---
kind: "section"
citation: "42 C.F.R. § 457.1130"
title: "42"
number: "457.1130"
heading: "Program specific review process: Matters subject to review."
url: "https://uscodex.org/cfr/42/457.1130"
---

# §457.1130. Program specific review process: Matters subject to review.

- (a) **Eligibility or enrollment matter.** A State must ensure that an applicant or enrollee has an opportunity for review, consistent with §§ [457.1140](/cfr/42/457.1140.md) and [457.1150](/cfr/42/457.1150.md), of a—
  - (1) Denial of eligibility;
  - (2) Failure to make a timely determination of eligibility; and
  - (3) **Suspension or termination of enrollment, including disenrollment for failure to pay cost sharing.**
- (b) **Health services matter.** A State must ensure that an enrollee has an opportunity for external review of a—
  - (1) Delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of services; and
  - (2) **Failure to approve, furnish, or provide payment for health services in a timely manner.**
- (c) **Exception.** A State is not required to provide an opportunity for review of a matter described in paragraph [(a)](#a) or [(b)](#b) of this section if the sole basis for the decision is a provision in the State plan or in Federal or State law requiring an automatic change in eligibility, enrollment, or a change in coverage under the health benefits package that affects all applicants or enrollees or a group of applicants or enrollees without regard to their individual circumstances.

## Notes

### Source

Source: 66 FR 2687, Jan. 11, 2001, unless otherwise noted.

### Authority

Authority: 42 U.S.C. 1302.

### Source

Source: 65 FR 33622, May 24, 2000, unless otherwise noted.