99–010

Calendar No. 541

107TH CONGRESS REPORT " SENATE ! 2d Session 107–233

MOTHERS AND NEWBORNS HEALTH INSURANCE ACT OF 

2002

AUGUST 1, 2002.—Ordered to be printed 

Mr. BAUCUS, from the Committee on Finance, 

submitted the following 

R E P O R T 

[To accompany S. 724]

The Committee on Finance, to which was referred the bill (S. 

724) to amend title XXI of the Social Security Act to provide for 

coverage of pregnancy-related assistance for targeted low-income 

pregnant women, reports favorably thereon and refers the bill to 

the full Senate with a recommendation that the bill pass. 

I. BACKGROUND 

Lack of health insurance is a significant barrier to receiving prenatal care, and contributes greatly to America’s high levels of infant and maternal mortality. With 4.3 million uninsured mothers 

living below 200 percent of the Federal poverty level, the United 

States currently ranks 21st in the world in infant mortality and 

26th in maternal mortality. These are the worst rates of any developed nation. 

In recent years, the United States has made significant progress 

toward extending health insurance coverage to children in low-income families. Unfortunately, the mothers of these children remain 

at high risk of going uninsured. Mothers in low-income families account for nearly three of every four uninsured mothers in the country. These women often lack access to affordable, employer-based 

health insurance coverage and are excluded from public programs 

such as Medicaid and the State Children’s Health Insurance Program (SCHIP). 

While a majority of states provide health insurance coverage 

through Medicaid or SCHIP to children in families up to 200 percent of the Federal poverty level, or about $24,000 for a family of 

two, the same level of coverage generally does not apply to their 

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mothers. Current law only requires states to cover pregnant women 

under Medicaid if they are under 133 percent of poverty, which is 

approximately $16,000 per year for a family of two. States also 

have the option to extend this coverage up to 185 percent of poverty, or about $22,000 a year, for that same family. Pregnant 

women are not eligible to receive coverage under SCHIP, unless a 

state is granted a Section 1115 waiver of current law to do so. 

There is no valid policy rationale for the existing disparities in 

health insurance coverage between mothers and their children. 

Current law essentially dictates that low-income children receive 

health insurance coverage only after their mothers have gone 

through nine months of pregnancy without crucial prenatal coverage. This disparity in coverage levels exposes both mothers and 

children to unnecessary health risks. Moreover, it is not cost-effective. Recent studies have shown that infants born to mothers receiving late or no prenatal care are more likely to face complications—which can result in hospitalization, expensive medical treatments, and increased costs to public programs. Closing the gap in 

coverage between mothers and their children will improve the 

health of both, while reducing costs for taxpayers. 

II. DESCRIPTION OF THE BILL 

The legislation reported by the Finance Committee consists of 

the following provisions: 

Section 1. Short title 

Section 2. State option to expand or add coverage of certain pregnant women under Medicaid and SCHIP 

(a) Medicaid 

PRESENT LAW

States are required to provide Medicaid coverage to pregnant 

women with no other children who have family income up to 133 

percent of the Federal poverty level (FPL), and have the option to 

extend such coverage to pregnant women with no other children 

who have family income above 133 percent FPL up to 185 percent 

FPL. Both of these eligibility categories are commonly referred to 

as ‘‘poverty-related pregnant women.’’ These pregnant women are 

entitled only to pregnancy-related services (e.g., prenatal, delivery 

and postpartum care up to 60 days after delivery). States may increase the effective income level above these standards by modifying applicable income and resource methodologies. In addition, 

states may seek waivers of program rules to extend Medicaid to 

pregnant women at higher income levels. 

The State Children’s Health Insurance Program (SCHIP) allows 

states to cover uninsured children under age 19 in families with income above applicable Medicaid financial standards. States may 

choose from among three benefit options when designing their 

SCHIP programs. They may expand Medicaid, create a new separate state program that must meet minimum benefit requirements, 

or devise a combination of both approaches. Among the many services available under SCHIP are prenatal care and hospital services. 

Pregnant women ages 19 and above are eligible for SCHIP only 

through special waivers of program rules, or when employer-sponVerDate Aug 1, 2002 06:54 Aug 07, 2002 Jkt 099010 PO 00000 Frm 00002 Fmt 6659 Sfmt 6602 E:\HR\OC\SR233.XXX pfrm15 PsN: SR233
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sored family coverage subsidized by SCHIP includes adults in families with eligible children. 

The Federal share of Medicaid costs is equal to the Federal medical assistance percentage (FMAP) of those costs. The FMAP is determined annually according to a formula designed to pay a higher 

Federal matching rate to states with lower per capita incomes relative to the national average. The law establishes a minimum 

FMAP of 50 percent and a maximum FMAP of 83 percent. Under 

SCHIP, an enhanced FMAP (E-FMAP) is available. The E-FMAP 

is defined as the FMAP under Medicaid increased by 30 percent of 

the number of percentage points by which the FMAP for the state 

is less than 100 percent. E-FMAP ranges from 65 percent to 85 

percent (the statutory upper limit). 

