I 

109TH CONGRESS 

1ST SESSION H. R. 3055

To amend the Social Security Act to guarantee comprehensive health care 

coverage for all children born after 2006. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 23, 2005

Mr. STARK (for himself, Mr. ABERCROMBIE, Mr. BERMAN, Mr. BRADY of 

Pennsylvania, Mr. BROWN of Ohio, Mrs. CHRISTENSEN, Mr. CONYERS, 

Mr. CROWLEY, Mr. CUMMINGS, Mr. DAVIS of Illinois, Mr. DOGGETT, Mr. 

ENGEL, Mr. FALEOMAVAEGA, Mr. FILNER, Mr. GUTIERREZ, Mr. HINCHEY, Mr. JEFFERSON, Mr. KILDEE, Mr. KUCINICH, Ms. LEE, Mrs. 

MCCARTHY, Mr. MCDERMOTT, Mr. MCGOVERN, Ms. MILLENDERMCDONALD, Mr. PALLONE, Mr. RANGEL, Mr. RUSH, Mr. RYAN of Ohio, 

Ms. SCHAKOWSKY, Mr. SHERMAN, Mr. VAN HOLLEN, Mr. WEINER, Mr. 

WEXLER, Ms. WOOLSEY, and Mr. GEORGE MILLER of California) introduced the following bill; which was referred to the Committee on Ways 

and Means, and in addition to the Committee on Energy and Commerce, 

for a period to be subsequently determined by the Speaker, in each case 

for consideration of such provisions as fall within the jurisdiction of the 

committee concerned 

A BILL

To amend the Social Security Act to guarantee comprehensive health care coverage for all children born after 2006.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,
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1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS; FINDINGS. 

2 (a) SHORT TITLE.—This Act may be cited as the 

3 ‘‘MediKids Health Insurance Act of 2005’’. 

4 (b) TABLE OF CONTENTS.—The table of contents of 

5 this Act is as follows:

Sec. 1. Short title; table of contents; findings. 

Sec. 2. Benefits for all children born after 2006. 

‘‘TITLE XXII—MEDIKIDS PROGRAM 

‘‘Sec. 2201. Eligibility. 

‘‘Sec. 2202. Benefits. 

‘‘Sec. 2203. Premiums. 

‘‘Sec. 2204. MediKids Trust Fund. 

‘‘Sec. 2205. Oversight and accountability. 

‘‘Sec. 2206. Inclusion of care coordination services. 

‘‘Sec. 2207. Administration and miscellaneous. 

Sec. 3. MediKids premium. 

Sec. 4. Refundable credit for cost-sharing expenses under MediKids program. 

Sec. 5. Report on long-term revenues.

6 (c) FINDINGS.—Congress finds the following: 

7 (1) More than 9 million American children are 

8 uninsured. 

9 (2) Children who are uninsured receive less 

10 medical care and less preventive care and have a 

11 poorer level of health, which result in lifetime costs 

12 to themselves and to the entire American economy. 

13 (3) Although SCHIP and Medicaid are success14 fully extending a health coverage safety net to a 

15 growing portion of the vulnerable low-income popu16 lation of uninsured children, they alone cannot 

17 achieve 100 percent health insurance coverage for 

18 our nation’s children due to inevitable gaps during 

19 outreach and enrollment, fluctuations in eligibility, 
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1 variations in access to private insurance at all in2 come levels, and variations in States’ ability to pro3 vide required matching funds. 

4 (4) As all segments of society continue to be5 come more transient, with many changes in employ6 ment over the working lifetime of parents, the need 

7 for a reliable safety net of health insurance which 

8 follows children across State lines, already a major 

9 problem for the children of migrant and seasonal 

10 farmworkers, will become a major concern for all 

11 families in the United States. 

12 (5) The medicare program has successfully 

13 evolved over the years to provide a stable, universal 

14 source of health insurance for the nation’s disabled 

15 and those over age 65, and provides a tested model 

16 for designing a program to reach out to America’s 

17 children. 

18 (6) The problem of insuring 100 percent of all 

19 American children could be gradually solved by auto20 matically enrolling all children born after December 

21 31, 2006, in a program modeled after Medicare (and 

22 to be known as ‘‘MediKids’’), and allowing those 

23 children to be transferred into other equivalent or 

24 better insurance programs, including either private 

25 insurance, SCHIP, or Medicaid, if they are eligible 
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1 to do so, but maintaining the child’s default enroll2 ment in MediKids for any times when the child’s ac3 cess to other sources of insurance is lost. 

4 (7) A family’s freedom of choice to use other in5 surers to cover children would not be interfered with 

6 in any way, and children eligible for SCHIP and 

7 Medicaid would continue to be enrolled in those pro8 grams, but the underlying safety net of MediKids 

9 would always be available to cover any gaps in insur10 ance due to changes in medical condition, employ11 ment, income, or marital status, or other changes af12 fecting a child’s access to alternate forms of insur13 ance. 

14 (8) The MediKids program can be administered 

15 without impacting the finances or status of the exist16 ing Medicare program. 

17 (9) The MediKids benefit package can be tai18 lored to the special needs of children and updated 

19 over time. 

20 (10) The financing of the program can be ad21 ministered without difficulty by a yearly payment of 

22 affordable premiums through a family’s tax filing (or 

23 adjustment of a family’s earned income tax credit). 

24 (11) The cost of the program will gradually rise 

25 as the number of children using MediKids as the in-
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1 surer of last resort increases, and a future Congress 

2 always can accelerate or slow down the enrollment 

3 process as desired, while the societal costs for emer4 gency room usage, lost productivity and work days, 

5 and poor health status for the next generation of 

6 Americans will decline. 

7 (12) Over time 100 percent of American chil8 dren will always have basic health insurance, and we 

9 can therefore expect a healthier, more equitable, and 

10 more productive society. 

