HR 3162 EH
For Further Action See H.R. 976, which
was Vetoed by President Bush
110th CONGRESS
1st Session
H. R. 3162
AN ACT
To amend titles XVIII, XIX, and XXI of the Social
Security Act to extend and improve the children's health insurance
program, to improve beneficiary protections under the Medicare,
Medicaid, and the CHIP program, and for other purposes.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title- This Act may be cited as the `Children's Health and Medicare Protection Act of 2007'.
(b) Table of Contents- The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
TITLE I--CHILDREN'S HEALTH INSURANCE PROGRAM
Subtitle A--Funding
Sec. 101. Establishment of new base CHIP allotments.
Sec. 102. 2-year initial availability of CHIP allotments.
Sec. 103. Redistribution of unused allotments to address State funding shortfalls.
Sec. 104. Extension of option for qualifying States.
Subtitle B--Improving Enrollment and Retention of Eligible Children
Sec. 111. CHIP performance bonus payment to offset additional enrollment costs resulting from enrollment and retention efforts.
Sec. 112. State option to rely on findings from an express lane agency to conduct simplified eligibility determinations.
Sec. 113. Application of medicaid outreach procedures to all children and pregnant women.
Sec. 114. Encouraging culturally appropriate enrollment and retention practices.
Sec. 115. Continuous coverage under CHIP.
Subtitle C--Coverage
Sec. 121. Ensuring child-centered coverage.
Sec. 122. Improving benchmark coverage options.
Sec. 123. Premium grace period.
Subtitle D--Populations
Sec. 131. Optional coverage of children up to age 21 under CHIP.
Sec. 132. Optional coverage of legal immigrants under the Medicaid program and CHIP.
Sec. 133. State option to expand or add coverage of certain pregnant women under CHIP.
Sec. 134. Limitation on waiver authority to cover adults.
Sec. 135. No Federal funding for illegal aliens.
Sec. 136. Auditing requirement to enforce citizenship restrictions on eligibility for Medicaid and CHIP benefits.
Subtitle E--Access
Sec. 141. Children's Access, Payment, and Equality Commission.
Sec. 142. Model of Interstate coordinated enrollment and coverage process.
Sec. 143. Medicaid citizenship documentation requirements.
Sec. 144. Access to dental care for children.
Sec. 145. Prohibiting initiation of new health opportunity account demonstration programs.
Subtitle F--Quality and Program Integrity
Sec. 151. Pediatric health quality measurement program.
Sec. 152. Application of certain managed care quality safeguards to CHIP.
Sec. 153. Updated Federal evaluation of CHIP.
Sec. 154. Access to records for IG and GAO audits and evaluations.
Sec. 155. References to title XXI.
Sec. 156. Reliance on law; exception for State legislation.
TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A--Improvements in Benefits
Sec. 201. Coverage and waiver of cost-sharing for preventive services.
Sec. 202. Waiver of deductible for colorectal cancer
screening tests regardless of coding, subsequent diagnosis, or
ancillary tissue removal.
Sec. 203. Parity for mental health coinsurance.
Subtitle B--Improving, Clarifying, and Simplifying Financial Assistance for Low Income Medicare Beneficiaries
Sec. 211. Improving assets tests for Medicare Savings Program and low-income subsidy program.
Sec. 212. Making QI program permanent and expanding eligibility.
Sec. 213. Eliminating barriers to enrollment.
Sec. 214. Eliminating application of estate recovery.
Sec. 215. Elimination of part D cost-sharing for certain non-institutionalized full-benefit dual eligible individuals.
Sec. 216. Exemptions from income and resources for determination of eligibility for low-income subsidy.
Sec. 217. Cost-sharing protections for low-income subsidy-eligible individuals.
Sec. 218. Intelligent assignment in enrollment.
Subtitle C--Part D Beneficiary Improvements
Sec. 221. Including costs incurred by AIDS drug
assistance programs and Indian Health Service in providing prescription
drugs toward the annual out of pocket threshold under Part D.
Sec. 222. Permitting mid-year changes in enrollment for formulary changes adversely impact an enrollee.
Sec. 223. Removal of exclusion of benzodiazepines from required coverage under the Medicare prescription drug program.
Sec. 224. Permitting updating drug compendia under part D using part B update process.
Sec. 225. Codification of special protections for six protected drug classifications.
Sec. 226. Elimination of Medicare part D late enrollment penalties paid by low-income subsidy-eligible individuals.
Sec. 227. Special enrollment period for subsidy eligible individuals.
Subtitle D--Reducing Health Disparities
Sec. 231. Medicare data on race, ethnicity, and primary language.
Sec. 232. Ensuring effective communication in Medicare.
Sec. 233. Demonstration to promote access for Medicare
beneficiaries with limited English proficiency by providing
reimbursement for culturally and linguistically appropriate services.
Sec. 234. Demonstration to improve care to previously uninsured.
Sec. 235. Office of the Inspector General report on
compliance with and enforcement of national standards on culturally and
linguistically appropriate services (CLAS) in medicare.
Sec. 236. IOM report on impact of language access services.
TITLE III--PHYSICIANS' SERVICE PAYMENT REFORM
Sec. 301. Establishment of separate target growth rates for service categories.
Sec. 302. Improving accuracy of relative values under the Medicare physician fee schedule.
Sec. 303. Feedback mechanism on practice patterns.
Sec. 304. Payments for efficient areas.
Sec. 305. Recommendations on refining the physician fee schedule.
Sec. 306. Improved and expanded medical home demonstration project.
Sec. 307. Repeal of Physician Assistance and Quality Initiative Fund.
Sec. 308. Adjustment to Medicare payment localities.
Sec. 309. Payment for imaging services.
Sec. 310. Reducing frequency of meetings of the Practicing Physicians Advisory Council.
TITLE IV--MEDICARE ADVANTAGE REFORMS
Subtitle A--Payment Reform
Sec. 401. Equalizing payments between Medicare Advantage plans and fee-for-service Medicare.
Subtitle B--Beneficiary Protections
Sec. 411. NAIC development of marketing, advertising, and related protections.
Sec. 412. Limitation on out-of-pocket costs for individual health services.
Sec. 413. MA plan enrollment modifications.
Sec. 414. Information for beneficiaries on MA plan administrative costs.
Subtitle C--Quality and Other Provisions
Sec. 421. Requiring all MA plans to meet equal standards.
Sec. 422. Development of new quality reporting measures on racial disparities.
Sec. 423. Strengthening audit authority.
Sec. 424. Improving risk adjustment for MA payments.
Sec. 425. Eliminating special treatment of private fee-for-service plans.
Sec. 426. Renaming of Medicare Advantage program.
Subtitle D--Extension of Authorities
Sec. 431. Extension and revision of authority for special needs plans (SNPs).
Sec. 432. Extension and revision of authority for Medicare reasonable cost contracts.
TITLE V--PROVISIONS RELATING TO MEDICARE PART A
Sec. 501. Inpatient hospital payment updates.
Sec. 502. Payment for inpatient rehabilitation facility (IRF) services.
Sec. 503. Long-term care hospitals.
Sec. 504. Increasing the DSH adjustment cap.
Sec. 505. PPS-exempt cancer hospitals.
Sec. 506. Skilled nursing facility payment update.
Sec. 507. Revocation of unique deeming authority of the Joint Commission for the Accreditation of Healthcare Organizations.
Sec. 508. Treatment of Medicare hospital reclassifications.
Sec. 509. Medicare critical access hospital designations.
TITLE VI--OTHER PROVISIONS RELATING TO MEDICARE PART B
Subtitle A--Payment and Coverage Improvements
Sec. 601. Payment for therapy services.
Sec. 602. Medicare separate definition of outpatient speech-language pathology services.
Sec. 603. Increased reimbursement rate for certified nurse-midwives.
Sec. 604. Adjustment in outpatient hospital fee schedule increase factor.
Sec. 605. Exception to 60-day limit on Medicare
substitute billing arrangements in case of physicians ordered to active
duty in the Armed Forces.
Sec. 606. Excluding clinical social worker services from
coverage under the medicare skilled nursing facility prospective
payment system and consolidated payment.
Sec. 607. Coverage of marriage and family therapist services and mental health counselor services.
Sec. 608. Rental and purchase of power-driven wheelchairs.
Sec. 609. Rental and purchase of oxygen equipment.
Sec. 610. Adjustment for Medicare mental health services.
Sec. 611. Extension of brachytherapy special rule.
Sec. 612. Payment for part B drugs.
Subtitle B--Extension of Medicare Rural Access Protections
Sec. 621. 2-year extension of floor on medicare work geographic adjustment.
Sec. 622. 2-year extension of special treatment of certain physician pathology services under Medicare.
Sec. 623. 2-year extension of medicare reasonable costs
payments for certain clinical diagnostic laboratory tests furnished to
hospital patients in certain rural areas.
Sec. 624. 2-year extension of Medicare incentive payment program for physician scarcity areas.
Sec. 625. 2-year extension of medicare increase payments for ground ambulance services in rural areas.
Sec. 626. Extending hold harmless for small rural hospitals under the HOPD prospective payment system.
Subtitle C--End Stage Renal Disease Program
Sec. 631. Chronic kidney disease demonstration projects.
Sec. 632. Medicare coverage of kidney disease patient education services.
Sec. 633. Required training for patient care dialysis technicians.
Sec. 634. MedPAC report on treatment modalities for patients with kidney failure.
Sec. 635. Adjustment for erythropoietin stimulating agents (ESAs).
Sec. 636. Site neutral composite rate.
Sec. 637. Development of ESRD bundling system and quality incentive payments.
Sec. 638. MedPAC report on ESRD bundling system.
Sec. 639. OIG study and report on erythropoietin.
Subtitle D--Miscellaneous
Sec. 651. Limitation on exception to the prohibition on certain physician referrals for hospitals.
TITLE VII--PROVISIONS RELATING TO MEDICARE PARTS A AND B
Sec. 701. Home health payment update for 2008.
Sec. 702. 2-year extension of temporary Medicare payment increase for home health services furnished in a rural area.
Sec. 703. Extension of Medicare secondary payer for beneficiaries with end stage renal disease for large group plans.
Sec. 704. Plan for Medicare payment adjustments for never events.
Sec. 705. Reinstatement of residency slots.
Sec. 706. Studies relating to home health.
Sec. 707. Rural home health quality demonstration projects.
TITLE VIII--MEDICAID
Subtitle A--Protecting Existing Coverage
Sec. 801. Modernizing transitional Medicaid.
Sec. 802. Family planning services.
Sec. 803. Authority to continue providing adult day health services approved under a State Medicaid plan.
Sec. 804. State option to protect community spouses of individuals with disabilities.
Sec. 805. County medicaid health insuring organizatios.
Subtitle B--Payments
Sec. 811. Payments for Puerto Rico and territories.
Sec. 812. Medicaid drug rebate.
Sec. 813. Adjustment in computation of Medicaid FMAP to disregard an extraordinary employer pension contribution.
Sec. 814. Moratorium on certain payment restrictions.
Sec. 816. Clarification treatment of regional medical center.
Sec. 817. Extension of SSI web-based asset demonstration project to the Medicaid program.
Subtitle C--Miscellaneous
Sec. 821. Demonstration project for employer buy-in.
Sec. 822. Diabetes grants.
Sec. 823. Technical correction.
TITLE IX--MISCELLANEOUS
Sec. 901. Medicare Payment Advisory Commission status.
Sec. 902. Repeal of trigger provision.
Sec. 903. Repeal of comparative cost adjustment (CCA) program.
Sec. 904. Comparative effectiveness research.
Sec. 905. Implementation of Health information technology (IT) under Medicare.
Sec. 906. Development, reporting, and use of health care measures.
Sec. 907. Improvements to the Medigap program.
Sec. 908. Implementation funding.
Sec. 909. Access to data on prescription drug plans and medicare advantage plans.
Sec. 910. Abstinence education.
TITLE X--REVENUES
Sec. 1001. Increase in rate of excise taxes on tobacco products and cigarette papers and tubes.
