42 U.S.C. § 1397cc | Coverage requirements for children’s health insurance

(a)

Required scope of health insurance coverage

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

(1)

Benchmark coverage

Health benefits coverage that is at least equivalent to the benefits coverage in a benchmark benefit package described in subsection (b).

(2)

Benchmark-equivalent coverage

Health benefits coverage that meets the following requirements:

(A)

Inclusion of basic services

The coverage includes benefits for items and services within each of the categories of basic services described in subsection (c)(1).

(B)

Aggregate actuarial value equivalent to benchmark package

The coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages.

(C)

Substantial actuarial value for additional services included in benchmark package

With respect to each of the categories of additional services described in subsection (c)(2) for which coverage is provided under the benchmark benefit package used under subparagraph (B), the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the coverage of that category of services in such package.

(3)

Existing comprehensive State-based coverage

Health benefits coverage under an existing comprehensive State-based program, described in subsection (d)(1).

(4)

Secretary-approved coverage

Any other health benefits coverage that the Secretary determines, upon application by a State, provides appropriate coverage for the population of targeted low-income children proposed to be provided such coverage.

(b)

Benchmark benefit packages

The benchmark benefit packages are as follows:

(1)

FEHBP-equivalent children’s health insurance coverage

section 8903(1) of title 5The standard Blue Cross/Blue Shield preferred provider option service benefit plan, described in and offered under .

(2)

State employee coverage

A health benefits coverage plan that is offered and generally available to State employees in the State involved.

(3)

Coverage offered through HMO

The health insurance coverage plan that—

(A)

42 U.S.C. 300gg–91(b)(3) is offered by a health maintenance organization (as defined in section 2791(b)(3) of the Public Health Service Act []), and

(B)

has the largest insured commercial, non-medicaid enrollment of covered lives of such coverage plans offered by such a health maintenance organization in the State involved.

(c)

Categories of services; determination of actuarial value of coverage

(1)

Categories of basic services

For purposes of this section, the categories of basic services described in this paragraph are as follows:

(A)

Inpatient and outpatient hospital services.

(B)

Physicians’ surgical and medical services.

(C)

Laboratory and x-ray services.

(D)

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

(E)

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

(2)

Categories of additional services

For purposes of this section, the categories of additional services described in this paragraph are as follows:

(A)

Coverage of prescription drugs.

(B)

Vision services.

(C)

Hearing services.

(3)

Treatment of other categories

Nothing in this subsection shall be construed as preventing a State child health plan from providing coverage of benefits that are not within a category of services described in paragraph (1) or (2).

(4)

Determination of actuarial value

The actuarial value of coverage of benchmark benefit packages, coverage offered under the State child health plan, and coverage of any categories of additional services under benchmark benefit packages and under coverage offered by such a plan, shall be set forth in an actuarial opinion in an actuarial report that has been prepared—

(A)

by an individual who is a member of the American Academy of Actuaries;

(B)

using generally accepted actuarial principles and methodologies;

(C)

using a standardized set of utilization and price factors;

(D)

using a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan;

(E)

applying the same principles and factors in comparing the value of different coverage (or categories of services);

(F)

without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used; and

(G)

taking into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage.

The actuary preparing the opinion shall select and specify in the memorandum the standardized set and population to be used under subparagraphs (C) and (D).

(5)

Mental health and substance use disorder services

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

(A)

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

(B)

be delivered in a culturally and linguistically appropriate manner.

(6)

Dental benefits

(A)

In general

The child health assistance provided to a targeted low-income child shall include coverage of dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.

(B)

Permitting use of dental benchmark plans by certain States

A State may elect to meet the requirement of subparagraph (A) through dental coverage that is equivalent to a benchmark dental benefit package described in subparagraph (C).

(C)

Benchmark dental benefit packages

The benchmark dental benefit packages are as follows:

(i)

FEHBP children’s dental coverage

A dental benefits plan under chapter 89A of title 5 that has been selected most frequently by employees seeking dependent coverage, among such plans that provide such dependent coverage, in either of the previous 2 plan years.

(ii)

State employee dependent dental coverage

A dental benefits plan that is offered and generally available to State employees in the State involved and that has been selected most frequently by employees seeking dependent coverage, among such plans that provide such dependent coverage, in either of the previous 2 plan years.