Under Medicaid presumptive eligibility rules, states are allowed 

to temporarily enroll children whose family income appears to be 

below applicable Medicaid income standards, until a formal determination of eligibility is made. Payments made on behalf of Medicaid children during periods of presumptive eligibility are matched 

at the regular Medicaid FMAP, but are paid out of state SCHIP allotments. 

Federal funds for SCHIP were appropriated in the original enacting statute for FY1998 through FY2007. From each year’s appropriation, a state is allotted an amount as determined by a formula 

set in law. Expenditures associated with presumptive eligibility for 

children under Medicaid are counted against a state’s SCHIP allotment. 

EXPLANATION OF PROVISION

The bill allows states meeting two conditions to cover under Medicaid additional pregnant women (up to 60 days postpartum) with 

no other children in families with income exceeding 185 percent 

FPL, up to the SCHIP income level for children in effect as of January 1, 2002. The two conditions include: (1) the state must cover 

under Medicaid and SCHIP such pregnant women in lower income 

families before or in addition to pregnant women in higher income 

families, and (2) the state must apply an income level to the new 

group of pregnant women that is no lower than the effective income 

level in place for pregnant women already covered under the state 

Medicaid plan as of January 1, 2002. 

For states expanding coverage to additional pregnant women 

with incomes exceeding 185 percent FPL, the SCHIP enhanced 

FMAP applies and all payments are counted against the state’s 

SCHIP allotment. 

Finally, the bill eliminates the requirement that expenditures associated with presumptive eligibility for children under Medicaid be 

counted against a state’s SCHIP allotment. 

REASONS FOR CHANGE

The Committee bill includes provisions based on S. 724, introduced by Senator Breaux, and S. 1016, introduced by Senator 

Bingaman, to extend Medicaid and SCHIP coverage to pregnant 

women. The provisions attempt to restore balance in eligibility levels between mothers and their children by allowing states to cover 

pregnant women in these programs up to the income eligibility 

level available for their children. The provision offers an incentive 

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to states to raise income eligibility levels for pregnant women by

providing the enhanced SCHIP matching rate to states that expand 

coverage above the current limit of 185 percent of poverty. 

(b) SCHIP 

PRESENT LAW

In general, SCHIP allows states to cover uninsured children 

under age 19 in families with incomes that are either: (1) above the 

state’s Medicaid financial eligibility standard but less than 200 percent of the federal poverty level, or (2) in states with Medicaid income levels for children already at or above 200 percent FPL, within 50 percentage points over the state’s Medicaid income eligibility 

limit for children in effect on March 31, 1997. 

Generally, states cover SCHIP-eligible kids by either enrolling 

them into Medicaid expansion programs, or into separate state 

health insurance plans that meet specific standards for benefits 

and cost-sharing, or through a combination of both. 

States covering SCHIP-eligible children through Medicaid must 

provide the full range of mandatory Medicaid benefits, including 

maternity care, and all optional services specified in their state 

Medicaid plans. Coverage for pregnant women under Medicaid is 

limited to services related to the pregnancy (e.g., prenatal, delivery, 

and postpartum care up to 60 days after delivery); complications of 

pregnancy; and family planning services. Alternatively, states operating separate state insurance plans may choose any one of three 

other benefit options: (1) a benchmark benefit package, (2) benchmark equivalent coverage, or (3) any other health benefits plan 

that the Secretary determines will provide appropriate coverage for 

the targeted population of uninsured children. These three additional benefit options may include maternity care. However, apart 

from requiring coverage of inpatient and outpatient hospital services, and physicians’ surgical and medical services, there is no specific language in the federal statute that requires provision of prenatal, delivery and postpartum services with these non-Medicaid 

benefit plan options. 

The SCHIP program does not include pregnancy status among its 

eligibility criteria, and does not cover individuals over age 18. 

There are two circumstances under which uninsured pregnant 

women over 18 years would be eligible for SCHIP. First, SCHIP 

has a ‘‘family coverage option’’ that allows states to provide coverage under a group health plan that may include maternity care 

to adult females in eligible families. States may cover entire families including parents if the purchase of family coverage is cost effective when compared with the cost of covering only the targeted 

low-income children in the families involved, and would not substitute for other health insurance coverage. Alternatively, states 

may apply for waivers of program rules to extend coverage to 

adults such as parents and pregnant women. 

Cost sharing refers to the out-of-pocket payments made by beneficiaries of a health insurance plan. States that chose to implement 

SCHIP as a Medicaid expansion must follow the nominal cost sharing rules of the Medicaid program. Under separate state programs, 

total annual aggregate cost-sharing (including premiums, enrollment fees, deductibles, copayments, coinsurance, and other similar 

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charges) for any family may not exceed 5 percent of total income 

in a year. Preventive services are exempt from cost-sharing. 

For each fiscal year, the states and the District of Columbia are 

allotted a proportion of the total amount of Federal SCHIP dollars 

available. From that amount, Federal matching funds are disbursed quarterly to each state by a formula set in statute. The 

original authorizing legislation for SCHIP requires that 0.25 percent of the program’s total authorization be set-aside for five territories. This total is distributed among these territories based on 

specific percentages defined in statute. 

