I

105TH CONGRESS

2D SESSION H. R. 4767

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

coverage of needy children under the State Children’s Health Insurance

Program (SCHIP) and the Medicaid Program.

IN THE HOUSE OF REPRESENTATIVES

OCTOBER 9, 1998

Ms. DEGETTE introduced the following bill; which was referred to the

Committee on Commerce

A BILL

To amend titles XIX and XXI of the Social Security Act

to improve the coverage of needy children under the

State Children’s Health Insurance Program (SCHIP)

and the Medicaid Program.

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; REFERENCES IN ACT; TABLE OF

4 CONTENTS.

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

6 ‘‘Improved Children’s Health Coverage Act of 1998’’.

7 (b) REFERENCES TO SOCIAL SECURITY ACT.—Ex8 cept as otherwise expressly provided, whenever in this Act
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1 an amendment or repeal is expressed in terms of an

2 amendment to, or repeal of, a section or other provision,

3 the reference shall be considered to be made to a section

4 or other provision of the Social Security Act.

5 (c) TABLE OF CONTENTS.—The table of contents of

6 this Act is as follows:

Sec. 1. Short title; references in Act; table of contents.

Sec. 2. Simplified outreach and enrollment.

Sec. 3. Family friendly coverage and enrollment.

Sec. 4. Expanded coverage options.

7 SEC. 2. SIMPLIFIED OUTREACH AND ENROLLMENT.

8 (a) USE OF UNIFORM APPLICATION AND COORDI9 NATED ENROLLMENT PROCESS.—

10 (1) SCHIP PROGRAM.—Section 2102 (42

11 U.S.C. 1397bb) is amended by adding at the end the

12 following new subsection:

13 ‘‘(d) DEVELOPMENT AND USE OF UNIFORM APPLI14 CATION FORMS AND COORDINATED ENROLLMENT PROC15 ESS.—

16 ‘‘(1) IN GENERAL.—A State child health plan

17 shall provide, by not later than October 1, 1999,

18 for—

19 ‘‘(A) the development and use of a uni20 form, simplified application form which is used

21 both for purposes of establishing eligibility for

22 benefits under this title and also under title

23 XIX;
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1 ‘‘(B) an enrollment process that is coordi2 nated with that under title XIX so that a fam3 ily need only interact with a single agency in

4 order to determine whether a child is eligible

5 for benefits under this title or title XIX; and

6 ‘‘(C) acceptance and timely response to

7 telephone inquiries and other electronic commu8 nications received through the national toll-free

9 system established under section 3 of the Im10 proved Children’s Health Coverage Act of

11 1998.’’.

12 (2) MEDICAID CONFORMING AMENDMENT.—

13 (A) IN GENERAL.—Section 1902(a) (42

14 U.S.C. 1396a(a)) is amended—

15 (i) by striking the period at the end of

16 paragraph (65) and inserting ‘‘; and’’, and

17 (ii) by inserting after paragraph (65)

18 the following new paragraph:

19 ‘‘(66) provide, by not later than October 1,

20 1999, in the case of a State with a State child

21 health plan under title XXI for—

22 ‘‘(A) the development and use of a uni23 form, simplified application form which is used

24 both for purposes of establishing eligibility for
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1 benefits under this title and also under title

2 XXI;

3 ‘‘(B) establishment and operation of an en4 rollment process that is coordinated with that

5 under title XXI so that a family need only

6 interact with a single agency in order to deter7 mine whether a child is eligible for benefits

8 under this title or title XXI; and

9 ‘‘(C) acceptance and timely response to

10 telephone inquiries and other electronic commu11 nications received through the national toll-free

12 system established under section 3 of the Im13 proved Children’s Health Coverage Act of

14 1998.’’.

15 (B) EFFECTIVE DATE.—The amendments

16 made by subparagraph (A) apply to calendar

17 quarters beginning on or after October 1, 1999.

18 (b) NATIONAL TOLL-FREE INFORMATION LINE.—

19 The Secretary of Health and Human Services shall estab20 lish, in coordination with State agencies responsible for

21 administration of State Medicaid and child health insur22 ance programs and by not later than October 1, 1999,

23 for a national toll-free telephone number that individuals

24 may access to obtain information on coverage of children

25 under such programs.
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1 (c) FINANCIAL INCENTIVES TO PROMOTE APPRO2 PRIATE ENROLLMENT.—

3 (1) ELIMINATING LIMITATION ON ADMINISTRA4 TIVE EXPENDITURES FOR ENROLLMENT AND OUT5 REACH ACTIVITIES.—Section 2105 (42 U.S.C.