(iii)

Coverage offered through commercial dental plan

A dental benefits plan that has the largest insured commercial, non-medicaid enrollment of dependent covered lives of such plans that is offered in the State involved.

(7)

Mental health services parity

(A)

In general

42 U.S.C. 300gg–26(a)42 U.S.C. 300gg–26(a)A State child health plan shall ensure that the financial requirements and treatment limitations applicable to mental health and substance use disorder services (as described in paragraph (5)) provided under such plan comply with the requirements of section 2726(a) of the Public Health Service Act [] in the same manner as such requirements or limitations apply to a group health plan under such section. In applying the previous sentence with respect to requirements under paragraph (8) of section 2726(a) of the Public Health Service Act [], a State child health plan described in such sentence shall be treated as in compliance with such requirements if the State child health plan is in compliance with section 457.496 of title 42, Code of Federal Regulations, or any successor regulation.

(B)

Deemed compliance

section 1396d(a)(4)(B) of this title section 1396a(a)(10)(A) of this title section 1396d(a)(4)(B) of this title section 1396d(r) of this title section 1396a(a)(43) of this titleTo the extent that a State child health plan includes coverage with respect to an individual described in and covered under the State plan under of the services described in (relating to early and periodic screening, diagnostic, and treatment services defined in ) and provided in accordance with , such plan shall be deemed to satisfy the requirements of subparagraph (A).

(8)

Construction on prohibited coverage

Nothing in this section shall be construed as requiring any health benefits coverage offered under the plan to provide coverage for items or services for which payment is prohibited under this subchapter, notwithstanding that any benchmark benefit package includes coverage for such an item or service.

(9)

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

section 1397jj(c)(9) of this titleNothing in this subchapter shall be construed as limiting a State’s ability to provide child health assistance for covered items and services that are furnished through school-based health centers (as defined in ).

(10)

Certain in vitro diagnostic products for COVID–19 testing

section 1396d(a)(3)(B) of this titleMarch 18, 20201

1 See References in Text note below.

The child health assistance provided to a targeted low-income child shall include coverage of any in vitro diagnostic product described in that is administered during any portion of the emergency period described in such section beginning on or after   (and the administration of such product).

(11)

Required coverage of COVID–19 vaccines and treatment

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

(A)

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

(B)

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

(12)

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

llsection 1396d(a)(13)(B) of this titleRegardless of the type of coverage elected by a State under subsection (a), if the State child health plan or a waiver of such plan provides child health assistance or pregnancy-related assistance (as defined in section 1397 of this title) to an individual who is 19 years of age or older, such assistance shall include coverage of vaccines described in and their administration.

(d)

Description of existing comprehensive State-based coverage

(1)

In general

A program described in this paragraph is a child health coverage program that—

(A)

includes coverage of a range of benefits;

(B)

is administered or overseen by the State and receives funds from the State;

(C)

is offered in New York, Florida, or Pennsylvania; and

(D)

August 5, 1997 was offered as of .

(2)

Modifications

A State may modify a program described in paragraph (1) from time to time so long as it continues to meet the requirement of subparagraph (A) and does not reduce the actuarial value of the coverage under the program below the lower of—

(A)

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

(B)

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

evaluated as of the time of the modification.

(e)

Cost-sharing

(1)

Description; general conditions

(A)

Description

A State child health plan shall include a description, consistent with this subsection, of the amount (if any) of premiums, deductibles, coinsurance, and other cost sharing imposed. Any such charges shall be imposed pursuant to a public schedule.

(B)

Protection for lower income children

The State child health plan may only vary premiums, deductibles, coinsurance, and other cost sharing based on the family income of targeted low-income children in a manner that does not favor children from families with higher income over children from families with lower income.

(2)

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

oooThe State child health plan may not impose deductibles, coinsurance, or other cost sharing with respect to benefits for services within the categories of services described in subsection (c)(1)(D), in vitro diagnostic products described in subsection (c)(10) (and administration of such products), vaccines described in subsection (c)(12) (and the administration of such vaccines), services described in section 1396(a)(2)(G) of this title, vaccines described in section 1396(a)(2)(H) of this title administered during the period described in such section (and the administration of such vaccines), testing or treatments described in section 1396(a)(2)(I) of this title furnished during the period described in such section, or for pregnancy-related assistance.

