§ 1397cc.
(a)
Required scope of health insurance coverage
The child health assistance provided to a targeted low-income child under the plan in the form described in paragraph (1) of
section 1397aa(a) of this title 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.
(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.
(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
Regardless 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 1397ll of this title, such pregnancy-related assistance for targeted low-income pregnant women (as defined in section 1397ll(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
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 [42 U.S.C. 300gg–26(a)] 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 [42 U.S.C. 300gg–26(a)], 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.
(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
Nothing 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 section 1397jj(c)(9) of this title).
(10)
Certain in vitro diagnostic products for COVID–19 testing
The child health assistance provided to a targeted low-income child shall include coverage of any in vitro diagnostic product described in section 1396d(a)(3)(B) of this title that is administered during any portion of the emergency period described in such section beginning on or after March 18, 2020
1
See References in Text note below.
(and the administration of such product).
(11)
Required coverage of COVID–19 vaccines and treatment
Regardless 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
ll 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
March 11, 2021, 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
section 1320b–5(g)(1)(B) of this title, 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).
([Aug. 14, 1935, ch. 531], title XXI, § 2103, as added [Pub. L. 105–33, title IV, § 4901(a)], Aug. 5, 1997, [111 Stat. 554]; amended [Pub. L. 111–3, title I, § 111(b)(1)], title IV, § 403(a), title V, §§ 501(a)(1), 502, 504(a), 505(a), Feb. 4, 2009, [123 Stat. 28], 84, 89, 90; [Pub. L. 115–271, title V, § 5022(a)]–(b)(2)(A), (d), Oct. 24, 2018, [132 Stat. 3964], 3965; [Pub. L. 116–127, div. F, § 6004(b)(1)], (3), Mar. 18, 2020, [134 Stat. 206]; [Pub. L. 116–260, div. BB, title II, § 203(a)(4)(C)], Dec. 27, 2020, [134 Stat. 2917]; [Pub. L. 117–2, title IX, § 9821(a)], Mar. 11, 2021, [135 Stat. 219]; [Pub. L. 117–169, title I, § 11405(b)], Aug. 16, 2022, [136 Stat. 1901].)