11 SEC. 2. BENEFITS FOR ALL CHILDREN BORN AFTER 2006. 

12 (a) IN GENERAL.—The Social Security Act is amend13 ed by adding at the end the following new title: 

14 ‘‘TITLE XXII—MEDIKIDS 

15 PROGRAM 

16 ‘‘SEC. 2201. ELIGIBILITY. 

17 ‘‘(a) ELIGIBILITY OF INDIVIDUALS BORN AFTER DE18 CEMBER 31, 2006; ALL CHILDREN UNDER 23 YEARS OF

19 AGE IN FIFTH YEAR.—An individual who meets the fol20 lowing requirements with respect to a month is eligible to 

21 enroll under this title with respect to such month: 

22 ‘‘(1) AGE.—

23 ‘‘(A) FIRST YEAR.—As of the first day of 

24 the first year in which this title is effective, the 

25 individual has not attained 6 years of age. 
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1 ‘‘(B) SECOND YEAR.—As of the first day 

2 of the second year in which this title is effec3 tive, the individual has not attained 11 years of 

4 age. 

5 ‘‘(C) THIRD YEAR.—As of the first day of 

6 the third year in which this title is effective, the 

7 individual has not attained 16 years of age. 

8 ‘‘(D) FOURTH YEAR.—As of the first day 

9 of the fourth year in which this title is effective, 

10 the individual has not attained 21 years of age. 

11 ‘‘(E) FIFTH AND SUBSEQUENT YEARS.—

12 As of the first day of the fifth year in which 

13 this title is effective and each subsequent year, 

14 the individual has not attained 23 years of age. 

15 ‘‘(2) CITIZENSHIP.—The individual is a citizen 

16 or national of the United States or is permanently 

17 residing in the United States under color of law. 

18 ‘‘(b) ENROLLMENT PROCESS.—An individual may 

19 enroll in the program established under this title only in 

20 such manner and form as may be prescribed by regula21 tions, and only during an enrollment period prescribed by 

22 the Secretary consistent with the provisions of this section. 

23 Such regulations shall provide a process under which—

24 ‘‘(1) individuals who are born in the United 

25 States after December 31, 2006, are deemed to be 
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1 enrolled at the time of birth and a parent or guard2 ian of such an individual is permitted to pre-enroll 

3 in the month prior to the expected month of birth; 

4 ‘‘(2) individuals who are born outside the 

5 United States after such date and who become eligi6 ble to enroll by virtue of immigration into (or an ad7 justment of immigration status in) the United 

8 States are deemed enrolled at the time of entry or 

9 adjustment of status; 

10 ‘‘(3) eligible individuals may otherwise be en11 rolled at such other times and manner as the Sec12 retary shall specify, including the use of outstationed 

13 eligibility sites as described in section 

14 1902(a)(55)(A) and the use of presumptive eligi15 bility provisions like those described in section 

16 1920A; and 

17 ‘‘(4) at the time of automatic enrollment of a 

18 child, the Secretary provides for issuance to a parent 

19 or custodian of the individual a card evidencing cov20 erage under this title and for a description of such 

21 coverage. 

22 The provisions of section 1837(h) apply with respect to 

23 enrollment under this title in the same manner as they 

24 apply to enrollment under part B of title XVIII. An indi25 vidual who is enrolled under this title is not eligible to 
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1 be enrolled under an MA or MA–PD plan under part C 

2 of title XVIII. 

3 ‘‘(c) DATE COVERAGE BEGINS.—

4 ‘‘(1) IN GENERAL.—The period during which 

5 an individual is entitled to benefits under this title 

6 shall begin as follows, but in no case earlier than 

7 January 1, 2007: 

8 ‘‘(A) In the case of an individual who is 

9 enrolled under paragraph (1) or (2) of sub10 section (b), the date of birth or date of obtain11 ing appropriate citizenship or immigration sta12 tus, as the case may be. 

13 ‘‘(B) In the case of another individual who 

14 enrolls (including pre-enrolls) before the month 

15 in which the individual satisfies eligibility for 

16 enrollment under subsection (a), the first day of 

17 such month of eligibility. 

18 ‘‘(C) In the case of another individual who 

19 enrolls during or after the month in which the 

20 individual first satisfies eligibility for enrollment 

21 under such subsection, the first day of the fol22 lowing month. 

23 ‘‘(2) AUTHORITY TO PROVIDE FOR PARTIAL

24 MONTHS OF COVERAGE.—Under regulations, the 

25 Secretary may, in the Secretary’s discretion, provide 
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1 for coverage periods that include portions of a 

2 month in order to avoid lapses of coverage. 

3 ‘‘(3) LIMITATION ON PAYMENTS.—No payments 

4 may be made under this title with respect to the ex5 penses of an individual enrolled under this title un6 less such expenses were incurred by such individual 

7 during a period which, with respect to the individual, 

8 is a coverage period under this section. 

9 ‘‘(d) EXPIRATION OF ELIGIBILITY.—An individual’s 

10 coverage period under this section shall continue until the 

11 individual’s enrollment has been terminated because the 

12 individual no longer meets the requirements of subsection 

13 (a) (whether because of age or change in immigration sta14 tus). 

15 ‘‘(e) ENTITLEMENT TO MEDIKIDS BENEFITS FOR

16 ENROLLED INDIVIDUALS.—An individual enrolled under 

17 this title is entitled to the benefits described in section 

18 2202. 