6 1397ee) is amended—

7 (A) in subsection (a)(2)(D), by striking the

8 period and inserting the following: ‘‘, including

9 costs to administer section 2102(d) regardless

10 of whether such expenditures might also be re11 lated to the administration of title XIX.

12 The Secretary shall permit common administrative ex13 penditures described in paragraph (2)(D) between this

14 title and title XIX to be paid for under this title.’’;

15 (B) in subsection (c)(2)(A), by striking

16 ‘‘paragraph (1)’’ and inserting ‘‘paragraphs (1)

17 and (2)(C)’’; and

18 (C) by adding at the end of subsection

19 (c)(2) the following:

20 ‘‘(C) EXCEPTION FOR COORDINATED OUT21 REACH AND ENROLLMENT EXPENDITURES.—

22 The limitation under subparagraph (A) on ex23 penditures for items described in subsection

24 (a)(2) shall not apply to reasonable administra25 tive costs incurred in carrying out section
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1 2102(d) or described in the last sentence of

2 subsection (a).’’.

3 (2) ADDITIONAL ACTIVITIES TO ASSURE APPRO4 PRIATE ENROLLMENT.—Section 2105 is further

5 amended by adding at the end the following new

6 subsection:

7 ‘‘(e) AUDITS OF ENROLLMENT PROCESSES; DIS8 ALLOWANCE BASED ON SUCH AUDITS.—

9 ‘‘(1) PERIODIC AUDITS.—Each State shall pro10 vide for periodic independent audits of the enroll11 ment practices to determine the extent to which chil12 dren provided assistance under this title are eligible

13 for medical assistance under title XIX (and, there14 fore, should be provided assistance under that title

15 rather than under this title).

16 ‘‘(2) DISALLOWANCE BASED ON EXTRAPO17 LATION OF AUDIT RESULTS.—Insofar as an audit

18 under paragraph (1) finds that the proportion of

19 children provided assistance in a State under this

20 title are eligible for medical assistance under title

21 XIX exceeds 5 percent, the Secretary shall provide

22 that the reference to the enhanced FMAP in sub23 section (a) shall be treated as a reference to the

24 Federal medical assistance percentage (as defined in

25 the first sentence of section 1905(b)) with respect to
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1 expenditures for child health assistance for such ex2 cess proportion of child health assistance.’’.

3 (3) EFFECTIVE DATE.—The amendments made

4 by this subsection take effect on the date of the en5 actment of this Act and apply to expenditures made

6 on or after the date of the enactment of this Act.

7 (d) ADDITIONAL ENTITIES QUALIFIED TO DETER8 MINE MEDICAID PRESUMPTIVE ELIGIBILITY FOR LOW-IN9 COME CHILDREN.—

10 (1) Section 1920A(b)(3)(A)(i) (42 U.S.C.

11 1396r–1a(b)(3)(A)(i)) is amended—

12 (A) by striking ‘‘or (II)’’ and inserting ‘‘,

13 (II)’’; and

14 (B) by inserting ‘‘eligibility of a child for

15 medical assistance under the State plan under

16 this title, or eligibility of a child for child health

17 assistance under the program funded under

18 title XXI, or (III) is an elementary school or

19 secondary school, as such terms are defined in

20 section 14101 of the Elementary and Secondary

21 Education Act of 1965 (20 U.S.C. 8801), an el22 ementary or secondary school operated or sup23 ported by the Bureau of Indian Affairs, a State

24 child support enforcement agency, a child care

25 resource and referral agency, or a State office
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1 or private contractor that accepts applications

2 for or administers a program funded under part

3 A of title IV or that determines eligibility for

4 any assistance or benefits provided under any

5 program of public or assisted housing that re6 ceives Federal funds, including the program

7 under section 8 or any other section of the

8 United States Housing Act of 1937 (42 U.S.C.

9 1437 et seq.)’’ before the semicolon.

10 SEC. 3. FAMILY FRIENDLY COVERAGE AND ENROLLMENT.

11 (a) ASSURING COORDINATION OF PEDIATRIC PRO12 VIDERS WITHIN A FAMILY.—

13 (1) IN GENERAL.—Section 2103 (42 U.S.C.

14 1397cc) is amended by adding at the end the follow15 ing new subsection:

16 ‘‘(g) STEPS TAKEN TO COORDINATE PROVISION OF

17 PEDIATRIC CARE WITHIN A FAMILY.—A State child

18 health plan—

19 ‘‘(1) shall specify methods being used to ensure

20 that children within a family who are eligible for as21 sistance under the plan (or under a State plan under

22 title XIX) are allowed to be seen by the same pedia23 trician or group of pediatricians in a manner that

24 permits the coordinated receipt of care by children

25 in the same family; and
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1 ‘‘(2) shall include a description of such methods

2 in each annual report submitted under section

3 2108(a).’’.

4 (2) EFFECTIVE DATE.—The amendment made

5 by paragraph (1) applies on the date of the enact6 ment of this Act and to reports submitted for years

7 beginning with 1999.

8 (b) REDUCTION IN BURDEN OF ADMINISTERING

9 COST-SHARING PROVISIONS.—

10 (1) STATE RESPONSIBLE FOR ASSURING CAP

11 ON COST-SHARING NOT EXCEEDED.—Section

12 2103(e)(3) (42 U.S.C. 1397cc(e)(3)) is amended by

13 adding at the end the following new subparagraph:

14 ‘‘(C) STATE AND CONTRACTORS RESPON15 SIBLE FOR APPLYING LIMITATIONS ON COST16 SHARING.—The State child health plan shall

17 provide that responsibility for assuring compli18 ance with the limitations on cost-sharing under

19 this paragraph falls on the State and on its

20 contractors, and not on beneficiaries and their

21 families.’’.

22 (2) STATE OPTION OF FLAT LIMIT ON OUT-OF23 POCKET EXPENDITURES.—Section 2103(e)(3)(B)

24 (42 U.S.C. 1397cc(e)(3)(B)) is amended by insert25 ing before the period at the end the following: ‘‘(or,
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1 at the option of a State, a limiting amount which is

2 not greater than $500)’’.

3 (3) EFFECTIVE DATE.—The amendment made

4 by paragraph (1) takes effect on the date that is 30

5 days after the date of the enactment of this Act.

6 (c) PROHIBITION OF WAITING PERIODS.—

7 (1) IN GENERAL.—Section 2102(b)(1)(B) (42

8 U.S.C. 1397bb(b)(1)(B)) is amended—

9 (A) by striking ‘‘and’’ at the end of clause

10 (i);

11 (B) by striking the period at the end of

12 clause (ii) and inserting ‘‘; and’’; and

13 (C) by adding at the end the following new

14 clause:

15 ‘‘(iii) shall not permit the use of any

16 mandatory waiting period (including any

17 such period in order to carry out para18 graph (3)(C)), unless the Secretary finds

19 that the imposition of such a period would

20 not be contrary to the provisions of this

21 title.’’.

22 (2) EFFECTIVE DATE.—The amendments made

23 by paragraph (1) apply to assistance furnished on or

24 after the date of the enactment of this Act.
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1 (d) GRACE PERIOD AND PRIOR NOTICE BEFORE

2 DISENROLLMENT FOR NONPAYMENT OF PREMIUMS.—

3 (1) IN GENERAL.—Section 2103(e) (42 U.S.C.

4 1397ee(e)) is amended by adding at the end the fol5 lowing new paragraph:

6 ‘‘(5) GRACE PERIOD.—Before disenrolling a

7 child under a State child health plan for non8 payment of a premium, the plan shall provide for

9 notice in writing to the family involved and a grace

10 period (of not less than 30 days) in which payment

11 may be made without disenrollment.’’.

12 (2) EFFECTIVE DATE.—The amendment made

13 by paragraph (1) applies to disenrollments occurring

14 on or after the date that is 30 days after the date

15 of the enactment of this Act.

16 SEC. 4. EXPANDED COVERAGE OPTIONS.

17 (a) AUTOMATIC REASSESSMENT OF ELIGIBILITY FOR

18 SCHIP BENEFITS FOR CHILDREN LOSING MEDICAID

19 ELIGIBILITY.—

20 (1) IN GENERAL.—Section 1902(a)(66) (42

21 U.S.C. 1396a(a)(66)), as inserted by section 2(a)(2),

22 is amended—

23 (A) by striking ‘‘and’’ at the end of sub24 paragraph (B),
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1 (B) by striking the period at the end of

2 subparagraph (C) and inserting ‘‘; and’’; and

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

4 subparagraph:

5 ‘‘(D) the automatic assessment, in the case

6 of a child who loses eligibility for medical assist7 ance under this title on the basis of changes in

8 income, assets, or age, of whether the child is

9 eligible for benefits under title XXI.’’.

