§ 1397jj — Definitions

(a) For purposes of this subchapter, the term “child health assistance” means payment for part or all of the cost of health benefits coverage for targeted low-income children that includes any of the following (and includes, in the case described in section 1397ee(a)(1)(D)(i) of this title, payment for part or all of the cost of providing any of the following), as specified under the State plan: (1) Inpatient hospital services. (2) Outpatient hospital services. (3) Physician services. (4) Surgical services. (5) Clinic services (including health center services) and other ambulatory health care services. (6) Prescription drugs and biologicals and the administration of such drugs and biologicals, only if such drugs and biologicals are not furnished for the purpose of causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a person. (7) Over-the-counter medications. (8) Laboratory and radiological services. (9) Prenatal care and prepregnancy family planning services and supplies. (10) Inpatient mental health services, other than services described in paragraph (18) but including services furnished in a State-operated mental hospital and including residential or other 24-hour therapeutically planned structured services. (11) Outpatient mental health services, other than services described in paragraph (19) but including services furnished in a State-operated mental hospital and including community-based services. (12) Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices). (13) Disposable medical supplies. (14) Home and community-based health care services and related supportive services (such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home). (15) Nursing care services (such as nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services) in a home, school, or other setting. (16) 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. (17) Dental services. (18) Inpatient substance use treatment services and residential substance use treatment services. (19) Outpatient substance use treatment services. (20) Case management services. (21) Care coordination services. (22) Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders. (23) (24) Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services (whether in a facility, home, school, or other setting) if recognized by State law and only if the service is— (A) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as defined by State law, (B) performed under the general supervision or at the direction of a physician, or (C) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license. (25) Premiums for private health care insurance coverage. (26) Medical transportation. (27) Enabling services (such as transportation, translation, and outreach services) only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals. (28) Any other health care services or items specified by the Secretary and not excluded under this section. (b) For purposes of this subchapter— (1) Subject to paragraph (2), the term “targeted low-income child” means a child— (A) who has been determined eligible by the State for child health assistance under the State plan; (i) who is a low-income child, or (ii) is a child— (I) whose family income (as determined under the State child health plan) exceeds the medicaid applicable income level (as defined in paragraph (4)), but does not exceed 50 percentage points above the medicaid applicable income level; (II) whose family income (as so determined) does not exceed the medicaid applicable income level (as defined in paragraph (4) but determined as if “June 1, 1997” were substituted for “March 31, 1997”); or (III) who resides in a State that does not have a medicaid applicable income level (as defined in paragraph (4)); and (C) who is not found to be eligible for medical assistance under subchapter XIX or, subject to paragraph (5), covered under a group health plan or under health insurance coverage (as such terms are defined in section 300gg–91 of this title). (2) Such term does not include— (A) except as provided in paragraph (7), a child who is an inmate of a public institution or a patient in an institution for mental diseases; or (B) except as provided in paragraph (6), a child who 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. (3) A child shall not be considered to be described in paragraph (1)(C) notwithstanding that the child is covered under a health insurance coverage program that has been in operation since before July 1, 1997, and that is offered by a State which receives no Federal funds for the program’s operation. (4) The term “medicaid applicable income level” means, with respect to a child, the effective income level (expressed as a percent of the poverty line) that has been specified under the State plan under subchapter XIX (including under a waiver authorized by the Secretary or under section 1396a(r)(2) of this title), as of March 31, 1997, for the child to be eligible for medical assistance under section 1396a(l)(2) or 1396d(n)(2) of this title (as selected by a State) for the age of such child. (A) Subject to subparagraphs (B) and (C), in the case of any child who is enrolled in a group health plan or health insurance coverage offered through an employer who would, but for the application of paragraph (1)(C), satisfy the requirements for being a targeted low-income child under a State child health plan that is implemented under this subchapter, a State may waive the application of such paragraph to the child in order to provide— (i) dental coverage consistent with the requirements of subsection (c)(6) of section 1397cc of this