19 ‘‘(f) LOW-INCOME INFORMATION.—

20 ‘‘(1) INQUIRY OF INCOME.—At the time of en21 rollment of a child under this title, the Secretary 

22 shall make an inquiry as to whether the family in23 come (as determined for purposes of section 

24 1905(p)) of the family that includes the child is 

25 within any of the following income ranges: 
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1 ‘‘(A) UP TO 150 PERCENT OF POVERTY.—

2 The income of the family does not exceed 150 

3 percent of the poverty line for a family of the 

4 size involved. 

5 ‘‘(B) BETWEEN 150 AND 200 PERCENT OF

6 POVERTY.—The income of the family exceeds 

7 150 percent, but does not exceed 200 percent, 

8 of such poverty line. 

9 ‘‘(C) BETWEEN 200 AND 300 PERCENT OF

10 POVERTY.—The income of the family exceeds 

11 200 percent, but does not exceed 300 percent, 

12 of such poverty line. 

13 ‘‘(2) CODING.—If the family income is within a 

14 range described in paragraph (1), the Secretary 

15 shall encode in the identification card issued in con16 nection with eligibility under this title a code indi17 cating the range applicable to the family of the child 

18 involved. 

19 ‘‘(3) PROVIDER VERIFICATION THROUGH ELEC20 TRONIC SYSTEM.—The Secretary also shall provide 

21 for an electronic system through which providers 

22 may verify which income range described in para23 graph (1), if any, is applicable to the family of the 

24 child involved. 
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1 ‘‘(g) CONSTRUCTION.—Nothing in this title shall be 

2 construed as requiring (or preventing) an individual who 

3 is enrolled under this title from seeking medical assistance 

4 under a State medicaid plan under title XIX or child 

5 health assistance under a State child health plan under 

6 title XXI. 

7 ‘‘SEC. 2202. BENEFITS. 

8 ‘‘(a) SECRETARIAL SPECIFICATION OF BENEFIT

9 PACKAGE.—

10 ‘‘(1) IN GENERAL.—The Secretary shall specify 

11 the benefits to be made available under this title 

12 consistent with the provisions of this section and in 

13 a manner designed to meet the health needs of en14 rollees. 

15 ‘‘(2) UPDATING.—The Secretary shall update 

16 the specification of benefits over time to ensure the 

17 inclusion of age-appropriate benefits to reflect the 

18 enrollee population. 

19 ‘‘(3) ANNUAL UPDATING.—The Secretary shall 

20 establish procedures for the annual review and up21 dating of such benefits to account for changes in 

22 medical practice, new information from medical re23 search, and other relevant developments in health 

24 science. 
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1 ‘‘(4) INPUT.—The Secretary shall seek the 

2 input of the pediatric community in specifying and 

3 updating such benefits. 

4 ‘‘(5) LIMITATION ON UPDATING.—In no case 

5 shall updating of benefits under this subsection re6 sult in a failure to provide benefits required under 

7 subsection (b). 

8 ‘‘(b) INCLUSION OF CERTAIN BENEFITS.—

9 ‘‘(1) MEDICARE CORE BENEFITS.—Such bene10 fits shall include (to the extent consistent with other 

11 provisions of this section) at least the same benefits 

12 (including coverage, access, availability, duration, 

13 and beneficiary rights) that are available under 

14 parts A and B of title XVIII. 

15 ‘‘(2) ALL REQUIRED MEDICAID BENEFITS.—

16 Such benefits shall also include all items and serv17 ices for which medical assistance is required to be 

18 provided under section 1902(a)(10)(A) to individuals 

19 described in such section, including early and peri20 odic screening, diagnostic services, and treatment 

21 services. 

22 ‘‘(3) INCLUSION OF PRESCRIPTION DRUGS.—

23 Such benefits also shall include (as specified by the 

24 Secretary) benefits for prescription drugs and 

25 biologicals which are not less than the benefits for 
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1 such drugs and biologicals under the standard op2 tion for the service benefit plan described in section 

3 8903(1) of title 5, United States Code, offered dur4 ing 2005. 

5 ‘‘(4) COST-SHARING.—

6 ‘‘(A) IN GENERAL.—Subject to subpara7 graph (B), such benefits also shall include the 

8 cost-sharing (in the form of deductibles, coin9 surance, and copayments) which is substantially 

10 similar to such cost-sharing under the health 

11 benefits coverage in any of the four largest 

12 health benefits plans (determined by enroll13 ment) offered under chapter 89 of title 5, 

14 United States Code, and including an out-of15 pocket limit for catastrophic expenditures for 

16 covered benefits, except that no cost-sharing 

17 shall be imposed with respect to early and peri18 odic screening and diagnostic services included 

19 under paragraph (2). 

20 ‘‘(B) REDUCED COST-SHARING FOR LOW

21 INCOME CHILDREN.—Such benefits shall pro22 vide that—

23 ‘‘(i) there shall be no cost-sharing for 

24 children in families the income of which is 
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1 within the range described in section 

2 2201(f)(1)(A); 

3 ‘‘(ii) the cost-sharing otherwise appli4 cable shall be reduced by 75 percent for 

5 children in families the income of which is 

6 within the range described in section 

7 2201(f)(1)(B); or 

8 ‘‘(iii) the cost-sharing otherwise appli9 cable shall be reduced by 50 percent for 

10 children in families the income of which is 

11 within the range described in section 

12 2201(f)(1)(C). 