10 (2) EFFECTIVE DATE.—The amendments made

11 by paragraph (1) apply to children who lose eligi12 bility under the medicaid program under title XIX

13 of the Social Security Act on or after the date that

14 is 30 days after the date of the enactment of this

15 Act.

16 (b) OPTIONAL COVERAGE OF LOW-INCOME, UNIN17 SURED PREGNANT WOMEN UNDER A STATE CHILD

18 HEALTH PLAN.—

19 (1) IN GENERAL.—Title XXI is amended by

20 adding at the end the following new section:

21 ‘‘SEC. 2111. OPTIONAL COVERAGE OF LOW-INCOME, UNIN22 SURED PREGNANT WOMEN.

23 ‘‘(a) OPTIONAL COVERAGE.—Notwithstanding any

24 other provision of this title, a State child health plan may

25 provide for coverage of pregnancy-related assistance for
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1 targeted low-income pregnant women in accordance with

2 this section.

3 ‘‘(b) DEFINITIONS.—For purposes of this section:

4 ‘‘(1) PREGNANCY-RELATED ASSISTANCE.—The

5 term ‘pregnancy-related assistance’ has the meaning

6 given the term child health assistance in section

7 2110(a) as if any reference to targeted low-income

8 children were a reference to targeted low-income

9 pregnant women, except that the assistance shall be

10 limited to services related to pregnancy (which in11 clude prenatal, delivery, and postpartum services)

12 and to other conditions that may complicate preg13 nancy and shall not include prepregnancy services

14 and supplies.

15 ‘‘(2) TARGETED LOW-INCOME PREGNANT

16 WOMAN.—The term ‘targeted low-income pregnant

17 woman’ has the meaning given the term targeted

18 low-income child in section 2110(b) as if any ref19 erence to a child were deemed a reference to a

20 woman during pregnancy and through the end of the

21 month in which the 60-day period (beginning on the

22 last day of her pregnancy) ends.

23 ‘‘(c) REFERENCES TO TERMS AND SPECIAL

24 RULES.—In the case of, and with respect to, a State pro25 viding for coverage of pregnancy-related assistance to tar-
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1 geted low-income pregnant women under subsection (a),

2 the following special rules apply:

3 ‘‘(1) Any reference in this title (other than sub4 section (b)) to a targeted low income child is deemed

5 to include a reference to a targeted low-income preg6 nant woman.

7 ‘‘(2) Any such reference to child health assist8 ance with respect to such women is deemed a ref9 erence to pregnancy-related assistance.

10 ‘‘(3) Any such reference to a child is deemed a

11 reference to a woman during pregnancy and the pe12 riod described in subsection (b)(2).

13 ‘‘(4) The medicaid applicable income level is

14 deemed a reference to the income level established

15 under section 1902(l)(2)(A).

16 ‘‘(5) Subsection (a) of section 2103 (relating to

17 required scope of health insurance coverage) shall

18 not apply insofar as a State limits coverage to serv19 ices described in subsection (b)(1) and the reference

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

21 to require, in such case, compliance with the require22 ments of section 2103(a).

23 ‘‘(6) There shall be no exclusion of benefits for

24 services described in subsection (b)(1) based on any

25 pre-existing condition.
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1 ‘‘(d) NO IMPACT ON ALLOTMENTS.—Nothing in this

2 section shall be construed as affecting the amount of any

3 initial allotment provided to a State under section

4 2104(b).

5 ‘‘(e) APPLICATION OF FUNDING RESTRICTIONS.—

6 The coverage under this section (and the funding of such

7 coverage) is subject to the restrictions of section 2105(c).

8 ‘‘(f) DEEMED ELIGIBILITY FOR 1-YEAR FOR CHIL9 DREN BORN TO PRESUMPTIVELY ELIGIBLE TARGETED

10 PREGNANT WOMEN.—If a child is born to a targeted low11 income pregnant woman who was receiving pregnancy-re12 lated assistance under this section at the time of the birth,

13 the child shall be deemed, notwithstanding any other pro14 vision of this title, to be a targeted low-income child until

15 the child attains 1 year of age.’’.

16 (2) EFFECTIVE DATE.—The amendment made

17 by paragraph (1) shall take effect on the date of the

18 enactment of this Act and shall apply to allotments

19 for all fiscal years

20 (c) STATE OPTION FOR COVERAGE OF LEGAL IMMI21 GRANTS UNDER THE MEDICAID AND CHILDREN’S

22 HEALTH INSURANCE PROGRAMS.—

23 (1) MEDICAID.—Section 1902(a)(10)(a)(ii) (42

24 U.S.C. 1396a(a)(10)(A)(ii)) is amended—
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1 (A) by striking ‘‘or’’ at the end of sub2 clause (XIII);

3 (B) by adding ‘‘or’’ at the end of subclause

4 (XIV); and

5 (C) by adding at the end the following new

6 subclause:

7 ‘‘(XV) who are described in sec8 tion 1905(a)(i) and who would be eli9 gible for medical assistance (or for a

10 greater amount of medical assistance)

11 under the State plan under this title

12 but for the provisions of section 403

13 or section 421 of Public Law 104–

14 193, but the State may not exercise

15 the option of providing medical assist16 ance under this subclause with respect

17 to a subcategory of individuals de18 scribed in this subclause;’’.

