{"data":{"id":"us/42-cfr-457.1130","jurisdiction":"us","citation":"42 CFR 457.1130","heading":"Program specific review process: Matters subject to review.","body":"(a) Eligibility or enrollment matter. A State must ensure that an applicant or enrollee has an opportunity for review, consistent with §§ 457.1140 and 457.1150, of a—\n(1) Denial of eligibility;\n(2) Failure to make a timely determination of eligibility; and\n(3) Suspension or termination of enrollment, including disenrollment for failure to pay cost sharing.\n(b) Health services matter. A State must ensure that an enrollee has an opportunity for external review of a—\n(1) Delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of services; and\n(2) Failure to approve, furnish, or provide payment for health services in a timely manner.\n(c) Exception. A State is not required to provide an opportunity for review of a matter described in paragraph (a) or (b) of this section if the sole basis for the decision is a provision in the State plan or in Federal or State law requiring an automatic change in eligibility, enrollment, or a change in coverage under the health benefits package that affects all applicants or enrollees or a group of applicants or enrollees without regard to their individual circumstances.","path":["Title 42—Public Health","CHAPTER IV—CENTERS FOR MEDICARE \u0026 MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES","SUBCHAPTER D—STATE CHILDREN'S HEALTH INSURANCE PROGRAMS (SCHIPs)","PART 457—ALLOTMENTS AND GRANTS TO STATES","Subpart K—State Plan Requirements: Applicant and Enrollee Protections"],"source_url":"https://www.ecfr.gov/api/versioner/v1/full/2026-08-25/title-42.xml","current_through":"2026-08-25","vintage":"","retrieved_at":"2026-08-27T02:26:11Z","sha256":"715092e2922a2a25a8bbb8597c23641e6a92503d452560ff61a0b2512c286809","source_id":"us-cfr","stale":true,"prev":"us/42-cfr-457.1120","next":"us/42-cfr-457.1140"},"notice":"GroundRules: Original legal text. Not legal advice."}