Sec. 1002. Exemption for emergency medical services transportation.
TITLE I--CHILDREN'S HEALTH INSURANCE PROGRAM
SEC. 100. PURPOSE.
It is the purpose of this title to provide dependable and
stable funding for children's health insurance under titles XXI and XIX
of the Social Security Act in order to enroll all six million uninsured
children who are eligible, but not enrolled, for coverage today through
such titles.
Subtitle A--Funding
SEC. 101. ESTABLISHMENT OF NEW BASE CHIP ALLOTMENTS.
Section 2104 of the Social Security Act (42 U.S.C. 1397dd) is amended--
(A) in paragraph (9), by striking `and' at the end;
(B) in paragraph (10), by striking the period at the end and inserting `; and'; and
(C) by adding at the end the following new paragraph:
`(11) for fiscal year 2008 and each succeeding fiscal
year, the sum of the State allotments provided under subsection (i) for
such fiscal year.'; and
(2) in subsections (b)(1) and (c)(1), by striking `subsection (d)' and inserting `subsections (d) and (i)'; and
(3) by adding at the end the following new subsection:
`(i) Allotments for States and Territories Beginning With Fiscal Year 2008-
`(1) GENERAL ALLOTMENT COMPUTATION- Subject to the
succeeding provisions of this subsection, the Secretary shall compute a
State allotment for each State for each fiscal year as follows:
`(A) FOR FISCAL YEAR 2008- For fiscal year 2008, the allotment of a State is equal to the greater of--
`(i) the State projection (in its submission on
forms CMS--21B and CMS--37 for May 2007) of Federal payments to the
State under this title for such fiscal year, except that, in the case
of a State that has enacted legislation to modify its State child
health plan during 2007, the State may substitute its projection in its
submission on forms CMS--21B and CMS--37 for August 2007, instead of
such forms for May 2007; or
`(ii) the allotment of the State under this
section for fiscal year 2007 multiplied by the allotment increase
factor under paragraph (2) for fiscal year 2008.
`(B) INFLATION UPDATE FOR FISCAL YEAR 2009 AND EACH
SECOND SUCCEEDING FISCAL YEAR- For fiscal year 2009 and each second
succeeding fiscal year, the allotment of a State is equal to the amount
of the State allotment under this paragraph for the previous fiscal
year multiplied by the allotment increase factor under paragraph (2)
for the fiscal year involved.
`(C) REBASING IN FISCAL YEAR 2010 AND EACH SECOND
SUCCEEDING FISCAL YEAR- For fiscal year 2010 and each second succeeding
fiscal year, the allotment of a State is equal to the Federal payments
to the State that are attributable to (and countable towards) the total
amount of allotments available under this section to the State
(including allotments made available under paragraph (3) as well as
amounts redistributed to the State) in the previous fiscal year
multiplied by the allotment increase factor under paragraph (2) for the
fiscal year involved.
`(D) SPECIAL RULES FOR TERRITORIES- Notwithstanding
the previous subparagraphs, the allotment for a State that is not one
of the 50 States or the District of Columbia for fiscal year 2008 and
for a succeeding fiscal year is equal to the Federal payments provided
to the State under this title for the previous fiscal year multiplied
by the allotment increase factor under paragraph (2) for the fiscal
year involved (but determined by applying under paragraph (2)(B) as if
the reference to `in the State' were a reference to `in the United
States').
`(2) ALLOTMENT INCREASE FACTOR- The allotment increase
factor under this paragraph for a fiscal year is equal to the product
of the following:
`(A) PER CAPITA HEALTH CARE GROWTH FACTOR- 1 plus
the percentage increase in the projected per capita amount of National
Health Expenditures from the calendar year in which the previous fiscal
year ends to the calendar year in which the fiscal year involved ends,
as most recently published by the Secretary before the beginning of the
fiscal year.
`(B) CHILD POPULATION GROWTH FACTOR- 1 plus the
percentage increase (if any) in the population of children under 19
years of age in the State from July 1 in the previous fiscal year to
July 1 in the fiscal year involved, as determined by the Secretary
based on the most recent published estimates of the Bureau of the
Census before the beginning of the fiscal year involved, plus 1
percentage point.
`(3) PERFORMANCE-BASED SHORTFALL ADJUSTMENT-
`(A) IN GENERAL- If a State's expenditures under
this title in a fiscal year (beginning with fiscal year 2008) exceed
the total amount of allotments available under this section to the
State in the fiscal year (determined without regard to any
redistribution it receives under subsection (f) that is available for
expenditure during such fiscal year, but including any carryover from a
previous fiscal year) and if the average monthly unduplicated number of
children enrolled under the State plan under this title (including
children receiving health care coverage through funds under this title
pursuant to a waiver under section 1115) during such fiscal year
exceeds its target average number of such enrollees (as determined
under subparagraph (B)) for that fiscal year, the allotment under this
section for the State for the subsequent fiscal year (or, pursuant to
subparagraph (F), for the fiscal year involved) shall be increased by
the product of--
`(i) the amount by which such average monthly caseload exceeds such target number of enrollees; and
`(ii) the projected per capita expenditures
under the State child health plan (as determined under subparagraph (C)
for the original fiscal year involved), multiplied by the enhanced FMAP
(as defined in section 2105(b)) for the State and fiscal year involved.
`(B) TARGET AVERAGE NUMBER OF CHILD ENROLLEES- In this subsection, the target average number of child enrollees for a State--
`(i) for fiscal year 2008 is equal to the
monthly average unduplicated number of children enrolled in the State
child health plan under this title (including such children receiving
health care coverage through funds under this title pursuant to a
waiver under section 1115) during fiscal year 2007 increased by the
population growth for children in that State for the year ending on
June 30, 2006 (as estimated by the Bureau of the Census) plus 1
percentage point; or
`(ii) for a subsequent fiscal year is equal to
the target average number of child enrollees for the State for the
previous fiscal year increased by the population growth for children in
that State for the year ending on June 30 before the beginning of the
fiscal year (as estimated by the Bureau of the Census) plus 1
percentage point.
`(C) PROJECTED PER CAPITA EXPENDITURES- For
purposes of subparagraph (A)(ii), the projected per capita expenditures
under a State child health plan--
`(i) for fiscal year 2008 is equal to the
average per capita expenditures (including both State and Federal
financial participation) under such plan for the targeted low-income
children counted in the average monthly caseload for purposes of this
paragraph during fiscal year 2007, increased by the annual percentage
increase in the per capita amount of National Health Expenditures (as
estimated by the Secretary) for 2008; or
`(ii) for a subsequent fiscal year is equal to
the projected per capita expenditures under such plan for the previous
fiscal year (as determined under clause (i) or this clause) increased
by the annual percentage increase in the per capita amount of National
Health Expenditures (as estimated by the Secretary) for the year in
which such subsequent fiscal year ends.
`(D) AVAILABILITY- Notwithstanding subsection (e),
an increase in allotment under this paragraph shall only be available
for expenditure during the fiscal year in which it is provided.
`(E) NO REDISTRIBUTION OF PERFORMANCE-BASED
SHORTFALL ADJUSTMENT- In no case shall any increase in allotment under
this paragraph for a State be subject to redistribution to other States.
`(F) INTERIM ALLOTMENT ADJUSTMENT- The Secretary
shall develop a process to administer the performance-based shortfall
adjustment in a manner so it is applied to (and before the end of) the
fiscal year (rather than the subsequent fiscal year) involved for a
State that the Secretary estimates will be in shortfall and will exceed
its enrollment target for that fiscal year.
`(G) PERIODIC AUDITING- The Comptroller General of
the United States shall periodically audit the accuracy of data used in
the computation of allotment adjustments under this paragraph. Based on
such audits, the Comptroller General shall make such recommendations to
the Congress and the Secretary as the Comptroller General deems
appropriate.
`(4) CONTINUED REPORTING- For purposes of paragraph (3)
and subsection (f), the State shall submit to the Secretary the State's
projected Federal expenditures, even if the amount of such expenditures
exceeds the total amount of allotments available to the State in such
fiscal year.'.
SEC. 102. 2-YEAR INITIAL AVAILABILITY OF CHIP ALLOTMENTS.
Section 2104(e) of the Social Security Act (42 U.S.C. 1397dd(e)) is amended to read as follows:
`(e) Availability of Amounts Allotted-
`(1) IN GENERAL- Except as provided in paragraph (2)
and subsection (i)(3)(D), amounts allotted to a State pursuant to this
section--
`(A) for each of fiscal years 1998 through 2007,
shall remain available for expenditure by the State through the end of
the second succeeding fiscal year; and
`(B) for fiscal year 2008 and each fiscal year
thereafter, shall remain available for expenditure by the State through
the end of the succeeding fiscal year.
`(2) AVAILABILITY OF AMOUNTS REDISTRIBUTED- Amounts
redistributed to a State under subsection (f) shall be available for
expenditure by the State through the end of the fiscal year in which
they are redistributed, except that funds so redistributed to a State
that are not expended by the end of such fiscal year shall remain
available after the end of such fiscal year and shall be available in
the following fiscal year for subsequent redistribution under such
subsection.'.
SEC. 103. REDISTRIBUTION OF UNUSED ALLOTMENTS TO ADDRESS STATE FUNDING SHORTFALLS.
Section 2104(f) of the Social Security Act (42 U.S.C. 1397dd(f)) is amended--
(1) by striking `The Secretary' and inserting the following:
`(1) IN GENERAL- The Secretary';
(2) by striking `States that have fully expended the
amount of their allotments under this section.' and inserting `States
that the Secretary determines with respect to the fiscal year for which
unused allotments are available for redistribution under this
subsection, are shortfall States described in paragraph (2) for such
fiscal year, but not to exceed the amount of the shortfall described in
paragraph (2)(A) for each such State (as may be adjusted under
paragraph (2)(C)). The amount of allotments not expended or
redistributed under the previous sentence shall remain available for
redistribution in the succeeding fiscal year.'; and
(3) by adding at the end the following new paragraph:
`(2) SHORTFALL STATES DESCRIBED-
`(A) IN GENERAL- For purposes of paragraph (1),
with respect to a fiscal year, a shortfall State described in this
subparagraph is a State with a State child health plan approved under
this title for which the Secretary estimates on the basis of the most
recent data available to the Secretary, that the projected expenditures
under such plan for the State for the fiscal year will exceed the sum
of--
`(i) the amount of the State's allotments for
any preceding fiscal years that remains available for expenditure and
that will not be expended by the end of the immediately preceding
fiscal year;
`(ii) the amount (if any) of the performance based adjustment under subsection (i)(3)(A); and
`(iii) the amount of the State's allotment for the fiscal year.
`(B) PRORATION RULE- If the amounts available for
redistribution under paragraph (1) for a fiscal year are less than the
total amounts of the estimated shortfalls determined for the year under
subparagraph (A), the amount to be redistributed under such paragraph
for each shortfall State shall be reduced proportionally.
`(C) RETROSPECTIVE ADJUSTMENT- The Secretary may
adjust the estimates and determinations made under paragraph (1) and
this paragraph with respect to a fiscal year as necessary on the basis
of the amounts reported by States not later than November 30 of the
succeeding fiscal year, as approved by the Secretary.'.
SEC. 104. EXTENSION OF OPTION FOR QUALIFYING STATES.
Section 2105(g)(1)(A) of the Social Security Act (42 U.S.C.
1397ee(g)(1)(A)) is amended by inserting after `or 2007' the following:
`or 100 percent of any allotment under section 2104 for any subsequent
fiscal year'.
Subtitle B--Improving Enrollment and Retention of Eligible Children
SEC. 111. CHIP PERFORMANCE BONUS PAYMENT TO OFFSET ADDITIONAL ENROLLMENT COSTS RESULTING FROM ENROLLMENT AND RETENTION EFFORTS.