13 ‘‘(C) CATASTROPHIC LIMIT ON COST-SHAR14 ING.—For a refundable credit for cost-sharing 

15 in the case of cost-sharing in excess of a per16 centage of the individual’s adjusted gross in17 come, see section 36 of the Internal Revenue 

18 Code of 1986. 

19 ‘‘(c) PAYMENT SCHEDULE.—The Secretary, with the 

20 assistance of the Medicare Payment Advisory Commission, 

21 shall develop and implement a payment schedule for bene22 fits covered under this title. To the extent feasible, such 

23 payment schedule shall be consistent with comparable pay24 ment schedules and reimbursement methodologies applied 

25 under parts A and B of title XVIII. 
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1 ‘‘(d) INPUT.—The Secretary shall specify such bene2 fits and payment schedules only after obtaining input from 

3 appropriate child health providers and experts. 

4 ‘‘(e) ENROLLMENT IN HEALTH PLANS.—The Sec5 retary shall provide for the offering of benefits under this 

6 title through enrollment in a health benefit plan that 

7 meets the same (or similar) requirements as the require8 ments that apply to Medicare Advantage plans under part 

9 C of title XVIII (other than any such requirements that 

10 relate to part D of such title). In the case of individuals 

11 enrolled under this title in such a plan, the payment rate 

12 shall be based on payment rates provided for under section 

13 1853(c) in effect before the date of the enactment of the 

14 Medicare Prescription Drug, Modernization, and Improve15 ment Act of 2003 (Public Law 108–173), except that such 

16 payment rates shall be adjusted in an appropriate manner 

17 to reflect differences between the population served under 

18 this title and the population under title XVIII. 

19 ‘‘SEC. 2203. PREMIUMS. 

20 ‘‘(a) AMOUNT OF MONTHLY PREMIUMS.—

21 ‘‘(1) IN GENERAL.—The Secretary shall, during 

22 September of each year (beginning with 2006), es23 tablish a monthly MediKids premium for the fol24 lowing year. Subject to paragraph (2), the monthly 

MediKids premium for a year is equal to 1 25 ⁄12 of the 
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1 annual premium rate computed under subsection 

2 (b). 

3 ‘‘(2) ELIMINATION OF MONTHLY PREMIUM FOR

4 DEMONSTRATION OF EQUIVALENT COVERAGE (IN5 CLUDING COVERAGE UNDER LOW-INCOME PRO6 GRAMS).—The amount of the monthly premium im7 posed under this section for an individual for a 

8 month shall be zero in the case of an individual who 

9 demonstrates to the satisfaction of the Secretary 

10 that the individual has basic health insurance cov11 erage for that month. For purposes of the previous 

12 sentence enrollment in a medicaid plan under title 

13 XIX, a State child health insurance plan under title 

14 XXI, or under the medicare program under title 

15 XVIII is deemed to constitute basic health insurance 

16 coverage described in such sentence. 

17 ‘‘(b) ANNUAL PREMIUM.—

18 ‘‘(1) NATIONAL PER CAPITA AVERAGE.—The 

19 Secretary shall estimate the average, annual per 

20 capita amount that would be payable under this title 

21 with respect to individuals residing in the United 

22 States who meet the requirement of section 

23 2201(a)(1) as if all such individuals were eligible for 

24 (and enrolled) under this title during the entire year 
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1 (and assuming that section 1862(b)(2)(A)(i) did not 

2 apply). 

3 ‘‘(2) ANNUAL PREMIUM.—Subject to subsection 

4 (d), the annual premium under this subsection for 

5 months in a year is equal to 25 percent of the aver6 age, annual per capita amount estimated under 

7 paragraph (1) for the year. 

8 ‘‘(c) PAYMENT OF MONTHLY PREMIUM.—

9 ‘‘(1) PERIOD OF PAYMENT.—In the case of an 

10 individual who participates in the program estab11 lished by this title, subject to subsection (d), the 

12 monthly premium shall be payable for the period 

13 commencing with the first month of the individual’s 

14 coverage period and ending with the month in which 

15 the individual’s coverage under this title terminates. 

16 ‘‘(2) COLLECTION THROUGH TAX RETURN.—

17 For provisions providing for the payment of monthly 

18 premiums under this subsection, see section 59B of 

19 the Internal Revenue Code of 1986. 

20 ‘‘(3) PROTECTIONS AGAINST FRAUD AND

21 ABUSE.—The Secretary shall develop, in coordina22 tion with States and other health insurance issuers, 

23 administrative systems to ensure that claims which 

24 are submitted to more than one payor are coordi25 nated and duplicate payments are not made. 
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1 ‘‘(d) REDUCTION IN PREMIUM FOR CERTAIN LOW2 INCOME FAMILIES.—For provisions reducing the premium 

3 under this section for certain low-income families, see sec4 tion 59B(d) of the Internal Revenue Code of 1986. 

5 ‘‘SEC. 2204. MEDIKIDS TRUST FUND. 

6 ‘‘(a) ESTABLISHMENT OF TRUST FUND.—

7 ‘‘(1) IN GENERAL.—There is hereby created on 

8 the books of the Treasury of the United States a 

9 trust fund to be known as the ‘MediKids Trust 

10 Fund’ (in this section referred to as the ‘Trust 

11 Fund’). The Trust Fund shall consist of such gifts 

12 and bequests as may be made as provided in section 

13 201(i)(1) and such amounts as may be deposited in, 

14 or appropriated to, such fund as provided in this 

15 title. 

16 ‘‘(2) PREMIUMS.—Premiums collected under 

17 section 59B of the Internal Revenue Code of 1986 

18 shall be periodically transferred to the Trust Fund. 

