II 

Calendar No. 17 

111TH CONGRESS 

1ST SESSION S. 275 

To amend title XXI of the Social Security Act to extend and improve the 

Children’s Health Insurance Program, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JANUARY 16, 2009 

Mr. BAUCUS, from the Committee on Finance, reported the following original 

bill; which was read twice and placed on the calendar 

A BILL 

To amend title XXI of the Social Security Act to extend 

and improve the Children’s Health Insurance Program, 

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; AMENDMENTS TO SOCIAL SECU4 RITY ACT; REFERENCES; TABLE OF CON5 TENTS. 

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

7 ‘‘Children’s Health Insurance Program Reauthorization 

8 Act of 2009’’. 


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1 (b) AMENDMENTS TO SOCIAL SECURITY ACT.—Ex2 cept as otherwise specifically provided, whenever in this 

3 Act an amendment is expressed in terms of an amendment 

4 to or repeal of a section or other provision, the reference 

5 shall be considered to be made to that section or other 

6 provision of the Social Security Act. 

7 (c) REFERENCES TO CHIP; MEDICAID; SEC8 RETARY.—In this Act: 

9 (1) CHIP.—The term ‘‘CHIP’’ means the 

10 State Children’s Health Insurance Program estab11 lished under title XXI of the Social Security Act (42 

12 U.S.C. 1397aa et seq.). 

13 (2) MEDICAID.—The term ‘‘Medicaid’’ means 

14 the program for medical assistance established under 

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

16 et seq.). 

17 (3) SECRETARY.—The term ‘‘Secretary’’ means 

18 the Secretary of Health and Human Services. 

19 (d) TABLE OF CONTENTS.—The table of contents of 

20 this Act is as follows: 

Sec. 1. Short title; amendments to Social Security Act; references; table of contents. 

Sec. 2. Purpose. 

Sec. 3. General effective date; exception for State legislation; contingent effective date; reliance on law. 

TITLE I—FINANCING 

Subtitle A—Funding 

Sec. 101. Extension of CHIP. 


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Sec. 102. Allotments for States and territories for fiscal years 2009 through 

2013. 

Sec. 103. Child Enrollment Contingency Fund. 

Sec. 104. CHIP performance bonus payment to offset additional enrollment 

costs resulting from enrollment and retention efforts. 

Sec. 105. Two-year initial availability of CHIP allotments. 

Sec. 106. Redistribution of unused allotments. 

Sec. 107. Option for qualifying States to receive the enhanced portion of the 

CHIP matching rate for Medicaid coverage of certain children. 

Sec. 108. One-time appropriation. 

Sec. 109. Improving funding for the territories under CHIP and Medicaid. 

Subtitle B—Focus on Low-Income Children and Pregnant Women 

Sec. 111. State option to cover low-income pregnant women under CHIP 

through a State plan amendment. 

Sec. 112. Phase-out of coverage for nonpregnant childless adults under CHIP; 

conditions for coverage of parents. 

Sec. 113. Elimination of counting Medicaid child presumptive eligibility costs 

against title XXI allotment. 

Sec. 114. Limitation on matching rate for States that propose to cover children 

with effective family income that exceeds 300 percent of the 

poverty line. 

Sec. 115. State authority under Medicaid. 

TITLE II—OUTREACH AND ENROLLMENT 

Subtitle A—Outreach and Enrollment Activities 

Sec. 201. Grants and enhanced administrative funding for outreach and enrollment. 

Sec. 202. Increased outreach and enrollment of Indians. 

Sec. 203. State option to rely on findings from an Express Lane agency to conduct simplified eligibility determinations. 

Subtitle B—Reducing Barriers to Enrollment 

Sec. 211. Verification of declaration of citizenship or nationality for purposes 

of eligibility for Medicaid and CHIP. 

Sec. 212. Reducing administrative barriers to enrollment. 

Sec. 213. Model of Interstate coordinated enrollment and coverage process. 

Sec. 214. Permitting States to ensure coverage without a 5-year delay of certain children and pregnant women under the Medicaid program 

and CHIP. 

TITLE III—REDUCING BARRIERS TO PROVIDING PREMIUM 

ASSISTANCE 

Subtitle A—Additional State Option for Providing Premium Assistance 

Sec. 301. Additional State option for providing premium assistance. 

Sec. 302. Outreach, education, and enrollment assistance. 

Subtitle B—Coordinating Premium Assistance With Private Coverage 


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Sec. 311. Special enrollment period under group health plans in case of termination of Medicaid or CHIP coverage or eligibility for assistance in purchase of employment-based coverage; coordination 

of coverage. 

TITLE IV—STRENGTHENING QUALITY OF CARE AND HEALTH 

OUTCOMES 

Sec. 401. Child health quality improvement activities for children enrolled in 

Medicaid or CHIP. 

Sec. 402. Improved availability of public information regarding enrollment of 

children in CHIP and Medicaid. 

Sec. 403. Application of certain managed care quality safeguards to CHIP. 

TITLE V—IMPROVING ACCESS TO BENEFITS 

Sec. 501. Dental benefits. 

Sec. 502. Mental health parity in CHIP plans. 

Sec. 503. Application of prospective payment system for services provided by 

Federally-qualified health centers and rural health clinics. 

Sec. 504. Premium grace period. 

Sec. 505. Clarification of coverage of services provided through school-based 

health centers. 

Sec. 506. Medicaid and CHIP Payment and Access Commission. 

TITLE VI—PROGRAM INTEGRITY AND OTHER MISCELLANEOUS 

PROVISIONS 

Subtitle A—Program Integrity and Data Collection 

Sec. 601. Payment error rate measurement (‘‘PERM’’). 

Sec. 602. Improving data collection. 

Sec. 603. Updated Federal evaluation of CHIP. 

Sec. 604. Access to records for IG and GAO audits and evaluations. 

Sec. 605. No Federal funding for illegal aliens; disallowance for unauthorized 

expenditures. 

Subtitle B—Miscellaneous Health Provisions 

Sec. 611. Deficit Reduction Act technical corrections. 