(a) In General- Section 2105(a) of the Social Security Act
(42 U.S.C. 1397ee(a)) is amended by adding at the end the following new
paragraphs:
`(3) PERFORMANCE BONUS PAYMENT TO OFFSET ADDITIONAL
MEDICAID AND CHIP CHILD ENROLLMENT COSTS RESULTING FROM ENROLLMENT AND
RETENTION EFFORTS-
`(A) IN GENERAL- In addition to the payments made
under paragraph (1), for each fiscal year (beginning with fiscal year
2008 and ending with fiscal year 2013) the Secretary shall pay to each
State that meets the condition under paragraph (4) for the fiscal year,
an amount equal to the amount described in subparagraph (B) for the
State and fiscal year. The payment under this paragraph shall be made,
to a State for a fiscal year, as a single payment not later than the
last day of the first calendar quarter of the following fiscal year.
`(B) AMOUNT- The amount described in this
subparagraph for a State for a fiscal year is equal to the sum of the
following amounts:
`(i) FOR ABOVE BASELINE MEDICAID CHILD ENROLLMENT COSTS-
`(I) FIRST TIER ABOVE BASELINE MEDICAID
ENROLLEES- An amount equal to the number of first tier above baseline
child enrollees (as determined under subparagraph (C)(i)) under title
XIX for the State and fiscal year multiplied by 35 percent of the
projected per capita State Medicaid expenditures (as determined under
subparagraph (D)(i)) for the State and fiscal year under title XIX.
`(II) SECOND TIER ABOVE BASELINE MEDICAID
ENROLLEES- An amount equal to the number of second tier above baseline
child enrollees (as determined under subparagraph (C)(ii)) under title
XIX for the State and fiscal year multiplied by 90 percent of the
projected per capita State Medicaid expenditures (as determined under
subparagraph (D)(i)) for the State and fiscal year under title XIX.
`(ii) FOR ABOVE BASELINE CHIP ENROLLMENT COSTS-
`(I) FIRST TIER ABOVE BASELINE CHIP
ENROLLEES- An amount equal to the number of first tier above baseline
child enrollees under this title (as determined under subparagraph
(C)(i)) for the State and fiscal year multiplied by 5 percent of the
projected per capita State CHIP expenditures (as determined under
subparagraph (D)(ii)) for the State and fiscal year under this title.
`(II) SECOND TIER ABOVE BASELINE CHIP
ENROLLEES- An amount equal to the number of second tier above baseline
child enrollees under this title (as determined under subparagraph
(C)(ii)) for the State and fiscal year multiplied by 75 percent of the
projected per capita State CHIP expenditures (as determined under
subparagraph (D)(ii)) for the State and fiscal year under this title.
`(C) NUMBER OF FIRST AND SECOND TIER ABOVE BASELINE
CHILD ENROLLEES; BASELINE NUMBER OF CHILD ENROLLEES- For purposes of
this paragraph:
`(i) FIRST TIER ABOVE BASELINE CHILD ENROLLEES-
The number of first tier above baseline child enrollees for a State for
a fiscal year under this title or title XIX is equal to the number (if
any, as determined by the Secretary) by which--
`(I) the monthly average unduplicated
number of qualifying children (as defined in subparagraph (E)) enrolled
during the fiscal year under the State child health plan under this
title or under the State plan under title XIX, respectively; exceeds
`(II) the baseline number of enrollees
described in clause (iii) for the State and fiscal year under this
title or title XIX, respectively;
but not to exceed 3 percent (in the case of
title XIX) or 7.5 percent (in the case of this title) of the baseline
number of enrollees described in subclause (II).
`(ii) SECOND TIER ABOVE BASELINE CHILD
ENROLLEES- The number of second tier above baseline child enrollees for
a State for a fiscal year under this title or title XIX is equal to the
number (if any, as determined by the Secretary) by which--
`(I) the monthly average unduplicated
number of qualifying children (as defined in subparagraph (E)) enrolled
during the fiscal year under this title or under title XIX,
respectively, as described in clause (i)(I); exceeds
`(II) the sum of the baseline number of
child enrollees described in clause (iii) for the State and fiscal year
under this title or title XIX, respectively, as described in clause
(i)(II), and the maximum number of first tier above baseline child
enrollees for the State and fiscal year under this title or title XIX,
respectively, as determined under clause (i).
`(iii) BASELINE NUMBER OF CHILD ENROLLEES- The baseline number of child enrollees for a State under this title or title XIX--
`(I) for fiscal year 2008 is equal to the
monthly average unduplicated number of qualifying children enrolled in
the State child health plan under this title or in the State plan under
title XIX, respectively, during fiscal year 2007 increased by the
population growth for children in that State for the year ending on
June 30, 2006 (as estimated by the Bureau of the Census) plus 1
percentage point; or
`(II) for a subsequent fiscal year is equal
to the baseline number of child enrollees for the State for the
previous fiscal year under this title or title XIX, respectively,
increased by the population growth for children in that State for the
year ending on June 30 before the beginning of the fiscal year (as
estimated by the Bureau of the Census) plus 1 percentage point.
`(D) PROJECTED PER CAPITA STATE EXPENDITURES- For purposes of subparagraph (B)--
`(i) PROJECTED PER CAPITA STATE MEDICAID
EXPENDITURES- The projected per capita State Medicaid expenditures for
a State and fiscal year under title XIX is equal to the average per
capita expenditures (including both State and Federal financial
participation) for children under the State plan under such title,
including under waivers but not including such children eligible for
assistance by virtue of the receipt of benefits under title XVI, for
the most recent fiscal year for which actual data are available (as
determined by the Secretary), increased (for each subsequent fiscal
year up to and including the fiscal year involved) by the annual
percentage increase in per capita amount of National Health
Expenditures (as estimated by the Secretary) for the calendar year in
which the respective subsequent fiscal year ends and multiplied by a
State matching percentage equal to 100 percent minus the Federal
medical assistance percentage (as defined in section 1905(b)) for the
fiscal year involved.
`(ii) PROJECTED PER CAPITA STATE CHIP
EXPENDITURES- The projected per capita State CHIP expenditures for a
State and fiscal year under this title is equal to the average per
capita expenditures (including both State and Federal financial
participation) for children under the State child health plan under
this title, including under waivers, for the most recent fiscal year
for which actual data are available (as determined by the Secretary),
increased (for each subsequent fiscal year up to and including the
fiscal year involved) by the annual percentage increase in per capita
amount of National Health Expenditures (as estimated by the Secretary)
for the calendar year in which the respective subsequent fiscal year
ends and multiplied by a State matching percentage equal to 100 percent
minus the enhanced FMAP (as defined in section 2105(b)) for the fiscal
year involved.
`(E) QUALIFYING CHILDREN DEFINED- For purposes of
this subsection, the term `qualifying children' means, with respect to
this title or title XIX, children who meet the eligibility criteria
(including income, categorical eligibility, age, and immigration status
criteria) in effect as of July 1, 2007, for enrollment under this title
or title XIX, respectively, taking into account criteria applied as of
such date under this title or title XIX, respectively, pursuant to a
waiver under section 1115.
`(4) ENROLLMENT AND RETENTION PROVISIONS FOR CHILDREN-
For purposes of paragraph (3)(A), a State meets the condition of this
paragraph for a fiscal year if it is implementing at least 4 of the
following enrollment and retention provisions (treating each
subparagraph as a separate enrollment and retention provision)
throughout the entire fiscal year:
`(A) CONTINUOUS ELIGIBILITY- The State has elected
the option of continuous eligibility for a full 12 months for all
children described in section 1902(e)(12) under title XIX under 19
years of age, as well as applying such policy under its State child
health plan under this title.
`(B) LIBERALIZATION OF ASSET REQUIREMENTS- The State meets the requirement specified in either of the following clauses:
`(i) ELIMINATION OF ASSET TEST- The State does
not apply any asset or resource test for eligibility for children under
title XIX or this title.
`(ii) ADMINISTRATIVE VERIFICATION OF ASSETS- The State--
`(I) permits a parent or caretaker relative
who is applying on behalf of a child for medical assistance under title
XIX or child health assistance under this title to declare and certify
by signature under penalty of perjury information relating to family
assets for purposes of determining and redetermining financial
eligibility; and
`(II) takes steps to verify assets through
means other than by requiring documentation from parents and applicants
except in individual cases of discrepancies or where otherwise
justified.
`(C) ELIMINATION OF IN-PERSON INTERVIEW
REQUIREMENT- The State does not require an application of a child for
medical assistance under title XIX (or for child health assistance
under this title), including an application for renewal of such
assistance, to be made in person nor does the State require a
face-to-face interview, unless there are discrepancies or individual
circumstances justifying an in-person application or face-to-face
interview.
`(D) USE OF JOINT APPLICATION FOR MEDICAID AND
CHIP- The application form and supplemental forms (if any) and
information verification process is the same for purposes of
establishing and renewing eligibility for children for medical
assistance under title XIX and child health assistance under this title.
`(E) AUTOMATIC RENEWAL (USE OF ADMINISTRATIVE RENEWAL)-
`(i) IN GENERAL- The State provides, in the
case of renewal of a child's eligibility for medical assistance under
title XIX or child health assistance under this title, a pre-printed
form completed by the State based on the information available to the
State and notice to the parent or caretaker relative of the child that
eligibility of the child will be renewed and continued based on such
information unless the State is provided other information. Nothing in
this clause shall be construed as preventing a State from verifying,
through electronic and other means, the information so provided.
`(ii) SATISFACTION THROUGH DEMONSTRATED USE OF
EX PARTE PROCESS- A State shall be treated as satisfying the
requirement of clause (i) if renewal of eligibility of children under
title XIX or this title is determined without any requirement for an
in-person interview, unless sufficient information is not in the
State's possession and cannot be acquired from other sources (including
other State agencies) without the participation of the applicant or the
applicant's parent or caretaker relative.
`(F) PRESUMPTIVE ELIGIBILITY FOR CHILDREN- The
State is implementing section 1920A under title XIX as well as,
pursuant to section 2107(e)(1), under this title.
`(G) EXPRESS LANE- The State is implementing the
option described in section 1902(e)(13) under title XIX as well as,
pursuant to section 2107(e)(1), under this title.'.
(1) IN GENERAL- The Comptroller General of the United
States shall conduct a study on the effectiveness of the performance
bonus payment program under the amendment made by subsection (a) on the
enrollment and retention of eligible children under the Medicaid and
CHIP programs and in reducing the rate of uninsurance among such
children.
(2) REPORT- Not later than January 1, 2013, the
Comptroller General shall submit a report to Congress on such study and
shall include in such report such recommendations for extending or
modifying such program as the Comptroller General determines
appropriate.
SEC. 112. STATE OPTION TO RELY ON FINDINGS FROM AN EXPRESS LANE AGENCY TO CONDUCT SIMPLIFIED ELIGIBILITY DETERMINATIONS.
(a) Medicaid- Section 1902(e) of the Social Security Act (42 U.S.C. 1396a(e)) is amended by adding at the end the following:
`(13) Express Lane Option-
`(i) OPTION TO USE A FINDING FROM AN EXPRESS LANE
AGENCY- At the option of the State, the State plan may provide that in
determining eligibility under this title for a child (as defined in
subparagraph (F)), the State may rely on a finding made within a
reasonable period (as determined by the State) from an Express Lane
agency (as defined in subparagraph (E)) when it determines whether a
child satisfies one or more components of eligibility for medical
assistance under this title. The State may rely on a finding from an
Express Lane agency notwithstanding sections 1902(a)(46)(B), 1903(x),
and 1137(d) and any differences in budget unit, disregard, deeming or
other methodology, if the following requirements are met:
`(I) PROHIBITION ON DETERMINING CHILDREN
INELIGIBLE FOR COVERAGE- If a finding from an Express Lane agency would
result in a determination that a child does not satisfy an eligibility
requirement for medical assistance under this title and for child
health assistance under title XXI, the State shall determine
eligibility for assistance using its regular procedures.
`(II) NOTICE REQUIREMENT- For any child who is
found eligible for medical assistance under the State plan under this
title or child health assistance under title XXI and who is subject to
premiums based on an Express Lane agency's finding of such child's
income level, the State shall provide notice that the child may qualify
for lower premium payments if evaluated by the State using its regular
policies and of the procedures for requesting such an evaluation.