19 ‘‘(3) TRANSITIONAL FUNDING BEFORE RECEIPT

20 OF PREMIUMS.—In order to provide for funds in the 

21 Trust Fund to cover expenditures from the fund in 

22 advance of receipt of premiums under section 2203, 

23 there are transferred to the Trust Fund from the 

24 general fund of the United States Treasury such 

25 amounts as may be necessary. 
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1 ‘‘(b) INCORPORATION OF PROVISIONS.—

2 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

3 subsection (b) (other than the last sentence) and 

4 subsections (c) through (i) of section 1841 shall 

5 apply with respect to the Trust Fund and this title 

6 in the same manner as they apply with respect to 

7 the Federal Supplementary Medical Insurance Trust 

8 Fund and part B, respectively. 

9 ‘‘(2) MISCELLANEOUS REFERENCES.—In apply10 ing provisions of section 1841 under paragraph 

11 (1)—

12 ‘‘(A) any reference in such section to ‘this 

13 part’ is construed to refer to title XXII; 

14 ‘‘(B) any reference in section 1841(h) to 

15 section 1840(d) and in section 1841(i) to sec16 tions 1840(b)(1) and 1842(g) are deemed ref17 erences to comparable authority exercised under 

18 this title; 

19 ‘‘(C) payments may be made under section 

20 1841(g) to the Trust Funds under sections 

21 1817 and 1841 as reimbursement to such funds 

22 for payments they made for benefits provided 

23 under this title; and 

24 ‘‘(D) the Board of Trustees of the 

25 MediKids Trust Fund shall be the same as the 
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1 Board of Trustees of the Federal Supple2 mentary Medical Insurance Trust Fund. 

3 ‘‘SEC. 2205. OVERSIGHT AND ACCOUNTABILITY. 

4 ‘‘(a) PERIODIC GAO REPORTS.—The Comptroller 

5 General of the United States shall periodically submit to 

6 Congress reports on the operation of the program under 

7 this title, including on the financing of coverage provided 

8 under this title. 

9 ‘‘(b) PERIODIC MEDPAC REPORTS.—The Medicare 

10 Payment Advisory Commission shall periodically report to 

11 Congress concerning the program under this title. 

12 ‘‘SEC. 2206. INCLUSION OF CARE COORDINATION SERVICES. 

13 ‘‘(a) IN GENERAL.—

14 ‘‘(1) PROGRAM AUTHORITY.—The Secretary, 

15 beginning in 2007, may implement a care coordina16 tion services program in accordance with the provi17 sions of this section under which, in appropriate cir18 cumstances, eligible individuals under section 2201 

19 may elect to have health care services covered under 

20 this title managed and coordinated by a designated 

21 care coordinator. 

22 ‘‘(2) ADMINISTRATION BY CONTRACT.—The 

23 Secretary may administer the program under this 

24 section through a contract with an appropriate pro25 gram administrator. 
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1 ‘‘(3) COVERAGE.—Care coordination services 

2 furnished in accordance with this section shall be 

3 treated under this title as if they were included in 

4 the definition of medical and other health services 

5 under section 1861(s) and benefits shall be available 

6 under this title with respect to such services without 

7 the application of any deductible or coinsurance. 

8 ‘‘(b) ELIGIBILITY CRITERIA; IDENTIFICATION AND

9 NOTIFICATION OF ELIGIBLE INDIVIDUALS.—

10 ‘‘(1) INDIVIDUAL ELIGIBILITY CRITERIA.—The 

11 Secretary shall specify criteria to be used in making 

12 a determination as to whether an individual may ap13 propriately be enrolled in the care coordination serv14 ices program under this section, which shall include 

15 at least a finding by the Secretary that for cohorts 

16 of individuals with characteristics identified by the 

17 Secretary, professional management and coordina18 tion of care can reasonably be expected to improve 

19 processes or outcomes of health care and to reduce 

20 aggregate costs to the programs under this title. 

21 ‘‘(2) PROCEDURES TO FACILITATE ENROLL22 MENT.—The Secretary shall develop and implement 

23 procedures designed to facilitate enrollment of eligi24 ble individuals in the program under this section. 

25 ‘‘(c) ENROLLMENT OF INDIVIDUALS.—
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1 ‘‘(1) SECRETARY’S DETERMINATION OF ELIGI2 BILITY.—The Secretary shall determine the eligi3 bility for services under this section of individuals 

4 who are enrolled in the program under this section 

5 and who make application for such services in such 

6 form and manner as the Secretary may prescribe. 

7 ‘‘(2) ENROLLMENT PERIOD.—

8 ‘‘(A) EFFECTIVE DATE AND DURATION.—

9 Enrollment of an individual in the program 

10 under this section shall be effective as of the 

11 first day of the month following the month in 

12 which the Secretary approves the individual’s 

13 application under paragraph (1), shall remain 

14 in effect for one month (or such longer period 

15 as the Secretary may specify), and shall be 

16 automatically renewed for additional periods, 

17 unless terminated in accordance with such pro18 cedures as the Secretary shall establish by regu19 lation. Such procedures shall permit an indi20 vidual to disenroll for cause at any time and 

21 without cause at re-enrollment intervals. 

22 ‘‘(B) LIMITATION ON REENROLLMENT.—

23 The Secretary may establish limits on an indi24 vidual’s eligibility to reenroll in the program 

25 under this section if the individual has 
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1 disenrolled from the program more than once 

2 during a specified time period. 

3 ‘‘(d) PROGRAM.—The care coordination services pro4 gram under this section shall include the following ele5 ments: 

6 ‘‘(1) BASIC CARE COORDINATION SERVICES.—

7 ‘‘(A) IN GENERAL.—Subject to the cost-ef8 fectiveness criteria specified in subsection 

9 (b)(1), except as otherwise provided in this sec10 tion, enrolled individuals shall receive services 

11 described in section 1905(t)(1) and may receive 

12 additional items and services as described in 

13 subparagraph (B). 