Sec. 612. References to title XXI. 

Sec. 613. Prohibiting initiation of new health opportunity account demonstration programs. 

Sec. 614. Adjustment in computation of Medicaid FMAP to disregard an extraordinary employer pension contribution. 

Sec. 615. Clarification treatment of regional medical center. 

Sec. 616. Extension of Medicaid DSH allotments for Tennessee and Hawaii. 

Sec. 617. GAO report on Medicaid managed care payment rates. 

Subtitle C—Other Provisions 

Sec. 621. Outreach regarding health insurance options available to children. 

Sec. 622. Sense of the Senate regarding access to affordable and meaningful 

health insurance coverage. 

TITLE VII—REVENUE PROVISIONS 

Sec. 701. Increase in excise tax rate on tobacco products. 


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Sec. 702. Administrative improvements. 

Sec. 703. Treasury study concerning magnitude of tobacco smuggling in the 

United States. 

Sec. 704. Time for payment of corporate estimated taxes. 

1 SEC. 2. PURPOSE. 

2 It is the purpose of this Act to provide dependable 

3 and stable funding for children’s health insurance under 

4 titles XXI and XIX of the Social Security Act in order 

5 to enroll all six million uninsured children who are eligible, 

6 but not enrolled, for coverage today through such titles. 

7 SEC. 3. GENERAL EFFECTIVE DATE; EXCEPTION FOR STATE 

8 LEGISLATION; CONTINGENT EFFECTIVE 

9 DATE; RELIANCE ON LAW. 

10 (a) GENERAL EFFECTIVE DATE.—Unless otherwise 

11 provided in this Act, subject to subsections (b) through 

12 (d), this Act (and the amendments made by this Act) shall 

13 take effect on April 1, 2009, and shall apply to child 

14 health assistance and medical assistance provided on or 

15 after that date. 

16 (b) EXCEPTION FOR STATE LEGISLATION.—In the 

17 case of a State plan under title XIX or State child health 

18 plan under XXI of the Social Security Act, which the Sec19 retary of Health and Human Services determines requires 

20 State legislation in order for the respective plan to meet 

21 one or more additional requirements imposed by amend22 ments made by this Act, the respective plan shall not be 

23 regarded as failing to comply with the requirements of 


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1 such title solely on the basis of its failure to meet such 

2 an additional requirement before the first day of the first 

3 calendar quarter beginning after the close of the first reg4 ular session of the State legislature that begins after the 

5 date of enactment of this Act. For purposes of the pre6 vious sentence, in the case of a State that has a 2-year 

7 legislative session, each year of the session shall be consid8 ered to be a separate regular session of the State legisla9 ture. 

10 (c) COORDINATION OF CHIP FUNDING FOR FISCAL

11 YEAR 2009.—Notwithstanding any other provision of law, 

12 insofar as funds have been appropriated under section 

13 2104(a)(11), 2104(k), or 2104(l) of the Social Security 

14 Act, as amended by section 201 of Public Law 110–173, 

15 to provide allotments to States under CHIP for fiscal year 

16 2009— 

17 (1) any amounts that are so appropriated that 

18 are not so allotted and obligated before April 1, 

19 2009 are rescinded; and 

20 (2) any amount provided for CHIP allotments 

21 to a State under this Act (and the amendments 

22 made by this Act) for such fiscal year shall be re23 duced by the amount of such appropriations so allot24 ted and obligated before such date. 


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1 (d) RELIANCE ON LAW.—With respect to amend2 ments made by this Act (other than title VII) that become 

3 effective as of a date— 

4 (1) such amendments are effective as of such 

5 date whether or not regulations implementing such 

6 amendments have been issued; and 

7 (2) Federal financial participation for medical 

8 assistance or child health assistance furnished under 

9 title XIX or XXI, respectively, of the Social Security 

10 Act on or after such date by a State in good faith 

11 reliance on such amendments before the date of pro12 mulgation of final regulations, if any, to carry out 

13 such amendments (or before the date of guidance, if 

14 any, regarding the implementation of such amend15 ments) shall not be denied on the basis of the 

16 State’s failure to comply with such regulations or 

17 guidance. 

18 TITLE I—FINANCING 

19 Subtitle A—Funding 

20 SEC. 101. EXTENSION OF CHIP. 

21 Section 2104(a) (42 U.S.C. 1397dd(a)) is amended— 

22 (1) in paragraph (10), by striking ‘‘and’’ at the 

23 end; 


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1 (2) by amending paragraph (11), by striking 

2 ‘‘each of fiscal years 2008 and 2009’’ and inserting 

3 ‘‘fiscal year 2008’’; and 

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

5 paragraphs: 

6 ‘‘(12) for fiscal year 2009, $10,562,000,000; 

7 ‘‘(13) for fiscal year 2010, $12,520,000,000; 

8 ‘‘(14) for fiscal year 2011, $13,459,000,000; 

9 ‘‘(15) for fiscal year 2012, $14,982,000,000; 

10 and 

11 ‘‘(16) for fiscal year 2013, for purposes of mak12 ing 2 semi-annual allotments— 

13 ‘‘(A) $2,850,000,000 for the period begin14 ning on October 1, 2012, and ending on March 

15 31, 2013, and 

16 ‘‘(B) $2,850,000,000 for the period begin17 ning on April 1, 2013, and ending on Sep18 tember 30, 2013.’’. 

