State Children's Insurance Program
CENTERS FOR MEDICARE AND MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
Balanced Budget Act of 1997, Title XXI, Subtitle J, Section 4901, Public Law 105-33; Public Law 105-100 and Medicare, Medicaid and SCHIP Balanced Budget Refinement Act of 1999 Public Law 106-113, Section 702; Medicare, Medicaid, and SCHIP Benefits Improvement Act of 2000, Title VIII, Section 801, 802, and 803, Public Law 106-554, Public Law 108-74, Public Law 108-127, Public Law 109-171 and Public Law 109-482 and Public Law 110-28.
To provide funds to States to enable them to initiate and expand child health assistance to uninsured, low-income children. Assistance should be provided primarily by two methods: (1) obtain health insurance coverage that meets the requirements in Section 2103 relating to the amount, duration, and scope of benefits; or (2) expand eligibility for children under the State's Medicaid program.
Types of Assistance
Uses and Use Restrictions
No State is eligible for payments for child health assistance for coverage provided prior to October 1, 1997. Standards used to determine eligibility may include those related to geographic areas to be served by the plan. Age, income and resources, residency, disability status (as long as the standard does not restrict eligibility), access to or coverage under other health coverage, and duration of eligibility are factors. Standards may not discriminate on the basis of diagnosis. Eligibility standards must not cover higher-income children without covering lower-income children, and must not deny eligibility based on a child having a preexisting medical condition. The State must ensure that only targeted low-income children are furnished child health assistance under the plan. Children found through screening to be eligible for Medicaid are to be enrolled in Medicaid. The insurance provided under the State plan does not substitute for coverage under group health plans. Coordination with other public and private programs providing creditable coverage for low-income children should occur. Child Health Assistance (other than Medicaid), must consist of any of the following: Benchmark coverage; benchmark equivalent coverage (which can be FEHBP-equivalent coverage); State employee coverage or coverage offered through the HMO with the largest insured commercial non-Medicaid enrollment in the State; existing comprehensive State-based coverage; or Secretary-approved coverage. A State child health plan must include a description of the amount (if any) of cost-sharing and must be in accordance with a public schedule. Cost-sharing may be varied in a way that does not favor higher-income children over lower-income children. No cost-sharing is permitted for well-baby and well-child care, including age-appropriate immunizations. Cost-sharing for children at 150 percent of poverty must be consistent with Medicaid; Cost-sharing for children at 150 percent of poverty and above must be based on an income-related sliding scale. The aggregate for all children in a family cannot exceed 5 percent of the family's income. The State child health plan may not impose pre-existing condition exclusions for covered benefits. States that provide for benefits through a group health plan or group health insurance coverage may permit pre-existing condition exclusions as allowed under the applicable Section of the Employee Retirement Income Security Act (ERISA) and the Health Insurance Portability and Accountability Act (HIPAA). Funds provided to a State under this Title may only be used to carry out the purposes of this Title. Health insurance coverage provided may include coverage of abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. States may spend up to 10 percent of their total SCHIP expenditures (Federal and State) on non-benefit activities, including: outreach conducted to identify and enroll eligible children in SCHIP; administration costs; health services initiatives; and other child health assistance. These expenditures are matched at the enhanced SCHIP matching rate and counted against both the 10 percent limit and the allotment. Monetary amounts provided by the Federal government or services assisted or subsidized to any significant extent by the Federal government, may not be included in determining the amount of nonfederal contributions required for State matching purposes.
All States and Territories may apply.
Targeted low-income children will benefit. These children are defined (for the purposes of Title XXI) as children who have been determined eligible by the State for child health assistance under their State plan; are low-income children; or are children whose family income exceeds the Medicaid applicable income level but does not exceed 50 percentage points above the Medicaid applicable income level; and are not found to be eligible for medical assistance under Title XIX or covered under a group health plan or under health insurance coverage. This term does not include a child that is a member of a family that is eligible for health benefits coverage under a State health benefits plan on the basis of a family member's employment with a public agency in the State.
States and Territories must submit and have approved by the Secretary of DHHS, a State Child Health Plan. Individuals must meet State requirements.
Application and Award Process
States are encouraged to work with DHHS in the development of their Title XXI plans. Central and regional office staff from the Centers for Medicare and Medicaid Services (CMS) and the Health Resources Services Administration (HRSA), as well as other DHHS components are available to furnish guidance and technical assistance to a State in preparing their plans. This program is excluded from coverage under E.O. 12372.
Title XXI plans and amendments are submitted by the State Governor, or designee, to the CMS Center for Medicaid and State Operations; Families and Children Health Program Group (CMSO/FCHPG). The Title XXI plan should be a stand alone document that fully addresses each relevant Section of the statutory requirements.
The CMS Administrator exercises delegated authority to approve Title XXI plans and amendments. Letters of approval will be signed by the CMS Administrator.