14 ‘‘(B) ADDITIONAL BENEFITS.—The Sec15 retary may specify additional benefits for which 

16 payment would not otherwise be made under 

17 this title that may be available to individuals 

18 enrolled in the program under this section (sub19 ject to an assessment by the care coordinator of 

20 an individual’s circumstance and need for such 

21 benefits) in order to encourage enrollment in, or 

22 to improve the effectiveness of, such program. 

23 ‘‘(2) CARE COORDINATION REQUIREMENT.—

24 Notwithstanding any other provision of this title, the 

25 Secretary may provide that an individual enrolled in 
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1 the program under this section may be entitled to 

2 payment under this title for any specified health 

3 care items or services only if the items or services 

4 have been furnished by the care coordinator, or co5 ordinated through the care coordination services pro6 gram. Under such provision, the Secretary shall pre7 scribe exceptions for emergency medical services as 

8 described in section 1852(d)(3), and other excep9 tions determined by the Secretary for the delivery of 

10 timely and needed care. 

11 ‘‘(e) CARE COORDINATORS.—

12 ‘‘(1) CONDITIONS OF PARTICIPATION.—In order 

13 to be qualified to furnish care coordination services 

14 under this section, an individual or entity shall—

15 ‘‘(A) be a health care professional or entity 

16 (which may include physicians, physician group 

17 practices, or other health care professionals or 

18 entities the Secretary may find appropriate) 

19 meeting such conditions as the Secretary may 

20 specify; 

21 ‘‘(B) have entered into a care coordination 

22 agreement; and 

23 ‘‘(C) meet such criteria as the Secretary 

24 may establish (which may include experience in 
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1 the provision of care coordination or primary 

2 care physician’s services). 

3 ‘‘(2) AGREEMENT TERM; PAYMENT.—

4 ‘‘(A) DURATION AND RENEWAL.—A care 

5 coordination agreement under this subsection 

6 shall be for one year and may be renewed if the 

7 Secretary is satisfied that the care coordinator 

8 continues to meet the conditions of participa9 tion specified in paragraph (1). 

10 ‘‘(B) PAYMENT FOR SERVICES.—The Sec11 retary may negotiate or otherwise establish pay12 ment terms and rates for services described in 

13 subsection (d)(1). 

14 ‘‘(C) LIABILITY.—Care coordinators shall 

15 be subject to liability for actual health damages 

16 which may be suffered by recipients as a result 

17 of the care coordinator’s decisions, failure or 

18 delay in making decisions, or other actions as 

19 a care coordinator. 

20 ‘‘(D) TERMS.—In addition to such other 

21 terms as the Secretary may require, an agree22 ment under this section shall include the terms 

23 specified in subparagraphs (A) through (C) of 

24 section 1905(t)(3). 
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1 ‘‘SEC. 2207. ADMINISTRATION AND MISCELLANEOUS. 

2 ‘‘(a) IN GENERAL.—Except as otherwise provided in 

3 this title—

4 ‘‘(1) the Secretary shall enter into appropriate 

5 contracts with providers of services, other health 

6 care providers, carriers, and fiscal intermediaries, 

7 taking into account the types of contracts used 

8 under title XVIII with respect to such entities, to 

9 administer the program under this title; 

10 ‘‘(2) beneficiary protections for individuals en11 rolled under this title shall not be less than the ben12 eficiary protections (including limits on balance bill13 ing) provided medicare beneficiaries under title 

14 XVIII; 

15 ‘‘(3) benefits described in section 2202 that are 

16 payable under this title to such individuals shall be 

17 paid in a manner specified by the Secretary (taking 

18 into account, and based to the greatest extent prac19 ticable upon, the manner in which they are provided 

20 under title XVIII); and 

21 ‘‘(4) provider participation agreements under 

22 title XVIII shall apply to enrollees and benefits 

23 under this title in the same manner as they apply 

24 to enrollees and benefits under title XVIII. 

25 ‘‘(b) COORDINATION WITH MEDICAID AND

26 SCHIP.—Notwithstanding any other provision of law, in-
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1 dividuals entitled to benefits for items and services under 

2 this title who also qualify for benefits under title XIX or 

3 XXI or any other Federally funded health care program 

4 that provides basic health insurance coverage described in 

5 section 2203(a)(2) may continue to qualify and obtain 

6 benefits under such other title or program, and in such 

7 case such an individual shall elect either—

8 ‘‘(1) such other title or program to be primary 

9 payor to benefits under this title, in which case no 

10 benefits shall be payable under this title and the 

11 monthly premium under section 2203 shall be zero; 

12 or 

13 ‘‘(2) benefits under this title shall be primary 

14 payor to benefits provided under such title or pro15 gram, in which case the Secretary shall enter into 

16 agreements with States as may be appropriate to 

17 provide that, in the case of such individuals, the ben18 efits under titles XIX and XXI or such other pro19 gram (including reduction of cost-sharing) are pro20 vided on a ‘wrap-around’ basis to the benefits under 

21 this title.’’. 