`(III) COMPLIANCE WITH SCREEN AND ENROLL
REQUIREMENT- The State shall satisfy the requirements under (A) and (B)
of section 2102(b)(3) (relating to screen and enroll) before enrolling
a child in child health assistance under title XXI. At its option, the
State may fulfill such requirements in accordance with either option
provided under subparagraph (C) of this paragraph.
`(ii) OPTION TO APPLY TO RENEWALS AND
REDETERMINATIONS- The State may apply the provisions of this paragraph
when conducting initial determinations of eligibility, redeterminations
of eligibility, or both, as described in the State plan.
`(B) RULES OF CONSTRUCTION- Nothing in this paragraph shall be construed--
`(i) to limit or prohibit a State from taking any
actions otherwise permitted under this title or title XXI in
determining eligibility for or enrolling children into medical
assistance under this title or child health assistance under title XXI;
or
`(ii) to modify the limitations in section
1902(a)(5) concerning the agencies that may make a determination of
eligibility for medical assistance under this title.
`(C) OPTIONS FOR SATISFYING THE SCREEN AND ENROLL REQUIREMENT-
`(i) IN GENERAL- With respect to a child whose
eligibility for medical assistance under this title or for child health
assistance under title XXI has been evaluated by a State agency using
an income finding from an Express Lane agency, a State may carry out
its duties under subparagraphs (A) and (B) of section 2102(b)(3)
(relating to screen and enroll) in accordance with either clause (ii)
or clause (iii).
`(ii) ESTABLISHING A SCREENING THRESHOLD-
`(I) IN GENERAL- Under this clause, the State
establishes a screening threshold set as a percentage of the Federal
poverty level that exceeds the highest income threshold applicable
under this title to the child by a minimum of 30 percentage points or,
at State option, a higher number of percentage points that reflects the
value (as determined by the State and described in the State plan) of
any differences between income methodologies used by the program
administered by the Express Lane agency and the methodologies used by
the State in determining eligibility for medical assistance under this
title.
`(II) CHILDREN WITH INCOME NOT ABOVE THRESHOLD-
If the income of a child does not exceed the screening threshold, the
child is deemed to satisfy the income eligibility criteria for medical
assistance under this title regardless of whether such child would
otherwise satisfy such criteria.
`(III) CHILDREN WITH INCOME ABOVE THRESHOLD- If
the income of a child exceeds the screening threshold, the child shall
be considered to have an income above the Medicaid applicable income
level described in section 2110(b)(4) and to satisfy the requirement
under section 2110(b)(1)(C) (relating to the requirement that CHIP
matching funds be used only for children not eligible for Medicaid). If
such a child is enrolled in child health assistance under title XXI,
the State shall provide the parent, guardian, or custodial relative
with the following:
`(aa) Notice that the child may be eligible
to receive medical assistance under the State plan under this title if
evaluated for such assistance under the State's regular procedures and
notice of the process through which a parent, guardian, or custodial
relative can request that the State evaluate the child's eligibility
for medical assistance under this title using such regular procedures.
`(bb) A description of differences between
the medical assistance provided under this title and child health
assistance under title XXI, including differences in cost-sharing
requirements and covered benefits.
`(iii) TEMPORARY ENROLLMENT IN CHIP PENDING SCREEN AND ENROLL-
`(I) IN GENERAL- Under this clause, a State
enrolls a child in child health assistance under title XXI for a
temporary period if the child appears eligible for such assistance
based on an income finding by an Express Lane agency.
`(II) DETERMINATION OF ELIGIBILITY- During such
temporary enrollment period, the State shall determine the child's
eligibility for child health assistance under title XXI or for medical
assistance under this title in accordance with this clause.
`(III) PROMPT FOLLOW UP- In making such a
determination, the State shall take prompt action to determine whether
the child should be enrolled in medical assistance under this title or
child health assistance under title XXI pursuant to subparagraphs (A)
and (B) of section 2102(b)(3) (relating to screen and enroll).
`(IV) REQUIREMENT FOR SIMPLIFIED DETERMINATION-
In making such a determination, the State shall use procedures that, to
the maximum feasible extent, reduce the burden imposed on the
individual of such determination. Such procedures may not require the
child's parent, guardian, or custodial relative to provide or verify
information that already has been provided to the State agency by an
Express Lane agency or another source of information unless the State
agency has reason to believe the information is erroneous.
`(V) AVAILABILITY OF CHIP MATCHING FUNDS DURING
TEMPORARY ENROLLMENT PERIOD- Medical assistance for items and services
that are provided to a child enrolled in title XXI during a temporary
enrollment period under this clause shall be treated as child health
assistance under such title.
`(D) OPTION FOR AUTOMATIC ENROLLMENT-
`(i) IN GENERAL- At its option, a State may
initiate an evaluation of an individual's eligibility for medical
assistance under this title without an application and determine the
individual's eligibility for such assistance using findings from one or
more Express Lane agencies and information from sources other than a
child, if the requirements of clauses (ii) and (iii) are met.
`(ii) INDIVIDUAL CHOICE REQUIREMENT- The
requirement of this clause is that the child is enrolled in medical
assistance under this title or child health assistance under title XXI
only if the child (or a parent, caretaker relative, or guardian on the
behalf of the child) has affirmatively assented to such enrollment.
`(iii) INFORMATION REQUIREMENT- The requirement of
this clause is that the State informs the parent, guardian, or
custodial relative of the child of the services that will be covered,
appropriate methods for using such services, premium or other cost
sharing charges (if any) that apply, medical support obligations (under
section 1912(a)) created by enrollment (if applicable), and the actions
the parent, guardian, or relative must take to maintain enrollment and
renew coverage.
`(E) EXPRESS LANE AGENCY DEFINED- In this paragraph,
the term `express lane agency' means an agency that meets the following
requirements:
`(i) The agency determines eligibility for
assistance under the Food Stamp Act of 1977, the Richard B. Russell
National School Lunch Act, the Child Nutrition Act of 1966, or the
Child Care and Development Block Grant Act of 1990.
`(ii) The agency notifies the child (or a parent, caretaker relative, or guardian on the behalf of the child)--
`(I) of the information which shall be disclosed;
`(II) that the information will be used by the
State solely for purposes of determining eligibility for and for
providing medical assistance under this title or child health
assistance under title XXI; and
`(III) that the child, or parent, caretaker
relative, or guardian, may elect to not have the information disclosed
for such purposes.
`(iii) The agency and the State agency are subject
to an interagency agreement limiting the disclosure and use of such
information to such purposes.
`(iv) The agency is determined by the State agency
to be capable of making the determinations described in this paragraph
and is identified in the State plan under this title or title XXI.
For purposes of this subparagraph, the term `State
agency' refers to the agency determining eligibility for medical
assistance under this title or child health assistance under title XXI.
`(F) CHILD DEFINED- For purposes of this paragraph, the
term `child' means an individual under 19 years of age, or, at the
option of a State, such higher age, not to exceed 21 years of age, as
the State may elect.'.
(b) CHIP- Section 2107(e)(1) of such Act (42 U.S.C.
1397gg(e)(1)) is amended by redesignating subparagraphs (B), (C), and
(D) as subparagraphs (E), (H), and (I), respectively, and by inserting
after subparagraph (A) the following new subparagraph:
`(C) Section 1902(e)(13) (relating to the State
option to rely on findings from an Express Lane agency to help evaluate
a child's eligibility for medical assistance).'.
(c) Electronic Transmission of Information- Section 1902 of
such Act (42 U.S.C. 1396a) is amended by adding at the end the
following new subsection:
`(dd) Electronic Transmission of Information- If the State
agency determining eligibility for medical assistance under this title
or child health assistance under title XXI verifies an element of
eligibility based on information from an Express Lane Agency (as
defined in subsection (e)(13)(F)), or from another public agency, then
the applicant's signature under penalty of perjury shall not be
required as to such element. Any signature requirement for an
application for medical assistance may be satisfied through an
electronic signature, as defined in section 1710(1) of the Government
Paperwork Elimination Act (44 U.S.C. 3504 note). The requirements of
subparagraphs (A) and (B) of section 1137(d)(2) may be met through
evidence in digital or electronic form.'.
(d) Authorization of Information Disclosure-
(1) IN GENERAL- Title XIX of the Social Security Act is amended--
(A) by redesignating section 1939 as section 1940; and
(B) by inserting after section 1938 the following new section:
`SEC. 1939. AUTHORIZATION TO RECEIVE PERTINENT INFORMATION.
`(a) In General- Notwithstanding any other provision of
law, a Federal or State agency or private entity in possession of the
sources of data potentially pertinent to eligibility determinations
under this title (including eligibility files maintained by Express
Lane agencies described in section 1902(e)(13)(F), information
described in paragraph (2) or (3) of section 1137(a), vital records
information about births in any State, and information described in
sections 453(i) and 1902(a)(25)(I)) is authorized to convey such data
or information to the State agency administering the State plan under
this title, to the extent such conveyance meets the requirements of
subsection (b).
`(b) Requirements for Conveyance- Data or information may
be conveyed pursuant to subsection (a) only if the following
requirements are met:
`(1) The individual whose circumstances are described
in the data or information (or such individual's parent, guardian,
caretaker relative, or authorized representative) has either provided
advance consent to disclosure or has not objected to disclosure after
receiving advance notice of disclosure and a reasonable opportunity to
object.
`(2) Such data or information are used solely for the purposes of--
`(A) identifying individuals who are eligible or
potentially eligible for medical assistance under this title and
enrolling or attempting to enroll such individuals in the State plan;
and
`(B) verifying the eligibility of individuals for medical assistance under the State plan.
`(3) An interagency or other agreement, consistent with standards developed by the Secretary--
`(A) prevents the unauthorized use, disclosure, or
modification of such data and otherwise meets applicable Federal
requirements safeguarding privacy and data security; and
`(B) requires the State agency administering the
State plan to use the data and information obtained under this section
to seek to enroll individuals in the plan.
`(c) Criminal Penalty- A private entity described in the
subsection (a) that publishes, discloses, or makes known in any manner,
or to any extent not authorized by Federal law, any information
obtained under this section shall be fined not more than $1,000 or
imprisoned not more than 1 year, or both, for each such unauthorized
publication or disclosure.
`(d) Rule of Construction- The limitations and requirements
that apply to disclosure pursuant to this section shall not be
construed to prohibit the conveyance or disclosure of data or
information otherwise permitted under Federal law (without regard to
this section).'.
(2) CONFORMING AMENDMENT TO TITLE XXI- Section
2107(e)(1) of such Act (42 U.S.C. 1397gg(e)(1)), as amended by
subsection (b), is amended by adding at the end the following new
subparagraph:
`(J) Section 1939 (relating to authorization to receive data potentially pertinent to eligibility determinations).'.
(3) CONFORMING AMENDMENT TO PROVIDE ACCESS TO DATA
ABOUT ENROLLMENT IN INSURANCE FOR PURPOSES OF EVALUATING APPLICATIONS
AND FOR CHIP- Section 1902(a)(25)(I)(i) of such Act (42 U.S.C.
1396a(a)(25)(I)(i)) is amended--
(A) by inserting `(and, at State option,
individuals who are potentially eligible or who apply)' after `with
respect to individuals who are eligible'; and
(B) by inserting `under this title (and, at State option, child health assistance under title XXI)' after `the State plan'.
(e) Effective Date- The amendments made by this section are effective on January 1, 2008.
SEC. 113. APPLICATION OF MEDICAID OUTREACH PROCEDURES TO ALL CHILDREN AND PREGNANT WOMEN.
(a) In General- Section 1902(a)(55) of the Social Security Act (42 U.S.C. 1396a(a)(55)) is amended--
(1) in the matter before subparagraph (A), by striking
`individuals for medical assistance under subsection (a)(10)(A)(i)(IV),
(a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or (a)(10)(A)(ii)(IX)' and
inserting `children and pregnant women for medical assistance under any
provision of this title'; and
(2) in subparagraph (B), by inserting before the
semicolon at the end the following: `, which need not be the same
application form for all such individuals'.
