HR 1142 IH

To amend title XIX of the Social Security Act to permit uninsured individuals to obtain coverage under the Medicaid Program, to assure coverage of prescription drugs, alcohol and drug abuse treatment services, mental health services, long-term care services, and other services, and for other purposes.

March 21, 2001

Mr. CONYERS (for himself, Mrs. CHRISTENSEN, Mr. BONIOR, and Mrs. JONES of Ohio) introduced the following bill; which was referred to the Committee on Energy and Commerce

To amend title XIX of the Social Security Act to permit uninsured individuals to obtain coverage under the Medicaid Program, to assure coverage of prescription drugs, alcohol and drug abuse treatment services, mental health services, long-term care services, and other services, 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.

This Act may be cited as the `Working American Families Access to Health Care Act of 2001' or `Medi-Access Act of 2001'.

SEC. 2. MEDI-ACCESS PROGRAM.

(a) AVAILABILITY OF MEDICAID COVERAGE FOR UNINSURED INDIVIDUAL UNDER MEDI-ACCESS-

(1) EXPANSION TO INDIVIDUALS WITH FAMILY INCOME BELOW 400 PERCENT (OR 600 PERCENT IN 2004) OF POVERTY LINE WITHOUT APPLYING ANY ASSET TEST-

(A) IN GENERAL- Section 1902 of the Social Security Act (42 U.S.C. 1396a) is amended--

(i) in subsection (a)(10)(A)(i)--

(I) by striking `or' at the end of subclause (VI);

(II) by striking the semicolon at the end of subclause (VII) and inserting `, or'; and

(III) by adding at the end the following new subclause:

`(VIII) described in subsection (cc);'; and

(ii) by adding at the end, as amended by section 2(a) of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Public Law 106-354; 114 Stat. 1381) and section 702(b) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (as enacted into law by section 1(a)(6) of Public Law 106-554), the following new subsection:

`(cc)(1) For purposes of (a)(10)(A)(i)(VIII), individuals described in this subsection are individuals who meet the following requirements:

`(A) Subject to paragraph (2), the income of the individual's family does not exceed 400 percent (or, effective January 1, 2004, 600 percent) of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved.

`(B) The individual is not otherwise described or covered under this title under any other provision.

`(C) Subject to paragraph (2), the individual does not have creditable coverage (described in section 2701(c)(1) of the Public Health Service Act, but not taking into account subparagraph (F) of that section or eligibility for benefits under title XXI).

`(2) The requirements of subparagraphs (A) and (C) of paragraph (1) shall not apply in the case of an individual if it is clearly demonstrated with respect to that individual that--

`(A) the individual has a life threatening, or a severe and debilitating, illness or injury; and

`(B)(i) any private health plan or health benefits coverage under which the individual is covered will not cover the illness or injury due to pre-existing condition policies, or (ii) the individual or family member would pay excessively high monthly premiums or out-of-pocket expenses if covered under such a plan or coverage due to having such illness or injury.

Eligibility under this paragraph shall be determined by the State on a case-by-case basis.

`(3) An individual who is described in this subsection is eligible for medical assistance without regard to the amount of the assets or resources of the individual or the individual's family.'.

(B) NO PREMIUMS FOR INDIVIDUALS WITH INCOME BELOW 300 PERCENT OF POVERTY LINE; REQUIRING PREMIUMS ONLY FOR INDIVIDUALS WITH HIGHER INCOME- Section 1916 of such Act (42 U.S.C. 1396o) is amended--

(i) in subsection (a), by striking `Subject to subsection (g)' and inserting `Subject to subsections (g) and (h)'; and

(ii) by adding at the end the following new subsection:

`(h) With respect to an individual provided medical assistance only under subclause (VIII) of section 1902(a)(10)(A)(i), if the individual's family income--

`(1) does not exceed 300 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved, a State shall not require payment of any monthly premium;

`(2) exceeds 300 percent (but does not exceed 350 percent) of such poverty line applicable to a family of the size involved, a State shall require such individuals to pay a monthly premium equal to $25 per month for each individual in the family so covered, but not to exceed $100 per month for all individuals in the family;

`(3) exceeds 350 percent (but does not exceed 400 percent) of such poverty line, the State shall require such individuals to pay a monthly premium equal to $50 per month for each individual in the family so covered, but not to exceed $150 per month for all individuals in the family; or

`(4) exceeds 400 percent of such poverty line, the State shall require such individuals to pay a monthly premium equal to $150 per month for each individual in the family so covered, but not to exceed $450 per month for all individuals in the family.