22 (b) CONFORMING AMENDMENTS TO SOCIAL SECU23 RITY ACT PROVISIONS.—

24 (1) Section 201(i)(1) of the Social Security Act 

25 (42 U.S.C. 401(i)(1)) is amended by striking ‘‘or the 
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1 Federal Supplementary Medical Insurance Trust 

2 Fund’’ and inserting ‘‘the Federal Supplementary 

3 Medical Insurance Trust Fund, and the MediKids 

4 Trust Fund’’. 

5 (2) Section 201(g)(1)(A) of such Act (42 

6 U.S.C. 401(g)(1)(A)) is amended by striking ‘‘and 

7 the Federal Supplementary Medical Insurance Trust 

8 Fund established by title XVIII’’ and inserting ‘‘, 

9 the Federal Supplementary Medical Insurance Trust 

10 Fund, and the MediKids Trust Fund established by 

11 title XVIII’’. 

12 (c) MAINTENANCE OF MEDICAID ELIGIBILITY AND

13 BENEFITS FOR CHILDREN.—

14 (1) IN GENERAL.—In order for a State to con15 tinue to be eligible for payments under section 

16 1903(a) of the Social Security Act (42 U.S.C. 

17 1396b(a))—

18 (A) the State may not reduce standards of 

19 eligibility, or benefits, provided under its State 

20 medicaid plan under title XIX of the Social Se21 curity Act or under its State child health plan 

22 under title XXI of such Act for individuals 

23 under 23 years of age below such standards of 

24 eligibility, and benefits, in effect on the date of 

25 the enactment of this Act; and 
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1 (B) the State shall demonstrate to the sat2 isfaction of the Secretary of Health and Human 

3 Services that any savings in State expenditures 

4 under title XIX or XXI of the Social Security 

5 Act that results from children enrolling under 

6 title XXII of such Act shall be used in a man7 ner that improves services to beneficiaries 

8 under title XIX of such Act, such as through 

9 expansion of eligibility, improved nurse and 

10 nurse aide staffing and improved inspections of 

11 nursing facilities, and coverage of additional 

12 services. 

13 (2) MEDIKIDS AS PRIMARY PAYOR.—In apply14 ing title XIX of the Social Security Act, the 

15 MediKids program under title XXII of such Act 

16 shall be treated as a primary payor in cases in which 

17 the election described in section 2207(b)(2) of such 

18 Act, as added by subsection (a), has been made. 

19 (d) EXPANSION OF MEDPAC MEMBERSHIP TO 19.—

20 (1) IN GENERAL.—Section 1805(c) of the So21 cial Security Act (42 U.S.C. 1395b–6(c)) is amend22 ed—

23 (A) in paragraph (1), by striking ‘‘17’’ and 

24 inserting ‘‘19’’; and 
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1 (B) in paragraph (2)(B), by inserting ‘‘ex2 perts in children’s health,’’ after ‘‘other health 

3 professionals,’’. 

4 (2) INITIAL TERMS OF ADDITIONAL MEM5 BERS.—

6 (A) IN GENERAL.—For purposes of stag7 gering the initial terms of members of the 

8 Medicare Payment Advisory Commission under 

9 section 1805(c)(3) of the Social Security Act 

10 (42 U.S.C. 1395b–6(c)(3)), the initial terms of 

11 the 2 additional members of the Commission 

12 provided for by the amendment under sub13 section (a)(1) are as follows: 

14 (i) One member shall be appointed for 

15 1 year. 

16 (ii) One member shall be appointed 

17 for 2 years. 

18 (B) COMMENCEMENT OF TERMS.—Such 

19 terms shall begin on January 1, 2006. 

20 (3) DUTIES.—Section 1805(b)(1)(A) of such 

21 Act (42 U.S.C. 1395b–6(b)(1)(A)) is amended by in22 serting before the semicolon at the end the following: 

23 ‘‘and payment policies under title XXII’’. 
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1 SEC. 3. MEDIKIDS PREMIUM. 

2 (a) GENERAL RULE.—Subchapter A of chapter 1 of 

3 the Internal Revenue Code of 1986 (relating to determina4 tion of tax liability) is amended by adding at the end the 

5 following new part: 

6 ‘‘PART VIII—MEDIKIDS PREMIUM

‘‘Sec. 59B. MediKids premium.

7 ‘‘SEC. 59B. MEDIKIDS PREMIUM. 

8 ‘‘(a) IMPOSITION OF TAX.—In the case of a taxpayer 

9 to whom this section applies, there is hereby imposed (in 

10 addition to any other tax imposed by this subtitle) a 

11 MediKids premium for the taxable year. 

12 ‘‘(b) INDIVIDUALS SUBJECT TO PREMIUM.—

13 ‘‘(1) IN GENERAL.—This section shall apply to 

14 a taxpayer if a MediKid is a dependent of the tax15 payer for the taxable year. 

16 ‘‘(2) MEDIKID.—For purposes of this section, 

17 the term ‘MediKid’ means any individual enrolled in 

18 the MediKids program under title XXII of the Social 

19 Security Act. 

20 ‘‘(c) AMOUNT OF PREMIUM.—For purposes of this 

21 section, the MediKids premium for a taxable year is the 

22 sum of the monthly premiums (for months in the taxable 

23 year) determined under section 2203 of the Social Secu24 rity Act with respect to each MediKid who is a dependent 

25 of the taxpayer for the taxable year. 
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1 ‘‘(d) EXCEPTIONS BASED ON ADJUSTED GROSS IN2 COME.—

3 ‘‘(1) EXEMPTION FOR VERY LOW-INCOME TAX4 PAYERS.—

5 ‘‘(A) IN GENERAL.—No premium shall be 

6 imposed by this section on any taxpayer having 

7 an adjusted gross income not in excess of the 

8 exemption amount. 