19 SEC. 102. ALLOTMENTS FOR STATES AND TERRITORIES 

20 FOR FISCAL YEARS 2009 THROUGH 2013. 

21 Section 2104 (42 U.S.C. 1397dd) is amended— 

22 (1) in subsection (b)(1), by striking ‘‘subsection 

23 (d)’’ and inserting ‘‘subsections (d) and (m)’’; 


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1 (2) in subsection (c)(1), by striking ‘‘subsection 

2 (d)’’ and inserting ‘‘subsections (d) and (m)(4)’’; 

3 and 

4 (3) by adding at the end the following new sub5 section: 

6 ‘‘(m) ALLOTMENTS FOR FISCAL YEARS 2009 

7 THROUGH 2013.— 

8 ‘‘(1) FOR FISCAL YEAR 2009.— 

9 ‘‘(A) FOR THE 50 STATES AND THE DIS10 TRICT OF COLUMBIA.—Subject to the suc11 ceeding provisions of this paragraph and para12 graph (4), the Secretary shall allot for fiscal 

13 year 2009 from the amount made available 

14 under subsection (a)(12), to each of the 50 

15 States and the District of Columbia 110 per16 cent of the highest of the following amounts for 

17 such State or District: 

18 ‘‘(i) The total Federal payments to 

19 the State under this title for fiscal year 

20 2008, multiplied by the allotment increase 

21 factor determined under paragraph (5) for 

22 fiscal year 2009. 

23 ‘‘(ii) The amount allotted to the State 

24 for fiscal year 2008 under subsection (b), 

25 multiplied by the allotment increase factor 


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1 determined under paragraph (5) for fiscal 

2 year 2009. 

3 ‘‘(iii) The projected total Federal pay4 ments to the State under this title for fis5 cal year 2009, as determined on the basis 

6 of the February 2009 projections certified 

7 by the State to the Secretary by not later 

8 than March 31, 2009. 

9 ‘‘(B) FOR THE COMMONWEALTHS AND

10 TERRITORIES.—Subject to the succeeding provi11 sions of this paragraph and paragraph (4), the 

12 Secretary shall allot for fiscal year 2009 from 

13 the amount made available under subsection 

14 (a)(12) to each of the commonwealths and ter15 ritories described in subsection (c)(3) an 

16 amount equal to the highest amount of Federal 

17 payments to the commonwealth or territory 

18 under this title for any fiscal year occurring 

19 during the period of fiscal years 1999 through 

20 2008, multiplied by the allotment increase fac21 tor determined under paragraph (5) for fiscal 

22 year 2009, except that subparagraph (B) there23 of shall be applied by substituting ‘the United 

24 States’ for ‘the State’. 


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1 ‘‘(C) ADJUSTMENT FOR QUALIFYING

2 STATES.—In the case of a qualifying State de3 scribed in paragraph (2) of section 2105(g), the 

4 Secretary shall permit the State to submit a re5 vised projection described in subparagraph 

6 (A)(iii) in order to take into account changes in 

7 such projections attributable to the application 

8 of paragraph (4) of such section. 

9 ‘‘(2) FOR FISCAL YEARS 2010 THROUGH 2012.— 

10 ‘‘(A) IN GENERAL.—Subject to paragraphs 

11 (4) and (6), from the amount made available 

12 under paragraphs (13) through (15) of sub13 section (a) for each of fiscal years 2010 

14 through 2012, respectively, the Secretary shall 

15 compute a State allotment for each State (in16 cluding the District of Columbia and each com17 monwealth and territory) for each such fiscal 

18 year as follows: 

19 ‘‘(i) GROWTH FACTOR UPDATE FOR

20 FISCAL YEAR 2010.—For fiscal year 2010, 

21 the allotment of the State is equal to the 

22 sum of— 

23 ‘‘(I) the amount of the State al24 lotment under paragraph (1) for fiscal 

25 year 2009; and 


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1 ‘‘(II) the amount of any pay2 ments made to the State under sub3 section (k), (l), or (n) for fiscal year 

4 2009, 

5 multiplied by the allotment increase factor 

6 under paragraph (5) for fiscal year 2010. 

7 ‘‘(ii) REBASING IN FISCAL YEAR

8 2011.—For fiscal year 2011, the allotment 

9 of the State is equal to the Federal pay10 ments to the State that are attributable to 

11 (and countable towards) the total amount 

12 of allotments available under this section 

13 to the State in fiscal year 2010 (including 

14 payments made to the State under sub15 section (n) for fiscal year 2010 as well as 

16 amounts redistributed to the State in fiscal 

17 year 2010), multiplied by the allotment in18 crease factor under paragraph (5) for fis19 cal year 2011. 

20 ‘‘(iii) GROWTH FACTOR UPDATE FOR

21 FISCAL YEAR 2012.—For fiscal year 2012, 

22 the allotment of the State is equal to the 

23 sum of— 


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1 ‘‘(I) the amount of the State al2 lotment under clause (ii) for fiscal 

3 year 2011; and 

4 ‘‘(II) the amount of any pay5 ments made to the State under sub6 section (n) for fiscal year 2011, 

7 multiplied by the allotment increase factor 

8 under paragraph (5) for fiscal year 2012. 

9 ‘‘(3) FOR FISCAL YEAR 2013.— 

10 ‘‘(A) FIRST HALF.—Subject to paragraphs 

11 (4) and (6), from the amount made available 

12 under subparagraph (A) of paragraph (16) of 

13 subsection (a) for the semi-annual period de14 scribed in such paragraph, increased by the 

15 amount of the appropriation for such period 

16 under section 108 of the Children’s Health In17 surance Program Reauthorization Act of 2009, 

18 the Secretary shall compute a State allotment 

19 for each State (including the District of Colum20 bia and each commonwealth and territory) for 

21 such semi-annual period in an amount equal to 

22 the first half ratio (described in subparagraph 

23 (D)) of the amount described in subparagraph 

24 (C). 


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1 ‘‘(B) SECOND HALF.—Subject to para2 graphs (4) and (6), from the amount made 

3 available under subparagraph (B) of paragraph 

4 (16) of subsection (a) for the semi-annual pe5 riod described in such paragraph, the Secretary 

6 shall compute a State allotment for each State 

7 (including the District of Columbia and each 

8 commonwealth and territory) for such semi-an9 nual period in an amount equal to the amount 

10 made available under such subparagraph, multi11 plied by the ratio of— 

12 ‘‘(i) the amount of the allotment to 

13 such State under subparagraph (A); to 

14 ‘‘(ii) the total of the amount of all of 

15 the allotments made available under such 

16 subparagraph. 