19 (2) CHILDREN’S HEALTH INSURANCE PRO20 GRAM.—Section 2110(b) (42 U.S.C. 1397jj(b)) is

21 amended—

22 (A) in paragraph (1)(A), by inserting be23 fore the semicolon ‘‘(including, at the option of

24 the State, a child described in paragraph

25 (3)(B))’’; and
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1 (B) in paragraph (3)—

2 (i) by striking ‘‘SPECIAL RULE.—’’

3 and inserting ‘‘SPECIAL RULES.—

4 ‘‘(i) HEALTH INSURANCE COV5 ERAGE.—’’ by indenting the remainder of

6 the text accordingly; and

7 (ii) by adding at the end the following

8 new subparagraph:

9 ‘‘(B) ELIGIBILITY FOR LEGAL IMMIGRANT

10 CHILDREN.—For purposes of paragraph (1)(A),

11 a child is described in this subparagraph if—

12 ‘‘(i) the child would be determined eli13 gible for child health assistance under this

14 title but for the provisions of sections 403

15 and 421 of Public Law 104–193; and

16 ‘‘(ii) the State exercises the option to

17 provide medical assistance to the category

18 of individuals described in section

19 1902(a)(10)(A)(ii)(XV).’’.

20 (d) CLARIFICATION OF COVERAGE UNDER VACCINE

21 FOR CHILDREN PROGRAM.—

22 (1) IN GENERAL.—Section 1928(b)(2)(A)(ii)

23 (42 U.S.C. 1396s(b)(2)(A)(ii)) is amended by insert24 ing ‘‘, except that for purposes of this paragraph a

25 child who is only insured under title XXI shall be
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1 considered as being not insured’’ after ‘‘not in2 sured’’.

3 (2) EFFECTIVE DATE.—The amendment made

4 by paragraph (1) shall take effect as if included in

5 the enactment of the Balanced Budget Act of 1997.

6 (e) ELIMINATION OF FUNDING OFFSET FOR EXER7 CISE OF PRESUMPTIVE ELIGIBILITY OPTION.—

8 (1) IN GENERAL.—Section 2104(d) (42 U.S.C.

9 1397dd(d)) is amended by striking ‘‘shall be reduced

10 by the sum of’’ and all that follows through ‘‘(2) the

11 amount of payments under such section’’ and insert12 ing ‘‘shall be reduced by the amount of payments

13 under section 1903(a)(1)’’.

14 (2) EFFECTIVE DATE.—The amendment made

15 by paragraph (1) first applies for allotments for fis16 cal year 1999.

17 (f) PROGRAM COORDINATION WITH THE MATERNAL

18 AND CHILD HEALTH PROGRAM (TITLE V).—

19 (1) IN GENERAL.—Section 2102(b)(3) (42

20 U.S.C. 1397bb(b)(3)) is amended—

21 (A) by striking ‘‘and’’ at the end of sub22 paragraph (D);

23 (B) by striking the period at the end of

24 subparagraph (E) and inserting ‘‘; and’’; and
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1 (C) by adding at the end the following new

2 subparagraph:

3 ‘‘(F) that operations and activities under

4 this title are developed and implemented in con5 sultation and coordination with the program op6 erated by the State under title V in areas in7 cluding outreach and enrollment, benefits and

8 services, service delivery standards, public

9 health and social service agency relationships,

10 and quality assurance and data reporting.’’.

11 (2) CONFORMING MEDICAID AMENDMENT.—

12 Section 1902(a)(11) (42 U.S.C. 1306a(a)(11)) is

13 amended—

14 (A) by striking ‘‘and’’ before ‘‘(C)’’; and

15 (B) by inserting before the semicolon at

16 the end the following: ‘‘, and (D) provide that

17 operations and activities under this title are de18 veloped and implemented in consultation and

19 coordination with the program operated by the

20 State under title V in areas including outreach

21 and enrollment, benefits and services, service

22 delivery standards, public health and social

23 service agency relationships, and quality assur24 ance and data reporting;’’.
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1 (3) EFFECTIVE DATE.—The amendments made

2 by this subsection take effect on January 1, 1999.

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