§1397bb. General contents of State child health plan; eligibility; outreach

42 U.S.C. § §1397bb. General contents of State child

• Title: 42 — The Public Health and Welfare
• Chapter: SUBCHAPTER XXI—STATE CHILDREN'S HEALTH INSURANCE PROGRAM

Text

(a) General background and description
A State child health plan shall include a description, consistent with the requirements of this subchapter, of—
(1) the extent to which, and manner in which, children in the State, including targeted low-income children and other classes of children classified by income and other relevant factors, currently have creditable health coverage (as defined in section 1397jj(c)(2) of this title);
(2) current State efforts to provide or obtain creditable health coverage for uncovered children, including the steps the State is taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs and health insurance programs that involve public-private partnerships;
(3) how the plan is designed to be coordinated with such efforts to increase coverage of children under creditable health coverage;
(4) the child health assistance provided under the plan for targeted low-income children, including the proposed methods of delivery, and utilization control systems;
(5) eligibility standards consistent with subsection (b);
(6) outreach activities consistent with subsection (c); and
(7) methods (including monitoring) used—
(A) to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan;
(B) to assure access to covered services, including emergency services and services described in paragraphs (5) and (6) of section 1397cc(c) of this title; and
(C) to ensure that the State agency involved is in compliance with subparagraphs (A), (B), and (C) of section 1320a–7n(b)(2) of this title.
(b) General description of eligibility standards and methodology
The plan shall include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. Such standards may include (to the extent consistent with this subchapter) those relating to the geographic areas to be served by the plan, age, income and resources (including any standards relating to spenddowns and disposition of resources), residency, disability status (so long as any standard relating to such status does not restrict eligibility), access to or coverage under other health coverage, and duration of eligibility. Such standards may not discriminate on the basis of diagnosis.
Such eligibility standards—
(i) shall, within any defined group of covered targeted low-income children, not cover such children with higher family income without covering children with a lower family income;
(ii) may not deny eligibility based on a child having a preexisting medical condition;
(iii) may not apply a waiting period (including a waiting period to carry out paragraph (3)(C)) in the case of a targeted low-income pregnant woman provided pregnancy-related assistance under section 1397ll of this title;
(iv) at State option, may not apply a waiting period in the case of a child provided dental-only supplemental coverage under section 1397jj(b)(5) of this title; and
(v) shall, beginning January 1, 2014, use modified adjusted gross income and household income (as defined in section 36B(d)(2) of the Internal Revenue Code of 1986) to determine eligibility for child health assistance under the State child health plan or under any waiver of such plan and for any other purpose applicable under the plan or waiver for which a determination of income is required, including with respect to the imposition of premiums and cost-sharing, consistent with section 1396a(e)(14) of this title.
The plan shall include a description of methods of establishing and continuing eligibility and enrollment.
The plan shall include a description of procedures to be used to ensure—
(A) through both intake and followup screening, that only targeted low-income children are furnished child health assistance under the State child health plan;
(B) that children found through the screening to be eligible for medical assistance under the State medicaid plan under subchapter XIX are enrolled for such assistance under such plan;
(C) that the insurance provided under the State child health plan does not substitute for coverage under group health plans;
(D) the provision of child health assistance to targeted low-income children in the State who are Indians (as defined in section 1603(c) 1 of title 25); and
(E) coordination with other public and private programs providing creditable coverage for low-income children.
Subject to subparagraph (B), the plan shall include a description of the procedures used to reduce administrative barriers to the enrollment of children and pregnant women who are eligible for medical assistance under subchapter XIX or for child health assistance or health benefits coverage under this subchapter. Such procedures shall be established and revised as often as the State determines appropriate to take into account the most recent information available to the State identifying such barriers.
A State shall be deemed to comply with subparagraph (A) if the State's application and renewal forms and supplemental forms (if any) and information verification process is the same for purposes of establishing and renewing eligibility for children and pregnant women for medical assistance under subchapter XIX and child health assistance under this subchapter, and such process does not require an application to be made in person or a face-to-face interview.
Nothing in this subchapter shall be construed as providing an individual with an entitlement to child health assistance under a State child health plan.
(c) Outreach and coordination
A State child health plan shall include a description of the procedures to be used by the State to accomplish the following:
Outreach (through community health workers and others) to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs to inform these families of the availability of, and to assist them in enrolling their children in, such a program.
Coordination of the administration of the State program under this subchapter with other public and private health insurance programs.
In the case of a State that provides for premium assistance subsidies under the State child health plan in accordance with paragraph (2)(B), (3), or (10) of section 1397ee(c) of this title, or a waiver approved under section 1315 of this title, outreach, education, and enrollment assistance for families of children likely to be eligible for such subsidies, to inform such families of the availability of, and to assist them in enrolling their children in, such subsidies, and for employers likely to provide coverage that is eligible for such subsidies, including 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.
(d) Treatment of children who are inmates of a public institution
The State child health plan shall provide that—
(A) the State shall not terminate eligibility for child health or pregnancy-related assistance under the State child health plan for a targeted low-income child or targeted low-income pregnant woman because the child or pregnant woman is an inmate of a public institution, but may suspend coverage during the period the child or pregnant woman is such an inmate;
(B) in the case of a targeted low-income child who was determined eligible for child health assistance under the State child health plan (or waiver of such plan) immediately before becoming an inmate of a public institution, the State shall, prior to the child's release from such public institution, conduct a redetermination of eligibility for such child with respect to such child health assistance (without requiring a new application from the child) and, if the State determines pursuant to such redetermination that the child continues to meet the eligibility requirements for such child health assistance, the State shall restore coverage for such child health assistance to such child upon the child's release from such public institution; and
(C) in the case of a targeted low-income child who is determined eligible for child health assistance while an inmate of a public institution (subject to the exception to the exclusion of children who are inmates of a public institution described in section 1397jj(b)(7) of this title), the State shall process any application for child health assistance submitted by, or on behalf of, the child such that the State makes a determination of eligibility for the child with respect to child health assistance upon release of the child from the public institution.
A State child health plan shall provide that, in the case of a targeted low-income child who is within 30 days of the date on which such child is scheduled to be released from a public institution following adjudication, the State shall have in place a plan for providing, and shall provide in accordance with such plan, screenings, diagnostic services, referrals, and case management services otherwise covered under the State child health plan (or waiver of such plan) in the same manner as described in section 1396a(a)(84)(D) of this title.
"(vi) shall, in the case that the State elects to provide child health or pregnancy-related assistance to an individual for any period prior to the month in which the individual made application for such assistance (or application was made on behalf of the individual), provide that such assistance is not made available to such individual for items and services included under the State child health plan (or waiver of such plan) that are furnished before the second month preceding the month in which such individual made application (or application was made on behalf of such individual) for assistance."