17 ‘‘(C) FULL YEAR AMOUNT BASED ON

18 REBASED AMOUNT.—The amount described in 

19 this subparagraph for a State is equal to the 

20 Federal payments to the State that are attrib21 utable to (and countable towards) the total 

22 amount of allotments available under this sec23 tion to the State in fiscal year 2012 (including 

24 payments made to the State under subsection 

25 (n) for fiscal year 2012 as well as amounts reVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 distributed to the State in fiscal year 2012), 

2 multiplied by the allotment increase factor 

3 under paragraph (5) for fiscal year 2013. 

4 ‘‘(D) FIRST HALF RATIO.—The first half 

5 ratio described in this subparagraph is the ratio 

6 of— 

7 ‘‘(i) the sum of— 

8 ‘‘(I) the amount made available 

9 under subsection (a)(16)(A); and 

10 ‘‘(II) the amount of the appro11 priation for such period under section 

12 108 of the Children’s Health Insur13 ance Program Reauthorization Act of 

14 2009; to 

15 ‘‘(ii) the sum of the— 

16 ‘‘(I) amount described in clause 

17 (i); and 

18 ‘‘(II) the amount made available 

19 under subsection (a)(16)(B). 

20 ‘‘(4) PRORATION RULE.—If, after the applica21 tion of this subsection without regard to this para22 graph, the sum of the allotments determined under 

23 paragraph (1), (2), or (3) for a fiscal year (or, in 

24 the case of fiscal year 2013, for a semi-annual pe25 riod in such fiscal year) exceeds the amount availVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 able under subsection (a) for such fiscal year or pe2 riod, the Secretary shall reduce each allotment for 

3 any State under such paragraph for such fiscal year 

4 or period on a proportional basis. 

5 ‘‘(5) ALLOTMENT INCREASE FACTOR.—The al6 lotment increase factor under this paragraph for a 

7 fiscal year is equal to the product of the following: 

8 ‘‘(A) PER CAPITA HEALTH CARE GROWTH

9 FACTOR.—1 plus the percentage increase in the 

10 projected per capita amount of National Health 

11 Expenditures from the calendar year in which 

12 the previous fiscal year ends to the calendar 

13 year in which the fiscal year involved ends, as 

14 most recently published by the Secretary before 

15 the beginning of the fiscal year. 

16 ‘‘(B) CHILD POPULATION GROWTH FAC17 TOR.—1 plus the percentage increase (if any) in 

18 the population of children in the State from 

19 July 1 in the previous fiscal year to July 1 in 

20 the fiscal year involved, as determined by the 

21 Secretary based on the most recent published 

22 estimates of the Bureau of the Census before 

23 the beginning of the fiscal year involved, plus 1 

24 percentage point. 


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1 ‘‘(6) INCREASE IN ALLOTMENT TO ACCOUNT

2 FOR APPROVED PROGRAM EXPANSIONS.—In the case 

3 of one of the 50 States or the District of Columbia 

4 that— 

5 ‘‘(A) has submitted to the Secretary, and 

6 has approved by the Secretary, a State plan 

7 amendment or waiver request relating to an ex8 pansion of eligibility for children or benefits 

9 under this title that becomes effective for a fis10 cal year (beginning with fiscal year 2010 and 

11 ending with fiscal year 2013); and 

12 ‘‘(B) has submitted to the Secretary, be13 fore the August 31 preceding the beginning of 

14 the fiscal year, a request for an expansion allot15 ment adjustment under this paragraph for such 

16 fiscal year that specifies— 

17 ‘‘(i) the additional expenditures that 

18 are attributable to the eligibility or benefit 

19 expansion provided under the amendment 

20 or waiver described in subparagraph (A), 

21 as certified by the State and submitted to 

22 the Secretary by not later than August 31 

23 preceding the beginning of the fiscal year; 

24 and 


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1 ‘‘(ii) the extent to which such addi2 tional expenditures are projected to exceed 

3 the allotment of the State or District for 

4 the year, 

5 subject to paragraph (4), the amount of the allot6 ment of the State or District under this subsection 

7 for such fiscal year shall be increased by the excess 

8 amount described in subparagraph (B)(i). A State or 

9 District may only obtain an increase under this 

10 paragraph for an allotment for fiscal year 2010 or 

11 fiscal year 2012. 

12 ‘‘(7) AVAILABILITY OF AMOUNTS FOR SEMI-AN13 NUAL PERIODS IN FISCAL YEAR 2013.—Each semi14 annual allotment made under paragraph (3) for a 

15 period in fiscal year 2013 shall remain available for 

16 expenditure under this title for periods after the end 

17 of such fiscal year in the same manner as if the al18 lotment had been made available for the entire fiscal 

19 year.’’. 

20 SEC. 103. CHILD ENROLLMENT CONTINGENCY FUND. 

21 Section 2104 (42 U.S.C. 1397dd), as amended by 

22 section 102, is amended by adding at the end the following 

23 new subsection: 

24 ‘‘(n) CHILD ENROLLMENT CONTINGENCY FUND.— 


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1 ‘‘(1) ESTABLISHMENT.—There is hereby estab2 lished in the Treasury of the United States a fund 

3 which shall be known as the ‘Child Enrollment Con4 tingency Fund’ (in this subsection referred to as the 

5 ‘Fund’). Amounts in the Fund shall be available 

6 without further appropriations for payments under 

7 this subsection. 

8 ‘‘(2) DEPOSITS INTO FUND.— 

9 ‘‘(A) INITIAL AND SUBSEQUENT APPRO10 PRIATIONS.—Subject to subparagraphs (B) and 

11 (D), out of any money in the Treasury of the 

12 United States not otherwise appropriated, there 

13 are appropriated to the Fund— 

14 ‘‘(i) for fiscal year 2009, an amount 

15 equal to 20 percent of the amount made 

16 available under paragraph (12) of sub17 section (a) for the fiscal year; and 

18 ‘‘(ii) for each of fiscal years 2010 

19 through 2012 (and for each of the semi20 annual allotment periods for fiscal year 

21 2013), such sums as are necessary for 

22 making payments to eligible States for 

23 such fiscal year or period, but not in excess 

24 of the aggregate cap described in subpara25 graph (B). 