(3)

Limitations on premiums and cost-sharing

(A)

Children in families with income below 150 percent of poverty line

In the case of a targeted low-income child whose family income is at or below 150 percent of the poverty line, the State child health plan may not impose—

(i)

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

(ii)

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

(B)

Other children

For children not described in subparagraph (A), subject to paragraphs (1)(B) and (2), any premiums, deductibles, cost sharing or similar charges imposed under the State child health plan may be imposed on a sliding scale related to income, except that the total annual aggregate cost-sharing with respect to all targeted low-income children in a family under this subchapter may not exceed 5 percent of such family’s income for the year involved.

(C)

Premium grace period

The State child health plan—

(i)

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

(ii)

shall provide to such an individual, not later than 7 days after the first day of such grace period, notice—

(I)

that failure to make a premium payment within the grace period will result in termination of coverage under the State child health plan; and

(II)

of the individual’s right to challenge the proposed termination pursuant to the applicable Federal regulations.

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

(4)

Relation to medicaid requirements

section 1397aa(a)(2) of this titleNothing in this subsection shall be construed as affecting the rules relating to the use of enrollment fees, premiums, deductions, cost sharing, and similar charges in the case of targeted low-income children who are provided child health assistance in the form of coverage under a medicaid program under .

(f)

Application of certain requirements

(1)

Restriction on application of preexisting condition exclusions

(A)

In general

Subject to subparagraph (B), the State child health plan shall not permit the imposition of any preexisting condition exclusion for covered benefits under the plan.

(B)

Group health plans and group health insurance coverage

29 U.S.C. 1181 42 U.S.C. 300ggIf the State child health plan provides for benefits through payment for, or a contract with, a group health plan or group health insurance coverage, the plan may permit the imposition of a preexisting condition exclusion but only insofar as it is permitted under the applicable provisions of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 [ et seq.] and title XXVII of the Public Health Service Act [ et seq.].

(2)

Compliance with other requirements

¹Coverage offered under this section shall comply with the requirements of subpart 2 of part A of title XXVII of the Public Health Service Act  insofar as such requirements apply with respect to a health insurance issuer that offers group health insurance coverage.

(3)

Compliance with managed care requirements

section 1396u–2 of this titleThe State child health plan shall provide for the application of subsections (a)(4), (a)(5), (b), (c), (d), (e), and (j) of (relating to requirements for managed care) to coverage, State agencies, enrollment brokers, managed care entities, and managed care organizations under this subchapter in the same manner as such subsections apply to coverage and such entities and organizations under subchapter XIX.

Aug. 14, 1935, ch. 531 Pub. L. 105–33, title IV, § 4901(a)Aug. 5, 1997111 Stat. 554 Pub. L. 111–3, title I, § 111(b)(1)Feb. 4, 2009123 Stat. 28 Pub. L. 115–271, title V, § 5022(a)Oct. 24, 2018132 Stat. 3964 Pub. L. 116–127, div. F, § 6004(b)(1)Mar. 18, 2020134 Stat. 206 Pub. L. 116–260, div. BB, title II, § 203(a)(4)(C)Dec. 27, 2020134 Stat. 2917 Pub. L. 117–2, title IX, § 9821(a)Mar. 11, 2021135 Stat. 219 Pub. L. 117–169, title I, § 11405(b)Aug. 16, 2022136 Stat. 1901 Pub. L. 119–21, title VII, § 71103(b)(2)July 4, 2025139 Stat. 293(, title XXI, § 2103, as added , , ; amended , title IV, § 403(a), title V, §§ 501(a)(1), 502, 504(a), 505(a), , , 84, 89, 90; –(b)(2)(A), (d), , , 3965; , (3), , ; , , ; , , ; , , ; , , .)

Editorial Notes

References in Text

March 18, 2020, referred to in subsec. (c)(10), was in the original “the date of the enactment of this subparagraph”, and was translated as if it had read “the date of the enactment of this paragraph” to reflect the probable intent of Congress.