History

(Aug. 14, 1935, ch. 531, title XXI, §2102, as added Pub. L. 105–33, title IV, §4901(a), Aug. 5, 1997, 111 Stat. 552; amended Pub. L. 111–3, title I, §111(b)(2), title II, §§201(b)(2)(B)(i), 212, title III, §302(a), title V, §501(a)(2), (b)(2), Feb. 4, 2009, 123 Stat. 28, 39, 55, 63, 85, 86; Pub. L. 111–148, title II, §2101(d)(1), Mar. 23, 2010, 124 Stat. 287; Pub. L. 111–152, title I, §1004(b)(2)(A), Mar. 30, 2010, 124 Stat. 1034; Pub. L. 114–198, title VII, §706(b)(2), July 22, 2016, 130 Stat. 754; Pub. L. 115–271, title V, §5022(c), Oct. 24, 2018, 132 Stat. 3964; Pub. L. 117–328, div. FF, title V, §5121(c)(1), Dec. 29, 2022, 136 Stat. 5942; Pub. L. 118–42, div. G, title I, §205(b)(1), Mar. 9, 2024, 138 Stat. 406; Pub. L. 119–21, title VII, §71112(c), July 4, 2025, 139 Stat. 299.)

Editorial Notes

Amendment of Subsection (b)(1)(B)
Pub. L. 119–21, title VII, §71112(c), (d), July 4, 2025, 139 Stat. 299, provided that, applicable to medical assistance, child health assistance, and pregnancy-related assistance with respect to individuals whose eligibility for such assistance is based on an application made on or after the first day of the first quarter that begins after Dec. 31, 2026, subsection (b)(1)(B) of this section is amended—
(1) in clause (iv), by striking "and" at the end;
(2) in clause (v), by striking the period and inserting "; and"; and
(3) by adding at the end the following new clause:
See 2025 Amendment note below.

Editorial Notes

References in Text
The Internal Revenue Code of 1986, referred to in subsec. (b)(1)(B)(v), is classified generally to Title 26, Internal Revenue Code.
Section 1603(c) of title 25, referred to in subsec. (b)(3)(D), was redesignated section 1603(13) of title 25 by Pub. L. 111–148, title X, §10221(a), Mar. 23, 2010, 124 Stat. 935.