A State may enter into an arrangement with an employer that employs at least 2, but fewer than 51, employees under which the employer will pay directly for premiums established under this subsection. Nothing in this subsection shall be construed as authorizing the use of premiums collected under this subsection for vouchers for the purchase of private health insurance.'.

(C) MISCELLANEOUS CONFORMING AMENDMENT- (i) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)) is amended by inserting `1902(a)(10)(A)(i)(VIII),' after `1902(a)(10)(A)(i)(VII),'.

(D) TECHNICAL AMENDMENTS- (i) Section 1902 of such Act (42 U.S.C. 1396a), as amended by section 702(b) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (as enacted into law by section 1(a)(6) of Public Law 106-554), is amended by redesignating the subsection (aa) added by such section as subsection (bb).

(ii) Section 1902(a)(15) of such Act (42 U.S.C. 1396a(a)(15)), as added by section 702(a)(2) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (as so enacted into law), is amended by striking `subsection (aa)' and inserting `subsection (bb)'.

(iii) Section 1915(b) of such Act (42 U.S.C. 1396n(b)), as amended by section 702(c)(2) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (as so enacted into law), is amended by striking `1902(aa)' and inserting `1902(bb)'.

(2) CLARIFICATION OF COVERAGE OF UNINSURED MEN AND WOMEN, REGARDLESS OF MARITAL STATUS- Section 1905(a) of such Act (42 U.S.C. 1396d(a)) is amended, in the matter before paragraph (1)--

(A) by striking `or' at the end of clause (xi);

(B) by adding `or' at the end of clause (xii); and

(C) by inserting after clause (xii) the following new clause:

`(xiii) individuals described in section 1902(cc) (which includes uninsured men and women, regardless of marital status),'.

(3) MAKING PRESUMPTIVE ELIGIBILITY MANDATORY-

(A) IN GENERAL- Sections 1920 and 1920A of such Act (42 U.S.C. 1396r-1, 1396r-1a) are each amended by striking `may provide' and inserting `shall provide'.

(B) EXPANSION OF PRESUMPTIVE ELIGIBILITY TO ALL INDIVIDUALS- Title XIX of the Act is amended by inserting after section 1920A the following new section:

`PRESUMPTIVE ELIGIBILITY FOR OTHER INDIVIDUALS

`SEC. 1920B. (a) A State plan approved under section 1902 shall provide for making medical assistance with respect to health care items and services covered under the State plan available to all individuals during a presumptive eligibility period.

`(b) For purposes of this section:

`(1) The term `presumptive eligibility period' means, with respect to an individual, the period that--

`(A) begins with the date on which a qualified entity determines, on the basis of preliminary information, that the family income of the individual does not exceed the applicable income level of eligibility under the State plan, and

`(B) ends with (and includes) the earlier of--

`(i) the day on which a determination is made with respect to the eligibility of the individual for medical assistance under the State plan, or

`(ii) in the case of an individual on whose behalf an application is not filed by the last day of the month following the month during which the entity makes the determination referred to in subparagraph (A), such last day.

`(3)(A) Subject to subparagraph (B), the term `qualified entity' means any entity that--

`(i)(I) is eligible for payments under a State plan approved under this title and provides items and services described in subsection (a) or (II) is a qualified provider described in section 1920(b)(2); and

`(ii) is determined by the State agency to be capable of making determinations of the type described in paragraph (1)(A).

`(B) The Secretary may issue regulations further limiting those entities that may become qualified entities in order to prevent fraud and abuse and for other reasons.

`(C) Nothing in this section shall be construed as preventing a State from limiting the classes of entities that may become qualified entities, consistent with any limitations imposed under subparagraph (B).

`(c)(1) The State agency shall provide qualified entities with--

`(A) such forms as are necessary for an application to be made on behalf of a child for medical assistance under the State plan, and

`(B) information on how to assist parents, guardians, and other persons in completing and filing such forms.