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1 ‘‘(B) AGGREGATE CAP.—The total amount 

2 available for payment from the Fund for each 

3 of fiscal years 2010 through 2012 (and for each 

4 of the semi-annual allotment periods for fiscal 

5 year 2013), taking into account deposits made 

6 under subparagraph (C), shall not exceed 20 

7 percent of the amount made available under 

8 subsection (a) for the fiscal year or period. 

9 ‘‘(C) INVESTMENT OF FUND.—The Sec10 retary of the Treasury shall invest, in interest 

11 bearing securities of the United States, such 

12 currently available portions of the Fund as are 

13 not immediately required for payments from the 

14 Fund. The income derived from these invest15 ments constitutes a part of the Fund. 

16 ‘‘(D) AVAILABILITY OF EXCESS FUNDS

17 FOR PERFORMANCE BONUSES.—Any amounts 

18 in excess of the aggregate cap described in sub19 paragraph (B) for a fiscal year or period shall 

20 be made available for purposes of carrying out 

21 section 2105(a)(3) for any succeeding fiscal 

22 year and the Secretary of the Treasury shall re23 duce the amount in the Fund by the amount so 

24 made available. 


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1 ‘‘(3) CHILD ENROLLMENT CONTINGENCY FUND

2 PAYMENTS.— 

3 ‘‘(A) IN GENERAL.—If a State’s expendi4 tures under this title in fiscal year 2009, fiscal 

5 year 2010, fiscal year 2011, fiscal year 2012, or 

6 a semi-annual allotment period for fiscal year 

7 2013, exceed the total amount of allotments 

8 available under this section to the State in the 

9 fiscal year or period (determined without regard 

10 to any redistribution it receives under sub11 section (f) that is available for expenditure dur12 ing such fiscal year or period, but including any 

13 carryover from a previous fiscal year) and if the 

14 average monthly unduplicated number of chil15 dren enrolled under the State plan under this 

16 title (including children receiving health care 

17 coverage through funds under this title pursu18 ant to a waiver under section 1115) during 

19 such fiscal year or period exceeds its target av20 erage number of such enrollees (as determined 

21 under subparagraph (B)) for that fiscal year or 

22 period, subject to subparagraph (D), the Sec23 retary shall pay to the State from the Fund an 

24 amount equal to the product of— 


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1 ‘‘(i) the amount by which such aver2 age monthly caseload exceeds such target 

3 number of enrollees; and 

4 ‘‘(ii) the projected per capita expendi5 tures under the State child health plan (as 

6 determined under subparagraph (C) for 

7 the fiscal year), multiplied by the enhanced 

8 FMAP (as defined in section 2105(b)) for 

9 the State and fiscal year involved (or in 

10 which the period occurs). 

11 ‘‘(B) TARGET AVERAGE NUMBER OF CHILD

12 ENROLLEES.—In this paragraph, the target av13 erage number of child enrollees for a State— 

14 ‘‘(i) for fiscal year 2009 is equal to 

15 the monthly average unduplicated number 

16 of children enrolled in the State child 

17 health plan under this title (including such 

18 children receiving health care coverage 

19 through funds under this title pursuant to 

20 a waiver under section 1115) during fiscal 

21 year 2008 increased by the population 

22 growth for children in that State for the 

23 year ending on June 30, 2007 (as esti24 mated by the Bureau of the Census) plus 

25 1 percentage point; or 


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1 ‘‘(ii) for a subsequent fiscal year (or 

2 semi-annual period occurring in a fiscal 

3 year) is equal to the target average num4 ber of child enrollees for the State for the 

5 previous fiscal year increased by the child 

6 population growth factor described in sub7 section (m)(5)(B) for the State for the 

8 prior fiscal year. 

9 ‘‘(C) PROJECTED PER CAPITA EXPENDI10 TURES.—For purposes of subparagraph (A)(ii), 

11 the projected per capita expenditures under a 

12 State child health plan— 

13 ‘‘(i) for fiscal year 2009 is equal to 

14 the average per capita expenditures (in15 cluding both State and Federal financial 

16 participation) under such plan for the tar17 geted low-income children counted in the 

18 average monthly caseload for purposes of 

19 this paragraph during fiscal year 2008, in20 creased by the annual percentage increase 

21 in the projected per capita amount of Na22 tional Health Expenditures (as estimated 

23 by the Secretary) for 2009; or 

24 ‘‘(ii) for a subsequent fiscal year (or 

25 semi-annual period occurring in a fiscal 


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1 year) is equal to the projected per capita 

2 expenditures under such plan for the pre3 vious fiscal year (as determined under 

4 clause (i) or this clause) increased by the 

5 annual percentage increase in the projected 

6 per capita amount of National Health Ex7 penditures (as estimated by the Secretary) 

8 for the year in which such subsequent fis9 cal year ends. 

10 ‘‘(D) PRORATION RULE.—If the amounts 

11 available for payment from the Fund for a fis12 cal year or period are less than the total 

13 amount of payments determined under subpara14 graph (A) for the fiscal year or period, the 

15 amount to be paid under such subparagraph to 

16 each eligible State shall be reduced proportion17 ally. 

18 ‘‘(E) TIMELY PAYMENT; RECONCILI19 ATION.—Payment under this paragraph for a 

20 fiscal year or period shall be made before the 

21 end of the fiscal year or period based upon the 

22 most recent data for expenditures and enroll23 ment and the provisions of subsection (e) of 

24 section 2105 shall apply to payments under this 


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1 subsection in the same manner as they apply to 

2 payments under such section. 

3 ‘‘(F) CONTINUED REPORTING.—For pur4 poses of this paragraph and subsection (f), the 

5 State shall submit to the Secretary the State’s 

6 projected Federal expenditures, even if the 

7 amount of such expenditures exceeds the total 

8 amount of allotments available to the State in 

9 such fiscal year or period. 