EXPLANATION OF PROVISION

The Committee bill allows states to cover additional pregnant 

women under SCHIP. The SCHIP expansion group includes pregnant women with family income above the state’s Medicaid financial eligibility standard for pregnant women in effect on January 

1, 2002, up to the income eligibility for SCHIP children in effect as 

of January 1, 2002. The provision also requires states to meet the 

following conditions before they are permitted to expand their eligibility. First, the state must have already expanded Medicaid eligibility for pregnant women up to at least 185 percent FPL. Second, 

the same two conditions required of states choosing to expand coverage to pregnant women under Medicaid must also be met: (1) the 

state must cover under Medicaid and SCHIP pregnant women in 

lower income families before or in addition to pregnant women in 

higher income families, and (2) the state must apply an income 

level to the new group of pregnant women that is no lower than 

the effective income level in place for pregnant women covered 

under the state Medicaid plan as of January 1, 2002. Coverage for 

pregnant women is limited to services related to the pregnancy 

(e.g., prenatal, delivery, and postpartum care up to 60 days after 

delivery); complications of pregnancy; and family planning services. 

The provision prohibits: (1) excluding pregnancy-related services 

based on a preexisting condition; (2) imposing a waiting period for 

the purpose of minimizing substitution; and (3) cost sharing for 

pregnancy-related services. 

Children born to women receiving pregnancy-related services 

under SCHIP Medicaid expansions or separate state plans are 

automatically enrolled in such program at the time of birth and remain eligible for such assistance until the child attains 1 year of 

age. Unless the state issues a separate eligibility number for the 

child, such child retains the medical assistance eligibility identification number of the mother during this eligibility period. 

For each of fiscal years 2003 through 2006, the Committee’s provision adds an additional appropriation, in the amount of $200 million, out of funds not otherwise appropriated from the Treasury. A 

total of 98.95 percent of such funds are distributed among the 

states in the same manner as SCHIP funds are distributed under 

current law. The remaining funds are distributed among the territories also in the same manner as defined in current law. Funds 

added to the SCHIP program may be used for child health assistance for targeted low-income children, as well as for pregnancy-related assistance for pregnant women. Funds are available to states 

that expand coverage to pregnant woman under title XXI (SCHIP), 

or title XIX (Medicaid) beyond those covered as of January 1, 2002. 

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Additional funds are not available to the states before October 1, 

2002. 

REASONS FOR CHANGE

Current Federal law enables low-income pregnant women to receive coverage under SCHIP through age 18, but it does not provide such coverage to women ages 19 and above. While states have 

the ability to add SCHIP coverage for pregnant women over age 18 

through Section 1115 waivers, states find this process to be both 

time-consuming and administratively burdensome. The Committee 

bill allows states to cover pregnant women under SCHIP regardless 

of age and gives states the flexibility to expand coverage to pregnant women through the simpler state plan amendment process. 

The committee bill also eliminates the disparity in coverage levels 

between pregnant women and infants that has been created 

through SCHIP, enabling both mothers and their newborn children 

to immediately receive health coverage under the program. 

(c)(1) Other amendments to Medicaid: Eligibility of a newborn 

PRESENT LAW

A child born to a woman eligible for and receiving medical assistance under a Medicaid state plan on the date of the child’s birth, 

is deemed to have applied for, and to have been found eligible for 

such assistance. The child remains eligible for such assistance until 

that child attains 1 year of age as long as the child is a member 

of the woman’s household, and the woman remains (or would remain if pregnant) eligible for Medicaid. 

EXPLANATION OF PROVISION

For a child born to a woman eligible for and receiving medical 

assistance under a Medicaid state plan on the date of the child’s 

birth, the Committee’s bill removes current law requirements that 

the child remain a member of the woman’s household; and the 

woman continues to be eligible (or would remain eligible if pregnant) for Medicaid. 

REASONS FOR CHANGE

The Committee bill ensures that children born to women enrolled 

in Medicaid or SCHIP are immediately enrolled in the program for 

which they are eligible, regardless of the eligibility status of the 

mother. The provision prevents newborns eligible for SCHIP from 

being subject to enrollment waiting periods that may apply to 

other, older children eligible for the program and helps ensure that 

infants receive appropriate health care in their first year of life. 

(c)(2) Other amendments to Medicaid: Application of qualified entities to presumptive eligibility for pregnant 

women under Medicaid 

PRESENT LAW

Under Medicaid presumptive eligibility rules, states are allowed 

to temporarily enroll children whose family income appears to be 

below Medicaid income standards, until a final formal determinaVerDate Aug 1, 2002 06:54 Aug 07, 2002 Jkt 099010 PO 00000 Frm 00006 Fmt 6659 Sfmt 6602 E:\HR\OC\SR233.XXX pfrm15 PsN: SR233
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tion of eligibility is made. Entities qualified to make presumptive 

eligibility determinations include Medicaid providers, agencies that 

determine eligibility for Head Start, subsidized child care, or the 

Special Supplemental Food Program for Women, Infants and Children (WIC). BIPA 2000 added several entities to the list of those 

qualified to make Medicaid presumptive eligibility determinations. 