`(2) A qualified entity that determines under subsection (b)(1)(A) that an individual is presumptively eligible for medical assistance under a State plan shall--

`(A) notify the State agency of the determination within 5 working days after the date on which determination is made, and

`(B) inform the individual at the time the determination is made that an application for medical

assistance under the State plan is required to be made by not later than the last day of the month following the month during which the determination is made.

`(3) In the case of an individual who is determined by a qualified entity to be presumptively eligible for medical assistance under a State plan, the individual shall make application for medical assistance under such plan by not later than the last day of the month following the month during which the determination is made.

`(d) Notwithstanding any other provision of this title, medical assistance for items and services described in subsection (a) that--

`(1) are furnished to an individual--

`(A) during a presumptive eligibility period,

`(B) by an entity that is eligible for payments under the State plan; and

`(2) are included in the care and services covered by a State plan;

shall be treated as medical assistance provided by such plan for purposes of section 1903.'.

(C) CONFORMING AMENDMENT- Section 1902(a)(47) of such Act (42 U.S.C. 1396a(a)(47)) is amended by striking `at the option of the State,'.

(4) MINIMUM ELIGIBILITY PERIOD FOR CATEGORICALLY NEEDY- Section 1902(e) of such Act (42 U.S.C. 1396a(e)) is amended by adding at the end the following new paragraph:

`(13) The State plan shall provide that an individual who is determined to be eligible for benefits under a State plan approved under this title under subsection (a)(10)(A) shall remain eligible for those benefits until the end of the 12-month period following the date of such determination.'.

(5) COVERAGE OF LEGAL IMMIGRANTS- Section 1902 of such Act (42 U.S.C. 1396a), as amended by paragraph (1)(A)(ii), is amended by adding at the end the following new subsection:

`(dd) Notwithstanding any other provision of law, the provisions title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (and of section 213A of the Immigration and Nationality Act) shall not apply to eligibility for medical assistance under this title for individuals who are lawful permanent residents of the United States.'.

(6) MAIL-IN AND ON-LINE APPLICATION PROCESS- Section 1902(a)(8) of such Act (42 U.S.C. 1396a(a)(8)) is amended after `opportunity to do so' the following: `and may do so through an application submitted by mail or through electronic means through the Internet, provide that applications are not longer than 3 pages and are made available in different languages in order to provide a fair and accessible application process,'.

(7) CONFORMING TERMINATION OF SCHIP- With respect to items and services furnished on or after October 1, 2002, no Federal payments shall be made under section 2105(a) of the Social Security Act (42 U.S.C. 1397ee(a)).

(b) REQUIRING COVERAGE OF EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT SERVICES (EPSDT), COVERAGE OF REHABILITATIVE SERVICES FOR DISABLED OR DEVELOPMENTALLY DELAYED CHILDREN, PRESCRIPTION DRUGS, MENTAL HEALTH AND PSYCHIATRIC SERVICES, ASSISTIVE TECHNOLOGY DEVICES AND SERVICES, DURABLE MEDICAL EQUIPMENT, DRUG AND ALCOHOL TREATMENT SERVICES FOR ALL MEDICAID ELIGIBLE INDIVIDUALS, ASSISTIVE TECHNOLOGY DEVICES AND SERVICES, DURABLE MEDICAL EQUIPMENT, PRENATAL AND POSTNATAL CARE, AND REPRODUCTIVE HEALTH SERVICES-

(1) REQUIRING COVERAGE OF SCREENING, DENTAL, VISION, HEARING, AND FOLLOWUP SERVICES (EPSDT) FOR INDIVIDUALS OF ALL AGES-

(A) IN GENERAL- Section 1905(a)(4)(B) of such Act (42 U.S.C. 1396d(a)(4)(B)) is amended by striking `and are under the age of 21'.

(B) CONFORMING AMENDMENTS- Section 1905(r) of such Act (42 U.S.C. 1396d(r)) is amended, in each of paragraphs (1)(A)(i), (2)(A)(i), (3)(A)(i), and (4)(A)(i), by inserting `, including for children, organizations' after `organizations'.