Under the Law, a State must have an approved State Plan for a fiscal year in order to receive an allotment that year.
Range of Approval/Disapproval Time
Section 2106 of the Law, specifies that a State plan is considered approved unless the Secretary notifies the State in writing, within 90 days after receipt of the plan, that the plan is disapproved (and the reasons for disapproval) or that specific additional information is needed. Informal clarification and discussion between the State and the DHHS review team is permitted and encouraged during the review period. This does not stop the "90-day clock." The 90-day review period may be stopped by formal written requests for additional information and clarification. The 90-day review period may be stopped as many times as necessary to obtain completed information necessary to disapprove or approve the plan. The 90-day period will resume when the finalized additional information is received by CMS.
If a State wishes to appeal a disapproval, it may petition for a reconsideration of this decision within 60 days after the date of receipt of the disapproval letter, by submitting a written request for reconsideration to the project officer and the regional office. States also have the option to submit a new application following the disapproval, starting a new 90-day review clock.
Formula and Matching Requirements
Section 2105(b), Title XXI, provides for an "enhanced Federal Matching Assistance Percentage (FMAP)" for child health assistance provided under Title XXI that is equal to the current FMAP for the fiscal year in the Medicaid Title XIX program, increased by 30 percent of the difference between 100 and the current FMAP for that fiscal year. The enhanced FMAP may not exceed 85 percent. The formula for determining the final allotment includes: determining the number of States with approved State Plans as of the end of the fiscal year. In order for a State to receive a final allotment for a fiscal year, CMS must approve the SCHIP State Plan for that State by the end of the fiscal year. Only States with approved State Plans by the end of the fiscal year will be included in the final allotment calculation. States' final allotments will be determined in accordance with the statutory formula that is based on two factors: (1) Number of children (those potentially eligible for SCHIP), and (2) the State cost factor. These factors will be multiplied to yield a final allotment product for each State. Once the final allotment product has been determined for all the States with approved SCHIP plans, the products for each State will be added to determine a national total. Each State's product will be divided by this national total to determine a State specific percentage of the national total available amount for allotment that each State would be eligible to receive. The State specific percentage is then multiplied by the national total amount available for allotment, resulting in the final allotment for each State.
Length and Time Phasing of Assistance
Enrolled children receive medical services as necessary. Federal funds are obligated to the States by issuing Title XXI grant awards. To ensure that all of the appropriated funds are available to States, CMS will issue grant awards to all States with Title XXI State plans approved by the end of the fiscal year equaling the national amount available for allotment to the 50 States, the District of Columbia, and the Commonwealths and Territories for that fiscal year. Grant awards must be issued by the time the CMS/HHS accounting system closes with respect to that fiscal year.
Post Assistance Requirements
Section 2108 of the Law specifies that States must develop annual reports assessing the operation of their State Plan for each fiscal year, including the progress made in reducing the number of uncovered low-income children and report to the Secretary by January 1, of the following year the results of the assessment. By March 31, 2000, each State with a child health plan must submit to the Secretary an evaluation that includes an assessment of the effectiveness of the State Plan in increasing the number of children with creditable health coverage, in increasing the availability of affordable quality individual and family health insurance for children, and in coordinating recommendations for improving the program under this Title. By December 31, 2001, the Secretary must submit to Congress and make available to the public, a report based on the evaluations submitted by the States recommendations and conclusions.
A State child health plan under Title XXI must include an assurance that the State will afford the Secretary access to any records or information relating to the plan for the purposes of review or audit.
A State child health plan must include an assurance that the State will collect the data, maintain the records, and furnish the report to the Secretary at the times and in standardized format (as the Secretary requires), in order to enable the Secretary to monitor State program administration and compliance and to evaluate and compare the effectiveness of State Plans under this Title.
(Grants) FY 07 $5,940,730,000; FY 08 est $6,640,000,000; and FY 09 est $5,315,000,000.
Range and Average of Financial Assistance
The range is from: $5,753,333 ($577,500 for the smallest territory) to $790,789,213 for the States. In the third year following the State allotment fiscal year, under a "redistribution process" CMS will determine the amounts of the unused fiscal year allotments from States that have not expended all of their allotment for that fiscal year and will redistribute the amounts to States that have fully expended the amount of their allotments for that fiscal year.
Regulations, Guidelines and Literature
Regulations and guidance issued related to the Children's Health Insurance Program may be accessed through the World Wide Web at: http://www.cms.hhs.gov/schip
Regional or Local Office
Contact the Regional Administrator, Centers for Medicare and Medicaid Services. (See Appendix IV of the Catalog for addresses and telephone numbers).
Center for Medicaid and State Operations, Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244; Telephone: (410) 786-3870.
Web Site Address
93.778, Medical Assistance Program
Examples of Funded Projects
Criteria for Selecting Proposals