable costs incurred by the State to administer the plan, if it demonstrates the
following (42CFR 457.1005(a)):
6.4.1.1.

Coverage provided to targeted low-income children through such
expenditures must meet the coverage requirements above; Describe the
86

coverage provided by the alternative delivery system. The State may cross
reference Section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR
457.1005(b))
6.4.1.2.

The cost of such coverage must not be greater, on an average per child
basis, than the cost of coverage that would otherwise be provided for the
coverage described above; Describe the cost of such coverage on an
average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

Guidance:

Check below if the State is requesting to provide cost-effective coverage
through a community-based health delivery system. This allows the State
to waive the 10 percent limitation on expenditures not used for Medicaid
or health insurance assistance if coverage provided to targeted low-income
children through such expenditures meets the requirements of Section
2103; the cost of such coverage is not greater, on an average per child
basis, than the cost of coverage that would otherwise be provided under
Section 2103; and such coverage is provided through the use of a
community-based health delivery system, such as through contracts with
health centers receiving funds under Section 330 of the Public Health
Services Act or with hospitals such as those that receive disproportionate
share payment adjustments under Section 1886(c)(5)(F) or 1923.
If the cost-effective alternative waiver is requested, the State must
demonstrate that payments in excess of the 10 percent limitation will be
used for other child health assistance for targeted low-income children;
expenditures for health services initiatives under the plan for improving
the health of children (including targeted low-income children and other
low-income children); expenditures for outreach activities as provided in
Section 2102(c)(1) under the plan; and other reasonable costs incurred by
the State to administer the plan. (42CFR, 457.1005(a))

6.4.1.3.

Guidance:

The coverage must be provided through the use of a community-based
health delivery system, such as through contracts with health centers
receiving funds under Section 330 of the Public Health Service Act or
with hospitals such as those that receive disproportionate share payment
adjustments under Section 1886(c)(5)(F) or 1923 of the Social Security
Act. Describe the community-based delivery system. (Section
2105(c)(2)(B)(iii)) (42CFR 457.1005(a))
Check 6.4.2.if the State is requesting to purchase family coverage. Any State
requesting to purchase such coverage will need to include information that
establishes to the Secretary’s satisfaction that: 1) when compared to the amount
of money that would have been paid to cover only the children involved with a
87

comparable package, the purchase of family coverage is cost effective; and 2) the
purchase of family coverage is not a substitution for coverage already being
provided to the child. (Section 2105(c)(3)) (42CFR 457.1010)
6.4.2.

Purchase of Family Coverage- Describe the plan to purchase family coverage.
Payment may be made to a State for the purpose of family coverage under a group
health plan or health insurance coverage that includes coverage of targeted lowincome children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR
457.1010)
6.4.2.1.

Purchase of family coverage is cost-effective. The State’s cost of
purchasing family coverage, including administrative expenditures, that
includes coverage for the targeted low-income children involved or the
family involved (as applicable) under premium assistance programs must
not be greater than the cost of obtaining coverage under the State plan for
all eligible targeted low-income children or families involved; and (2)
The State may base its demonstration of cost effectiveness on an
assessment of the cost of coverage, including administrative costs, for
children or families under premium assistance programs to the cost of
other CHIP coverage for these children or families, done on a case-by-case
basis, or on the cost of premium assisted coverage in the aggregate.

6.4.2.2.

The State assures that the family coverage would not otherwise substitute
for health insurance coverage that would be provided to such children but
for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR
457.1010(b))

6.4.2.3.

The State assures that the coverage for the family otherwise meets title
XXI requirements. (42CFR 457.1010(c))

6.4.3-PA: Additional State Options for Providing Premium Assistance (CHIPRA # 13, SHO
# 10-002 issued February 2, 2010) A State may elect to offer a premium assistance subsidy for
qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(B), to all targeted
low-income children who are eligible for child health assistance under the plan and have access
to such coverage. No subsidy shall be provided to a targeted low-income child (or the child’s
parent) unless the child voluntarily elects to receive such a subsidy. (Section 2105(c)(10)(A)).
Please remember to update section 9.10 when electing this option. Does the State provide this
option to targeted low-income children?
Yes
No
6.4.3.1-PA

Qualified Employer-Sponsored Coverage and Premium Assistance
Subsidy
88

6.4.3.1.1-PA Provide an assurance that the qualified employer-sponsored
insurance meets the definition of qualified employer-sponsored coverage as
defined in Section 2105(c)(10)(B), and that the premium assistance subsidy meets
the definition of premium assistance subsidy as defined in 2105(c)(10)(C).
6.4.3.1.2-PA Describe whether the State is providing the premium assistance
subsidy as reimbursement to an employee or for out-of-pocket expenditures or
directly to the employee’s employer.
6.4.3.2-PA:

Supplemental Coverage for Benefits and Cost Sharing Protections
Provided under the Child Health Plan.