(2) REQUIRING COVERAGE OF REHABILITATIVE SERVICES AND ASSISTIVE TECHNOLOGIES FOR DISABLED OR DEVELOPMENTALLY DELAYED CHILDREN- Section 1905(r)(5) of such Act (42 U.S.C. 1396d(r)(5)) is amended by inserting before the period at the end the following: `, and including rehabilitative services and assistive technologies for disabled or developmentally disabled children, regardless of whether the disability was discovered by the screening services'.

(3) REQUIRING COVERAGE OF PRESCRIPTION DRUGS- Section 1902(a)(10) of such Act (42 U.S.C. 1396a(a)(10)) is amended--

(A) in subparagraph (A), by inserting `(12),' after `(5),';

(B) in subparagraph (D)(iv), by inserting `, (12),' after `(5)';

(C) by striking `and' at the end of subparagraph (F);

(D) by adding `and' at the end of subparagraph (G); and

(E) by inserting after subparagraph (G) the following new subparagraph:

`(H) that the plan shall not deny medical assistance for prescribed drugs for individuals described in subparagraph (A)(i) if the drugs have been prescribed by a treating physician (or any other treating health care professional authorized under law to prescribe the drugs);'.

(4) REQUIRING COVERAGE OF DRUG AND ALCOHOL TREATMENT SERVICES-

(A) REQUIREMENT- Section 1902(a)(10) of such Act (42 U.S.C. 1396a(a)(10)) is amended--

(i) in subparagraph (A), by striking `(17) and (21)' and inserting `(10), (17), (21), and (27)'; and

(ii) in subparagraph (D)(iv), by striking `and (17)' and inserting `(10), (17), and (27)' and by striking `through (24)' and inserting `through (27)'.

(B) DRUG AND ALCOHOL TREATMENT SERVICES DESCRIBED- Section 1905(a) of such Act (42 U.S.C. 1396d(a)) is amended--

(i) by striking `and' at the end of paragraph (26);

(ii) by redesignating paragraph (27) as paragraph (28); and

(iii) by inserting after paragraph (26) the following new paragraph:

`(27) alcohol and drug treatment services, including coverage of inpatient and outpatient treatment without durational restriction; and'.

(5) REQUIRING COVERAGE OF INPATIENT AND OUTPATIENT MENTAL HEALTH AND PSYCHIATRIC SERVICES- Section 1905(a)(5) of such Act (42 U.S.C. 1396d(a)(5)) is amended--

(A) by striking `and' before `(B)'; and

(B) by inserting before the semicolon at the end the following: `, and (C) mental health services and psychiatric services furnished by a physician or other qualified mental health professional, whether furnished on an inpatient or outpatient basis'.

(6) REQUIRING COVERAGE OF MENTAL HEALTH SERVICES WITHOUT DURATIONAL RESTRICTION- Section 1902(a)(10) of such Act (42 U.S.C. 1396a(a)(10)) is amended--

(A) by striking `and' at the end of subparagraph (F);

(B) by adding `and' at the end of subparagraph (G); and

(C) by inserting after subparagraph (G) the following new subparagraph:

`(H) that does not impose durational limits with respect to medical assistance for mental health services;'.

(7) REQUIRING COVERAGE OF SOME CHIROPRACTIC SERVICES- Section 1902(a)(10)(A) of such Act (42 U.S.C. 1396a(a)(10)(A)) is amended, in the matter before clause (i), by inserting `and professional services of chiropractors (other than electrical stimulation and for up to 2 visits per month)' after `(21) of section 1905(a)'.

(8) REQUIRING COVERAGE OF ASSISTIVE TECHNOLOGY DEVICES AND SERVICES, DURABLE MEDICAL EQUIPMENT, SEXUALLY-TRANSMITTED DISEASE (STD) DIAGNOSIS AND TREATMENT, AND PRENATAL AND POST-NATAL CARE- Section 1905(a)(3) of such Act (42 U.S.C. 1396d(a)(3)) is amended by inserting before the semicolon at the end the following: `, assistive technology devices and services, durable medical equipment, diagnosis and treatment for sexually-transmitted disease, and prenatal and postnatal care'.

(9) REQUIRING COVERAGE OF REPRODUCTIVE HEALTH SERVICES- Section 1905(a)(4)(C) of such Act (42 U.S.C. 1396d(a)(4)(C)) is amended by inserting `, including reproductive health services such as fertility drugs and contraceptives' after `such services and supplies'.