Pub. L. 93–406Sept. 2, 197488 Stat. 832 section 1001 of Title 29The Employee Retirement Income Security Act of 1974, referred to in subsec. (f)(1)(B), is , , . Part 7 of subtitle B of title I of the Act is classified generally to part 7 (§ 1181 et seq.) of subtitle B of subchapter I of chapter 18 of Title 29, Labor. For complete classification of this Act to the Code, see Short Title note set out under and Tables.

act July 1, 1944, ch. 373 58 Stat. 682 Pub. L. 111–148, title IMar. 23, 2010124 Stat. 130subpart ii—improving coveragesection 300gg–11 of this titlesubpart 2—other requirementssection 300gg–4 of this titleexclusion of plans; enforcement; preemptionsection 300gg–21 of this title section 201 of this titleThe Public Health Service Act, referred to in subsec. (f), is , . Title XXVII of the Act is classified generally to subchapter XXV (§ 300gg et seq.) of chapter 6A of this title. Subpart 2 of part A of title XXVII of the Act may refer to subpart II of part A of subchapter XXV of chapter 6A of this title. , §§ 1001(5), 1563(c)(2), (11), formerly § 1562(c)(2), (11), title X, § 10107(b)(1), , , 265, 268, 911, amended part A by inserting “” (preceding ), by striking out “” (preceding ), and by redesignating subpart 4 as subpart 2 “” (preceding ). For complete classification of this Act to the Code, see Short Title note set out under and Tables.

Amendments

Pub. L. 119–212025—Subsec. (f)(3). substituted “(e), and (j)” for “and (e)”.

Pub. L. 117–169, § 11405(b)(1)2022—Subsec. (c)(12). , added par. (12).

Pub. L. 117–169, § 11405(b)(2)Subsec. (e)(2). , inserted “vaccines described in subsection (c)(12) (and the administration of such vaccines),” after “in vitro diagnostic products described in subsection (c)(10) (and administration of such products),”.

Pub. L. 117–2, § 9821(a)(1)2021—Subsec. (c)(11). , added par. (11).

Pub. L. 117–2, § 9821(a)(2)ooooSubsec. (e)(2). , in heading, inserted “a COVID–19 vaccine, COVID–19 treatment,” before “or pregnancy-related assistance” and, in text, substituted “services described in section 1396(a)(2)(G) of this title, vaccines described in section 1396(a)(2)(H) of this title administered during the period described in such section (and the administration of such vaccines), testing or treatments described in section 1396(a)(2)(I) of this title furnished during the period described in such section, or” for “visits described in section 1396(a)(2)(G) of this title, or”.

Pub. L. 116–260, § 203(a)(4)(C)(ii)2020—Subsec. (c)(7)(A). , inserted at end “In applying the previous sentence with respect to requirements under paragraph (8) of section 2726(a) of the Public Health Service Act, a State child health plan described in such sentence shall be treated as in compliance with such requirements if the State child health plan is in compliance with section 457.496 of title 42, Code of Federal Regulations, or any successor regulation.”

Pub. L. 116–260, § 203(a)(4)(C)(i)Pub. L. 115–271, § 5022(d), which directed substitution of “section 2726(a)” for “section 2705(a)”, could not be executed because of the intervening general amendment by . See 2018 Amendment note below.

Pub. L. 116–127, § 6004(b)(1)Subsec. (c)(10). , added par. (10).

Pub. L. 116–127, § 6004(b)(3)oSubsec. (e)(2). , in heading, inserted “, COVID–19 testing,” before “or pregnancy-related assistance” and, in text, substituted “categories of services described in subsection (c)(1)(D), in vitro diagnostic products described in subsection (c)(10) (and administration of such products), visits described in section 1396(a)(2)(G) of this title, or” for “category of services described in subsection (c)(1)(D) or”.

Pub. L. 115–271, § 5022(b)(2)(A)2018—Subsec. (a). , substituted “paragraphs (5), (6), (7), and (8)” for “paragraphs (5), (6), and (7)” in introductory provisions.

Pub. L. 115–271, § 5022(a)Subsec. (c)(1)(E). , added subpar. (E).