6.4.3.2.1-PA If the State is providing premium assistance for qualified employersponsored coverage, as defined in Section 2105(c)(10)(E)(i), provide an assurance
that the State is providing for each targeted low-income child enrolled in such
coverage, supplemental coverage consisting of all items or services that are not
covered or are only partially covered, under the qualified employer-sponsored
coverage consistent with 2103(a) and cost sharing protections consistent with
Section 2103(e).
6.4.3.2.2-PA Describe whether these benefits are being provided through the
employer or by the State providing wraparound benefits.
6.4.3.2.3-PA If the State is providing premium assistance for benchmark or
benchmark-equivalent coverage, the State ensures that such group health plans or
health insurance coverage offered through an employer will be certified by an
actuary as coverage that is equivalent to a benchmark benefit package described
in Section 2103(b) or benchmark equivalent coverage that meets the requirements
of Section 2103(a)(2).
6.4.3.3-PA:

Application of Waiting Period Imposed Under State Plan: States are
required to apply the same waiting period to premium assistance as is
applied to direct coverage for children under their CHIP State plan, as
specified in Section 2105(c)(10)(F).

6.4.3.3.1-PA Provide an assurance that the waiting period for children in premium
assistance is the same as for those children in direct coverage (if State has a
waiting period in place for children in direct CHIP coverage).
6.4.3.4-PA:

Opt-Out and Outreach, Education, and Enrollment Assistance

6.4.3.4.1-PA Describe the State’s process for ensuring parents are permitted to
89

disenroll their child from qualified employer-sponsored coverage and to enroll in
CHIP effective on the first day of any month for which the child is eligible for
such assistance and in a manner that ensures continuity of coverage for the child
(Section 2105(c)(10)(G)).
6.4.3.4.2-PA Describe the State’s outreach, education, and enrollment efforts
related to premium assistance programs, as required under Section 2102(c)(3).
How does the State inform families of the availability of premium assistance, and
assist them in obtaining such subsidies? What are the specific significant
resources the State intends to apply to educate employers about the availability of
premium assistance subsidies under the State child health plan? (Section 2102(c))
6.4.3.5-PA

Purchasing Pool- A State may establish an employer-family premium
assistance purchasing pool and may provide a premium assistance subsidy
for enrollment in coverage made available through this pool (Section
2105(c)(10)(I)). Does the State provide this option?
Yes
No

6.6.3.5.1-PA Describe the plan to establish an employer-family premium
assistance purchasing pool.
6.6.3.5.2-PA Provide an assurance that employers who are eligible to participate:
1) have less than 250 employees; 2) have at least one employee who is a pregnant
woman eligible for CHIP or a member of a family that has at least one child
eligible under the State’s CHIP plan.
6.6.3.5.3-PA Provide an assurance that the State will not claim for any
administrative expenditures attributable to the establishment or operation of such
a pool except to the extent such payment would otherwise be permitted under this
title.
6.4.3.6-PA

Notice of Availability of Premium Assistance- Describe the procedures
that assure that if a State provides premium assistance subsidies under this
Section, it must: 1) provide as part of the application and enrollment
process, information describing the availability of premium assistance and
how to elect to obtain a subsidy; and 2) establish other procedures to
ensure that parents are fully informed of the choices for child health
assistance or through the receipt of premium assistance subsidies (Section
2105(c)(10)(K)).

6.4.3.6.1-PA Provide an assurance that the State includes information about
premium assistance on the CHIP application or enrollment form.
90

6.5-Vaccine coverages
Guidance:

States are required to provide coverage for age-appropriate vaccines and their
administration, without cost sharing. States that elect to cover children under the State
plan (indicated in Section 4.1) should check box 6.5.1 States that elect to cover pregnant
individuals under the State plan should also check box 6.5.2. States that elect to cover the
from-conception-to-end-of-pregnancy population (previously referred to as the “unborn”)
option under the State plan should also check box 6.5.3.

6.5.1- Vaccine coverage for targeted-low-income children.
The State provides coverage
for age-appropriate vaccines and their administration in accordance with the
recommendations of the Advisory Committee on Immunization Practices (ACIP),
without cost sharing. (Section 2103(c)(1)(D)) (42CFR 457.410(b)(2) and 457.520(b)(4)).
6.5.2- Vaccine coverage for targeted-low-income pregnant individuals.
The State
provides coverage for approved adult vaccines recommended by the ACIP, and their
administration, without cost sharing. (SHO # 23-003, issued June 27, 2023); (Section
2103(c)(12))
6.5.3-Vaccine coverage for from-conception-to-end-of-pregnancy population option.
state provides coverage for age appropriate (child or adult) vaccines and their
administration in accordance with the recommendations of the ACIP, without costsharing, to benefit the unborn child.

The

Section 7.