(c) FMAP-

(1) FEDERAL ASSUMPTION OF INCREASED EXPENSES- Section 1903 of such Act (42 U.S.C. 1396b) is amended by inserting after subsection (g) the following new subsection:

`(h) Notwithstanding subsection (a), with respect to expenditures incurred under the plan which are attributable to additional populations, or services, covered as a result of the implementation of the amendments made by the Working American Families Access to Health Care Act of 2001 (including administrative costs related to such implementation), the percentages otherwise specified under such subsection with respect to such expenditures shall be increased to 100 percent. For purposes of applying the previous sentence, the fact that a population or service was covered under this title under a waiver under section 1115 shall not be taken into account and shall not prevent such sentence applying to such population or service.'.

(2) SPECIAL RULES IN APPLYING TO TERRITORIES- (A) Section 1905(b)(2) of such Act (42 U.S.C. 1396d(b)(2)) is amended by striking `50 percent' and inserting `70 percent'.

(B) Section 1108 of such Act (42 U.S.C. 1308) is amended--

(i) in subsection (f), by striking `subsection (g)' and inserting `subsections (g) and (h)'; and

(ii) by adding at the end the following new subsection:

`(h) The limitations under subsection (f)--

`(1) shall not apply with respect to expenditures described in section 1903(h); and

`(2) with respect to other expenditures made for fiscal years beginning with fiscal year 2002 with respect to a territory shall be 250 percent of the amount otherwise permitted under such subsection and subsection (g) with respect to such territory.'.

(d) STATE-LIKE TREATMENT OF TERRITORIES- Section 1108 of such Act (42 U.S.C. 1308) is amended--

(1) in subsection (f), by striking `subsection (g)' and inserting `subsections (g) and (h)'; and

(2) by adding at the end the following new subsection:

`(h) EXEMPTION OF CERTAIN EXPENDITURES FROM LIMITATION- Amounts of expenditures attributable to medical assistance provided under section 1902(a)(10)(A)(i)(VIII) (or otherwise required to carry out the amendments made by the Working American Families Access to Health Care Act of 2001) shall not be taken into account in applying subsections (f) and (g).'.

(e) REQUIRED USE OF COMMUNITY-BASED ORGANIZATIONS IN EXPENDITURES FOR OUTREACH AND MEDIA- Section 1903(i) of such Act (42 U.S.C.

1396b(i)) is amended by inserting after paragraph (8) the following new paragraph:

`(9) with respect to amounts expended for outreach and media education campaigns (including amounts expended for assistance to those applying for medical assistance), unless at least 25 percent of such amounts are made available for such expenditures through community-based organizations; or'.

(f) FLOOR FOR MEDICAID HMO PAYMENT FOR ALL SERVICES- Section 1932(b) of such Act (42 U.S.C. 1396u-2(b)) is amended by adding at the end the following new paragraph:

`(9) PAYMENT FLOOR FOR ALL SERVICES- A medicaid managed care organization shall not reimburse a hospital or other health care provider or professional for the provision of services under this section at a rate that is less the fee-for-service rate provided by the State for payment for such a hospital, provider, or professional for such services under this title in the case of individuals who are not enrolled with such an organization under this section.'.

(g) TOLL-FREE NUMBER- Section 1902 of such Act (42 U.S.C. 1396a) is amended by inserting after subsection (j) the following new subsection:

`(k) The Secretary shall establish a toll-free telephone number at which individuals who are eligible for medical assistance under this title may file complaints concerning health care providers who do not accept medical assistance under this title for services they provide or concerning other problems they have with the program under this title.'.

(h) COLLECTION OF DATA BY RACE AND ETHNICITY- The Secretary of Health and Human Services shall provide for the collection of data on enrollment, receipt of services, and health outcomes under the medicaid program under title XIX of the Social Security Act, broken down at least by the race and ethnicity of medicaid recipients. The Director of the Office of Management and Budget shall make such revisions in data collection standards as may be necessary to carry out this subsection.

(i) EFFECTIVE DATE- The amendments made by this section shall take effect on January 1, 2002.

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