II 

117TH CONGRESS 

1ST SESSION S. 439 

To amend title XIX of the Social Security Act to increase Federal support 

to State Medicaid programs during economic downturns, and for other 

purposes. 

IN THE SENATE OF THE UNITED STATES 

FEBRUARY 25, 2021 

Mr. CASEY (for himself, Ms. CORTEZ MASTO, Mr. BENNET, Mr. BROWN, Mr. 

WYDEN, Mrs. SHAHEEN, Mr. MERKLEY, Mr. WARNER, Mr. MENENDEZ, 

Ms. ROSEN, Ms. SMITH, Mr. PETERS, Mr. BOOKER, Mr. VAN HOLLEN, 

Mr. TESTER, Ms. STABENOW, Mr. WHITEHOUSE, Mr. CARDIN, Ms. WARREN, Ms. KLOBUCHAR, Mr. KING, Ms. HASSAN, and Mr. CARPER) introduced the following bill; which was read twice and referred to the Committee on Finance 

A BILL 

To amend title XIX of the Social Security Act to increase 

Federal support to State Medicaid programs during economic downturns, and for other purposes. 

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 ‘‘Coronavirus Medicaid 

5 Response Act’’. 


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1 SEC. 2. INCREASING FEDERAL SUPPORT TO STATE MED2 ICAID PROGRAMS DURING ECONOMIC 

3 DOWNTURNS. 

4 (a) IN GENERAL.—Section 1905 of the Social Secu5 rity Act (42 U.S.C. 1396d) is amended— 

6 (1) in subsection (b), by striking ‘‘and (ff)’’ and 

7 inserting ‘‘(ff), and (hh)’’; and 

8 (2) by adding at the end the following new sub9 section: 

10 ‘‘(hh) INCREASED FMAP DURING ECONOMIC

11 DOWNTURNS.— 

12 ‘‘(1) IN GENERAL.—If a fiscal quarter that be13 gins on or after January 1, 2020, is an economic 

14 downturn quarter (as defined in paragraph (2)) with 

15 respect to a State, then the Federal medical assist16 ance percentage determined for the State and quar17 ter under subsection (b) shall be equal to the per18 centage determined for the State and quarter under 

19 paragraph (3). 

20 ‘‘(2) ECONOMIC DOWNTURN QUARTER.— 

21 ‘‘(A) IN GENERAL.— 

22 ‘‘(i) IN GENERAL.—In this subsection, 

23 the term ‘economic downturn quarter’ 

24 means, with respect to a State, a fiscal 

25 quarter during which the State’s unem26 ployment rate for the quarter exceeds the 


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1 percentage determined for the State and 

2 quarter under clause (ii). 

3 ‘‘(ii) THRESHOLD PERCENTAGE.—The 

4 percentage determined under this clause 

5 for a State and fiscal quarter is the per6 centage equal to the lower of— 

7 ‘‘(I) the State unemployment 

8 rate at the 20th percentile of the dis9 tribution of the State’s quarterly un10 employment rates for the 60-quarter 

11 period preceding the quarter involved, 

12 increased by 1 percentage point; and 

13 ‘‘(II) the State’s average quar14 terly unemployment rate for the 12- 

15 quarter period preceding the quarter 

16 involved, increased by 1 percentage 

17 point. 

18 ‘‘(B) UNEMPLOYMENT DATA.— 

19 ‘‘(i) IN GENERAL.—Except as pro20 vided in clause (ii), for purposes of deter21 mining unemployment rates for a State 

22 and a quarter under this paragraph, the 

23 Secretary shall use data from the Local 

24 Area Unemployment Statistics from the 

25 Bureau of Labor Statistics. 


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1 ‘‘(ii) APPLICATION TO CERTAIN TER2 RITORIES.—In the case of the Virgin Is3 lands, Guam, the Northern Mariana Is4 lands, American Samoa, or any other juris5 diction for which suitable data from the 

6 Local Area Unemployment Statistics from 

7 the Bureau of Labor Statistics are unavail8 able, the Secretary shall use data from the 

9 U–3 unemployment measure of the Bureau 

10 of Labor Statistics to make any necessary 

11 determinations under subparagraph (A). 

12 ‘‘(3) INCREASED FMAP DURING ECONOMIC

13 DOWNTURN QUARTER.— 

14 ‘‘(A) IN GENERAL.—During a fiscal quar15 ter that is an economic downturn quarter with 

16 respect to a State, the Federal medical assist17 ance percentage for the State and quarter de18 termined under subsection (b) shall be equal 

19 to— 

20 ‘‘(i) the Federal medical assistance 

21 percentage determined for the State and 

22 quarter under subsection (b) without re23 gard to this subsection (but including any 

24 increase to such percentage for such quar25 ter made pursuant to section 6008(a) of 


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1 the Families First Coronavirus Response 

2 Act); increased by 

3 ‘‘(ii) the number of percentage points 

4 (rounded to the nearest tenth of a percent5 age point) equal to the product of— 

6 ‘‘(I) the number of percentage 

7 points (rounded to the nearest tenth 

8 of a percentage point) by which the 

9 unemployment rate for the State and 

10 quarter exceeds the percentage deter11 mined for the State and quarter 

12 under paragraph (2)(A)(ii); and 

13 ‘‘(II) 4.8. 

14 ‘‘(B) RULES OF APPLICATION.—The fol15 lowing rules shall apply with respect to the Fed16 eral medical assistance percentage determined 

17 for a State and an economic downturn quarter 

18 under this subsection: 

19 ‘‘(i) SCOPE OF APPLICATION.—Such 

20 Federal medical assistance percentage shall 

21 not apply for purposes of— 

22 ‘‘(I) disproportionate share hos23 pital payments described in section 

24 1923; 


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1 ‘‘(II) payments under part D of 

2 title IV; or 

3 ‘‘(III) any payments under this 

4 title that are based on a Federal med5 ical assistance percentage determined 

6 for a State under subsection (aa) (but 

7 only to the extent that such Federal 

8 medical assistance percentage is high9 er than the economic recovery 

10 FMAP). 

11 ‘‘(ii) LIMITATION.—In no case shall— 

12 ‘‘(I) the Federal medical assist13 ance percentage determined for a 

14 State and quarter pursuant to this 

15 subsection exceed 95 percent; or 

16 ‘‘(II) any increase to the Federal 

17 medical assistance percentage deter18 mined for a State and quarter pursu19 ant to this subsection result in the ap20 plication of a Federal medical assist21 ance percentage that exceeds 95 per22 cent. 

23 ‘‘(iii) APPLICATION TO CHIP.—Not24 withstanding the first sentence of section 

25 2105(b), the application of this subsection 


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1 may result in the enhanced FMAP of a 

2 State for a fiscal year under such section 

3 exceeding 85 percent, but in no case may 

4 the application of this subsection before 

5 application of the second sentence of such 

6 section result in the enhanced FMAP of 

7 the State exceeding 95 percent. 

8 ‘‘(4) ADVANCE PAYMENT; RETROSPECTIVE AD9 JUSTMENT.— 

10 ‘‘(A) IN GENERAL.—Prior to the beginning 

11 of each fiscal quarter that begins on or after 

12 July 1, 2020, the Secretary shall, with respect 

13 to each State— 

14 ‘‘(i) make an initial determination, 

15 based on the projections made for the 

16 State and quarter under subparagraph 

17 (B), as to— 

18 ‘‘(I) whether the application of 

19 this subsection is expected to result in 

20 the application of a higher Federal 

21 medical assistance percentage for the 

22 State and quarter than the percentage 

23 that would otherwise apply without re24 gard to this subsection; and— 


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1 ‘‘(II) if the application of this 

2 subsection is expected to result in 

3 such a higher Federal medical assist4 ance percentage for the State and 

5 quarter, what such higher percentage 

6 is expected to be; and 

7 ‘‘(ii) if the Secretary determines under 

8 clause (i) that the application of this sub9 section is expected to result in the applica10 tion of a higher Federal medical assistance 

11 percentage for the State and quarter than 

12 the percentage that would otherwise apply 

13 without regard to this subsection— 

14 ‘‘(I) apply such higher Federal 

15 medical assistance percentage of the 

16 State for purposes of making pay17 ments to the State for amounts ex18 pended during such quarter as med19 ical assistance under the State plan; 

20 and 

21 ‘‘(II) take into account such 

22 higher Federal medical assistance per23 centage of the State for purposes of 

24 calculating the enhanced FMAP for 


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1 the State and quarter under section 

2 2105(b). 