(b) Effective Date- The amendments made by subsection (a) take effect on January 1, 2008.
SEC. 114. ENCOURAGING CULTURALLY APPROPRIATE ENROLLMENT AND RETENTION PRACTICES.
(a) Use of Medicaid Funds- Section 1903(a)(2) of the Social
Security Act (42 U.S.C. 1396b(a)(2)) is amended by adding at the end
the following new subparagraph:
`(E) an amount equal to 75 percent of so much of the
sums expended during such quarter (as found necessary by the Secretary
for the proper and efficient administration of the State plan) as are
attributable to translation or interpretation services in connection
with the enrollment and retention under this title of children of
families for whom English is not the primary language; plus'.
(b) Use of Community Health Workers for Outreach Activities-
(1) IN GENERAL- Section 2102(c)(1) of such Act (42
U.S.C. 1397bb(c)(1)) is amended by inserting `(through community health
workers and others)' after `Outreach'.
(2) IN FEDERAL EVALUATION- Section 2108(c)(3)(B) of
such Act (42 U.S.C. 1397hh(c)(3)(B)) is amended by inserting `(such as
through community health workers and others)' after `including
practices'.
SEC. 115. CONTINUOUS COVERAGE UNDER CHIP.
(a) In General- Section 2102(b) of the Social Security Act
(42 U.S.C. 1397bb(b)) is amended by adding at the end the following new
paragraph:
`(5) 12-months CONTINUOUS ELIGIBILITY- In the case of a
State child health plan that provides child health assistance under
this title through a means other than described in section 2101(a)(2),
the plan shall provide for implementation under this title of the
12-months continuous eligibility option described in section
1902(e)(12) for targeted low-income children whose family income is
below 200 percent of the poverty line.'.
(b) Effective Date- The amendment made by subsection (a)
shall apply to determinations (and redeterminations) of eligibility
made on or after January 1, 2008.
Subtitle C--Coverage
SEC. 121. ENSURING CHILD-CENTERED COVERAGE.
(a) Additional Required Services-
(1) CHILD-CENTERED COVERAGE- Section 2103 of the Social Security Act (42 U.S.C. 1397cc) is amended--
(i) in the matter before paragraph (1), by
striking `subsection (c)(5)' and inserting `paragraphs (5) and (6) of
subsection (c)'; and
(ii) in paragraph (1), by inserting `at least' after `that is'; and
(i) by redesignating paragraph (5) as paragraph (6); and
(ii) by inserting after paragraph (4), the following:
`(5) DENTAL, FQHC, AND RHC SERVICES- The child health
assistance provided to a targeted low-income child (whether through
benchmark coverage or benchmark-equivalent coverage or otherwise) shall
include coverage of the following:
`(A) Dental services necessary to prevent disease
and promote oral health, restore oral structures to health and
function, and treat emergency conditions.
`(B) Federally-qualified health center services (as
defined in section 1905(l)(2)) and rural health clinic services (as
defined in section 1905(l)(1)).
Nothing in this section shall be construed as preventing
a State child health plan from providing such services as part of
benchmark coverage or in addition to the benefits provided through
benchmark coverage.'.
(2) REQUIRED PAYMENT FOR FQHC AND RHC SERVICES- Section
2107(e)(1) of such Act (42 U.S.C. 1397gg(e)(1)), as amended by sections
112(b) and 112(d)(2), is amended by inserting after subparagraph (C)
the following new subparagraph:
`(D) Section 1902(bb) (relating to payment for
services provided by Federally-qualified health centers and rural
health clinics).'.
(3) MENTAL HEALTH PARITY- Section 2103(a)(2)(C) of such
Act (42 U.S.C. 1397aa(a)(2)(C)) is amended by inserting `(or 100
percent in the case of the category of services described in
subparagraph (B) of such subsection)' after `75 percent'.
(4) EFFECTIVE DATE- The amendments made by this
subsection and subsection (d) shall apply to health benefits coverage
provided on or after October 1, 2008.
(b) Clarification of Requirement to Provide EPSDT Services for All Children in Benchmark Benefit Packages Under Medicaid-
(1) IN GENERAL- Section 1937(a)(1) of the Social Security Act (42 U.S.C. 1396u-7(a)(1)) is amended--
(A) in subparagraph (A)--
(i) in the matter before clause (i), by
striking `Notwithstanding any other provision of this title' and
inserting `Subject to subparagraph (E)'; and
(ii) by striking `enrollment in coverage that
provides' and all that follows and inserting `benchmark coverage
described in subsection (b)(1) or benchmark equivalent coverage
described in subsection (b)(2).';
(B) by striking subparagraph (C) and inserting the following new subparagraph:
`(C) STATE OPTION TO PROVIDE ADDITIONAL BENEFITS- A
State, at its option, may provide such additional benefits to benchmark
coverage described in subsection (b)(1) or benchmark equivalent
coverage described in subsection (b)(2) as the State may specify.'; and
(C) by adding at the end the following new subparagraph:
`(E) REQUIRING COVERAGE OF EPSDT SERVICES- Nothing
in this paragraph shall be construed as affecting a child's entitlement
to care and services described in subsections (a)(4)(B) and (r) of
section 1905 and provided in accordance with section 1902(a)(43)
whether provided through benchmark coverage, benchmark equivalent
coverage, or otherwise.'.
(2) EFFECTIVE DATE- The amendments made by paragraph
(1) shall take effect as if included in the amendment made by section
6044(a) of the Deficit Reduction Act of 2005.
(c) Clarification of Coverage of Services in School-Based Health Centers Included as Child Health Assistance-
(1) IN GENERAL- Section 2110(a)(5) of such Act (42
U.S.C. 1397jj(a)(5)) is amended by inserting after `health center
services' the following: `and school-based health center services for
which coverage is otherwise provided under this title when furnished by
a school-based health center that is authorized to furnish such
services under State law'.
(2) EFFECTIVE DATE- The amendment made by paragraph (1)
shall apply to child health assistance furnished on or after the date
of the enactment of this Act.
(d) Assuring Access to Care-
(1) STATE CHILD HEALTH PLAN REQUIREMENT- Section
2102(a)(7)(B) of such Act (42 U.S.C. 1397bb(c)(2)) is amended by
inserting `and services described in section 2103(c)(5)' after
`emergency services'.
(2) REFERENCE TO EFFECTIVE DATE- For the effective date for the amendments made by this subsection, see subsection (a)(5).
SEC. 122. IMPROVING BENCHMARK COVERAGE OPTIONS.
(a) Limitation on Secretary-Approved Coverage-
(1) UNDER CHIP- Section 2103(a)(4) of the Social
Security Act (42 U.S.C. 1397cc(a)(4)) is amended by inserting before
the period at the end the following: `if the health benefits coverage
is at least equivalent to the benefits coverage in a benchmark benefit
package described in subsection (b)'.
(2) UNDER MEDICAID- Section 1937(b)(1)(D) of the Social
Security Act (42 U.S.C. 1396u-7(b)(1)(D)) is amended by inserting
before the period at the end the following: `if the health benefits
coverage is at least equivalent to the benefits coverage in benchmark
coverage described in subparagraph (A), (B), or (C)'.
(b) Requirement for Most Popular Family Coverage for State Employee Coverage Benchmark-
(1) CHIP- Section 2103(b)(2) of such Act (42 U.S.C.
1397(b)(2)) is amended by inserting `and that has been selected most
frequently by employees seeking dependent coverage, among such plans
that provide such dependent coverage, in either of the previous 2 plan
years' before the period at the end.
(2) MEDICAID- Section 1937(b)(1)(B) of such Act is
amended by inserting `and that has been selected most frequently, by
employees seeking dependent coverage, among such plans that provide
such dependent coverage, in either of the previous 2 plan years' before
the period at the end.
(c) Effective Date- The amendments made by this section
shall apply to health benefits coverage provided on or after October 1,
2008.
SEC. 123. PREMIUM GRACE PERIOD.
(a) In General- Section 2103(e)(3) of the Social Security
Act (42 U.S.C. 1397cc(e)(3)) is amended by adding at the end the
following new subparagraph:
`(C) PREMIUM GRACE PERIOD- The State child health plan--
`(i) shall afford individuals enrolled under
the plan a grace period of at least 30 days from the beginning of a new
coverage period to make premium payments before the individual's
coverage under the plan may be terminated; and
`(ii) shall provide to such an individual, not later than 7 days after the first day of such grace period, notice--
`(I) that failure to make a premium payment
within the grace period will result in termination of coverage under
the State child health plan; and
`(II) of the individual's right to challenge the proposed termination pursuant to the applicable Federal regulations.
For purposes of clause (i), the term `new coverage
period' means the month immediately following the last month for which
the premium has been paid.'.
(b) Effective Date- The amendment made by subsection (a)
shall apply to new coverage periods beginning on or after January 1,
2009.
Subtitle D--Populations
SEC. 131. OPTIONAL COVERAGE OF CHILDREN UP TO AGE 21 UNDER CHIP.
(a) In General- Section 2110(c)(1) of the Social Security
Act (42 U.S.C. 1397jj(c)(1)) is amended by inserting `(or, at the
option of the State, under 20 or 21 years of age)' after `19 years of
age'.
(b) Effective Date- The amendment made by subsection (a) shall take effect on January 1, 2008.
SEC. 132. OPTIONAL COVERAGE OF LEGAL IMMIGRANTS UNDER THE MEDICAID PROGRAM AND CHIP.
(a) Medicaid Program- Section 1903(v) of the Social Security Act (42 U.S.C. 1396b(v)) is amended--
(1) in paragraph (1), by striking `paragraph (2)' and inserting `paragraphs (2) and (4)'; and
(2) by adding at the end the following new paragraph:
`(4)(A) A State may elect (in a plan amendment under this
title) to provide medical assistance under this title, notwithstanding
sections 401(a), 402(b), 403, and 421 of the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996, for aliens who are
lawfully residing in the United States (including battered aliens
described in section 431(c) of such Act) and who are otherwise eligible
for such assistance, within either or both of the following eligibility
categories:
`(i) PREGNANT WOMEN- Women during pregnancy (and during the 60-day period beginning on the last day of the pregnancy).
`(ii) CHILDREN- Individuals under age 19 (or such
higher age as the State has elected under section 1902(l)(1)(D)),
including optional targeted low-income children described in section
1905(u)(2)(B).
`(B) In the case of a State that has elected to provide
medical assistance to a category of aliens under subparagraph (A), no
debt shall accrue under an affidavit of support against any sponsor of
such an alien on the basis of provision of medical assistance to such
category and the cost of such assistance shall not be considered as an
unreimbursed cost.'.
(b) CHIP- Section 2107(e)(1) of such Act (42 U.S.C.
1397gg(e)(1)), as amended by section 112(b), 112(d)(2),and 121(a)(2),
is amended by inserting after subparagraph (E) the following new
subparagraphs:
`(F) Section 1903(v)(4)(A) (relating to optional
coverage of certain categories of lawfully residing immigrants),
insofar as it relates to the category of pregnant women described in
clause (i) of such section, but only if the State has elected to apply
such section with respect to such women under title XIX and the State
has elected the option under section 2111 to provide assistance for
pregnant women under this title.
`(G) Section 1903(v)(4)(A) (relating to optional
coverage of categories of lawfully residing immigrants), insofar as it
relates to the category of children described in clause (ii) of such
section, but only if the State has elected to apply such section with
respect to such children under title XIX.'.
(c) Effective Date- The amendments made by this section take effect on the date of the enactment of this Act.
SEC. 133. STATE OPTION TO EXPAND OR ADD COVERAGE OF CERTAIN PREGNANT WOMEN UNDER CHIP.
(1) COVERAGE- Title XXI (42 U.S.C. 1397aa et seq.) of
the Social Security Act is amended by adding at the end the following
new section:
`SEC. 2111. OPTIONAL COVERAGE OF TARGETED LOW-INCOME PREGNANT WOMEN.
