(a) Child health assistance
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)(2)(A) 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 abuse treatment services and residential substance abuse treatment services.
(19) Outpatient substance abuse 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) Hospice care.
(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) “Targeted low-income child” defined
For purposes of this subchapter—
(1) In general
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;
(B)(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 of this chapter or covered under a group health plan or under health insurance coverage (as such terms are defined in section 300gg–91 of this title).
(2) Children excluded
Such term does not include—
(A) a child who is an inmate of a public institution or a patient in an institution for mental diseases; or
(B) 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) Special rule
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) Medicaid applicable income level
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 of this chapter (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.
(c) Additional definitions
For purposes of this subchapter:
The term “child” means an individual under 19 years of age.
(2) Creditable health coverage
The term “creditable health coverage” has the meaning given the term “creditable coverage” under section 300gg(c) of this title 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) Group health plan; health insurance coverage; etc.
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) Low-income child
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) Poverty line defined
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) Preexisting condition exclusion
The term “preexisting condition exclusion” has the meaning given such term in section 300gg(b)(1)(A) of this title.
(7) State child health plan; plan
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) Uncovered child
The term “uncovered child” means a child that does not have creditable health coverage.
(Aug. 14, 1935, ch. 531, title XXI, §2110, as added Pub. L. 105–33, title IV, §4901(a), Aug. 5, 1997, 111 Stat. 567; amended Pub. L. 105–100, title I, §162(3), (9), Nov. 19, 1997, 111 Stat. 2189, 2190.)
1997—Subsec. (b)(1)(B)(ii). Pub. L. 105–100, §162(3)(A), amended cl. (ii) generally. Prior to amendment, cl. (ii) read as follows: “is a child 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; and”.
Subsec. (b)(4). Pub. L. 105–100, §162(3)(B), substituted “March 31, 1997” for “June 1, 1997” and “1396a(l)(2) or 1396d(n)(2) of this title (as selected by a State)” for “1396a(l)(2) of this title”.
Subsec. (c)(3). Pub. L. 105–100, §162(9), made technical amendment to reference in original act which appears in text as reference to section 300gg–91 of this title.
Effective Date of 1997 Amendment
Section 162 of Pub. L. 105–100 provided in part that the amendment made by that section is effective as if included in the enactment of subtitle J (§§4901–4923) of title IV of the Balanced Budget Act of 1997, Pub. L. 105–33.
Section Referred to in Other Sections
This section is referred to in sections 1396d, 1397bb of this title.