9 ‘‘(B) EXEMPTION AMOUNT.—For purposes 

10 of this paragraph, the exemption amount is—

11 ‘‘(i) $19,245 in the case of a taxpayer 

12 having 1 MediKid, 

13 ‘‘(ii) $24,135 in the case of a tax14 payer having 2 MediKids, 

15 ‘‘(iii) $29,025 in the case of a tax16 payer having 3 MediKids, and 

17 ‘‘(iv) $33,915 in the case of a tax18 payer having 4 or more MediKids. 

19 ‘‘(C) PHASEOUT OF EXEMPTION.—In the 

20 case of a taxpayer having an adjusted gross in21 come which exceeds the exemption amount but 

22 does not exceed twice the exemption amount, 

23 the premium shall be the amount which bears 

24 the same ratio to the premium which would 

25 (but for this subparagraph) apply to the tax-
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1 payer as such excess bears to the exemption 

2 amount. 

3 ‘‘(D) INFLATION ADJUSTMENT OF EXEMP4 TION AMOUNTS.—In the case of any taxable 

5 year beginning in a calendar year after 2005, 

6 each dollar amount contained in subparagraph 

7 (C) shall be increased by an amount equal to 

8 the product of—

9 ‘‘(i) such dollar amount, and 

10 ‘‘(ii) the cost-of-living adjustment de11 termined under section 1(f)(3) for the cal12 endar year in which the taxable year be13 gins, determined by substituting ‘calendar 

14 year 2004’ for ‘calendar year 1992’ in sub15 paragraph (B) thereof. 

16 If any increase determined under the preceding 

17 sentence is not a multiple of $50, such increase 

18 shall be rounded to the nearest multiple of $50. 

19 ‘‘(2) PREMIUM LIMITED TO 5 PERCENT OF AD20 JUSTED GROSS INCOME.—In no event shall any tax21 payer be required to pay a premium under this sec22 tion in excess of an amount equal to 5 percent of the 

23 taxpayer’s adjusted gross income. 

24 ‘‘(e) COORDINATION WITH OTHER PROVISIONS.—
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1 ‘‘(1) NOT TREATED AS MEDICAL EXPENSE.—

2 For purposes of this chapter, any premium paid 

3 under this section shall not be treated as expense for 

4 medical care. 

5 ‘‘(2) NOT TREATED AS TAX FOR CERTAIN PUR6 POSES.—The premium paid under this section shall 

7 not be treated as a tax imposed by this chapter for 

8 purposes of determining—

9 ‘‘(A) the amount of any credit allowable 

10 under this chapter, or 

11 ‘‘(B) the amount of the minimum tax im12 posed by section 55. 

13 ‘‘(3) TREATMENT UNDER SUBTITLE F.—For 

14 purposes of subtitle F, the premium paid under this 

15 section shall be treated as if it were a tax imposed 

16 by section 1.’’. 

17 (b) TECHNICAL AMENDMENTS.—

18 (1) Subsection (a) of section 6012 of such Code 

19 is amended by inserting after paragraph (9) the fol20 lowing new paragraph: 

21 ‘‘(10) Every individual liable for a premium 

22 under section 59B.’’. 

23 (2) The table of parts for subchapter A of chap24 ter 1 of such Code is amended by adding at the end 

25 the following new item:

‘‘PART VIII. MEDIKIDS PREMIUM’’.
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1 (c) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to months beginning after Decem3 ber 2006, in taxable years ending after such date. 

4 SEC. 4. REFUNDABLE CREDIT FOR CERTAIN COST-SHARING 

5 EXPENSES UNDER MEDIKIDS PROGRAM. 

6 (a) IN GENERAL.—Subpart C of part IV of sub7 chapter A of chapter 1 of the Internal Revenue Code of 

8 1986 (relating to refundable credits) is amended by redes9 ignating section 36 as section 37 and by inserting after 

10 section 35 the following new section: 

11 ‘‘SEC. 36. CATASTROPHIC LIMIT ON COST-SHARING EX12 PENSES UNDER MEDIKIDS PROGRAM. 

13 ‘‘(a) IN GENERAL.—In the case of a taxpayer who 

14 has a MediKid (as defined in section 59B) at any time 

15 during the taxable year, there shall be allowed as a credit 

16 against the tax imposed by this subtitle an amount equal 

17 to the excess of—

18 ‘‘(1) the amount paid by the taxpayer during 

19 the taxable year as cost-sharing under section 

20 2202(b)(4) of the Social Security Act, over 

21 ‘‘(2) 5 percent of the taxpayer’s adjusted gross 

22 income for the taxable year.’’. 

23 (b) COORDINATION WITH OTHER PROVISIONS.—The 

24 excess described in subsection (a) shall not be taken into 
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1 account in computing the amount allowable to the tax2 payer as a deduction under section 162(l) or 213(a). 

3 (c) TECHNICAL AMENDMENTS.—

4 (1) The table of sections for subpart C of part 

5 IV of subchapter A of chapter 1 of such Code is 

6 amended by redesignating the item relating to sec7 tion 36 as an item relating to section 37 and by in8 serting before such item the following new item:

‘‘Sec. 36. Catastrophic limit on cost-sharing expenses under MediKids program.’’.

9 (2) Paragraph (2) of section 1324(b) of title 

10 31, United States Code, is amended by inserting ‘‘or 

11 36’’ after ‘‘section 35’’. 

12 (d) EFFECTIVE DATE.—The amendments made by 

13 this section shall apply to taxable years beginning after 

14 December 31, 2006. 

15 SEC. 5. REPORT ON LONG-TERM REVENUES. 

16 Within one year after the date of the enactment of 

17 this Act, the Secretary of the Treasury shall propose a 

18 gradual schedule of progressive tax changes to fund the 

19 program under title XXII of the Social Security Act, as 

20 the number of enrollees grows in the out-years.

Æ