Pub. L. 115–271, § 5022(b)(1)Subsec. (c)(5) to (7). , added par. (5) and redesignated former pars. (5) and (6) as (6) and (7), respectively. Former par. (7) redesignated (8).

Pub. L. 115–271, § 5022(d)Subsec. (c)(7)(A). , amended subpar. (A) generally. Prior to amendment, text read as follows: “In the case of a State child health plan that provides both medical and surgical benefits and mental health or substance use disorder benefits, such plan shall ensure that the financial requirements and treatment limitations applicable to such mental health or substance use disorder benefits comply with the requirements of section 2705(a) of the Public Health Service Act in the same manner as such requirements apply to a group health plan.”

Pub. L. 115–271, § 5022(b)(1)Subsec. (c)(8), (9). , redesignated pars. (7) and (8) as (8) and (9), respectively.

Pub. L. 111–3, § 502(b)(1)2009—Subsec. (a). , inserted “, (6),” after “(5)” in introductory provisions.

Pub. L. 111–3, § 501(a)(1)(A)(i), substituted “paragraphs (5) and (7) of subsection (c)” for “subsection (c)(5)” in introductory provisions.

Pub. L. 111–3, § 501(a)(1)(A)(ii)Subsec. (a)(1). , inserted “at least” after “that is”.

Pub. L. 111–3, § 502(b)(2)Subsec. (c)(2)(B) to (D). , redesignated subpars. (C) and (D) as (B) and (C), respectively, and struck out former subpar. (B) which read as follows: “Mental health services.”

Pub. L. 111–3, § 501(a)(1)(B)(ii)Subsec. (c)(5). , added par. (5). Former par. (5) redesignated (7).

Pub. L. 111–3, § 502(a)Subsec. (c)(6). , added par. (6).

Pub. L. 111–3, § 501(a)(1)(B)(i)Subsec. (c)(7). , redesignated par. (5) as (7).

Pub. L. 111–3, § 505(a)Subsec. (c)(8). , added par. (8).

Pub. L. 111–3, § 111(b)(1)Subsec. (e)(2). , inserted “or pregnancy-related assistance” after “preventive services” in heading and “or for pregnancy-related assistance” before period at end.

Pub. L. 111–3, § 504(a)Subsec. (e)(3)(C). , added subpar. (C).

Pub. L. 111–3, § 403(a)Subsec. (f)(3). , added par. (3).

Statutory Notes and Related Subsidiaries

Effective Date of 2022 Amendment

Pub. L. 117–169Aug. 16, 2022section 11405(c) of Pub. L. 117–169 section 1396a of this titleAmendment by effective on the 1st day of the 1st fiscal quarter that begins on or after the date that is 1 year after and applicable to expenditures made under a State plan or waiver of such plan under title XIX of the Social Security Act or under a State child health plan or waiver of such plan under title XXI of such Act on or after such effective date, see , set out as a note under .

Effective Date of 2018 Amendment

Pub. L. 115–271Oct. 24, 2018section 5022(e) of Pub. L. 115–271 section 1397bb of this titleAmendment by effective with respect to child health assistance provided on or after the date that is 1 year after , with exception if State legislation required, see , set out as a note under .

Effective Date of 2009 Amendment

Pub. L. 111–3Apr. 1, 2009section 3 of Pub. L. 111–3 section 1396 of this titleAmendment by sections 111(b)(1), 502, and 505(a) of effective , and applicable to child health assistance and medical assistance provided on or after that date, with certain exceptions, see , set out as an Effective Date note under .

Pub. L. 111–3, title IV, § 403(b)Feb. 4, 2009123 Stat. 84

July 1, 2009“The amendment made by subsection (a) [amending this section] shall apply to contract years for health plans beginning on or after .”

, , , provided that:

section 501(a)(1) of Pub. L. 111–3Oct. 1, 2009section 501(a)(3) of Pub. L. 111–3 section 1397bb of this titleAmendment by applicable to coverage of items and services furnished on or after , see , set out as a note under .

Pub. L. 111–3, title V, § 504(b)Feb. 4, 2009123 Stat. 90

Feb. 4, 2009“The amendment made by subsection (a) [amending this section] shall apply to new coverage periods beginning on or after the date of the enactment of this Act [].”

, , , provided that: