II

107TH CONGRESS

1ST SESSION S. 1471

To amend titles XIX and XXI of the Social Security Act to ensure that

children enrolled in the medicaid and State children’s health insurance

program are identified and treated for lead poisoning.

IN THE SENATE OF THE UNITED STATES

SEPTEMBER 26, 2001

Mr. TORRICELLI (for himself, Mr. REED, Mrs. CLINTON, Mr. WELLSTONE,

Mr. DURBIN, Mrs. CARNAHAN, and Mr. LIEBERMAN) introduced the following bill; which was read twice and referred to the Committee on Finance

A BILL

To amend titles XIX and XXI of the Social Security Act

to ensure that children enrolled in the medicaid and

State children’s health insurance program are identified

and treated for lead poisoning.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Children’s Lead

5 Screening Accountability For Early-Intervention Act of

6 2001’’ or the ‘‘Children’s Lead SAFE Act’’.
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1 SEC. 2. FINDINGS AND PURPOSES.

2 (a) FINDINGS.—Congress finds that—

3 (1) lead poisoning remains a serious environ4 mental risk, especially to the health of young chil5 dren;

6 (2) childhood lead poisoning can cause reduc7 tions in IQ, attention span, reading, and learning

8 disabilities, and other growth and behavior problems;

9 (3) children under the age of 6 are at the great10 est risk of suffering the effects of lead poisoning be11 cause of the sensitivity of their developing brains

12 and nervous systems, while children under the age of

13 3 are especially at risk due to their stage of develop14 ment and hand-to-mouth activities;

15 (4) poor children and minority children are at

16 substantially higher risk of lead poisoning;

17 (5) three-fourths of all children ages 1 through

18 5 found to have an elevated blood lead level in a

19 Centers for Disease Control and Prevention nation20 ally representative sample were enrolled in or tar21 geted by Federal health care programs, specifically

22 the medicaid program, the special supplemental nu23 trition program for women, infants, and children

24 (WIC), and the community health centers programs

25 under section 330 of the Public Health Service Act,
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1 equating to an estimated 688,000 children nation2 wide;

3 (6) the General Accounting Office estimates

that 2 4 ⁄3 of the 688,000 children who have elevated

5 blood lead levels and are enrolled in or targeted by

6 Federal health care programs have never been

7 screened for lead;

8 (7) although the Health Care Financing Admin9 istration has required mandatory blood lead

10 screenings for children enrolled in the medicaid pro11 gram who are not less than 1 nor more than 5 years

12 of age, less than 20 percent of these children have

13 received such screenings;

14 (8) the Health Care Financing Administration

15 mandatory screening policy has not been effective, or

16 sufficient, to properly identify and screen children

17 enrolled in the medicaid program who are at risk;

(9) only about 1 18 ⁄2 of State programs have

19 screening policies consistent with Federal policy; and

20 (10) adequate treatment services are not uni21 formly available for children with elevated blood lead

22 levels.

23 (b) PURPOSE.—The purpose of this Act is to create

24 a lead screening safety net that will, through the medicaid

25 and State children’s health insurance program, ensure
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1 that children enrolled in those programs receive blood lead

2 screenings and appropriate followup care.

3 SEC. 3. INCREASED LEAD POISONING SCREENINGS AND

4 TREATMENTS UNDER THE MEDICAID PRO5 GRAM.

6 (a) REPORTING REQUIREMENT.—Section

7 1902(a)(43)(D) of the Social Security Act (42 U.S.C.

8 1396a(a)(43)(D)) is amended—

9 (1) in clause (iii), by striking ‘‘and’’ at the end;

10 (2) in clause (iv), by striking the semicolon and

11 inserting ‘‘, and’’; and

12 (3) by adding at the end the following new

13 clause:

14 ‘‘(v) the number of children who are

15 under the age of 3 and enrolled in the

16 State plan under this title and the number

17 of those children who have received a blood

18 lead screening test;’’.

19 (b) MANDATORY SCREENING REQUIREMENTS.—Sec20 tion 1902(a) of the Social Security Act (42 U.S.C.

21 1396a(a)) is amended—

22 (1) in paragraph (64), by striking ‘‘and’’ at the

23 end;

24 (2) in paragraph (65), by striking the period

25 and inserting ‘‘; and’’; and
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1 (3) by inserting after paragraph (65) the fol2 lowing new paragraph:

3 ‘‘(66) provide that each contract entered into

4 between the State and an entity (including a health

5 insuring organization and a medicaid managed care

6 organization) that is responsible for the provision

7 (directly or through arrangements with providers of

8 services) of medical assistance under the State plan

9 shall provide for—

10 ‘‘(A) compliance with mandatory blood

11 lead screening requirements that are consistent

12 with prevailing guidelines of the Centers for

13 Disease Control and Prevention for such screen14 ing; and

15 ‘‘(B) coverage of qualified lead treatment

16 services described in section 1905(x) including

17 diagnosis, treatment, and follow-up furnished

18 for children with elevated blood lead levels in

19 accordance with prevailing guidelines of the

20 Centers for Disease Control and Prevention.’’.

21 (c) REIMBURSEMENT FOR TREATMENT OF CHIL22 DREN WITH ELEVATED BLOOD LEAD LEVELS.—Section

23 1905 of the Social Security Act (42 U.S.C. 1396d) is

24 amended—

25 (1) in subsection (a)—
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1 (A) in paragraph (26), by striking ‘‘and’’

2 at the end;

3 (B) by redesignating paragraph (27) as

4 paragraph (28); and

5 (C) by inserting after paragraph (26) the

6 following new paragraph:

7 ‘‘(27) qualified lead treatment services (as de8 fined in subsection (x)); and’’; and

9 (2) by adding at the end the following new sub10 section:

11 ‘‘(x)(1) In this subsection:

12 ‘‘(A) The term ‘qualified lead treatment serv13 ices’ means the following:

14 ‘‘(i) Lead-related medical management, as

15 defined in subparagraph (B).

16 ‘‘(ii) Lead-related case management, as de17 fined in subparagraph (C), for a child described

18 in paragraph (2).

19 ‘‘(iii) Lead-related anticipatory guidance,

20 as defined in subparagraph (D), provided as

21 part of—

22 ‘‘(I) prenatal services;

23 ‘‘(II) early and periodic screening, di24 agnostic, and treatment services (EPSDT)

25 described in subsection (r) and available
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1 under subsection (a)(4)(B) (including as

2 described and available under imple3 menting regulations and guidelines) to in4 dividuals enrolled in the State plan under

5 this title who have not attained age 21;

6 and

7 ‘‘(III) routine pediatric preventive

8 services.

9 ‘‘(B) The term ‘lead-related medical manage10 ment’ means the provision and coordination of the

11 diagnostic, treatment, and follow-up services pro12 vided for a child diagnosed with an elevated blood

13 lead level (EBLL) that includes—

14 ‘‘(i) a clinical assessment, including a

15 physical examination and medically indicated

16 tests (in addition to diagnostic blood lead level

17 tests) and other diagnostic procedures to deter18 mine the child’s developmental, neurological,

19 nutritional, and hearing status, and the extent,

20 duration, and possible source of the child’s ex21 posure to lead;

22 ‘‘(ii) repeat blood lead level tests furnished

23 when medically indicated for purposes of moni24 toring the blood lead concentrations in the

25 child;
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1 ‘‘(iii) pharmaceutical services, including

2 chelation agents and other drugs, vitamins, and

3 minerals prescribed for treatment of an EBLL;

4 ‘‘(iv) medically indicated inpatient services

5 including pediatric intensive care and emer6 gency services;

7 ‘‘(v) medical nutrition therapy when medi8 cally indicated by a nutritional assessment, that

9 shall be furnished by a dietitian or other nutri10 tion specialist who is authorized to provide such

11 services under State law;

12 ‘‘(vi) referral—

13 ‘‘(I) when indicated by a nutritional

14 assessment, to the State agency or con15 tractor administering the program of as16 sistance under the special supplemental

17 nutrition program for women, infants and

18 children (WIC) under section 17 of the

19 Child Nutrition Act of 1966 (42 U.S.C.

20 1786) and coordination of clinical manage21 ment with that program; and

22 ‘‘(II) when indicated by a clinical or

23 developmental assessment, to the State

24 agency responsible for early intervention

25 and special education programs under the
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1 Individuals with Disabilities Education Act

2 (20 U.S.C. 1400 et seq.); and

3 ‘‘(vii) environmental investigation, as de4 fined in subparagraph (E).

5 ‘‘(C) The term ‘lead-related case management’

6 means the coordination, provision, and oversight of

7 the nonmedical services for a child with an EBLL

8 necessary to achieve reductions in the child’s blood

9 lead levels, improve the child’s nutrition, and secure

10 needed resources and services to protect the child by

11 a case manager trained to develop and oversee a

12 multi-disciplinary plan for a child with an EBLL or

13 by a childhood lead poisoning prevention program,

14 as defined by the Secretary. Such services include—

15 ‘‘(i) assessing the child’s environmental,

16 nutritional, housing, family, and insurance sta17 tus and identifying the family’s immediate

18 needs to reduce lead exposure through an initial

19 home visit;

20 ‘‘(ii) developing a multidisciplinary case

21 management plan of action that addresses the

22 provision and coordination of each of the fol23 lowing items as appropriate—
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1 ‘‘(I) determination of whether or not

2 such services are covered under the State

3 plan under this title;

4 ‘‘(II) lead-related medical manage5 ment of an EBLL (including environ6 mental investigation);

7 ‘‘(III) nutrition services;

8 ‘‘(IV) family lead education;

9 ‘‘(V) housing;

10 ‘‘(VI) early intervention services;

11 ‘‘(VII) social services; and

12 ‘‘(VIII) other services or programs

13 that are indicated by the child’s clinical

14 status and environmental, social, edu15 cational, housing, and other needs;

16 ‘‘(iii) assisting the child (and the child’s

17 family) in gaining access to covered and non18 covered services in the case management plan

19 developed under clause (ii);

20 ‘‘(iv) providing technical assistance to the

21 provider that is furnishing lead-related medical

22 management for the child; and

23 ‘‘(v) implementation and coordination of

24 the case management plan developed under
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1 clause (ii) through home visits, family lead edu2 cation, and referrals.

3 ‘‘(D) The term ‘lead-related anticipatory guid4 ance’ means education and information for families

5 of children and pregnant women enrolled in the

6 State plan under this title about prevention of child7 hood lead poisoning that addresses the following top8 ics:

9 ‘‘(i) The importance of lead screening tests

10 and where and how to obtain such tests.

11 ‘‘(ii) Identifying lead hazards in the home.

12 ‘‘(iii) Specialized cleaning, home mainte13 nance, nutritional, and other measures to mini14 mize the risk of childhood lead poisoning.

15 ‘‘(iv) The rights of families under the Resi16 dential Lead-Based Paint Hazard Reduction

17 Act of 1992 (42 U.S.C. 4851 et seq.).

18 ‘‘(E) The term ‘environmental investigation’

19 means the process of determining the source of a

20 child’s exposure to lead by an individual that is cer21 tified or registered to perform such investigations

22 under State or local law, including the collection and

23 analysis of information and environmental samples

24 from a child’s living environment. For purposes of

25 this subparagraph, a child’s living environment in-
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1 cludes the child’s residence or residences, residences

2 of frequently visited caretakers, relatives, and play3 mates, and the child’s day care site. Such investiga4 tions shall be conducted in accordance with the

5 standards of the Department of Housing and Urban

6 Development for the evaluation and control of lead7 based paint hazards in housing and in compliance

8 with State and local health agency standards for en9 vironmental investigation and reporting.

10 ‘‘(2) For purposes of paragraph (1)(A)(ii), a child de11 scribed in this paragraph is a child who—

12 ‘‘(A) has attained 6 months but has not at13 tained 6 years of age; and

14 ‘‘(B) has been identified as having a blood lead

15 level that equals or exceeds 20 micrograms per deci16 liter (or after 2 consecutive tests, equals or exceeds

17 15 micrograms per deciliter, or the applicable num18 ber of micrograms designated for such tests under

19 prevailing guidelines of the Centers for Disease Con20 trol and Prevention).’’.

21 (d) ENHANCED MATCH FOR DATA COMMUNICATIONS

22 SYSTEM.—Section 1903(a)(3) of the Social Security Act

23 (42 U.S.C. 1396b(a)(3)) is amended—

24 (1) in subparagraph (D), by striking ‘‘plus’’ at

25 the end and inserting ‘‘and’’; and
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1 (2) by inserting after subparagraph (D), the

2 following new subparagraph:

3 ‘‘(E)(i) 90 percent of so much of the sums

4 expended during such quarter as are attrib5 utable to the design, development, or installa6 tion of an information retrieval system that

7 may be easily accessed and used by other feder8 ally-funded means-tested public benefit pro9 grams to determine whether a child is enrolled

10 in the State plan under this title and whether

11 an enrolled child has received mandatory early

12 and periodic screening, diagnostic, and treat13 ment services, as described in section 1905(r);

14 and

15 ‘‘(ii) 75 percent of so much of the sums ex16 pended during such quarter as are attributable

17 to the operation of a system (whether such sys18 tem is operated directly by the State or by an19 other person under a contract with the State)

20 of the type described in clause (i); plus’’.

21 (e) REPORT.—The Secretary of Health and Human

22 Services, acting through the Administrator of the Health

23 Care Financing Administration, annually shall report to

24 Congress on the number of children enrolled in the med25 icaid program under title XIX of the Social Security Act
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1 (42 U.S.C. 1396 et seq.) who have received a blood lead

2 screening test during the prior fiscal year, noting the per3 centage that such children represent as compared to all

4 children enrolled in that program.

5 (f) EMERGENCY MEASURES.—

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

7 the Secretary of Health and Human Services or the

8 State agency administering the State plan under

9 title XIX of the Social Security Act (42 U.S.C. 1396

10 et seq.) shall use funds provided under title XIX of

11 that Act to reimburse a State or entity for expendi12 tures for medically necessary activities in the home

13 of a lead-poisoned child with an EBLL of at least

14 20, or a pregnant woman with an EBLL of at least

15 20, to prevent additional exposure to lead, including

16 specialized cleaning of lead-contaminated dust, emer17 gency relocation, safe repair of peeling paint, dust

18 control, and other activities that reduce lead expo19 sure. Such reimbursement, when provided by the

20 State agency administering the State plan under

21 title XIX of the Social Security Act, shall be consid22 ered medical assistance for purposes of section

23 1903(a) of such Act.

24 (2) LIMITATION.—Not more than $1,000 in ex25 penditures for the emergency measures described in
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1 paragraph (1) may be incurred on behalf of a child

2 or pregnant woman to which that paragraph applies.

3 (g) RULE OF CONSTRUCTION.—Nothing in this Act

4 or any amendment made by this Act shall be construed

5 as requiring a child enrolled in the State medicaid pro6 gram under title XIX of the Social Security Act to under7 go a lead blood screening test if the child’s parent or

8 guardian objects to the test on the ground that the test

9 is inconsistent with the parent’s or guardian’s religious be10 liefs.

11 SEC. 4. BONUS PROGRAM FOR IMPROVEMENT OF CHILD12 HOOD LEAD SCREENING RATES.

13 (a) IN GENERAL.—The Secretary of Health and

14 Human Services (in this section referred to as the ‘‘Sec15 retary’’) may establish a program to improve the blood

16 lead screening rates of States for children under the age

17 of 3 enrolled in the medicaid program.

18 (b) PAYMENTS.—If the Secretary establishes a pro19 gram under subsection (a), the Secretary, using State-spe20 cific blood lead screening data, shall, subject to the avail21 ability of appropriations, annually pay a State an amount

22 determined as follows:

23 (1) $25 per each 2 year-old child enrolled in the

24 medicaid program in the State who has received the

25 minimum required (for that age) screening blood
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1 lead level tests (capillary or venous samples) to de2 termine the presence of elevated blood lead levels,

3 as established by the Centers for Disease Control

4 and Prevention, if the State rate for such screenings

5 exceeds 65 but does not exceed 75 percent of all 2

6 year-old children in the State.

7 (2) $50 per each such child who has received

8 such minimum required tests if the State rate for

9 such screenings exceeds 75 but does not exceed 85

10 percent of all 2 year-old children in the State.

11 (3) $75 per each such child who has received

12 such minimum required tests if the State rate for

13 such screenings exceeds 85 percent of all 2 year-old

14 children in the State.

15 (c) USE OF BONUS FUNDS.—Funds awarded to a

16 State under subsection (b) shall only be used—

17 (1) by the State department of health in the

18 case of a child with an elevated blood lead level who

19 is enrolled in medicaid or another Federal means20 tested program designed to reduce the source of the

21 child’s exposure to lead; or

22 (2) in accordance with guidelines for the use of

23 such funds developed by the Secretary in collabora24 tion with the Secretary of Housing and Urban De25 velopment.
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1 (d) AUTHORIZATION OF APPROPRIATIONS.—There is

2 authorized to be appropriated to carry out this section,

3 $30,000,000 for each of fiscal years 2002 through 2006.

4 SEC. 5. AUTHORIZATION TO USE SCHIP FUNDS FOR BLOOD

5 LEAD SCREENING.

6 (a) OPTIONAL APPLICATION TO SCHIP.—

7 (1) IN GENERAL.—Section 2107(e)(1) of the

8 Social Security Act (42 U.S.C. 1397gg(e)(1)) is

9 amended by adding at the end the following new

10 subparagraph:

11 ‘‘(E) At State option, section 1902(a)(66)

12 (relating to blood lead screening and coverage

13 of qualified lead treatment services defined in

14 section 1905(x)).’’.

15 (2) CONFORMING AMENDMENT.—Section

16 2110(a) of the Social Security Act (42 U.S.C.

17 1397jj(a)) is amended—

18 (A) by redesignating paragraph (28) as

19 paragraph (29); and

20 (B) by inserting after paragraph (27) the

21 following new paragraph:

22 ‘‘(28) qualified lead treatment services (as de23 fined in section 1905(x)), but only if the State has

24 elected under section 2107(e)(1)(E) to apply section
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1 1902(a)(66) to the State child health plan under

2 this title.’’.

3 (b) INCLUSION IN MEDICAID REPORTING REQUIRE4 MENT.—

5 (1) IN GENERAL.—Section 1902(a)(43)(D)(v)

6 of the Social Security Act (42 U.S.C.

7 1396a(a)(43)(D)(v)), as added by section 3(a)(3), is

8 amended by inserting ‘‘or, if the State has elected

9 under section 2107(e)(1)(E) to apply paragraph

10 (66) to the State child health plan under title XXI,

11 in the State plan under title XXI,’’ after ‘‘this title’’.

12 (2) REPORT TO CONGRESS.—Section 3(e) of

13 this Act is amended—

14 (A) by inserting ‘‘or in the State children’s

15 health insurance program under title XXI of

16 that Act (42 U.S.C 1397aa et seq.)’’ after ‘‘(42

17 U.S.C. 1396 et seq.)’’; and

18 (B) by striking ‘‘that program’’ and insert19 ing ‘‘those programs’’.

20 SEC. 6. EFFECTIVE DATE.

21 This Act and the amendments made by this Act take

22 effect on the date that is 18 months after the date of en23 actment of this Act.

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