10 ‘‘(G) APPLICATION TO COMMONWEALTHS

11 AND TERRITORIES.—No payment shall be made 

12 under this paragraph to a commonwealth or 

13 territory described in subsection (c)(3) until 

14 such time as the Secretary determines that 

15 there are in effect methods, satisfactory to the 

16 Secretary, for the collection and reporting of re17 liable data regarding the enrollment of children 

18 described in subparagraphs (A) and (B) in 

19 order to accurately determine the common20 wealth’s or territory’s eligibility for, and 

21 amount of payment, under this paragraph.’’. 


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1 SEC. 104. CHIP PERFORMANCE BONUS PAYMENT TO OFF2 SET ADDITIONAL ENROLLMENT COSTS RE3 SULTING FROM ENROLLMENT AND RETEN4 TION EFFORTS. 

5 Section 2105(a) (42 U.S.C. 1397ee(a)) is amended 

6 by adding at the end the following new paragraphs: 

7 ‘‘(3) PERFORMANCE BONUS PAYMENT TO OFF8 SET ADDITIONAL MEDICAID AND CHIP CHILD EN9 ROLLMENT COSTS RESULTING FROM ENROLLMENT

10 AND RETENTION EFFORTS.— 

11 ‘‘(A) IN GENERAL.—In addition to the 

12 payments made under paragraph (1), for each 

13 fiscal year (beginning with fiscal year 2009 and 

14 ending with fiscal year 2013), the Secretary 

15 shall pay from amounts made available under 

16 subparagraph (E), to each State that meets the 

17 condition under paragraph (4) for the fiscal 

18 year, an amount equal to the amount described 

19 in subparagraph (B) for the State and fiscal 

20 year. The payment under this paragraph shall 

21 be made, to a State for a fiscal year, as a single 

22 payment not later than the last day of the first 

23 calendar quarter of the following fiscal year. 

24 ‘‘(B) AMOUNT FOR ABOVE BASELINE MED25 ICAID CHILD ENROLLMENT COSTS.—Subject to 

26 subparagraph (E), the amount described in this 


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1 subparagraph for a State for a fiscal year is 

2 equal to the sum of the following amounts: 

3 ‘‘(i) FIRST TIER ABOVE BASELINE

4 MEDICAID ENROLLEES.—An amount equal 

5 to the number of first tier above baseline 

6 child enrollees (as determined under sub7 paragraph (C)(i)) under title XIX for the 

8 State and fiscal year, multiplied by 15 per9 cent of the projected per capita State Med10 icaid expenditures (as determined under 

11 subparagraph (D)) for the State and fiscal 

12 year under title XIX. 

13 ‘‘(ii) SECOND TIER ABOVE BASELINE

14 MEDICAID ENROLLEES.—An amount equal 

15 to the number of second tier above baseline 

16 child enrollees (as determined under sub17 paragraph (C)(ii)) under title XIX for the 

18 State and fiscal year, multiplied by 62.5 

19 percent of the projected per capita State 

20 Medicaid expenditures (as determined 

21 under subparagraph (D)) for the State and 

22 fiscal year under title XIX. 

23 ‘‘(C) NUMBER OF FIRST AND SECOND TIER

24 ABOVE BASELINE CHILD ENROLLEES; BASELINE


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1 NUMBER OF CHILD ENROLLEES.—For purposes 

2 of this paragraph: 

3 ‘‘(i) FIRST TIER ABOVE BASELINE

4 CHILD ENROLLEES.—The number of first 

5 tier above baseline child enrollees for a 

6 State for a fiscal year under title XIX is 

7 equal to the number (if any, as determined 

8 by the Secretary) by which— 

9 ‘‘(I) the monthly average 

10 unduplicated number of qualifying 

11 children (as defined in subparagraph 

12 (F)) enrolled during the fiscal year 

13 under the State plan under title XIX, 

14 respectively; exceeds 

15 ‘‘(II) the baseline number of en16 rollees described in clause (iii) for the 

17 State and fiscal year under title XIX, 

18 respectively; 

19 but not to exceed 10 percent of the base20 line number of enrollees described in sub21 clause (II). 

22 ‘‘(ii) SECOND TIER ABOVE BASELINE

23 CHILD ENROLLEES.—The number of sec24 ond tier above baseline child enrollees for 

25 a State for a fiscal year under title XIX is 


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1 equal to the number (if any, as determined 

2 by the Secretary) by which— 

3 ‘‘(I) the monthly average 

4 unduplicated number of qualifying 

5 children (as defined in subparagraph 

6 (F)) enrolled during the fiscal year 

7 under title XIX as described in clause 

8 (i)(I); exceeds 

9 ‘‘(II) the sum of the baseline 

10 number of child enrollees described in 

11 clause (iii) for the State and fiscal 

12 year under title XIX, as described in 

13 clause (i)(II), and the maximum num14 ber of first tier above baseline child 

15 enrollees for the State and fiscal year 

16 under title XIX, as determined under 

17 clause (i). 

18 ‘‘(iii) BASELINE NUMBER OF CHILD

19 ENROLLEES.—Subject to subparagraph 

20 (H), the baseline number of child enrollees 

21 for a State under title XIX— 

22 ‘‘(I) for fiscal year 2009 is equal 

23 to the monthly average unduplicated 

24 number of qualifying children enrolled 

25 in the State plan under title XIX durVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00029 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 ing fiscal year 2007 increased by the 

2 population growth for children in that 

3 State from 2007 to 2008 (as esti4 mated by the Bureau of the Census) 

5 plus 4 percentage points, and further 

6 increased by the population growth 

7 for children in that State from 2008 

8 to 2009 (as estimated by the Bureau 

9 of the Census) plus 4 percentage 

10 points; 

11 ‘‘(II) for each of fiscal years 

12 2010, 2011, and 2012, is equal to the 

13 baseline number of child enrollees for 

14 the State for the previous fiscal year 

15 under title XIX, increased by the pop16 ulation growth for children in that 

17 State from the calendar year in which 

18 the respective fiscal year begins to the 

19 succeeding calendar year (as esti20 mated by the Bureau of the Census) 

