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Notes

42 C.F.R. §§ 457.310–457.320

3 sections in range

§457.310. Targeted low-income child.

42 C.F.R. § 457.310

(a)
Definition. A targeted low-income child is a child who meets the standards set forth below and the eligibility standards established by the State under § 457.320.
(b)
Standards. A targeted low-income child must meet the following standards:
(1)
Financial need standard. A targeted low-income child:
(i)
Has a household income, as determined in accordance with § 457.315 of this subpart, at or below 200 percent of the Federal poverty level for a family of the size involved;
(ii)
Resides in a State with no Medicaid applicable income level;
(iii)
Resides in a State that has a Medicaid applicable income level and has a household income that either—
(A)
Exceeds the Medicaid applicable income level for the age of such child, but not by more than 50 percentage points; or
(B)
Does not exceed the income level specified for such child to be eligible for medical assistance under policies of the State plan under title XIX on June 1, 1997.
(2)
No other coverage standard. A targeted low-income child must not be—
(i)
Found eligible or potentially eligible for Medicaid under policies of the State plan (determined through either the Medicaid application process or the screening process described at § 457.350), except for eligibility under § 435.214 of this chapter (related to coverage for family planning services);
(ii)
Covered under a group health plan or under health insurance coverage, as defined in section 2791 of the Public Health Service Act, unless the plan or health insurance coverage program has been in operation since before July 1, 1997 and is administered by a State that receives no Federal funds for the program's operation. A child is not considered covered under a group health plan or health insurance coverage if the child does not have reasonable geographic access to care under that plan.
(3)
For purposes of this section, policies of the State plan under title XIX plan include policies under a Statewide demonstration project under section 1115(a) of the Act other than a demonstration project that covered an expanded group of eligible children but that either—
(i)
Did not provide inpatient hospital coverage; or
(ii)
Limited eligibility to children previously enrolled in Medicaid, imposed premiums as a condition of initial or continued enrollment, and did not impose a general time limit on eligibility.
(c)
Exclusions. Notwithstanding paragraph (a) of this section, the following groups are excluded from the definition of targeted low-income children:
(1)
Children eligible for certain State health benefits coverage.
(i)
A targeted low-income child may not be eligible for health benefits coverage under a State health benefits plan in the State on the basis of a family member's employment with a public agency, even if the family declines to accept the coverage.
(ii)
A child is considered eligible for health benefits coverage under a State health benefits plan if a more than nominal contribution to the cost of health benefits coverage under a State health benefits plan is available from the State or public agency with respect to the child or would have been available from those sources on November 8, 1999. A contribution is considered more than nominal if the State or public agency makes a contribution toward the cost of an employee's dependent(s) that is $10 per family, per month, more than the State or public agency's contribution toward the cost of covering the employee only.
(2)
Residents of an institution. A child must not be—
(i)
An inmate of a public institution as defined at § 435.1010 of this chapter; or
(ii)
A patient in an institution for mental diseases, as defined at § 435.1010 of this chapter, at the time of initial application or any redetermination of eligibility.
(d)
A targeted low-income child must also include any child enrolled in Medicaid on December 31, 2013 who is determined to be ineligible for Medicaid as a result of the elimination of income disregards as specified under § 435.603(g) of this chapter, regardless of any other standards set forth in this section except those in paragraph (c) of this section. Such a child shall continue to be a targeted low-income child under this paragraph until the date of the child's next renewal under § 457.343 of this subpart.
Notes, amendments, and revision history

Amendments

[66 FR 2675, Jan. 11, 2001, as amended at 71 FR 39229, July 12, 2006; 77 FR 17214, Mar. 23, 2012; 81 FR 86463, Nov. 30, 2016]

Source

Source: 66 FR 2675, Jan. 11, 2001, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

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

Amendments

[66 FR 2675, Jan. 11, 2001, as amended at 71 FR 39229, July 12, 2006; 77 FR 17214, Mar. 23, 2012; 81 FR 86463, Nov. 30, 2016]

§457.315. Application of modified adjusted gross income and household definition.