3 ‘‘(B) PROJECTION OF STATE UNEMPLOY4 MENT RATES.—Prior to the beginning of each 

5 fiscal quarter that begins on or after July 1, 

6 2020, the Secretary, acting through the Chief 

7 Actuary of the Centers for Medicare & Medicaid 

8 Services, shall, using the most recently available 

9 data described in paragraph (2)(B), make pro10 jections with respect to— 

11 ‘‘(i) the unemployment rates for each 

12 State for such quarter; 

13 ‘‘(ii) the threshold percentages de14 scribed in paragraph (2)(A)(ii) for each 

15 State for such quarter; and 

16 ‘‘(iii) the national unemployment rate 

17 for such quarter. 

18 ‘‘(C) RETROSPECTIVE ADJUSTMENT.—As 

19 soon as practicable after final unemployment 

20 data becomes available for a fiscal quarter that 

21 begins on or after July 1, 2020, the Secretary 

22 shall, with respect to each State— 

23 ‘‘(i) make a final determination with 

24 respect to the application of this subsection 

25 for purposes of determining the Federal 


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1 medical assistance percentage and en2 hanced FMAP of the State for the quarter; 

3 and 

4 ‘‘(ii) in accordance with section 

5 1903(d)(2) and section 2105(e), reduce or 

6 increase the amount payable to the State 

7 under section 1903(a) or section 2105 for 

8 a subsequent fiscal quarter to the extent of 

9 any overpayment or underpayment under 

10 either such section which the Secretary de11 termines was made as a result of an incor12 rect initial determination under subpara13 graph (A)(i) with respect to the application 

14 of this subsection for purposes of deter15 mining the Federal medical assistance per16 centage and enhanced FMAP of the State 

17 for such prior fiscal quarter. 

18 ‘‘(5) RETROSPECTIVE APPLICATION OF OVER19 THE-LIMIT FMAP INCREASES.— 

20 ‘‘(A) IN GENERAL.—If a State has excess 

21 percentage points with respect to an economic 

22 downturn quarter and an applicable FMAP (as 

23 determined under subparagraph (B)), the State 

24 may elect to apply such excess percentage 

25 points to increase such applicable FMAP for 


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1 one or more quarters during the look-back pe2 riod for the State and economic downturn quar3 ter in accordance with this paragraph. 

4 ‘‘(B) EXCESS PERCENTAGE POINTS.—For 

5 purposes of this paragraph, the number of ex6 cess percentage points for a State, economic 

7 downturn quarter, and an applicable FMAP 

8 shall be equal to the number of percentage 

9 points by which— 

10 ‘‘(i) the applicable FMAP for the 

11 State and quarter (after application of 

12 paragraph (3) but without regard to sub13 paragraph (B)(ii) of such paragraph); ex14 ceeds 

15 ‘‘(ii) 95 percent. 

16 ‘‘(C) EFFECT OF APPLICATION OF EXCESS

17 PERCENTAGE POINTS.—If a State elects to 

18 apply excess percentage points to an applicable 

19 FMAP to a quarter during a look-back period 

20 under this paragraph, the Secretary shall deter21 mine the additional amount of payment under 

22 section 1903(a) to which the State would have 

23 been entitled for such quarter if the applicable 

24 FMAP (as so increased) had been in effect for 


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1 such quarter, and shall treat such additional 

2 amount as an underpayment for such quarter. 

3 ‘‘(D) DISTRIBUTION OF EXCESS PERCENT4 AGE POINTS.—A State that has excess percent5 age points with respect to an economic down6 turn quarter and applicable FMAP may elect to 

7 divide such points among more than 1 quarter 

8 during the look-back period for such State and 

9 quarter provided that no excess percentage 

10 point (or fraction of an excess percentage point) 

11 is applied to the applicable FMAP of more than 

12 1 quarter. 

13 ‘‘(E) LIMITATIONS.— 

14 ‘‘(i) NO INCREASES OVER 100 PER15 CENT.—A State may not increase an appli16 cable FMAP for any quarter during a look17 back period under this paragraph if such 

18 increase would result in the applicable 

19 FMAP for such quarter exceeding 100 per20 cent. 

21 ‘‘(ii) SCOPE OF APPLICATION.—Any 

22 increase to an applicable FMAP of a State 

23 for a fiscal quarter under this paragraph— 

24 ‘‘(I) shall only apply with respect 

25 to payments for amounts expended by 


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1 the State for medical assistance for 

2 services furnished during such quarter 

3 to which such applicable FMAP is ap4 plicable; and 

5 ‘‘(II) shall not apply with respect 

6 to payments described in paragraph 

7 (3)(B)(i). 

8 ‘‘(F) DEFINITIONS.—In this paragraph: 

9 ‘‘(i) APPLICABLE FMAP.—The term 

10 ‘applicable FMAP’ means, with respect to 

11 a State and fiscal quarter— 

12 ‘‘(I) the Federal medical assist13 ance percentage determined for the 

14 State and quarter under subsection 

15 (b); 

16 ‘‘(II) the Federal medical assist17 ance percentage applicable under sub18 section (y); 

19 ‘‘(III) the Federal medical assist20 ance percentage applicable under sub21 section (z)(2); 

22 ‘‘(IV) the Federal medical assist23 ance percentage determined for the 

24 State and quarter under subsection 

25 (ff); or 


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1 ‘‘(V) the enhanced FMAP deter2 mined for the State and quarter 

3 under section 2105(b). 

4 ‘‘(ii) LOOK-BACK PERIOD.—The term 

5 ‘look-back period’ means, with respect to a 

6 State and a fiscal quarter that is an eco7 nomic downturn quarter for the State, the 

8 period of 4 fiscal quarters that ends with 

9 the fourth quarter which precedes the most 

10 recent fiscal quarters that was not an eco11 nomic downturn quarter for the State. 

12 ‘‘(6) REQUIREMENT FOR ALL STATES.—This 

13 subsection shall not apply to a State with respect to 

14 a fiscal quarter, if— 

15 ‘‘(A) eligibility standards, methodologies, 

16 or procedures under the State plan or a waiver 

17 of such plan are more restrictive during such 

18 quarter than the eligibility standards, meth19 odologies, or procedures, respectively, under 

20 such plan (or waiver) as in effect on the last 

21 day of the most recent fiscal quarter that was 

22 not an economic downturn quarter for the 

23 State; 

24 ‘‘(B) the amount of any premium imposed 

25 by the State pursuant to section 1916 or 1916A 


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1 during such quarter, with respect to an indi2 vidual enrolled under such plan (or waiver), ex3 ceeds the amount of such premium as of the 

4 date described in subparagraph (A); or 

5 ‘‘(C) the State fails to provide that an in6 dividual who is enrolled for benefits under such 

7 plan (or waiver) as of the date described in sub8 paragraph (A) or enrolls for benefits under 

9 such plan (or waiver) during the period begin10 ning with such date and ending with the day 

11 before the first day of the next quarter that is 

12 not an economic downturn quarter for the State 

13 shall be treated as eligible for such benefits for 

14 not less than 12 months after such date or (if 

15 later) the date that such individual so enrolls 

16 unless the individual requests a voluntary ter17 mination of eligibility or the individual ceases to 

18 be a resident of the State.’’. 

19 (b) EXCLUSION OF ECONOMIC DOWNTURN FMAP 

20 INCREASES FROM TERRITORIAL CAPS; SPECIAL RULE

21 FOR CHIP ALLOTMENTS.— 

22 (1) EXCLUSION FROM TERRITORIAL CAPS.— 

23 Section 1108 of the Social Security Act (42 U.S.C. 

24 1308) is amended— 


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1 (A) in subsection (f), in the matter pre2 ceding paragraph (1), by striking ‘‘subsection 

3 (g) and section 1935(e)(1)(B)’’ and inserting 

4 ‘‘subsections (g) and (h) and section 

5 1935(e)(1)(B)’’; and 

6 (B) by adding at the end the following: 

7 ‘‘(h) EXCLUSION FROM CAPS OF AMOUNTS ATTRIB8 UTABLE TO ECONOMIC DOWNTURN FMAP.—Any pay9 ment made to a territory for a fiscal year in which the 

10 Federal medical assistance percentage for the territory is 

11 determined under section 1905(hh) shall not be taken into 

12 account for purposes of applying payment limits under 

13 subsections (f) and (g) to the extent that such payment 

14 exceeds the amount of the payment that would have been 

15 made to the territory for the year if the Federal medical 

16 assistance percentage for the territory had been deter17 mined without regard to such section.’’. 

18 (2) CHIP ALLOTMENTS.—Section 2104(m) of 

19 the Social Security Act (42 U.S.C. 1397dd(m)) is 

20 amended— 

21 (A) in paragraph (2)(B), in the matter 

22 preceding clause (i), by striking ‘‘paragraphs 

23 (5) and (7)’’ and inserting ‘‘paragraphs (5), 

24 (7), and (12)’’; and 


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1 (B) by adding at the end the following new 

2 paragraph: 

3 ‘‘(12) SPECIAL RULE FOR ADJUSTING ALLOT4 MENTS DURING FISCAL YEARS WITH ECONOMIC

5 DOWNTURN QUARTERS.— 

6 ‘‘(A) IN GENERAL.—If a fiscal quarter oc7 curring during fiscal year 2020 or any suc8 ceeding fiscal year is determined to be an eco9 nomic downturn quarter with respect to a State 

10 (as determined under section 1905(hh)) then, 

11 as soon as practicable after such determination, 

12 the Secretary shall increase the allotment for 

13 the State and fiscal year in accordance with 

14 subparagraph (B). 

15 ‘‘(B) AMOUNT OF INCREASE.— 

16 ‘‘(i) IN GENERAL.—The amount of an 

17 increase to the allotment of a State de18 scribed in subparagraph (A) for a fiscal 

19 year shall be equal to the amount by which 

20 Federal payments made to the State for 

21 the preceding fiscal year under this title 

22 would have been increased (without regard 

23 to whether such payments would exceed 

24 the amount of the State’s allotment for 

25 such preceding fiscal year) if the enhanced 


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1 FMAP determined for the State for such 

2 preceding fiscal year had been increased to 

3 the same extent that the State’s enhanced 

4 FMAP for the fiscal year involved is ex5 pected to be increased as a result of the 

6 application of section 1905(hh) relative to 

7 the enhanced FMAP that would apply to 

8 the State for the fiscal year involved with9 out the application of such section. 

10 ‘‘(ii) INCLUSION OF PROJECTED IN11 CREASES.—In increasing the allotment of a 

12 State for a fiscal year under this para13 graph, the Secretary may base the calcula14 tion of such increase on projections made 

15 by the Secretary with respect to— 

16 ‘‘(I) the number of fiscal quar17 ters during such fiscal year that will 

18 be economic downturn quarters; and 

19 ‘‘(II) the effect that the applica20 tion of section 1905(hh) is expected to 

21 have on the enhanced FMAP of the 

22 State for such fiscal year. 

23 ‘‘(C) DISREGARD OF INCREASED PAY24 MENTS FOR PURPOSES OF FUTURE ALLOT25 MENTS.—Any Federal payment made to a State 


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1 under this title for a fiscal year in which the 

2 Federal medical assistance percentage for the 

3 State is determined under section 1905(hh) 

4 shall be disregarded when determining the allot5 ment of the State for any subsequent year, in6 cluding for purposes of applying this paragraph, 

7 to the extent that such payment exceeds the 

8 amount of the payment that would have been 

9 made to the State for the year if the Federal 

10 medical assistance percentage for the State and 

11 year had been determined without regard to 

12 such section.’’. 

13 (c) CONFORMING AMENDMENTS.—Section 1905(cc) 

14 of the Social Security Act (42 U.S.C. 1396d(cc)) is 

15 amended— 

16 (1) by striking ‘‘and section 6008 of the Fami17 lies First Coronavirus Response Act’’ and inserting 

18 ‘‘, section 6008 of the Families First Coronavirus 

19 Response Act, and subsection (hh) of this section’’; 

20 and 

21 (2) by inserting ‘‘, and, in applying such treat22 ments to an increase in the Federal medical assist23 ance percentage of a State under subsection (hh) 

24 with respect to a fiscal quarter that is an economic 

25 downturn quarter for the State, the reference to 


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1 ‘December 31, 2009’ shall be deemed to be a ref2 erence to ‘March 11, 2020’, or, if later, the last day 

3 of the most recent fiscal quarter that was not an 

4 economic downturn quarter for the State’’ before the 

5 period. 

Æ 


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