These include agencies that determine eligibility for Medicaid or 

the State Children’s Health Insurance Program (SCHIP); certain 

elementary and secondary schools; state or tribal child support enforcement agencies; certain organizations providing food and shelter to the homeless; entities involved in enrollment under Medicaid, TANF, SCHIP, or that determine eligibility for federally 

funded housing assistance; or any other entity deemed by a state, 

as approved by the Secretary of HHS. 

EXPLANATION OF PROVISION

For purposes of presumptive eligibility determinations, the Committee bill clarifies that qualified providers be included under 

qualified entities as defined in current law. The bill further clarifies that qualified entities be permitted to make presumptive eligibility determinations for pregnant women in addition to children. 

REASON FOR CHANGE

Given the established value of early prenatal care for ensuring 

the health of both mother and child, it is important to clarify and 

extend presumptive eligibility rules to pregnant women. 

(d) Effective date 

Section 2 of the Committee bill applies to items and services furnished on or after October 1, 2002, regardless of whether implementing regulations have been issued. 

Section 3. Review of State agency blindness and disability determinations 

PRESENT LAW

State agencies are required to conduct blindness and disability 

determinations to establish an individual’s eligibility for: (1) Title 

II, (Federal Old-Age, Survivors, and Disability Insurance (OASDI) 

benefits); and (2) Title XVI (Supplemental Security Income, (SSI)). 

Disability determinations are made in accordance with disability 

criteria defined in statute as well as standards promulgated under 

regulations or other guidance. 

Under current law, the Commissioner of Social Security is required to review the state agency’s Title II initial blindness and 

disability determinations in advance of awarding payment to individuals determined eligible under such requirements. This requirement for review is met when: (1) at least 50 percent of all such determinations have been reviewed, or (2) other such determinations 

have been reviewed as necessary to ensure a high level of accuracy. 

EXPLANATION OF PROVISION

After a 1-year phase-in, the bill aligns the initial review requirements for Title XVI with those currently required under Title II. 

As under Title II, the Commissioner of Social Security is required 

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to review initial Title XVI SSI blindness and disability determinations made by state agencies in advance awarding payments. For 

FY2003, the SSI review is required for 25 percent of all state-determined allowances. In FY2004 and thereafter, review is required for 

at least 50 percent of state-determined allowances. To the extent 

feasible, the Committee’s bill requires the Commissioner to select 

for review, determinations that are most likely to be incorrect.

REASON FOR CHANGE

The Committee bill includes a requirement that determinations 

in the SSI program be reviewed to improve program integrity. 

EFFECTIVE DATE

Section 3 of the Committee bill is effective at the time of enactment of such Act. 

III. REGULATORY IMPACT STATEMENT AND RELATED 

MATTERS 

A. REGULATORY IMPACT

In accordance with paragraph 11(b) of rule XXVI of the Standing 

Rules of the Senate, the Committee makes the following statement 

concerning the regulatory impact of the Mothers and Newborns 

Health Insurance Act of 2002. 

IMPACT ON INDIVIDUALS AND BUSINESSES

Section 2(a) creates a state option for states to cover additional 

pregnant women under Medicaid. Because the provision merely 

creates an option for states to consider, it does not impose any additional paperwork or regulatory burdens on individuals or businesses. 

Section 2(b) creates a state option for states to cover additional 

pregnant women under the State Children’s Health Insurance Program (SCHIP), and it appropriates additional funds for the SCHIP 

allotment of states that chose to take up the option. Because the 

provision merely creates an option for states to consider enacting, 

it does not impose any additional paperwork or regulatory burdens 

on individuals or businesses. 

For a child born to a woman receiving Medicaid on the date of 

the child’s birth, Section 2(c)(1) removes current law requirements 

that the child remain eligible only as long as the child is a member 

of the woman’s household and the woman remains eligible for Medicaid. Because it removes requirements for eligibility for infants, 

the provision reduces paperwork and regulatory burdens on individuals, and does not impose additional paperwork or regulatory 

burdens on businesses. 

Section 2(c)(2) clarifies that qualified providers are qualified entities for purposes of determining presumptive eligibility for children 

for Medicaid. It also allows qualified entities to make presumptive 

determinations of eligibility for pregnant women. This provision reduces the paperwork and regulatory burdens on qualified providers 

and qualified entities, and it does not impose additional paperwork 

and regulatory burdens on other businesses or individuals. 

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IMPACT ON PERSONAL PRIVACY

The Committee bill permits states to provide health coverage 

through Medicaid or SCHIP to pregnant women who are not presently eligible. To establish their eligibility for coverage in states 

that take up the new options, pregnant women may be required to 

provide information regarding their income, their assets, and their 

medical condition, but they would not be required to provide any 

more information than presently eligible pregnant women would 

have to provide. Infants who were born to mothers eligible for and 

receiving Medicaid would have to provide less information about 

household and income to maintain their Medicaid coverage for one 

year. Finally, because the law clarifies that certain private entities 

may make presumptive eligibility determinations, it would give 

children and pregnant women the option to obtain eligibility by 

sharing income, asset, and medical condition information with private and public entities. However, no child or pregnant woman 

would be required to share the information. 