42 C.F.R. § 457.315

(a)
Effective January 1, 2014, the State must apply the financial methodologies set forth in paragraphs (b) through (i) of § 435.603 of this chapter in determining the financial eligibility of all individuals for CHIP. The exception to application of such methods for individuals for whom the State relies on a finding of income made by an Express Lane agency at § 435.603(j)(1) of this subpart also applies.
(b)
In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 2013, application of the financial methodologies set forth in this section will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility for such individual under § 457.343, whichever is later.
Notes, amendments, and revision history

Amendments

[77 FR 17214, Mar. 23, 2012]

Source

Source: 66 FR 2675, Jan. 11, 2001, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

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

Amendments

[77 FR 17214, Mar. 23, 2012]

§457.320. Other eligibility standards.

42 C.F.R. § 457.320

(a)
Eligibility standards. To the extent consistent with title XXI of the Act and except as provided in paragraph (b) of this section, the State plan may adopt eligibility standards for one or more groups of children related to—
(1)
Geographic area(s) served by the plan;
(2)
Age (up to, but not including, age 19);
(3)
Income;
(4)
Spenddowns;
(5)
Residency, in accordance with paragraph (d) of this section;
(6)
Disability status, provided that such standards do not restrict eligibility;
(7)
Access to, or coverage under, other health coverage; and
(8)
Duration of eligibility, in accordance with paragraph (e) of this section.
(b)
Prohibited eligibility standards. In establishing eligibility standards and methodologies, a State may not—
(1)
Cover children with a higher household income without covering children with a lower household income within any defined group of covered targeted low-income children;
(2)
Deny eligibility based on a preexisting medical condition;
(3)
Discriminate on the basis of diagnosis;
(4)
Require any family member who is not requesting services to provide a social security number (including those family members whose income or resources might be used in making the child's eligibility determination);
(5)
Exclude American Indian or Alaska Native children based on eligibility for, or access to, medical care funded by the Indian Health Service;
(6)
Exclude individuals based on citizenship or nationality, to the extent that the children are U.S. citizens, U.S. nationals or qualified noncitizens (as defined at paragraph (c) of this section); or
(7)
Violate any other Federal laws or regulations pertaining to eligibility for a separate child health program under title XXI.
(c)
Definitions. As used in this subpart:

Qualified noncitizen has the meaning assigned at § 435.4 of this chapter.

(d)
Citizenship and immigration status. All individuals seeking coverage under a separate child health plan must make a declaration of United States citizenship or satisfactory immigration status. Such declaration may be made by an adult member of the individual's household, an authorized representative, as defined in § 435.923 of this chapter (referenced at § 457.340), or if the individual is a minor or incapacitated, someone acting responsibly for the individual provided that such individual attests to having knowledge of the individual's status.
(e)
Residency.
(1)
Residency for a non-institutionalized child who is not a ward of the State must be determined in accordance with § 435.403(i) of this chapter.
(2)
Residency for a targeted low-income pregnant woman defined at 2112 of the Act must be determined in accordance with § 435.403(h) of this chapter.
(3)
A State may not—
(i)
Impose a durational residency requirement;
(ii)
Preclude the following individuals from declaring residence in a State—
(A)
An institutionalized child who is not a ward of a State, if the State is the State of residence of the child's custodial parent or caretaker at the time of placement; or
(B)
A child who is a ward of a State, regardless of where the child lives
(4)
In cases of disputed residency, the State must follow the process described in § 435.403(m) of this chapter.
(f)
Duration of eligibility.
(1)
The State may not impose a lifetime cap or other time limit on the eligibility of an individual applicant or enrollee, based on the length of time such applicant or enrollee has received benefits under the State's separate child health program.
(2)
[Reserved]
Notes, amendments, and revision history

Amendments

[66 FR 2675, Jan. 11, 2001, as amended at 66 FR 33823, June 25, 2001, 77 FR 17214, Mar. 23, 2012; 81 FR 86463, Nov. 30, 2016; 89 FR 39436, May 8, 2024]

Source

Source: 66 FR 2675, Jan. 11, 2001, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

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

Amendments

[66 FR 2675, Jan. 11, 2001, as amended at 66 FR 33823, June 25, 2001, 77 FR 17214, Mar. 23, 2012; 81 FR 86463, Nov. 30, 2016; 89 FR 39436, May 8, 2024]