title; or (ii) cost-sharing protection for dental coverage consistent with such requirements and the requirements of subsection (e)(3)(B) of such section. (B) A State may limit the application of a waiver of paragraph (1)(C) to children whose family income does not exceed a level specified by the State, so long as the level so specified does not exceed the maximum income level otherwise established for other children under the State child health plan. (C) A State may not offer dental-only supplemental coverage under this paragraph unless the State satisfies the following conditions: (i) The State child health plan under this subchapter— (I) has the highest income eligibility standard permitted under this subchapter (or a waiver) as of January 1, 2009; (II) does not limit the acceptance of applications for children or impose any numerical limitation, waiting list, or similar limitation on the eligibility of such children for child health assistance under such State plan; and (III) provides benefits to all children in the State who apply for and meet eligibility standards. (ii) The State child health plan may not provide more favorable dental coverage or cost-sharing protection for dental coverage to children provided dental-only supplemental coverage under this paragraph than the dental coverage and cost-sharing protection for dental coverage provided to targeted low-income children who are eligible for the full range of child health assistance provided under the State child health plan. (A) A child shall not be considered to be described in paragraph (2)(B) if— (i) the public agency that employs a member of the child’s family to which such paragraph applies satisfies subparagraph (B); or (ii) subparagraph (C) applies to such child. (B) For purposes of subparagraph (A)(i), a public agency satisfies this subparagraph if the amount of annual agency expenditures made on behalf of employees enrolled in health coverage paid for by the agency that includes dependent coverage for the most recent State fiscal year is not less than the amount of such expenditures made by the agency for the 1997 State fiscal year, increased by the percentage increase in the medical care expenditure category of the Consumer Price Index for All-Urban Consumers (all items: U.S. City Average) for such preceding fiscal year. (C) For purposes of subparagraph (A)(ii), this subparagraph applies to a child if the State determines that the annual aggregate amount of premiums and cost-sharing imposed for coverage of the family of the child would exceed 5 percent of such family’s income for the year involved. (7) In the case of a child who is an inmate of a public institution, during the 30 days prior to the release of the child from such institution the child shall not be considered to be described in paragraph (2)(A) with respect to the screenings, diagnostic services, referrals, and case management services otherwise covered under the State child health plan (or waiver of such plan) that the State is required to provide under section 1397bb(d)(2) of this title. At the option of the State, a child who is an inmate of a public institution shall not be considered to be described in paragraph (2)(A) during the period that the child is an inmate of such institution pending disposition of charges. (c) For purposes of this subchapter: (1) The term “child” means an individual under 19 years of age. (2) of the Public Health Service Act (42 U.S.C. 300gg(c)) and includes coverage that meets the requirements of section 1397cc of this title provided to a targeted low-income child under this subchapter or under a waiver approved under section 1397ee(c)(2)(B) of this title (relating to a direct service waiver). (3) The terms “group health plan”, “group health insurance coverage”, and “health insurance coverage” have the meanings given such terms in section 300gg–91 of this title. (4) The term “low-income child” means a child whose family income is at or below 200 percent of the poverty line for a family of the size involved. (5) The term “poverty line” has the meaning given such term in section 9902(2) of this title, including any revision required by such section. (6) The term “preexisting condition exclusion” has the meaning given such term in section 2701(b)(1)(A) 2 of the Public Health Service Act (42 U.S.C. 300gg(b)(1)(A)). (7) Unless the context otherwise requires, the terms “State child health plan” and “plan” mean a State child health plan approved under section 1397ff of this title. (8) The term “uncovered child” means a child that does not have creditable health coverage. (A) The term “school-based health center” means a health clinic that— (i) is located in or near a school facility of a school district or board or of an Indian tribe or tribal organization; (ii) is organized through school, community, and health provider relationships; (iii) is administered by a sponsoring facility; (iv) provides through health professionals primary health services to children in accordance with State and local law, including laws relating to licensure and certification; and (v) satisfies such other requirements as a State may establish for the operation of such a clinic. (B) For purposes of subparagraph (A)(iii), the term “sponsoring facility” includes any of the following: (i) A hospital. (ii) A public health department. (iii) A community health center. (iv) A nonprofit health care agency. (v) A local educational agency (as defined under section 7801 of title 20.1 (vi) A program administered by the Indian Health Service or the Bureau of Indian Affairs or operated by an Indian tribe or a tribal organization.