Quality and Appropriateness of Care

Guidance:

Methods for Evaluating and Monitoring Quality- Methods to assure quality include
the application of performance measures, quality standards consumer information
strategies, and other quality improvement strategies.
Performance measurement strategies could include using measurements for external
reporting either to the State or to consumers and for internal quality improvement
purposes. They could be based on existing measurement sets that have undergone
rigorous evaluation for their appropriateness (e.g., HEDIS). They may include the
use of standardized member satisfaction surveys (e.g., CAHPS) to assess members’
experience of care along key dimensions such as access, satisfaction, and system
performance.
Quality standards are often used to assure the presence of structural and process
measures that promote quality and could include such approaches as: the use of
external and periodic review of health plans by groups such as the National
Committee for Quality Assurance; the establishment of standards related to consumer
91

protection and quality such as those developed by the National Association of
Insurance Commissioners; and the formation of an advisory group to the State or plan
to facilitate consumer and community participation in the plan.
Information strategies could include: the disclosure of information to beneficiaries
about their benefits under the plan and their rights and responsibilities; the provision
of comparative information to consumers on the performance of available health
plans and providers; and consumer education strategies on how to access and
effectively use health insurance coverage to maximize quality of care.
Quality improvement strategies should include the establishment of quantified quality
improvement goals for the plan or the State and provider education. Other strategies
include specific purchasing specifications, ongoing contract monitoring mechanisms,
focus groups, etc.
Where States use managed care organizations to deliver CHIP care, recent legal
changes require the State to use managed care quality standards and quality
strategies similar to those used in Medicaid managed care.
Tools for Evaluating and Monitoring Quality- Tools and types of information
available include, HEDIS (Health Employer Data Information Set) measures, CAHPS
(Consumer Assessments of Health Plans Study) measures, vital statistics data, and
State health registries (e.g., immunization registries).
Quality monitoring may be done by external quality review organizations, or, if the
State wishes, internally by a State board or agency independent of the State CHIP
Agency. Establishing grievance measures is also an important aspect of monitoring.
Check here if the State elects to use funds provided under Title XXI only to provide expanded
eligibility under the State’s Medicaid plan, and continue on to Section 8.
Guidance:

The State must specify the qualifications of entities that will provide coverage and the
conditions of participation. States should also define the quality standard they are using,
for example, NCQA Standards or other professional standards. Any description of the
information strategies used should be linked to Section 9. (Section 2102(a)(7)(A))
(42CFR, 457.495)

7.1.

Describe the methods (including external and internal monitoring) used to assure the
quality and appropriateness of care, particularly with respect to well-baby care, well-child
care, and immunizations provided under the plan. (Section 2102(a)(7)(A)) (42CFR
457.495(a)) Will the State utilize any of the following tools to assure quality? (Check all
that apply and describe the activities for any categories utilized.)
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7.1.1.

Quality standards

7.1.2.

Performance measurement
7.1.2 (a)

CHIPRA Quality Core Set

7.1.2 (b)

Other

7.1.3.

Information strategies

7.1.4.

Quality improvement strategies

Guidance:

Provide a brief description of methods to be used to assure access to covered services,
including a description of how the State will assure the quality and appropriateness of the
care provided. The State should consider whether there are sufficient providers of care for
the newly enrolled populations and whether there is reasonable access to care. (Section
2102(a)(7)(B))

7.2.

Describe the methods used, including monitoring, to assure: (Section 2102(a)(7)(B))
(42CFR 457.495)
7.2.1. Access to well-baby care, well-child care, well-adolescent care and childhood and
adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))
7.2.2. Access to covered services, including emergency services as defined in 42 CFR 457.10.
(Section 2102(a)(7)) 42CFR 457.495(b))
7.2.3. Appropriate and timely procedures to monitor and treat enrollees with chronic, complex,
or serious medical conditions, including access to an adequate number of visits to
specialists experienced in treating the specific medical condition and access to out-ofnetwork providers when the network is not adequate for the enrollee’s medical condition.
(Section 2102(a)(7)) (42CFR 457.495(c))
7.2.4. Decisions related to the prior authorization of health services are completed in
accordance with State law or, in accordance with the medical needs of the patient, within
14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR
457.495(d)) Exigent medical circumstances may require more rapid response according
to the medical needs of the patient.

93

Section 8.

Cost-Sharing and Payment

Check here if the State elects to use funds provided under Title XXI only to provide expanded
eligibility under the State’s Medicaid plan, and continue on to Section 9.
8.1.

Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)
Indicate if this also applies for pregnant women. (CHIPRA #2, SHO # 09-006, issued
May 11, 2009)
8.1.1.
8.1.2.

Yes
No, skip to question 8.8.

8.1.1-PW
8.1.2-PW

Yes
No, skip to question 8.8.

Guidance:

It is important to note that for families below 150 percent of poverty, the same limitations
on cost sharing that are under the Medicaid program apply. (These cost-sharing
limitations have been set forth in Section 1916 of the Social Security Act, as
implemented by regulations at 42 CFR 447.50 - 447.59). For families with incomes of
150 percent of poverty and above, cost sharing for all children in the family cannot
exceed 5 percent of a family's income per year. Include a statement that no cost sharing
will be charged for pregnancy-related services. (CHIPRA #2, SHO # 09-006, issued May
11, 2009) (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) and (c), 457.515(a)
and (c))

8.2.