21 plus 3.5 percentage points; 

22 ‘‘(III) for each of fiscal years 

23 2013, 2014, and 2015, is equal to the 

24 baseline number of child enrollees for 

25 the State for the previous fiscal year 


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1 under title XIX, increased by the pop2 ulation growth for children in that 

3 State from the calendar year in which 

4 the respective fiscal year begins to the 

5 succeeding calendar year (as esti6 mated by the Bureau of the Census) 

7 plus 3 percentage points; and 

8 ‘‘(IV) for a subsequent fiscal year 

9 is equal to the baseline number of 

10 child enrollees for the State for the 

11 previous fiscal year under title XIX, 

12 increased by the population growth 

13 for children in that State from the 

14 calendar year in which the fiscal year 

15 involved begins to the succeeding cal16 endar year (as estimated by the Bu17 reau of the Census) plus 2 percentage 

18 points. 

19 ‘‘(D) PROJECTED PER CAPITA STATE MED20 ICAID EXPENDITURES.—For purposes of sub21 paragraph (B), the projected per capita State 

22 Medicaid expenditures for a State and fiscal 

23 year under title XIX is equal to the average per 

24 capita expenditures (including both State and 

25 Federal financial participation) for children 


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1 under the State plan under such title, including 

2 under waivers but not including such children 

3 eligible for assistance by virtue of the receipt of 

4 benefits under title XVI, for the most recent 

5 fiscal year for which actual data are available 

6 (as determined by the Secretary), increased (for 

7 each subsequent fiscal year up to and including 

8 the fiscal year involved) by the annual percent9 age increase in per capita amount of National 

10 Health Expenditures (as estimated by the Sec11 retary) for the calendar year in which the re12 spective subsequent fiscal year ends and multi13 plied by a State matching percentage equal to 

14 100 percent minus the Federal medical assist15 ance percentage (as defined in section 1905(b)) 

16 for the fiscal year involved. 

17 ‘‘(E) AMOUNTS AVAILABLE FOR PAY18 MENTS.— 

19 ‘‘(i) INITIAL APPROPRIATION.—Out of 

20 any money in the Treasury not otherwise 

21 appropriated, there are appropriated 

22 $3,225,000,000 for fiscal year 2009 for 

23 making payments under this paragraph, to 

24 be available until expended. 


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1 ‘‘(ii) TRANSFERS.—Notwithstanding 

2 any other provision of this title, the fol3 lowing amounts shall also be available, 

4 without fiscal year limitation, for making 

5 payments under this paragraph: 

6 ‘‘(I) UNOBLIGATED NATIONAL

7 ALLOTMENT.— 

8 ‘‘(aa) FISCAL YEARS 2009

9 THROUGH 2012.—As of December 

10 31 of fiscal year 2009, and as of 

11 December 31 of each succeeding 

12 fiscal year through fiscal year 

13 2012, the portion, if any, of the 

14 amount appropriated under sub15 section (a) for such fiscal year 

16 that is unobligated for allotment 

17 to a State under subsection (m) 

18 for such fiscal year or set aside 

19 under subsection (a)(3) or (b)(2) 

20 of section 2111 for such fiscal 

21 year. 

22 ‘‘(bb) FIRST HALF OF FIS23 CAL YEAR 2013.—As of December 

24 31 of fiscal year 2013, the por25 tion, if any, of the sum of the 


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1 amounts appropriated under sub2 section (a)(16)(A) and under sec3 tion 108 of the Children’s Health 

4 Insurance Reauthorization Act of 

5 2009 for the period beginning on 

6 October 1, 2012, and ending on 

7 March 31, 2013, that is unobli8 gated for allotment to a State 

9 under subsection (m) for such 

10 fiscal year or set aside under 

11 subsection (b)(2) of section 2111 

12 for such fiscal year. 

13 ‘‘(cc) SECOND HALF OF FIS14 CAL YEAR 2013.—As of June 30 

15 of fiscal year 2013, the portion, 

16 if any, of the amount appro17 priated under subsection 

18 (a)(16)(B) for the period begin19 ning on April 1, 2013, and end20 ing on September 30, 2013, that 

21 is unobligated for allotment to a 

22 State under subsection (m) for 

23 such fiscal year or set aside 

24 under subsection (b)(2) of section 

25 2111 for such fiscal year. 


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1 ‘‘(II) UNEXPENDED ALLOT2 MENTS NOT USED FOR REDISTRIBU3 TION.—As of November 15 of each of 

4 fiscal years 2010 through 2013, the 

5 total amount of allotments made to 

6 States under section 2104 for the sec7 ond preceding fiscal year (third pre8 ceding fiscal year in the case of the 

9 fiscal year 2006, 2007, and 2008 al10 lotments) that is not expended or re11 distributed under section 2104(f) dur12 ing the period in which such allot13 ments are available for obligation. 

14 ‘‘(III) EXCESS CHILD ENROLL15 MENT CONTINGENCY FUNDS.—As of 

16 October 1 of each of fiscal years 2010 

17 through 2013, any amount in excess 

18 of the aggregate cap applicable to the 

19 Child Enrollment Contingency Fund 

20 for the fiscal year under section 

21 2104(n). 

22 ‘‘(IV) UNEXPENDED TRANSI23 TIONAL COVERAGE BLOCK GRANT FOR

24 NONPREGNANT CHILDLESS ADULTS.— 

25 As of October 1, 2011, any amounts 


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1 set aside under section 2111(a)(3) 

2 that are not expended by September 

3 30, 2011. 