`(a) Optional Coverage- Notwithstanding any other provision
of this title, a State may provide for coverage, through an amendment
to its State child health plan under section 2102, of assistance for
pregnant women for targeted low-income pregnant women in accordance
with this section, but only if--
`(1) the State has established an income eligibility level--
`(A) for pregnant women, under any of clauses
(i)(III), (i)(IV), or (ii)(IX) of section 1902(a)(10)(A), that is at
least 185 percent (or such higher percent as the State has in effect
for pregnant women under this title) of the poverty line applicable to
a family of the size involved, but in no case a percent lower than the
percent in effect under any such clause as of July 1, 2007; and
`(B) for children under 19 years of age under this
title (or title XIX) that is at least 200 percent of the poverty line
applicable to a family of the size involved; and
`(2) the State does not impose, with respect to the
enrollment under the State child health plan of targeted low-income
children during the quarter, any enrollment cap or other numerical
limitation on enrollment, any waiting list, any procedures designed to
delay the consideration of applications for enrollment, or similar
limitation with respect to enrollment.
`(b) Definitions- For purposes of this title:
`(1) ASSISTANCE FOR PREGNANT WOMEN- The term
`assistance for pregnant women' has the meaning given the term child
health assistance in section 2110(a) as if any reference to targeted
low-income children were a reference to targeted low-income pregnant
women.
`(2) TARGETED LOW-INCOME PREGNANT WOMAN- The term `targeted low-income pregnant woman' means a woman--
`(A) during pregnancy and through the end of the
month in which the 60-day period (beginning on the last day of her
pregnancy) ends;
`(B) whose family income exceeds 185 percent (or,
if higher, the percent applied under subsection (a)(1)(A)) of the
poverty level applicable to a family of the size involved, but does not
exceed the income eligibility level established under the State child
health plan under this title for a targeted low-income child; and
`(C) who satisfies the requirements of paragraphs
(1)(A), (1)(C), (2), and (3) of section 2110(b), applied as if any
reference to a child was a reference to a pregnant woman.
`(c) References to Terms and Special Rules- In the case of,
and with respect to, a State providing for coverage of assistance for
pregnant women to targeted low-income pregnant women under subsection
(a), the following special rules apply:
`(1) Any reference in this title (other than in
subsection (b)) to a targeted low-income child is deemed to include a
reference to a targeted low-income pregnant woman.
`(2) Any reference in this title to child health
assistance (other than with respect to the provision of early and
periodic screening, diagnostic, and treatment services) with respect to
such women is deemed a reference to assistance for pregnant women.
`(3) Any such reference (other than in section 2105(d))
to a child is deemed a reference to a woman during pregnancy and the
period described in subsection (b)(2)(A).
`(4) In applying section 2102(b)(3)(B), any reference
to children found through screening to be eligible for medical
assistance under the State medicaid plan under title XIX is deemed a
reference to pregnant women.
`(5) There shall be no exclusion of benefits for
services described in subsection (b)(1) based on any preexisting
condition and no waiting period (including any waiting period imposed
to carry out section 2102(b)(3)(C)) shall apply.
`(6) In applying section 2103(e)(3)(B) in the case of a
pregnant woman provided coverage under this section, the limitation on
total annual aggregate cost-sharing shall be applied to such pregnant
woman.
`(7) In applying section 2104(i)--
`(A) in the case of a State which did not provide
for coverage for pregnant women under this title (under a waiver or
otherwise) during fiscal year 2007, the allotment amount otherwise
computed for the first fiscal year in which the State elects to provide
coverage under this section shall be increased by an amount (determined
by the Secretary) equal to the enhanced FMAP of the expenditures under
this title for such coverage, based upon projected enrollment and per
capita costs of such enrollment; and
`(B) in the case of a State which provided for coverage of pregnant women under this title for the previous fiscal year--
`(i) in applying paragraph (2)(B) of such
section, there shall also be taken into account (in an appropriate
proportion) the percentage increase in births in the State for the
relevant period; and
`(ii) in applying paragraph (3), pregnant women
(and per capita expenditures for such women) shall be accounted for
separately from children, but shall be included in the total amount of
any allotment adjustment under such paragraph.
`(d) Automatic Enrollment for Children Born to Women
Receiving Assistance for Pregnant Women- If a child is born to a
targeted low-income pregnant woman who was receiving assistance for
pregnant women under this section on the date of the child's birth, the
child shall be deemed to have applied for child health assistance under
the State child health plan and to have been found eligible for such
assistance under such plan or to have applied for medical assistance
under title XIX and to have been found eligible for such assistance
under such title on the date of such birth, based on the mother's
reported income as of the time of her enrollment under this section and
applicable income eligibility levels under this title and title XIX,
and to remain eligible for such assistance until the child attains 1
year of age. During the period in which a child is deemed under the
preceding sentence to be eligible for child health or medical
assistance, the assistance for pregnant women or medical assistance
eligibility identification number of the mother shall also serve as the
identification number of the child, and all claims shall be submitted
and paid under such number (unless the State issues a separate
identification number for the child before such period expires).'.
(2) ADDITIONAL AMENDMENT- Section 2107(e)(1)(I) of such
Act (42 U.S.C. 1397gg(e)(1)(H)), as redesignated by section 112(b), is
amended to read as follows:
`(I) Sections 1920 and 1920A (relating to presumptive eligibility for pregnant women and children).'.
(b) Amendments to Medicaid-
(1) ELIGIBILITY OF A NEWBORN- Section 1902(e)(4) of the
Social Security Act (42 U.S.C. 1396a(e)(4)) is amended in the first
sentence by striking `so long as the child is a member of the woman's
household and the woman remains (or would remain if pregnant) eligible
for such assistance'.
(2) APPLICATION OF QUALIFIED ENTITIES TO PRESUMPTIVE
ELIGIBILITY FOR PREGNANT WOMEN UNDER MEDICAID- Section 1920(b) of the
Social Security Act (42 U.S.C. 1396r-1(b)) is amended by adding after
paragraph (2) the following flush sentence:
`The term `qualified provider' also includes a qualified entity, as defined in section 1920A(b)(3).'.
SEC. 134. LIMITATION ON WAIVER AUTHORITY TO COVER ADULTS.
Section 2102 of the Social Security Act (42 U.S.C. 1397bb) is amended by adding at the end the following new subsection:
`(d) Limitation on Coverage of Adults- Notwithstanding any
other provision of this title, the Secretary may not, through the
exercise of any waiver authority on or after January 1, 2008, provide
for Federal financial participation to a State under this title for
health care services for individuals who are not targeted low-income
children or pregnant women unless the Secretary determines that no
eligible targeted low-income child in the State would be denied
coverage under this title for health care services because of such
eligibility. In making such determination, the Secretary must receive
assurances that--
`(1) there is no waiting list under this title in the
State for targeted low-income children to receive child health
assistance under this title; and
`(2) the State has in place an outreach program to
reach all targeted low-income children in families with incomes less
than 200 percent of the poverty line.'.
SEC. 135. NO FEDERAL FUNDING FOR ILLEGAL ALIENS.
Nothing in this Act allows Federal payment for individuals who are not legal residents.
SEC. 136. AUDITING REQUIREMENT TO ENFORCE CITIZENSHIP RESTRICTIONS ON ELIGIBILITY FOR MEDICAID AND CHIP BENEFITS.
Section 1903(x) of the Social Security Act (as amended by
section 405(c)(1)(A) of division B of the Tax Relief and Health Care
Act of 2006 (Public Law 109-432)) is amended by adding at the end the
following new paragraph:
`(4)(A) Each State shall audit a statistically-based sample
of cases of individuals whose eligibility for medical assistance (or
child health assistance) is determined under section 1902(a)(46)(B) or
under subsection (v)(4)(A) in order to demonstrate to the satisfaction
of the Secretary that Federal funds under this title or title XXI are
not unlawfully spent for benefits for individuals who are not legal
residents. In conducting such audits, a State may rely on case reviews
regularly conducted pursuant to its Medicaid Quality Control or Payment
Error Rate Measurement (PERM) eligibility reviews under subsection (u)
and the provisions of subsection (e) of section 1137 shall apply under
this paragraph in the same manner as they apply under subsection (b) of
such section.
`(B) The State shall remit to the Secretary the Federal
share of any unlawful expenditures for benefits, for aliens who are not
legal residents, which are identified under an audit conducted under
subparagraph (A).'.
Subtitle E--Access
SEC. 141. CHILDREN'S ACCESS, PAYMENT, AND EQUALITY COMMISSION.
Title XIX of the Social Security Act is amended by inserting before section 1901 the following new section:
`CHILDREN'S ACCESS, PAYMENT, AND EQUALITY COMMISSION
`Sec. 1900. (a) Establishment- There is hereby established
as an agency of Congress the Children's Access, Payment, and Equality
Commission (in this section referred to as the `Commission').
`(1) REVIEW OF PAYMENT POLICIES AND ANNUAL REPORTS- The Commission shall--
`(A) review Federal and State payment policies of
the Medicaid program established under this title (in this section
referred to as `Medicaid') and the State Children's Health Insurance
Program established under title XXI (in this section referred to as
`CHIP'), including topics described in paragraph (2);
`(B) review access to, and affordability of, coverage and services for enrollees under Medicaid and CHIP;
`(C) make recommendations to Congress concerning such policies;
`(D) by not later than March 1 of each year, submit
to Congress a report containing the results of such reviews and its
recommendations concerning such policies; and
`(E) by not later than June 1 of each year, submit
to Congress a report containing an examination of issues affecting
Medicaid and CHIP, including the implications of changes in health care
delivery in the United States and in the market for health care
services on such programs.
`(2) SPECIFIC TOPICS TO BE REVIEWED- Specifically, the Commission shall review the following:
`(A) The factors affecting expenditures for
services in different sectors (such as physician, hospital and other
sectors), payment methodologies, and their relationship to access and
quality of care for Medicaid and CHIP beneficiaries.
`(B) The impact of Federal and State Medicaid and
CHIP payment policies on access to services (including dental services)
for children (including children with disabilities) and other Medicaid
and CHIP populations.
`(C) The impact of Federal and State Medicaid and
CHIP policies on reducing health disparities, including geographic
disparities and disparities among minority populations.
`(D) The overall financial stability of the health
care safety net, including Federally-qualified health centers, rural
health centers, school-based clinics, disproportionate share hospitals,
public hospitals, providers and grantees under section 2612(a)(5) of
the Public Health Service Act (popularly known as the Ryan White CARE
Act), and other providers that have a patient base which includes a
disproportionate number of uninsured or low-income individuals and the
impact of CHIP and Medicaid policies on such stability.
`(E) The relation (if any) between payment rates
for providers and improvement in care for children as measured under
the children's health quality measurement program established under
section 151 of the Children's Health and Medicare Protection Act of
2007.
`(F) The affordability, cost effectiveness, and
accessibility of services needed by special populations under Medicaid
and CHIP as compared with private-sector coverage.
`(G) The extent to which the operation of Medicaid
and CHIP ensures access, comparable to access under employer-sponsored
or other private health insurance coverage (or in the case of
federally-qualified health center services (as defined in section
1905(l)(2)) and rural health clinic services (as defined in section
1905(l)(1)), access comparable to the access to such services under
title XIX), for targeted low-income children.
`(H) The effect of demonstrations under section
1115, benchmark coverage under section 1937, and other coverage under
section 1938, on access to care, affordability of coverage, provider
ability to achieve children's health quality performance measures, and
access to safety net services.
`(3) COMMENTS ON CERTAIN SECRETARIAL REPORTS- If the
Secretary submits to Congress (or a committee of Congress) a report
that is required by law and that relates to payment policies under
Medicaid or CHIP, the Secretary shall transmit a copy of the report to
the Commission. The Commission shall review the report and, not later
than 6 months after the date of submittal of the Secretary's report to
Congress, shall submit to the appropriate committees of Congress
written comments on such report. Such comments may include such
recommendations as the Commission deems appropriate.
`(4) AGENDA AND ADDITIONAL REVIEWS- The Commission
shall consult periodically with the Chairmen and Ranking Minority
Members of the appropriate committees of Congress regarding the
Commission's agenda and progress towards achieving the agenda. The
Commission may conduct additional reviews, and submit additional
reports to the appropriate committees of Congress, from time to time on
such topics relating to the program under this title or title XXI as
may be requested by such Chairmen and Members and as the Commission
deems appropriate.
`(5) AVAILABILITY OF REPORTS- The Commission shall
transmit to the Secretary a copy of each report submitted under this
subsection and shall make such reports available to the public.
`(6) APPROPRIATE COMMITTEE OF CONGRESS- For purposes of
this section, the term `appropriate committees of Congress' means the
Committees on Energy and Commerce of the House of Representatives and
the Committee on Finance of the Senate.
`(7) VOTING AND REPORTING REQUIREMENTS- With respect to
each recommendation contained in a report submitted under paragraph
(1), each member of the Commission shall vote on the recommendation,
and the Commission shall include, by member, the results of that vote
in the report containing the recommendation.
`(8) EXAMINATION OF BUDGET CONSEQUENCES- Before making
any recommendations, the Commission shall examine the budget
consequences of such recommendations, directly or through consultation
with appropriate expert entities.
`(c) Application of Provisions- The following provisions of
section 1805 shall apply to the Commission in the same manner as they
apply to the Medicare Payment Advisory Commission:
`(1) Subsection (c) (relating to membership), except
that the membership of the Commission shall also include
representatives of children, pregnant women, individuals with
disabilities, seniors, low-income families, and other groups of CHIP
and Medicaid beneficiaries.
`(2) Subsection (d) (relating to staff and consultants).
`(3) Subsection (e) (relating to powers).
`(d) Authorization of Appropriations-
`(1) REQUEST FOR APPROPRIATIONS- The Commission shall
submit requests for appropriations in the same manner as the
Comptroller General submits requests for appropriations, but amounts
appropriated for the Commission shall be separate from amounts
appropriated for the Comptroller General.
`(2) AUTHORIZATION- There are authorized to be
appropriated such sums as may be necessary to carry out the provisions
of this section.'.
SEC. 142. MODEL OF INTERSTATE COORDINATED ENROLLMENT AND COVERAGE PROCESS.
(a) In General- In order to assure continuity of coverage
of low-income children under the Medicaid program and the State
Children's Health Insurance Program (CHIP), not later than 18 months
after the date of the enactment of this Act, the Comptroller General of
the United States, in consultation with State Medicaid and CHIP
directors and organizations representing program beneficiaries, shall
develop a model process for the coordination of the enrollment,
retention, and coverage under such programs of children who, because of
migration of families, emergency evacuations, educational needs, or
otherwise, frequently change their State of residency or otherwise are
temporarily located outside of the State of their residency.
(b) Report to Congress- After development of such model
process, the Comptroller General shall submit to Congress a report
describing additional steps or authority needed to make further
improvements to coordinate the enrollment, retention, and coverage
under CHIP and Medicaid of children described in subsection (a).
SEC. 143. MEDICAID CITIZENSHIP DOCUMENTATION REQUIREMENTS.
(a) State Option to Require Children to Present
Satisfactory Documentary Evidence of Proof of Citizenship or
Nationality for Purposes of Eligibility for Medicaid; Requirement for
Auditing-
(1) IN GENERAL- Section 1902 of the Social Security Act (42 U.S.C. 1396a) is amended--
(A) in subsection (a)(46)--
(i) by inserting `(A)' after `(46)'; and
(ii) by adding at the end the following new subparagraphs:
`(B) at the option of the State, require that, with
respect to a child under 21 years of age (other than an individual
described in section 1903(x)(2)) who declares to be a citizen or
national of the United States for purposes of establishing initial
eligibility for medical assistance under this title (or, at State
option, for purposes of renewing or redetermining such eligibility to
the extent that such satisfactory documentary evidence of citizenship
or nationality has not yet been presented), there is presented
satisfactory documentary evidence of citizenship or nationality of the
individual (using criteria determined by the State, which shall be no
more restrictive than the documentation specified in section
1903(x)(3)); and
`(C) comply with the auditing requirements of section 1903(x)(4);'; and
(B) in subsection (b)(3), by inserting `or any
citizenship documentation requirement for a child under 21 years of age
that is more restrictive than what a State may provide under section
1903(x)' before the period at the end.
(2) ELIMINATION OF DENIAL OF PAYMENTS FOR CHILDREN-
Section 1903(i)(22) of such Act (42 U.S.C. 1396b(i)(22)) is amended by
inserting `(other than a child under the age of 21)' after `for an
individual'.
(b) Clarification of Rules for Children Born in the United
States to Mothers Eligible for Medicaid- Section 1903(x)(2) of such Act
(42 U.S.C. 1396b(x)(2)) is amended--
(1) in subparagraph (C), by striking `or' at the end;
(2) by redesignating subparagraph (D) as subparagraph (E); and
(3) by inserting after subparagraph (C) the following new subparagraph:
`(D) pursuant to the application of section 1902(e)(4)
(and, in the case of an individual who is eligible for medical
assistance on such basis, the individual shall be deemed to have
provided satisfactory documentary evidence of citizenship or
nationality and shall not be required to provide further documentary
evidence on any date that occurs during or after the period in which
the individual is eligible for medical assistance on such basis; or'.
(c) Documentation for Native Americans - Section 1903(x)(3)(B) of such Act is amended--
(1) by redesignating clause (v) as clause (vi); and
(2) by inserting after clause (iv) the following new clause:
`(v) For an individual who is a member of, or enrolled
in or affiliated with, a federally-recognized Indian tribe, a document
issued by such tribe evidencing such membership, enrollment, or
affiliation with the tribe (such as a tribal enrollment card or
certificate of degree of Indian blood), and, only with respect to those
federally-recognized Indian tribes located within States having an
international border whose membership includes individuals who are not
citizens of the United States, such other forms of documentation
(including tribal documentation, if appropriate) as the Secretary,
after consulting with such tribes, determines to be satisfactory
documentary evidence of citizenship or nationality for purposes of
satisfying the requirement of this subparagraph.'.
(d) Reasonable Opportunity- Section 1903(x) of such Act, as
amended by subsection (a)(2), is further amended by adding at the end
the following new paragraph:
`(5) In the case of an individual declaring to be a citizen
or national of the United States with respect to whom a State requires
the presentation of satisfactory documentary evidence of citizenship or
nationality under section 1902(a)(46)(B), the individual shall be
provided at least the reasonable opportunity to present satisfactory
documentary evidence of citizenship or nationality under this
subsection as is provided under clauses (i) and (ii) of section
1137(d)(4)(A) to an individual for the submittal to the State of
evidence indicating a satisfactory immigration status and shall not be
denied medical assistance on the basis of failure to provide such
documentation until the individual has had such an opportunity.'.
(1) RETROACTIVE APPLICATION- The amendments made by
this section shall take effect as if included in the enactment of the
Deficit Reduction Act of 2005 (Public Law 109-171; 120 Stat. 4).
(2) RESTORATION OF ELIGIBILITY- In the case of an
individual who, during the period that began on July 1, 2006, and ends
on the date of the enactment of this Act, was determined to be
ineligible for medical assistance under a State Medicaid program solely
as a result of the application of subsections (i)(22) and (x) of
section 1903 of the Social Security Act (as in effect during such
period), but who would have been determined eligible for such
assistance if such subsections, as amended by this section, had applied
to the individual, a State may deem the individual to be eligible for
such assistance as of the date that the individual was determined to be
ineligible for such medical assistance on such basis.
SEC. 144. ACCESS TO DENTAL CARE FOR CHILDREN.
(a) Dental Education for Parents of Newborns- The Secretary
of Health and Human Services shall develop and implement, through
entities that fund or provide perinatal care services to targeted
low-income children under a State child health plan under title XXI of
the Social Security Act, a program to deliver oral health educational
materials that inform new parents about risks for, and prevention of,
early childhood caries and the need for a dental visit within their
newborn's first year of life.
(b) Provision of Dental Services Through FQHCs-
(1) MEDICAID- Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)) is amended--
(A) by striking `and' at the end of paragraph (69);
(B) by striking the period at the end of paragraph (70) and inserting `; and'; and
(C) by inserting after paragraph (70) the following new paragraph:
`(71) provide that the State will not prevent a
Federally-qualified health center from entering into contractual
relationships with private practice dental providers in the provision
of Federally-qualified health center services.'.
(2) CHIP- Section 2107(e)(1) of such Act (42 U.S.C.
1397g(e)(1)), as amended by section 112(b), is amended by inserting
after subparagraph (A) the following new subparagraph:
`(B) Section 1902(a)(71) (relating to limiting FQHC contracting for provision of dental services).'.
(3) EFFECTIVE DATE- The amendments made by this subsection shall take effect on January 1, 2008.
(c) Reporting Information on Dental Health-
(1) MEDICAID- Section 1902(a)(43)(D)(iii) of such Act
(42 U.S.C. 1396a(a)(43)(D)(iii)) is amended by inserting `and other
information relating to the provision of dental services to such
children described in section 2108(e)' after `receiving dental
services,'.
(2) CHIP- Section 2108 of such Act (42 U.S.C. 1397hh) is amended by adding at the end the following new subsection:
`(e) Information on Dental Care for Children-
`(1) IN GENERAL- Each annual report under subsection
(a) shall include the following information with respect to care and
services described in section 1905(r)(3) provided to targeted
low-income children enrolled in the State child health plan under this
title at any time during the year involved:
`(A) The number of enrolled children by age grouping used for reporting purposes under section 1902(a)(43).
`(B) For children within each such age grouping,
information of the type contained in questions 12(a)-(c) of CMS Form
416 (that consists of the number of enrolled targeted low income
children who receive any, preventive, or restorative dental care under
the State plan).
`(C) For the age grouping that includes children 8
years of age, the number of such children who have received a
protective sealant on at least one permanent molar tooth.
`(2) INCLUSION OF INFORMATION ON ENROLLEES IN MANAGED
CARE PLANS- The information under paragraph (1) shall include
information on children who are enrolled in managed care plans and
other private health plans and contracts with such plans under this
title shall provide for the reporting of such information by such plans
to the State.'.
(3) EFFECTIVE DATE- The amendments made by this
subsection shall be effective for annual reports submitted for years
beginning after date of enactment.
(d) GAO Study and Report-
(1) STUDY- The Comptroller General of the United States shall provide for a study that examines--
(A) access to dental services by children in underserved areas; and
(B) the feasibility and appropriateness of using
qualified mid-level dental health providers, in coordination with
dentists, to improve access for children to oral health services and
public health overall.
(2) REPORT- Not later than 1 year after the date of the
enactment of this Act, the Comptroller General shall submit to Congress
a report on the study conducted under paragraph (1).
SEC. 145. PROHIBITING INITIATION OF NEW HEALTH OPPORTUNITY ACCOUNT DEMONSTRATION PROGRAMS.
After the date of the enactment of this Act, the Secretary
of Health and Human Services may not approve any new demonstration
programs under section 1938 of the Social Security Act (42 U.S.C.
1396u-8).
Subtitle F--Quality and Program Integrity
SEC. 151. PEDIATRIC HEALTH QUALITY MEASUREMENT PROGRAM.
(a) Quality Measurement of Children's Health-
(1) ESTABLISHMENT OF PROGRAM TO DEVELOP QUALITY
MEASURES FOR CHILDREN'S HEALTH- The Secretary of Health and Human
Services (in this section referred to as the `Secretary') shall
establish a child health care quality measurement program (in this
subsection referred to as the `children's health quality measurement
program') to develop and implement--
(A) pediatric quality measures on children's health
care that may be used by public and private health care purchasers (and
a system for reporting such measures); and
(B) measures of overall program performance that may be used by public and private health care purchasers.
The Secretary shall publish, not later than September
30, 2009, the recommended measures under the program for application
under the amendments made by subsection (b) for years beginning with
2010.
(A) SCOPE- The measures developed under the children's health quality measurement program shall--
(i) provide comprehensive information with
respect to the provision and outcomes of health care for young
children, school age children, and older children;
(ii) be designed to identify disparities by
pediatric characteristics (including, at a minimum, those specified in
subparagraph (C)) in child health and the provision of health care;
(iii) be designed to ensure that the data
required for such measures is collected and reported in a standard
format that permits comparison at a State, plan, and provider level,
and between insured and uninsured children;
(iv) take into account existing measures of child health quality and be periodically updated;
(v) include measures of clinical health care
quality which meet the requirements for pediatric quality measures in
paragraph (1);
(vi) improve and augment existing measures of
clinical health care quality for children's health care and develop new
and emerging measures; and
(vii) increase the portfolio of evidence-based
pediatric quality measures available to public and private purchasers,
providers, and consumers.
(B) SPECIFIC MEASURES- Such measures shall include
measures relating to at least the following aspects of health care for
children:
(i) The proportion of insured (and uninsured)
children who receive age-appropriate preventive health and dental care
(including age appropriate immunizations) at each stage of child health
development.
(ii) The proportion of insured (and uninsured)
children who receive dental care for restoration of teeth, relief of
pain and infection, and maintenance of dental health.
(iii) The effectiveness of early health care
interventions for children whose assessments indicate the presence or
risk of physical or mental conditions that could adversely affect
growth and development.
(iv) The effectiveness of treatment to
ameliorate the effects of diagnosed physical and mental health
conditions, including chronic conditions.
(v) The proportion of children under age 21 who are continuously insured for a period of 12 months or longer.
(vi) The effectiveness of health care for children with disabilities.
(vii) Data on State efforts to reduce
hospitalization rate of premature infants under the age of 12 months
who were born prior to 35 weeks.
In carrying out clause (vi), the Secretary shall develop quality measures and best practices relating to cystic fibrosis.
(C) REPORTING METHODOLOGY FOR ANALYSIS BY PEDIATRIC
CHARACTERISTICS- The children's health quality measurement program
shall describe with specificity such measures and the process by which
such measures will be reported in a manner that permits analysis based
on each of the following pediatric characteristics:
(v) Primary language of the child's parents (or caretaker relative).
(vi) Disability or chronic condition (including cystic fibrosis).
(vii) Geographic location.
(viii) Coverage status under public and private health insurance programs.
(D) PEDIATRIC QUALITY MEASURE- In this subsection,
the term `pediatric quality measure' means a measurement of clinical
care that assesses one or more aspects of pediatric health care quality
(in various settings) including the structure of the clinical care
system, the process and outcome of care, or patient experience in such
care.
(3) CONSULTATION IN DEVELOPING QUALITY MEASURES FOR
CHILDREN'S HEALTH SERVICES- In developing and implementing the
children's health quality measurement program, the Secretary shall
consult with--
(B) pediatric hospitals, pediatricians, and other
primary and specialized pediatric health care professionals (including
members of the allied health professions) who specialize in the care
and treatment of children, particularly children with special physical,
mental, and developmental health care needs;
(C) dental professionals;
(D) health care providers that furnish primary
health care to children and families who live in urban and rural
medically underserved communities or who are members of distinct
population sub-groups at heightened risk for poor health outcomes;
(E) national organizations representing children, including children with disabilities and children with chronic conditions;
(F) national organizations and individuals with expertise in pediatric health quality performance measurement; and
(G) voluntary consensus standards setting
organizations and other organizations involved in the advancement of
evidence based measures of health care.
(4) USE OF GRANTS AND CONTRACTS- In carrying out the
children's health quality measurement program, the Secretary may award
grants and contracts to develop, test, validate, update, and
disseminate quality measures under the program.
(5) TECHNICAL ASSISTANCE- The Secretary shall provide
technical assistance to States to establish for the reporting of
quality measures under titles XIX and XXI of the Social Security Act in
accordance with the children's health quality measurement program.
(b) Dissemination of Information on the Quality of Program
Performance- Not later than January 1, 2009, and annually thereafter,
the Secretary shall collect, analyze, and make publicly available on a
public website of the Department of Health and Human Services in an
online format--
(1) a complete list of all measures in use by States as
of such date and used to measure the quality of medical and dental
health services furnished to children enrolled under title XIX of XXI
of the Social Security Act by participating providers, managed care
entities, and plan issuers; and
(2) information on health care quality for children
contained in external quality review reports required under section
1932(c)(2) of such Act (42 U.S.C. 1396u-2) or produced by States that
administer separate plans under title XXI of such Act.
(c) Reports to Congress on Program Performance- Not later
than January 1, 2010, and every 2 years thereafter, the Secretary shall
report to Congress on--
(1) the quality of health care for children enrolled
under titles XIX and XXI of the Social Security Act under the
children's health quality measurement program; and
(2) patterns of health care utilization with respect to
the measures specified in subsection (a)(2)(B) among children by the
pediatric characteristics listed in subsection (a)(2)(C).
SEC. 152. APPLICATION OF CERTAIN MANAGED CARE QUALITY SAFEGUARDS TO CHIP.
(a) In General- Section 2103(f) of Social Security Act (42
U.S.C. 1397bb(f)) is amended by adding at the end the following new
paragraph:
`(3) COMPLIANCE WITH MANAGED CARE REQUIREMENTS- The
State child health plan shall provide for the application of
subsections (a)(4), (a)(5), (b), (c), (d), and (e) of section 1932
(relating to requirements for managed care) to coverage, State
agencies, enrollment brokers, managed care entities, and managed care
organizations under this title in the same manner as such subsections
apply to coverage and such entities and organizations under title XIX.'.
(b) Effective Date- The amendment made by subsection (a)
shall apply to contract years for health plans beginning on or after
July 1, 2008.
SEC. 153. UPDATED FEDERAL EVALUATION OF CHIP.
Section 2108(c) of the Social Security Act (42 U.S.C.
1397hh(c)) is amended by striking paragraph (5) and inserting the
following:
`(5) SUBSEQUENT EVALUATION USING UPDATED INFORMATION-
`(A) IN GENERAL- The Secretary, directly or through
contracts or interagency agreements, shall conduct an independent
subsequent evaluation of 10 States with approved child health plans.
`(B) SELECTION OF STATES AND MATTERS INCLUDED-
Paragraphs (2) and (3) shall apply to such subsequent evaluation in the
same manner as such provisions apply to the evaluation conducted under
paragraph (1).
`(C) SUBMISSION TO CONGRESS- Not later than
December 31, 2010, the Secretary shall submit to Congress the results
of the evaluation conducted under this paragraph.
`(D) FUNDING- Out of any money in the Treasury of
the United States not otherwise appropriated, there are appropriated
$10,000,000 for fiscal year 2009 for the purpose of conducting the
evaluation authorized under this paragraph. Amounts appropriated under
this subparagraph shall remain available for expenditure through fiscal
year 2011.'.
SEC. 154. ACCESS TO RECORDS FOR IG AND GAO AUDITS AND EVALUATIONS.
Section 2108(d) of the Social Security Act (42 U.S.C. 1397hh(d)) is amended to read as follows:
`(d) Access to Records for IG and GAO Audits and
Evaluations- For the purpose of evaluating and auditing the program
established under this title, the Secretary, the Office of Inspector
General, and the Comptroller General shall have access to any books,
accounts, records, correspondence, and other documents that are related
to the expenditure of Federal funds under this title and that are in
the possession, custody, or control of States receiving Federal funds
under this title or political subdivisions thereof, or any grantee or
contractor of such States or political subdivisions.'.
SEC. 155. REFERENCES TO TITLE XXI.
Section 704 of the Medicare, Medicaid, and SCHIP Balanced
Budget Refinement Act of 1999 (Appendix F, 113 Stat. 1501A-321), as
enacted into law by section 1000(a)(6) of Public Law 106-113) is
repealed and the item relating to such section in the table of contents
of such Act is repealed.
SEC. 156. RELIANCE ON LAW; EXCEPTION FOR STATE LEGISLATION.
(a) Reliance on Law- With respect to amendments made by this title or title VIII that become effective as of a date--
(1) such amendments are effective as of such date
whether or not regulations implementing such amendments have been
issued; and
(2) Federal financial participation for medical
assistance or child health assistance furnished under title XIX or XXI,
respectively, of the Social Security Act on or after such date by a
State in good faith reliance on such amendments before the date of
promulgation of final regulations, if any, to carry out such amendments
(or before the date of guidance, if any, regarding the implementation
of such amendments) shall not be denied on the basis of the State's
failure to comply with such regulations or guidance.
(b) Exception for State Legislation- In the case of a State
plan under title XIX or State child health plan under XXI of the Social
Security Act, which the Secretary of Health and Human Services
determines requires State legislation in order for respective plan to
meet one or more additional requirements imposed by amendments made by
this title or title VIII, the respective State plan shall not be
regarded as failing to comply with the requirements of such title
solely on the basis of its failure to meet such an additional
requirement before the first day of the first calendar quarter
beginning after the close of the first regular session of the State
legislature that begins after the date of enactment of this Act. For
purposes of the previous sentence, in the case of a State that has a
2-year legislative session, each year of the session shall be
considered to be a separate regular session of the State legislature.
TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A--Improvements in Benefits
SEC. 201. COVERAGE AND WAIVER OF COST-SHARING FOR PREVENTIVE SERVICES.
(a) Preventive Services Defined; Coverage of Additional
Preventive Services- Section 1861 of the Social Security Act (42 U.S.C.
1395x) is amended--
(1) in subsection (s)(2)--
(A) in subparagraph (Z), by striking `and' after the semicolon at the end;
(B) in subparagraph (AA), by adding `and' after the semicolon at the end; and
(C) by adding at the end the following new subparagraph:
`(BB) additional preventive services (described in subsection (ccc)(1)(M));'; and
(2) by adding at the end the following new subsection:
`Preventive Services
`(ccc)(1) The term `preventive services' means the following:
`(A) Prostate cancer screening tests (as defined in subsection (oo)).
`(B) Colorectal cancer screening tests (as defined in subsection (pp)).
`(C) Diabetes outpatient self-management training services (as defined in subsection (qq)).
`(D) Screening for glaucoma for certain individuals (as described in subsection (s)(2)(U)).
`(E) Medical nutrition therapy services for certain individuals (as described in subsection (s)(2)(V)).
`(F) An initial preventive physical examination (as defined in subsection (ww)).
`(G) Cardiovascular screening blood tests (as defined in subsection (xx)(1)).
`(H) Diabetes screening tests (as defined in subsection described in subsection (s)(2)(Y)).
`(I) Ultrasound screening for abdominal aortic
aneurysm for certain individuals (as described in described in
subsection (s)(2)(AA)).
`(J) Pneumococcal and influenza vaccine and their administration (as described in subsection (s)(10)(A)).
`(K) Hepatitis B vaccine and its administration for certain individuals (as described in subsection (s)(10)(B)).
`(L) Screening mammography (as defined in subsection (jj)).
`(M) Screening pap smear and screening pelvic exam (as described in subsection (s)(14)).
`(N) Bone mass measurement (as defined in subsection (rr)).
`(O) Additional preventive services (as determined under paragraph (2)).
`(2)(A) The term `additional preventive services' means
items and services, including mental health services, not described in
subparagraphs (A) through (N) of paragraph (1) that the Secretary
determines to be reasonable and necessary for the prevention or early
detection of an illness or disability.
`(B) In making determinations under subparagraph (1), the Secretary shall--
`(i) take into account evidence-based
recommendations by the United States Preventive Services Task Force and
other appropriate organizations; and
`(ii) use the process for making national coverage determinations (as defined in section 1869(f)(1)(B)) under this title.'.
(b) Payment and Elimination of Cost-Sharing-
(A) IN GENERAL- Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended--
(i) in clause (T), by striking `80 percent' and inserting `100 percent';
(ii) by striking `and' before `(V)'; and
(iii) by inserting before the semicolon at the
end the following: `, and (W) with respect to additional preventive
services (as defined in section 1861(ccc)(2)) and other preventive
services for which a payment rate is not otherwise established under
this section, the amount paid shall be 100 percent of the lesser of the
actual charge for the services or the amount determined under a fee
schedule established by the Secretary for purposes