42 CFR 457.10 - Definitions and use of terms.
For purposes of this part the following definitions apply:
Actuarially sound principles means generally accepted actuarial principles and practices that are applied to determine aggregate utilization patterns, are appropriate for the population and services to be covered, and have been certified by actuaries who meet the qualification standards established by the Actuarial Standards Board.
Advanced payments of the premium tax credit (APTC) has the meaning given the term in 45 CFR 155.20.
Affordable Insurance Exchange (Exchange) has the meaning given the term “Exchange” in 45 CFR 155.20.
American Indian/Alaska Native (AI/AN) means -
(1) A member of a Federally recognized Indian tribe, band, or group;
(3) A person who is considered by the Secretary of the Interior to be an Indian for any purpose.
Applicant means a child who has filed an application (or who has an application filed on their behalf) for health benefits coverage through the Children's Health Insurance Program. A child is an applicant until the child receives coverage through CHIP.
Application means the single, streamlined application form that is used by the State in accordance with § 435.907(b) of this chapter and 45 CFR 155.405 for individuals to apply for coverage for all insurance affordability programs.
Child means an individual under the age of 19 including the period from conception to birth.
Children's Health Insurance Program (CHIP) means a program established and administered by a State, jointly funded with the Federal government, to provide child health assistance to uninsured, low-income children through a separate child health program, a Medicaid expansion program, or a combination program.
Combined eligibility notice means an eligibility notice that informs an individual, or multiple family members of a household of eligibility for each of the insurance affordability programs and enrollment in a qualified health plan through the Exchange, for which a determination or denial of eligibility was made, as well as any right to request a review, fair hearing or appeal related to the determination made for each program. A combined notice must meet the requirements of § 457.340(e) and contain the content described in § 457.340(e)(1), except that information described in § 457.340(e)(1)(i)(C) may be provided in a combined notice issued by another insurance affordability program or in a supplemental notice provided by the State. A combined eligibility notice must be issued in accordance with the agreement(s) consummated by the State in accordance with § 457.348(a).
Comprehensive risk contract means a risk contract between the State and an MCO that covers comprehensive services, that is, inpatient hospital services and any of the following services, or any three or more of the following services:
(1) Outpatient hospital services.
(2) Rural health clinic services.
(3) Federally Qualified Health Center (FQHC) services.
(4) Other laboratory and X-ray services.
(5) Nursing facility (NF) services.
(6) Early and periodic screening, diagnostic, and treatment (EPSDT) services.
(7) Family planning services.
(8) Physician services.
(9) Home health services.
Coordinated content means information included in an eligibility notice regarding, if applicable -
(3) The potential impact, if any, of -
Cost sharing means premium charges, enrollment fees, deductibles, coinsurance, copayments, or other similar fees that the enrollee has responsibility for paying.
Creditable health coverage has the meaning given the term “creditable coverage” at 45 CFR 146.113 and includes coverage that meets the requirements of § 457.410 and is provided to a targeted low-income child.
Electronic account means an electronic file that includes all information collected and generated by the State regarding each individual's CHIP eligibility and enrollment, including all documentation required under § 457.380 and including any information collected or generated as part of a review process conducted in accordance with subpart K of this part, the Exchange appeals process conducted under 45 CFR part 155, subpart F or other insurance affordability program appeals process.
Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in -
(1) Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of a woman or her unborn child;
(2) Serious impairment of bodily function; or
(3) Serious dysfunction of any bodily organ or part.
Emergency services means health care services that are -
External quality review (EQR) means the analysis and evaluation by an EQRO, of aggregated information on quality, timeliness, and access to the health care services that an MCO, PIHP, or PAHP, or their contractors furnish to CHIP beneficiaries.
External quality review organization (EQRO) means an organization that meets the competence and independence requirements set forth in § 438.354 of this chapter, and holds a contract with a State to perform external quality review, other EQR-related activities as set forth in § 438.358 of this chapter, or both.
Federal fiscal year starts on the first day of October each year and ends on the last day of the following September.
Fee-for-service entity means any individual or entity that furnishes services under the program on a fee-for-service basis, including health insurance services.
Group health insurance coverage has the meaning assigned at 45 CFR 144.103.
Group health plan has the meaning assigned at 45 CFR 144.103.
Health care services means any of the services, devices, supplies, therapies, or other items listed in § 457.402.
Health insurance coverage has the meaning assigned at 45 CFR 144.103.
Health insurance issuer has the meaning assigned at 45 CFR 144.103.
Health maintenance organization (HMO) plan has the meaning assigned at § 457.420.
Health services initiatives means activities that protect the public health, protect the health of individuals, improve or promote a State's capacity to deliver public health services, or strengthen the human and material resources necessary to accomplish public health goals relating to improving the health of children (including targeted low-income children and other low-income children).
Household income is defined as provided in § 435.603(d) of this chapter.
Insurance affordability program is defined as provided in § 435.4 of this chapter.
Joint application has the meaning assigned at § 457.301.