Describe the amount of cost-sharing, any sliding scale based on income, the group or
groups of enrollees that may be subject to the charge by age and income (if applicable)
and the service for which the charge is imposed or time period for the charge, as
appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) and (c), 457.515(a)
and (c))

8.2-DS

8.2.1.

Premiums:

8.2.2.

Deductibles:

8.2.3.

Coinsurance or copayments:

8.2.4.

Other:
Supplemental Dental (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) For
children enrolled in the dental-only supplemental coverage, describe the amount of costsharing, specifying any sliding scale based on income. Also describe how the State will
track that the cost sharing does not exceed 5 percent of gross family income. The 5
94

percent of income calculation shall include all cost-sharing for health insurance and
dental insurance. (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b), and (c),
457.515(a) and (c), and 457.560(a)) Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, 6.2DS, and 9.10 when electing this option.
8.2.1-DS

Premiums:

8.2.2-DS

Deductibles:

8.2.3-DS

Coinsurance or copayments:

8.2.4-DS

Other:

8.3.

Describe how the public will be notified, including the public schedule, of this cost
sharing (including the cumulative maximum) and changes to these amounts and any
differences based on income. (Section 2103(e)(1)(A)) (42CFR 457.505(b))

Guidance:

The State should be able to demonstrate upon request its rationale and justification
regarding these assurances. This section also addresses limitations on payments for
certain expenditures and requirements for maintenance of effort.

8.4.

The State assures that it has made the following findings with respect to the cost sharing
in its plan: (Section 2103(e))
8.4.1.
8.4.2.
8.4.3

Cost-sharing does not favor children from higher income families over lower
income families. (Section 2103(e)(1)(B)) (42CFR 457.530)
No cost-sharing applies to well-baby and well-child care, including ageappropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520)
No additional cost-sharing applies to the costs of emergency medical services
delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

8.4.1- MHPAEA
There is no separate accumulation of cumulative financial requirements,
as defined in §457.496(a), for mental health and substance abuse disorder benefits compared to
medical/surgical benefits (§457.496(d)(3)(iii)).
8.4.2- MHPAEA
If applicable, any different levels of financial requirements that are
applied to different tiers of prescription drugs are determined based on reasonable factors,
regardless of whether a drug is generally prescribed for medical/surgical benefits or mental
health/substance use disorder benefits (§457.496(d)(3)(ii)(A)).
8.4.3- MHPAEA
Cost sharing applied to benefits provided under the State child health plan
will remain capped at five percent of the beneficiary’s income as required §457.560
(§457.496(d)(i)(D)).
95

8.4.4- MHPAEA Does the State apply financial requirements to any mental health or substance
use disorder benefits? If yes, specify the classification(s) of benefits in which the State applies
financial requirements on any mental health or substance use disorder benefits.
Yes (Specify:

)

No
Guidance: If the state does not apply financial requirements on any mental health
or substance use disorder benefits, the state meets parity requirements for financial
requirements. If the state does apply financial requirements to mental health or
substance use disorder benefits, the state must conduct a parity analysis. Please
continue below.
8.4.5- MHPAEA Does the State apply any type of financial requirements on any
medical/surgical benefits?
Yes
No
Guidance: If the State does not apply financial requirements on any
medical/surgical benefits, the State may not impose financial requirements on
mental health or substance use disorder benefits.
8.4.6- MHPAEA Within each classification of benefits in which the State applies a type of
financial requirement on any mental health or substance use disorder benefits, the State must
determine the proportion of medical and surgical benefits in the class which are subject to the
limitation.
The State assures it has applied a reasonable methodology to determine the dollar
amounts used in the ratio described above (Section 6.2.5.2) for each classification or
within which the State applies financial requirements to mental health or substance use
disorder benefits (§457.496(d)(3)(i)(E)).
Guidance: Please include the state’s methodology as an attachment to the State
child health plan.
8.4.7- MHPAEA For each type of financial requirement applied to any mental health or
substance use disorder benefits within a given classification, does the State apply the same type
of financial requirement to at least two-thirds (“substantially all”) of all the medical/surgical
benefits within the same classification? (§457.496(d)(3)(i)(A))
96