B. UNFUNDED MANDATES STATEMENT

Due to time constraints, the Congressional Budget Office estimate was not included in the report. When received by the Committee, it will appear in the Congressional Record at a later time. 

IV. BUDGET EFFECTS 

Due to time constraints, the Congressional Budget Office estimate was not included in the report. When received by the Committee, it will appear in the Congressional Record at a later time. 

V. VOTES 

On July 11, 2002, a substitute for S. 724, entitled, the ‘‘Mothers 

and Newborns Health Insurance Act of 2002,’’ was ordered favorably reported by a voice vote. A quorum was present. 

No amendments were offered. 

VI. CHANGES IN EXISTING LAW 

In compliance with paragraph 12 of the rule XXVI of the Standing Rules of the Senate, changes in existing law made by the bill, 

as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italic, 

existing law in which no changes is proposed is shown in roman):

SOCIAL SECURITY ACT 

* * * * * * *

TITLE XVI—GRANTS TO STATES FOR AID TO THE AGED, 

BLIND, OR DISABLED 

* * * * * * *

ADMINISTRATION

SEC. 1633. (a) Subject to subsection (b), the Commissioner of Social Security may make such administrative and other arrangements (including arrangements for the determination of blindness 

10

and disability under section 1614(a)(2) and (3) in the same manner 

and subject to the same conditions as provided with respect to disability determinations under section 221) as may be necessary or 

appropriate to carry out the Commissioner’s functions under this 

title. 

* * * * * * *

(e)(1) The Commissioner of Social Security shall review determinations, made by State agencies pursuant to subsection (a) in 

connection with applications for benefits under this title on the 

basis of blindness or disability, that individuals who have attained 

18 years of age are blind or disabled as of a specified onset date. 

The Commissioner of Social Security shall review such a determination before any action is taken to implement the determination. 

(2)(A) In carrying out paragraph (1), the Commissioner of Social Security shall review—

(i) at least 25 percent of all determinations referred to in 

paragraph (1) that are made in fiscal year 2003; and 

(ii) at least 50 percent of all such determinations that are 

made in fiscal year 2004 or thereafter. 

(B) In carrying out subparagraph (A), the Commissioner of 

Social Security shall, to the extent feasible, select for review the 

determinations which the Commissioner of Social Security identifies as being the most likely to be incorrect. 

* * * * * * *

TITLE XIX—GRANTS TO STATES FOR MEDICAL ASSISTANCE 

PROGRAMS 

STATE PLANS FOR MEDICAL ASSISTANCE

SEC. 1902. (a) A State plan for medical assistance must—

* * * * * * *

(e)(1)(A) * * *

* * * * * * *

(4) A child born to a woman eligible for and receiving medical assistance under a State plan on the date of the child’s birth shall 

be deemed to have applied for medical assistance and to have been 

found eligible for such assistance under such plan on the date of 

such birth and to remain eligible for such assistance for a period 

of one year øso 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¿. During the period in which a child is 

deemed under the preceding sentence to be eligible for medical assistance, the 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). 

* * * * * * *

(l)(1) Individuals described in this paragraph are— (A) women during pregnancy (and during the 60-day period 

beginning on the last day of the pregnancy), 

(B) infants under one year of age, 

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(C) children who have attained one year of age but have not 

attained 6 years of age, and 

(D) children born after September 30, 1983 (or, at the option 

of a State, after any earlier date), who have attained 6 years 

of age but have not attained 19 years of age, 

who are not described in any of subclauses (I) through (III) of subsection (a)(10)(A)(i) and whose family income does not exceed the 

income level established by the State under paragraph (2) for a 

family size equal to the size of the family, including the woman, 

infant, or child. 

(2)(A)(i) For purposes of paragraph (1) with respect to individuals 

described in subparagraph (A) or (B) of that paragraph, the State 

shall establish an income level which is a percentage (not less than 

the percentage provided under clause (ii) and not more than 185 

percent (or such higher percent as the State may elect for purposes 

of expenditures for medical assistance for pregnant women described in section 1905(u)(4)(A)) of the income official poverty line 

(as defined by the Office of Management and Budget and Budget, 

and revised annually in accordance with section 673(2) of the Omnibus Budget Reconciliation Act of 1981) applicable to a family of 

the size involved. 

* * * * * * *

DEFINITIIONS

SEC. 1905. * * *

(b) Subject to section 1933(d), the term ‘‘Federal medical assistance percentage’’ for any State shall be 100 per centum less the 

State percentage; and the State percentage shall be that percentage which bears the same ratio to 45 per centum as the square of 

the per capita income of such State bears to the square of the per 

capita income of the continental United States (including Alaska) 

and Hawaii; except that (1) the Federal medical assistance percentage shall in no case be less than 50 per centum or more than 83 

per centum, (2) the Federal medical assistance percentage for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, 

and American Samoa shall be 50 per centum. The Federal medical 

assistance percentage for any State shall be determined and promulgated in accordance with the provisions of section 1101(a)(8)(B). 