Joint review request means a request for a review under subpart K of this part which is included in an appeal request submitted to an Exchange or Exchange appeals entity or other insurance affordability program or appeals entity, in accordance with the signed agreement between the State and an Exchange or Exchange appeals entity or other program or appeals entity in accordance with § 457.348(b).
Managed care entity (MCE) means an entity that enters into a contract to provide services in a managed care delivery system, including but not limited to managed care organizations, prepaid health plans, and primary care case managers.
(2) Makes the services it provides to its CHIP enrollees as accessible (in terms of timeliness, amount, duration, and scope) as those services are to other CHIP beneficiaries within the area served by the entity and
(3) Meets the solvency standards of § 438.116 of this chapter.
Period of presumptive eligibility has the meaning assigned at § 457.301.
Preexisting condition exclusion has the meaning assigned at 45 CFR 144.103.
Premium assistance program means a component of a separate child health program, approved under the State plan, under which a State pays part or all of the premiums for a CHIP enrollee or enrollees' group health insurance coverage or coverage under a group health plan.
Premium Lock-Out is defined as a State-specified period of time not to exceed 90 days that a CHIP eligible child who has an unpaid premium or enrollment fee (as applicable) will not be permitted to reenroll for coverage in CHIP. Premium lock-out periods are not applicable to children who have paid outstanding premiums or enrollment fees.
Prepaid ambulatory health plan (PAHP) means an entity that -
(3) Does not have a comprehensive risk contract.
Prepaid inpatient health plan (PIHP) means an entity that -
(3) Does not have a comprehensive risk contract.
Presumptive income standard has the meaning assigned at § 457.301.
Primary care case management means a system under which:
Primary care case management entity (PCCM entity) means an organization that provides any of the following functions, in addition to primary care case management services, for the State:
(1) Provision of intensive telephonic or face-to-face case management, including operation of a nurse triage advice line.
(2) Development of enrollee care plans.
(3) Execution of contracts with and/or oversight responsibilities for the activities of fee-for-service providers in the fee-for-service program.
(5) Provision of enrollee outreach and education activities.
(6) Operation of a customer service call center.
(8) Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers.
(9) Coordination with behavioral health systems/providers.
(10) Coordination with long-term services and supports systems/providers.
(1) A physician assistant.
(2) A nurse practitioner.
(3) A certified nurse-midwife.
Provider means any individual or entity that is engaged in the delivery of services, or ordering or referring for those services, and is legally authorized to do so by the State in which it delivers the services.
Public agency has the meaning assigned in § 457.301.
Qualified entity has the meaning assigned at § 457.301.
Risk contract means a contract under which the contractor -
(1) Assumes risk for the cost of the services covered under the contract.
Secure electronic interface is defined as provided in § 435.4 of this chapter.
Separate child health program means a program under which a State receives Federal funding from its title XXI allotment to provide child health assistance through obtaining coverage that meets the requirements of section 2103 of the Act and § 457.402.
Shared eligibility service is defined as provided in § 435.4 of this chapter.
State means all States, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa and the Northern Mariana Islands. The Territories are excluded from this definition for purposes of § 457.740.
State health benefits plan has the meaning assigned in § 457.301.
Targeted low-income child has the meaning assigned in § 457.310.
Well-baby and well-child care services means regular or preventive diagnostic and treatment services necessary to ensure the health of babies, children and adolescents as defined by the State. For purposes of cost sharing, the term has the meaning assigned at § 457.520.
- 42 CFR 436.3 — Definitions and Use of Terms.
- 42 CFR 457.495 — State Assurance of Access to Care and Procedures to Assure Quality and Appropriateness of Care.
- 42 CFR 457.80 — Current State Child Health Insurance Coverage and Coordination.
- 42 CFR 457.805 — State Plan Requirement: Procedures to Address Substitution Under Group Health Plans.
- 42 CFR 435.4 — Definitions and Use of Terms.
- 42 CFR 457.555 — Maximum Allowable Cost-Sharing Charges on Targeted Low-Income Children in Families With Income From 101 to 150 Percent of the FPL.
- 42 CFR 457.340 — Application for and Enrollment in CHIP.
- 42 CFR 457.348 — Determinations of Children's Health Insurance Program Eligibility by Other Insurance Affordability Programs.
- 42 CFR 457.515 — Co-Payments, Coinsurance, Deductibles, or Similar Cost-Sharing Charges: State Plan Requirements.
- 42 CFR 457.410 — Health Benefits Coverage Options.
- 42 CFR 457.496 — Parity in Mental Health and Substance Use Disorder Benefits.
- 42 CFR 457.570 — Disenrollment Protections.
- 42 CFR 457.535 — Cost-Sharing Protection to Ensure Enrollment of American Indians and Alaska Natives.
- 42 CFR 457.810 — Premium Assistance Programs: Required Protections Against Substitution.
- 42 CFR 435.229 — Optional Targeted Low-Income Children.
- 42 CFR 457.1203 — Rate Development Standards and Medical Loss Ratio.
- 42 CFR 457.1200 — Basis, Scope, and Applicability.