Yes
No
Guidance: If the State does not apply a type of financial requirement to
substantially all medical/surgical benefits in a given classification of benefits, the
State may not impose financial requirements on mental health or substance use
disorder benefits in that classification. (§457.496(d)(3)(i)(A))
8.4.8- MHPAEA For each type of financial requirement applied to substantially all
medical/surgical benefits in a classification, the State must determine the predominant level (as
defined in §457.496(d)(3)(i)(B)(1)) of that type which is applied to medical/surgical benefits in
the classification. For each type of financial requirement applied to substantially all
medical/surgical benefits in a classification, the State assures:
The same reasonable methodology applied in determining the dollar amounts used in
determining whether substantially all medical/surgical benefits within a classification are
subject to a type of financial requirement also is applied in determining the dollar
amounts used to determine the predominant level of a type of financial requirement
applied to medical/surgical benefits within a classification. (§457.496(d)(3)(i)(E))
The level of each type of financial requirement applied by the State to mental health
or substance use disorder benefits in any classification is no more restrictive than the
predominate level of that type which is applied by the State to medical/surgical benefits
within the same classification. (§457.496(d)(2)(i))
Guidance: If there is no single level of a type of financial requirement that exceeds
the one-half threshold, the State may combine levels within a type of financial
requirement such that the combined levels are applied to at least half of all
medical/surgical benefits within a classification; the predominate level is the least
restrictive level of the levels combined to meet the one-half threshold
(§457.496(d)(3)(i)(B)(2)).
8.5.

Describe how the State will ensure that the annual aggregate cost-sharing for a family
does not exceed 5 percent of such family’s income for the length of the child’s eligibility
period in the State. Include a description of the procedures that do not primarily rely on a
refund given by the State for overpayment by an enrollee: (Section 2103(e)(3)(B))
(42CFR 457.560(b) and 457.505(e))

8.6.

Describe the procedures the State will use to ensure American Indian (as defined by the
Indian Health Care Improvement Act of 1976) and Alaska Native children will be
97

excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)
8.7.

Provide a description of the consequences for an enrollee or applicant who does not pay a
charge. (42CFR 457.570 and 457.505(c))

Guidance:

Section 8.7.1 is based on Section 2101(a) of the Act provides that the purpose of title
XXI is to provide funds to States to enable them to initiate and expand the provision of
child health assistance to uninsured, low-income children in an effective and efficient
manner that is coordinated with other sources of health benefits coverage for children.

8.7.1. Provide an assurance that the following disenrollment protections are being applied:
Guidance:

8.8.

Provide a description below of the State’s premium grace period process and how
the State notifies families of their rights and responsibilities with respect to
payment of premiums. (Section 2103(e)(3)(C))

8.7.1.1.

State has established a process that gives enrollees reasonable notice of
and an opportunity to pay past due premiums, copayments, coinsurance,
deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

8.7.1.2.

The disenrollment process affords the enrollee an opportunity to show that
the enrollee’s family income has declined prior to disenrollment for nonpayment of cost-sharing charges. (42CFR 457.570(b))

8.7.1.3.

In the instance mentioned above, that the State will facilitate enrolling the
child in Medicaid or adjust the child’s cost-sharing category as
appropriate. (42CFR 457.570(b))

8.7.1.4

The State provides the enrollee with an opportunity for an impartial
review to address disenrollment from the program. (42CFR 457.570(c))

The State assures that it has made the following findings with respect to the payment
aspects of its plan: (Section 2103(e))
8.8.1.
8.8.2.
8.8.3.

No Federal funds will be used toward State matching requirements. (Section
2105(c)(4)) (42CFR 457.220)
No cost-sharing (including premiums, deductibles, copayments, coinsurance and
all other types) will be used toward State matching requirements. (Section
2105(c)(5) (42CFR 457.224) (Previously 8.4.5)
No funds under this title will be used for coverage if a private insurer would have
been obligated to provide such assistance except for a provision limiting this
obligation because the child is eligible under the this title. (Section 2105(c)(6)(A))
(42CFR 457.626(a)(1))
98

8.8.4.
8.8.5.

8.8.6.

Income and resource standards and methodologies for determining Medicaid
eligibility are not more restrictive than those applied as of June 1, 1997. (Section
2105(d)(1)) (42CFR 457.622(b)(5))
No funds provided under this title or coverage funded by this title will include
coverage of abortion except if necessary to save the life of the mother or if the
pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B))
(42CFR 457.475)
No funds provided under this title will be used to pay for any abortion or to assist
in the purchase, in whole or in part, for coverage that includes abortion (except as
described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

Section 9.

Strategic Objectives and Performance Goals and Plan Administration

Guidance:

States should consider aligning its strategic objectives with those discussed in Section II
of the CHIP Annual Report.

9.1.

Describe strategic objectives for increasing the extent of creditable health coverage
among targeted low-income children and other low-income children: (Section
2107(a)(2)) (42CFR 457.710(b))

Guidance:

Goals should be measurable, quantifiable and convey a target the State is working
towards.

9.2.

Specify one or more performance goals for each strategic objective identified: (Section
2107(a)(3)) (42CFR 457.710(c))

Guidance:

The State should include data sources to be used to assess each performance goal. In
addition, check all appropriate measures from 9.3.1 to 9.3.8 that the State will be utilizing
to measure performance, even if doing so duplicates what the State has already discussed
in Section 9.
It is acceptable for the State to include performance measures for population subgroups
chosen by the State for special emphasis, such as racial or ethnic minorities, particular
high-risk or hard to reach populations, children with special needs, etc.
HEDIS (Health Employer Data and Information Set) 2008 contains performance
measures relevant to children and adolescents younger than 19. In addition, HEDIS 3.0
contains measures for the general population, for which breakouts by children’s age
bands (e.g., ages < 1, 1-9, 10-19) are required. Full definitions, explanations of data
sources, and other important guidance on the use of HEDIS measures can be found in the
HEDIS 2008 manual published by the National Committee on Quality Assurance. So that
State HEDIS results are consistent and comparable with national and regional data, states
should check the HEDIS 2008 manual for detailed definitions of each measure, including
99

definitions of the numerator and denominator to be used. For states that do not plan to
offer managed care plans, HEDIS measures may also be able to be adapted to
organizations of care other than managed care.
9.3.

Describe how performance under the plan will be measured through objective,
independently verifiable means and compared against performance goals in order to
determine the State’s performance, taking into account suggested performance indicators
as specified below or other indicators the State develops: (Section 2107(a)(4)(A),(B))
(42CFR 457.710(d))
Check the applicable suggested performance measurements listed below that the State plans to
use: (Section 2107(a)(4))
9.3.1.
The increase in the percentage of Medicaid-eligible children enrolled in Medicaid.
9.3.2.
The reduction in the percentage of uninsured children.
9.3.3.
The increase in the percentage of children with a usual source of care.
9.3.4.
The extent to which outcome measures show progress on one or more of the
health problems identified by the state.
HEDIS Measurement Set relevant to children and adolescents younger than 19.
9.3.5.
9.3.6.
Other child appropriate measurement set. List or describe the set used.
9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will
be collected, such as:
Immunizations
9.3.7.1.
9.3.7.2.
Well childcare
9.3.7.3.
Adolescent well visits
9.3.7.4.
Satisfaction with care
Mental health
9.3.7.5.
9.3.7.6.
Dental care
9.3.7.7.
Other, list:

9.3.8.

Performance measures for special targeted populations.

9.4.

The State assures it will collect all data, maintain records and furnish reports to the
Secretary at the times and in the standardized format that the Secretary requires. (Section
2107(b)(1)) (42CFR 457.720)

Guidance:

The State should include an assurance of compliance with the annual reporting
requirements, including an assessment of reducing the number of low-income uninsured
children. The State should also discuss any annual activities to be undertaken that relate
to assessment and evaluation of the program.

9.5.

The State assures it will comply with the annual assessment and evaluation required
under Section 10. Briefly describe the State’s plan for these annual assessments and
100

reports. (Section 2107(b)(2)) (42CFR 457.750)
9.6.

The State assures it will provide the Secretary with access to any records or information
relating to the plan for purposes of review or audit. (Section 2107(b)(3)) (42CFR
457.720)

Guidance:

The State should verify that they will participate in the collection and evaluation of data
as new measures are developed or existing measures are revised as deemed necessary by
CMS, the states, advocates, and other interested parties.

9.7.

The State assures that, in developing performance measures, it will modify those
measures to meet national requirements when such requirements are developed. (42CFR
457.710(e))

9.8.

The State assures, to the extent they apply, that the following provisions of the Social
Security Act will apply under Title XXI, to the same extent they apply to a State under
Title XIX: (Section 2107(e)) (42CFR 457.135)
9.8.1.
9.8.2.
9.8.3.
9.8.4.

Section 1902(a)(4)(C) (relating to conflict of interest standards)
Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on
payment)
Section 1903(w) (relating to limitations on provider donations and taxes)
Section 1132 (relating to periods within which claims must be filed)

Guidance:

Section 9.9 can include discussion of community-based providers and consumer
representatives in the design and implementation of the plan and the method for ensuring
ongoing public involvement. Issues to address include a listing of public meetings or
announcements made to the public concerning the development of the children's health
insurance program or public forums used to discuss changes to the State plan.

9.9.

Describe the process used by the State to accomplish involvement of the public in the
design and implementation of the plan and the method for ensuring ongoing public
involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))
9.9.1. Describe the process used by the State to ensure interaction with Indian Tribes and
organizations in the State on the development and implementation of the procedures
required in 42 CFR 457.125. States should provide notice and consultation with Tribes on
proposed pregnant women expansions. (Section 2107(c)) (42CFR 457.120(c))
9.9.2. For an amendment relating to eligibility or benefits (including cost sharing and
enrollment procedures), describe how and when prior public notice was provided as
required in 42 CFR 457.65(b) through (d).
101

9.9.3. Describe the State’s interaction, consultation, and coordination with any Indian tribes and
organizations in the State regarding implementation of the Express Lane eligibility
option.
9.10.

Provide a 1-year projected budget. A suggested financial form for the budget is below.
The budget must describe: (Section 2107(d)) (42CFR 457.140)
•

Planned use of funds, including:
• Projected amount to be spent on health services;
• Projected amount to be spent on administrative costs, such as outreach, child
health initiatives, and evaluation; and
• Assumptions on which the budget is based, including cost per child and
expected enrollment.
• Projected expenditures for the separate child health plan, including but not
limited to expenditures for targeted low income children, the optional
coverage of the unborn, lawfully residing eligibles, dental services, etc.
• All cost sharing, benefit, payment, eligibility need to be reflected in the
budget.

•

Projected sources of non-Federal plan expenditures, including any requirements for
cost-sharing by enrollees.
Include a separate budget line to indicate the cost of providing coverage to pregnant
women.
States must include a separate budget line item to indicate the cost of providing
coverage to premium assistance children.
Include a separate budget line to indicate the cost of providing dental-only
supplemental coverage.
Include a separate budget line to indicate the cost of implementing Express Lane
Eligibility.
Provide a 1-year projected budget for all targeted low-income children covered under
the state plan using the attached form. Additionally, provide the following:
- Total 1-year cost of adding prenatal coverage
- Estimate of unborn children covered in year 1

•
•
•
•
•

STATE:

CHIP Budget

Federal Fiscal Year
State’s enhanced FMAP rate
Benefit Costs
Insurance payments
102

FFY Budget

STATE:
Managed care
per member/per month rate
Fee for Service
Total Benefit Costs
(Offsetting beneficiary cost sharing payments)
Net Benefit Costs
Cost of Proposed SPA Changes – Benefit

FFY Budget

Administration Costs
Personnel
General administration
Contractors/Brokers
Claims Processing
Outreach/marketing costs
Health Services Initiatives
Other
Total Administration Costs
10% Administrative Cap
Cost of Proposed SPA Changes
Federal Share
State Share
Total Costs of Approved CHIP Plan
NOTE: Include the costs associated with the current SPA.
The Source of State Share Funds:
Section 10.

Annual Reports and Evaluations

Guidance:

The National Academy for State Health Policy (NASHP), CMS and the states developed
framework for the annual report that states have the option to use to complete the
required evaluation report. The framework recognizes the diversity in State approaches to
implementing CHIP and provides consistency across states in the structure, content, and
format of the evaluation report. Use of the framework and submission of this information
will allow comparisons to be made between states and on a nationwide basis. The
framework for the annual report can be obtained from NASHP’s website at
http://www.nashp.org. Per the title XXI statute at Section 2108(a), states must submit
reports by January 1st to be compliant with requirements.
103

10.1.

Annual Reports. The State assures that it will assess the operation of the State plan
under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)
10.1.1.

The progress made in reducing the number of uninsured low-income children and
report to the Secretary by January 1 following the end of the fiscal year on the
result of the assessment, and

10.2.

The State assures it will comply with future reporting requirements as they are developed.
(42CFR 457.710(e))

10.3.

The State assures that it will comply with all applicable Federal laws and regulations,
including but not limited to Federal grant requirements and Federal reporting
requirements.

10.3-DC

The State agrees to submit yearly the approved dental benefit package and to submit
quarterly current and accurate information on enrolled dental providers in the State to the
Health Resources and Services Administration for posting on the Insure Kids Now!
Website. Please update Sections 6.2-DC and 9.10 when electing this option.

Section 11.

Program Integrity (Section 2101(a))

Check here if the State elects to use funds provided under Title XXI only to provide expanded
eligibility under the State’s Medicaid plan, and continue to Section 12.
11.1.

The State assures that services are provided in an effective and efficient manner through
free and open competition or through basing rates on other public and private rates that
are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2.

The State assures, to the extent they apply, that the following provisions of the Social
Security Act will apply under Title XXI, to the same extent they apply to a State under
Title XIX: (Section 2107(e)) (42CFR 457.935(b)) (The items below were moved from
section 9.8. Previously 9.8.6. - 9.8.9.)
11.2.1.
11.2.2.
11.2.3.
11.2.4.
11.2.5.
11.2.6.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers
and fiscal agents)
Section 1124 (relating to disclosure of ownership and related information)
Section 1126 (relating to disclosure of information about certain convicted
individuals)
Section 1128A (relating to civil monetary penalties)
Section 1128B (relating to criminal penalties for certain additional charges)
Section 1128E (relating to the National health care fraud and abuse data collection
104

program)
Section 12.

Applicant and Enrollee Protections (Sections 2101(a))

Check here if the State elects to use funds provided under Title XXI only to provide expanded
eligibility under the State’s Medicaid plan.
12.1.

Eligibility and Enrollment Matters- Describe the review process for eligibility and
enrollment matters that complies with 42 CFR 457.1120. Describe any special processes
and procedures that are unique to the applicant’s rights when the State is using the
Express Lane option when determining eligibility.

Guidance:

“Health services matters” refers to grievances relating to the provision of health care.

12.2.