Notwithstanding the first sentence of this section, the Federal medical assistance percentage shall be 100 per centum with respect to 

amounts expended as medical assistance for services which are received through an Indian Health Service facility whether operated 

by the Indian Health Service or by an Indian tribe or tribal organization (as defined in section 4 of the Indian Health Care Improvement Act). Notwithstanding the first sentence of this subsection, in 

the case of a State plan that meets the condition described in subsection (u)(1), with respect to expenditures (other than expenditures under section 1923) described in subsection (u)(2)(A) øor subsection (u)(3)¿, (u)(3), or (u)(4) for the State for a fiscal year, and 

that do not exceed the amount of the State’s available allotment 

under section 2104, the Federal medical assistance percentage is 

equal to the enhanced FMAP described in section 2105(b), for purpose of this title and title XXI, the Federal medical assistance percentage for the District of Columbia shall be 70 percent and (4) the 

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Federal medical assistance percentage shall be equal to the enhanced FMAP described in section 2105(b) with respect to medical 

assistance provided to individuals who are eligible for such assistance only on the basis of section 1902(a)(10)(A)(ii)(XVIII). 

* * * * * * *

(u)(1) The conditions described in this paragraph for a State plan 

are as follows: 

(A) The State is complying with the requirement of section 

2105(d)(1). 

(B) The Plan provides for such reporting of information 

about expenditures and payments attributable to the operation 

of this subsection as the Secretary deems necessary in order to 

carry out the fourth sentence of subsection (b). 

(2)(A) For purposes of subsection (b), the expenditures described 

in this subparagraph are expenditures for medical assistance for 

optional target low-income children described in subparagraph (B). 

(B) For purposes of this paragraph, the term ‘‘optional targeted 

low-income child’’ means a targeted low-income child as defined in 

section 2110(b)(1) (determined without regard to that portion of 

subparagraph (C) of such section concerning eligibility for medical 

assistance under this title) who would not qualify for medical assistance under the State plan under this title as in effect on March 

31, 1997 (but taking into account the expansion of age of eligibility 

effected through the operation of section 1902(l)(1)(D)). 

(3) For purposes of subsection (b), the expenditures described in 

this paragraph are expenditures for medical assistance for children 

who are born before October 1, 1983, and who would be described 

in section 1902(l)(1)(D) if they had been born on or after such date, 

and who are not eligible for such assistance under the State plan 

under this title based on such State plan as in effect as of March 

31, 1997. 

(4) For purposes of the fourth sentence of subsection (b) and section 2105(a), the expenditures described in this paragraph are the 

following:

(A) CERTAIN PREGNANT WOMEN.—If the conditions described 

in subparagraph (B) are met, expenditures for medical assistance for pregnant women described in subsection (n) or under 

section 1902(l)(1)(A) in a family the income of which exceeds 

185 percent of the poverty line, but does not exceed the income 

eligibility level established under title XXI for a targeted lowincome child. 

(B) CONDITIONS.—The conditions described in this subparagraph are the following: 

(i) The State plans under this title and title XXI do not 

provide coverage for pregnant women described in subparagraph (A) with higher family income without covering such 

pregnant women with a lower family income. 

(ii) The State does not apply an effective income level for 

pregnant women that is lower than the effective income 

level (expressed as a percent of the poverty line and considering applicable income disregards) that has been specified 

under the State plan under subsection (a)(10)(A)(i)(III) or 

(l)(2)(A) of section 1902, as of January 1, 2002, to be eligible for medical assistance as a pregnant woman. 

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(C) DEFINITION OF POVERTY LINE.—In this subsection, the 

term ‘‘poverty line’’ has the meaning given such term in section 

2110(c)(5).

ø(4)¿(5) The limitations on payment under subsections (f) and (g) 

of section 1108 shall not apply to Federal payments made under 

section 1903(a)(1) based on an enhanced FMAP described in section 

2105(b). 

* * * * * * *

PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN

SEC. 1920. (a) A State plan approved under section 1902 may 

provide for making ambulatory prenatal care available to a pregnant woman during a presumptive eligibility period. 

(b) For purposes of this section— (1) the term ‘‘presumptive eligibility period’’ means, with respect to a pregnant woman, the period that—

* * * * * * *

(2) the term ‘‘qualified provider’’ means any provider that— (A) is eligible for payments under a State plan approved 

under this subchapter, 

(B) provides services of the type described in subparagraph (A) or (B) of section 1396d(a)(2) of this title or in 

section 1396b(a)(9) of this title, 

(C) is determined by the State agency to be capable of 

making determinations of the type described in paragraph 

(1)(A), and 

(D)(i) receives funds under— (I) section 330 or 330A of the Public Health Service 

Act 

(II) title V of this Act, or 

(III) title V of the Indian Health Care Improvement 

Act; 

(ii) participates in a program established under—

(I) section 17 of the Child Nutrition Act of 1966, or 

(II) section 4(a) of the Agriculture and Consumer 

Protection Act of 1973, 

(iii) participates in a State perinatal program; or 

(iv) is the Indian Health Service or is a health program 

or facility operated by a tribe or tribal organization under 

the Indian Self-Determination Act (Public Law 93–638). 

The term ‘‘qualified provider’’ includes a qualified entity as defined 

in section 1920A(b)(3).

* * * * * * *

TITLE XXI—STATE CHILDREN’S HEALTH INSURANCE 

PROGRAM

GENERAL CONTENTS OF STATE CHILD HEALTH PLAN; ELIGIBILITY; 

OUTREACH

SEC. 2102. (a) GENERAL BACKGROUND AND DESCRIPTION.—A 

State child health plan shall include a description, consistent with 

the requirements of this title, of—

* * * * * * * 

14

(b) GENERAL DESCRIPTION OF ELIGIBILITY STANDARDS AND METHODOLOGY.—

(1) ELIGIBILITY STANDARDS.—

(A) IN GENERAL.—The plan shall include a description of 

the standard used to determine the eligibility of targeted 

low-income children for child health assistance under the 

plan. such standards may include (to the extent consistent 

with this title) those relating to the geographic areas to be 

served by the plan, age, income and resources (including 

any standards relating to spenddowns and disposition of 

resources), residency, disability status (so long as any 

standard relating to such status does not restrict eligibility), access to or coverage under other health coverage, 

and duration of eligibility. Such standards may not discriminate on the basis of diagnosis. 

(B) LIMITATIONS ON ELIGIBILITY STANDARDS.—Such eligibility standards—

(i) shall, within any defined group of covered targeted low-income children, not cover such children 

with higher family income without covering children 

with a lower family incomeø, and ¿;

(ii) may not deny eligibility based on a child having 

a preexisting medical conditionø.¿; and

(iii) may not apply a waiting period (including a 

waiting period to carry out paragraph (3)(C)) in the 

case of a targeted low-income pregnant woman.

COVERAGE REQUIREMENTS FOR CHILDREN’S HEALTH INSURANCE

SEC. 2103. (a) REQUIRED SCOPE OF HEALTH INSURANCE COVERAGE.—The child health assistance provided to a targeted low-income child under the plan in the form described in paragraph (1) 

of section 2101(a) shall consist, consistent with subsection (c)(5), of 

any of the following: 

* * * * * * *

(e) COST-SHARING.—

(1) DESCRIPTION; GENERAL CONDITIONS.—

(A) DESCRIPTION.—A State child health plan shall include a description, consistent with this subsection, of the 

amount (if any) of premiums, deductibles, coinsurance, and 

other cost sharing imposed. Any such charges shall be imposed pursuant to a public schedule. 

(B) PROTECTION FOR LOWER INCOME CHILDREN.—The 

State child health plan may only vary premiums, 

deductibles, coinsurance, and other cost sharing based on 

the family income of targeted low-income children in a 

manner that does not favor children from families with 

higher income over children from families with lower income. 

(2) NO COST SHARING ON BENEFITS FOR PREVENTIVE SERVICES

OR PREGNANCY-RELATED SERVICES.—The State child health 

plan may not impose deductibles, coinsurance, or other cost 

sharing with respect to benefits for services within the catVerDate Aug 1, 2002 06:54 Aug 07, 2002 Jkt 099010 PO 00000 Frm 00014 Fmt 6659 Sfmt 6602 E:\HR\OC\SR233.XXX pfrm15 PsN: SR233
15

egory of services described in subsection (c)(1)(D) or for pregnancy-related services.

* * * * * * *

ALLOTMENTS

SEC. 2104. (a) APPROPRIATION; TOTAL ALLOTMENT.—For the purpose of providing allotments to States under this section, subject to 

subsection (d), there is appropriated, out of any money in the 

Treasury not otherwise appropriated—

* * * * * * *

(b) ALLOTMENTS TO 50 STATES AND DISTRICT OF COLUMBIA.— (1) IN GENERAL.—Subject to paragraph (4) and subsection (d), of the amount available for allotment under subsection (a) for 

a fiscal year, reduced by the amount of allotments made under 

subsection (c) (determined without regard to paragraph (4) 

thereof) for the fiscal year, the Secretary shall allot to each 

State (other than a State described in such subsection) with a 

State child health plan approved under this title the same proportion as the ratio of—

* * * * * * *

(c) ALLOTMENTS TO TERRITORIES.— (1) IN GENERAL.—Of the amount available for allotment 

under subsection (d) for a fiscal year subject to subsection (d), 

the Secretary shall allot 0.25 percent among each of the commonwealths and territories described in paragraph (3) in the 

same proportion as the percentage specified in paragraph (2) 

for such commonwealth or territory bears to the sum of such 

percentages for all such commonwealths or territories so described. 

* * * * * * *

(d) ADDITIONAL ALLOTMENTS FOR PROVIDING COVERAGE OF PREG- NANT WOMEN.— (1) APPROPRIATION; TOTAL ALLOTMENT.—For the purpose of 

providing additional allotments to States under this title, there 

is appropriated, out of any money in the Treasury not otherwise 

appropriated, for each of fiscal years 2003 through 2006, 

$200,000,000. 