Amendments
2025—Subsec. (b)(1)(B)(vi). Pub. L. 119–21 added cl. (vi).
2024—Subsec. (d)(1)(A). Pub. L. 118–42, §205(b)(1)(B)–(D), inserted "or targeted low-income pregnant woman" after "targeted low-income child", "or pregnant woman" after "because the child", and "or pregnant woman" after "during the period the child".
Pub. L. 118–42, §205(b)(1)(A), which directed insertion of "or pregnancy-related" after "child health", was executed by making the insertion before "assistance under the State child health plan" to reflect the probable intent of Congress.
2022—Subsec. (d). Pub. L. 117–328 added subsec. (d).
2018—Subsec. (a)(7)(B). Pub. L. 115–271 substituted "paragraphs (5) and (6) of section 1397cc(c)" for "section 1397cc(c)(5)".
2016—Subsec. (a)(7)(C). Pub. L. 114–198 added subpar. (C).
2010—Subsec. (b)(1)(B)(v). Pub. L. 111–152 substituted "modified adjusted gross income" for "modified gross income".
Pub. L. 111–148 added cl. (v).
2009—Subsec. (a)(7)(B). Pub. L. 111–3, §501(a)(2), inserted "and services described in section 1397cc(c)(5) of this title" after "emergency services".
Subsec. (b)(1)(B)(iii), (iv). Pub. L. 111–3, §§111(b)(2), 501(b)(2), added cls. (iii) and (iv).
Subsec. (b)(4), (5). Pub. L. 111–3, §212, added par. (4) and redesignated former par. (4) as (5).
Subsec. (c)(1). Pub. L. 111–3, §201(b)(2)(B)(i), inserted "(through community health workers and others)" after "Outreach".
Subsec. (c)(3). Pub. L. 111–3, §302(a), added par. (3).

Statutory Notes and Related Subsidiaries

Effective Date of 2025 Amendment
Amendment by Pub. L. 119–21 applicable to medical assistance, child health assistance, and pregnancy-related assistance with respect to individuals whose eligibility for such assistance is based on an application made on or after the first day of the first quarter that begins after Dec. 31, 2026, see section 71112(d) of Pub. L. 119–21, set out as a note under section 1396a of this title.

Effective Date of 2024 Amendment
Pub. L. 118–42, div. G, title I, §205(b)(2), Mar. 9, 2024, 138 Stat. 406, provided that: "The amendments made by paragraph (1) [amending this section] shall apply beginning January 1, 2026."

Effective Date of 2022 Amendment
Amendment by Pub. L. 117–328 applicable beginning on the first day of the first calendar quarter that begins on or after the date that is 24 months after Dec. 29, 2022, see section 5121(d) of Pub. L. 117–328, set out as a note under section 1396a of this title.

Effective Date of 2018 Amendment
Pub. L. 115–271, title V, §5022(e), Oct. 24, 2018, 132 Stat. 3965, provided that:
"(1) In general.—Subject to paragraph (2), the amendments made by this section [amending this section and sections 1397cc and 1397jj of this title] shall take effect with respect to child health assistance provided on or after the date that is 1 year after the date of the enactment of this Act [Oct. 24, 2018].
"(2) Exception for state legislation.—In the case of a State child health plan under title XXI of the Social Security Act [42 U.S.C. 1397aa et seq.] (or a waiver of such plan), which the Secretary of Health and Human Services determines requires State legislation in order for the respective plan (or waiver) to meet any requirement imposed by the amendments made by this section, the respective plan (or waiver) shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such an additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of enactment of this section [Oct. 24, 2018]. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of the session shall be considered to be a separate regular session of the State legislature."

Effective Date of 2009 Amendment
Amendment by sections 111(b)(2), 201(b)(2)(B)(i), 212, 302(a), and 501(b)(2) of Pub. L. 111–3 effective Apr. 1, 2009, and applicable to child health assistance and medical assistance provided on or after that date, with certain exceptions, see section 3 of Pub. L. 111–3, set out as an Effective Date note under section 1396 of this title.
Pub. L. 111–3, title V, §501(a)(3), Feb. 4, 2009, 123 Stat. 85, provided that: "The amendments made by paragraphs (1) and (2) [amending this section and section 1397cc of this title] shall apply to coverage of items and services furnished on or after October 1, 2009."