Health Services Matters- Describe the review process for health services matters that
complies with 42 CFR 457.1120.

12.3.

Premium Assistance Programs- If providing coverage through a group health plan that
does not meet the requirements of 42 CFR 457.1120, describe how the State will assure
that applicants and enrollees have the option to obtain health benefits coverage other than
through the group health plan at initial enrollment and at each redetermination of
eligibility.

105

Key for Newly Incorporated Templates
The newly incorporated templates are indicated with the following letters after the numerical section
throughout the template.
•
•
•
•
•
•
•
•

PC- Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002)
PW- Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009)
TC- Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009)
DC- Dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009)
DS- Supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009)
PA- Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010)
EL- Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010)
LR- Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010)

106

CMS Regional Offices
CMS
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Offices
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Associate
Regional
Regional Office Address
Administrator
Richard R.
John F. Kennedy Federal Bldg.
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richard.mcgreal@ Boston, MA 02203-0003
cms.hhs.gov
Michael
Melendez
michael.melendez
@cms.hhs.gov
Ted Gallagher
ted.gallagher@c
ms.hhs.gov

26 Federal Plaza
Room 3811
New York, NY 10278-0063
The Public Ledger Building
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Suite 216
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Jackie Glaze
Atlanta Federal Center
jackie.glaze@cms 4th Floor
.hhs.gov
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Suite 4T20
Atlanta, GA 30303-8909

Verlon Johnson
verlon.johnson@
cms.hhs.gov

233 North Michigan Avenue,
Suite 600
Chicago, IL 60601

Bill Brooks
bill.brooks@cms.
hhs.gov

1301 Young Street, 8th Floor
Dallas, TX 75202

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CMS Regional Offices
CMS
Regional
Offices
Region 7Kansas City
Region 8Denver

Region 9San
Francisco

Region 10Seattle

States
Iowa
Kansas
Missouri
Nebraska
Colorado
Montana
North Dakota
South Dakota
Utah
Wyoming
Arizona
California
Hawaii
Nevada
American Samoa
Guam
Northern Mariana Islands
Idaho
Washington
Alaska
Oregon

Associate
Regional
Administrator
James G.
Scott
james.scott1@cm
s.hhs.gov
Richard Allen
richard.allen@cm
s.hhs.gov

Regional Office Address
Richard Bulling Federal Bldg.
601 East 12 Street, Room 235
Kansas City, MO 64106-2808
Federal Office Building, Room 522 1961 Stout
Street
Denver, CO 80294-3538

Gloria Nagle
90 Seventh Street Suite 5-300
gloria.nagle@cms San Francisco Federal Building
.hhs.gov
San Francisco, CA 94103

Carol Peverly
carol.peverly@c
ms.hhs.gov

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2001 Sixth Avenue
MS RX-43
Seattle, WA 98121

GLOSSARY
Adapted directly from Sec. 2110. DEFINITIONS.
CHILD HEALTH ASSISTANCE- For purposes of this title, 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
2105(a)(2)(A), 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.
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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.
TARGETED LOW-INCOME CHILD DEFINED- For purposes of this title-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 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; and
c. who is not found to be eligible for medical assistance under title XIX or covered under a
group health plan or under health insurance coverage (as such terms are defined in Section
2791 of the Public Health Service Act).
2. CHILDREN EXCLUDED- Such term does not include-a. a child who is a resident 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 title XIX (including under a waiver authorized by
the Secretary or under Section 1902(r)(2)), as of June 1, 1997, for the child to be eligible for medical
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assistance under Section 1902(l)(2) for the age of such child.
5. TARGETED LOW-INCOME PREGNANT WOMAN.—The term ‘targeted low-income pregnant
woman’ means an individual— (A) during pregnancy and through the end of the month in which the
60-day period (beginning on the last day of her pregnancy) ends; (B) whose family income exceeds
185 percent (or, if higher, the percent applied under subsection (b)(1)(A)) of the poverty line
applicable to a family of the size involved, but does not exceed the income eligibility level
established under the State child health plan under this title for a targeted low-income child; and (C)
who satisfies the requirements of paragraphs (1)(A), (1)(C), (2), and (3) of Section 2110(b) in the
same manner as a child applying for child health assistance would have to satisfy such requirements.
ADDITIONAL DEFINITIONS- For purposes of this title:
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 2701(c) of the Public Health Service Act (42
U.S.C. 300gg(c)) and includes coverage that meets the requirements of section 2103 provided to
a targeted low-income child under this title or under a waiver approved under section
2105(c)(2)(B) (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 2191 of the Public Health Service Act.
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 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any
revision required by such section.
6. PREEXISTING CONDITION EXCLUSION- The term ‘preexisting condition exclusion’ has the
meaning given such term in section 2701(b)(1)(A) of the Public Health Service Act (42 U.S.C.
300gg(b)(1)(A)).
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 2106.
8. UNINSURED CHILD- The term ‘uninsured child’ means a child that does not have creditable
health coverage.

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