(2) STATE AND TERRITORIAL ALLOTMENTS.—In addition to the 

allotments provided under subsections (b) and (c), subject to 

paragraphs (3) and (4), of the amount available for the additional allotments under paragraph (1) for a fiscal year, the Secretary shall allot to each State with a State child health plan 

approved under this title—

(A) in the case of such a State other than a commonwealth or territory described in subparagraph (B), the same 

proportion as the proportion of the State’s allotment under 

subsection (b) (determined without regard to subsection (f)) 

to the total amount of the allotments under subsection (b) 

for such States eligible for an allotment under this paragraph for such fiscal year; and 

(B) in the case of a commonwealth or territory described 

in subsection (c)(3), the same proportion as the proportion 

of the commonwealth’s or territory’s allotment under subVerDate Aug 1, 2002 06:54 Aug 07, 2002 Jkt 099010 PO 00000 Frm 00015 Fmt 6659 Sfmt 6603 E:\HR\OC\SR233.XXX pfrm15 PsN: SR233
16

section (c) (determined without regard to subsection (f)) to 

the total amount of the allotments under subsection (c) for 

commonwealths and territories eligible for an allotment 

under this paragraph for such fiscal year. 

(3) USE OF ADDITIONAL ALLOTMENT.—Additional allotments 

provided under this subsection are not available for amounts 

expended before October 1, 2002. Such amounts are available 

for amounts expended on or after such date for child health assistance for targeted low-income children, as well as for pregnancy-related assistance for targeted low-income pregnant 

women. 

(4) NO PAYMENTS UNLESS ELECTION TO EXPAND COVERAGE OF

PREGNANT WOMEN.—No payments may be made to a State 

under this title from an allotment provided under this subsection unless the State provides pregnancy-related assistance 

for targeted low-income pregnant women under this title, or 

provides medical assistance for pregnant women under title 

XIX, whose family income exceeds the effective income level applicable under subsection (a)(10)(A)(i)(III) or (l)(2)(A) of section 

1902 to a family of the size involved as of January 1, 2002.

PAYMENTS TO STATES

SEC. 2105. (a) PAYMENTS.—

(1) IN GENERAL.—Subject to the succeeding provisions of this 

section, the Secretary shall pay to each State with a plan approved under this title, from its allotment under section 2104, 

an amount for each quarter equal to the enhanced FMAP ø(or, 

in the case of expenditures described in subparagraph (B), the 

Federal medical assistance percentage (as defined in the first 

sentence of section 1905(b)))¿ of expenditures in the quarter—

(A) for child health assistance under the plan for targeted low-income children in the form of providing medical 

assistance for which payment is made on the basis of an 

enhanced FMAP under the fourth sentence of section 

1905(b); 

ø(B) for the provision of medical assistance on behalf of 

a child during a presumptive eligibility period under section 1920A;¿

(B) for the provision of medical assistance that is attributable to expenditures described in section 1905(u)(4)(A);

* * * * * * *

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 pregnancy-related assistance for targeted low-income pregnant women in 

accordance with this section, but only if—

(1) the State has established an income eligibility level for 

pregnant women under subsection (a)(10)(A)(i)(III) or (l)(2)(A) of 

section 1902 that is at least 185 percent of the income official 

poverty line; and 

(2) the State meets the conditions described in section 

1905(u)(4)(B). 

17

(b) DEFINITIONS.—For purposes of this title: 

(1) PREGNANCY-RELATED ASSISTANCE.—The term ‘‘pregnancyrelated assistance’’ has the meaning given the term child health 

assistance in section 2110(a) as if any reference to targeted lowincome children were a reference to targeted low-income pregnant women, except that the assistance shall be limited to services related to pregnancy (which include prenatal, delivery, and 

postpartum services and services described in section 

1905(a)(4)(C)) and to other conditions that may complicate 

pregnancy.

(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 the effective income level 

(expressed as a percent of the poverty line and considering 

applicable income disregards) that has been specified under 

subsection (a)(10)(A)(i)(III) or (l)(2)(A) of section 1902, as of 

January 1, 2002, to be eligible for medical assistance as a 

pregnant woman under title XIX 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 requirement of paragraphs (1)(A), 

(1)(C), (2), and (3) of section 2110(b). 

(c) REFERENCES TO TERMS AND SPECIAL RULES.—In the case of, 

and with respect to, a State providing for coverage of pregnancy-related assistance 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 such reference to child health assistance with respect 

to such women is deemed a reference to pregnancy-related assistance. 

(3) Any such reference 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) Subsection (a) of section 2103 (relating to required scope 

of health insurance coverage) shall not apply insofar as a State 

limits coverage to services described in subsection (b)(1) and the 

reference to such section in section 2105(a)(1)(C) is deemed not 

to require, in such case, compliance with the requirements of 

section 2103(a). 

(7) In applying section 2103(e)(3)(B) in the case of a pregnant 

woman provided coverage under this section, the limitation on 

18

total annual aggregate cost-sharing shall be applied to such 

pregnant woman. 

(8) The reference in section 2107(e)(1)(D) to section 1920A (relating to presumptive eligibility for children) is deemed a reference to section 1920 (relating to presumptive eligibility for 

pregnant women). 

(d) AUTOMATIC ENROLLMENT FOR CHILDREN BORN TO WOMEN RE- CEIVING PREGNANCY-RELATED ASSISTANCE.—If a child is born to a 

targeted low-income pregnant woman who was receiving pregnancyrelated assistance 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, as appropriate, on the date of such birth 

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 child health 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).

Æ