4 ‘‘(iii) PROPORTIONAL REDUCTION.—If 

5 the sum of the amounts otherwise payable 

6 under this paragraph for a fiscal year ex7 ceeds the amount available for the fiscal 

8 year under this subparagraph, the amount 

9 to be paid under this paragraph to each 

10 State shall be reduced proportionally. 

11 ‘‘(F) QUALIFYING CHILDREN DEFINED.— 

12 ‘‘(i) IN GENERAL.—For purposes of 

13 this subsection, subject to clauses (ii) and 

14 (iii), the term ‘qualifying children’ means 

15 children who meet the eligibility criteria 

16 (including income, categorical eligibility, 

17 age, and immigration status criteria) in ef18 fect as of July 1, 2008, for enrollment 

19 under title XIX, taking into account cri20 teria applied as of such date under title 

21 XIX pursuant to a waiver under section 

22 1115. 

23 ‘‘(ii) LIMITATION.—A child described 

24 in clause (i) who is provided medical as25 sistance during a presumptive eligibility 


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1 period under section 1920A shall be con2 sidered to be a ‘qualifying child’ only if the 

3 child is determined to be eligible for med4 ical assistance under title XIX. 

5 ‘‘(iii) EXCLUSION.—Such term does 

6 not include any children for whom the 

7 State has made an election to provide med8 ical assistance under paragraph (4) of sec9 tion 1903(v). 

10 ‘‘(G) APPLICATION TO COMMONWEALTHS

11 AND TERRITORIES.—The provisions of subpara12 graph (G) of section 2104(n)(3) shall apply 

13 with respect to payment under this paragraph 

14 in the same manner as such provisions apply to 

15 payment under such section. 

16 ‘‘(H) APPLICATION TO STATES THAT IM17 PLEMENT A MEDICAID EXPANSION FOR CHIL18 DREN AFTER FISCAL YEAR 2008.—In the case of 

19 a State that provides coverage under section 

20 115 of the Children’s Health Insurance Pro21 gram Reauthorization Act of 2009 for any fis22 cal year after fiscal year 2008— 

23 ‘‘(i) any child enrolled in the State 

24 plan under title XIX through the applica25 tion of such an election shall be disVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00037 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 regarded from the determination for the 

2 State of the monthly average unduplicated 

3 number of qualifying children enrolled in 

4 such plan during the first 3 fiscal years in 

5 which such an election is in effect; and 

6 ‘‘(ii) in determining the baseline num7 ber of child enrollees for the State for any 

8 fiscal year subsequent to such first 3 fiscal 

9 years, the baseline number of child enroll10 ees for the State under title XIX for the 

11 third of such fiscal years shall be the 

12 monthly average unduplicated number of 

13 qualifying children enrolled in the State 

14 plan under title XIX for such third fiscal 

15 year. 

16 ‘‘(4) ENROLLMENT AND RETENTION PROVI17 SIONS FOR CHILDREN.—For purposes of paragraph 

18 (3)(A), a State meets the condition of this para19 graph for a fiscal year if it is implementing at least 

20 5 of the following enrollment and retention provi21 sions (treating each subparagraph as a separate en22 rollment and retention provision) throughout the en23 tire fiscal year: 

24 ‘‘(A) CONTINUOUS ELIGIBILITY.—The 

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1 bility for a full 12 months for all children de2 scribed in section 1902(e)(12) under title XIX 

3 under 19 years of age, as well as applying such 

4 policy under its State child health plan under 

5 this title. 

6 ‘‘(B) LIBERALIZATION OF ASSET REQUIRE7 MENTS.—The State meets the requirement 

8 specified in either of the following clauses: 

9 ‘‘(i) ELIMINATION OF ASSET TEST.— 

10 The State does not apply any asset or re11 source test for eligibility for children under 

12 title XIX or this title. 

13 ‘‘(ii) ADMINISTRATIVE VERIFICATION

14 OF ASSETS.—The State— 

15 ‘‘(I) permits a parent or care16 taker relative who is applying on be17 half of a child for medical assistance 

18 under title XIX or child health assist19 ance under this title to declare and 

20 certify by signature under penalty of 

21 perjury information relating to family 

22 assets for purposes of determining 

23 and redetermining financial eligibility; 

24 and 


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1 ‘‘(II) takes steps to verify assets 

2 through means other than by requir3 ing documentation from parents and 

4 applicants except in individual cases 

5 of discrepancies or where otherwise 

6 justified. 

7 ‘‘(C) ELIMINATION OF IN-PERSON INTER8 VIEW REQUIREMENT.—The State does not re9 quire an application of a child for medical as10 sistance under title XIX (or for child health as11 sistance under this title), including an applica12 tion for renewal of such assistance, to be made 

13 in person nor does the State require a face-to14 face interview, unless there are discrepancies or 

15 individual circumstances justifying an in-person 

16 application or face-to-face interview. 

17 ‘‘(D) USE OF JOINT APPLICATION FOR

18 MEDICAID AND CHIP.—The application form 

19 and supplemental forms (if any) and informa20 tion verification process is the same for pur21 poses of establishing and renewing eligibility for 

22 children for medical assistance under title XIX 

23 and child health assistance under this title. 

24 ‘‘(E) AUTOMATIC RENEWAL (USE OF AD25 MINISTRATIVE RENEWAL).— 


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1 ‘‘(i) IN GENERAL.—The State pro2 vides, in the case of renewal of a child’s 

3 eligibility for medical assistance under title 

4 XIX or child health assistance under this 

5 title, a pre-printed form completed by the 

6 State based on the information available to 

7 the State and notice to the parent or care8 taker relative of the child that eligibility of 

9 the child will be renewed and continued 

10 based on such information unless the State 

11 is provided other information. Nothing in 

12 this clause shall be construed as preventing 

13 a State from verifying, through electronic 

14 and other means, the information so pro15 vided. 

16 ‘‘(ii) SATISFACTION THROUGH DEM17 ONSTRATED USE OF EX PARTE PROCESS.— 

18 A State shall be treated as satisfying the 

19 requirement of clause (i) if renewal of eli20 gibility of children under title XIX or this 

21 title is determined without any require22 ment for an in-person interview, unless 

23 sufficient information is not in the State’s 

24 possession and cannot be acquired from 

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1 cies) without the participation of the appli2 cant or the applicant’s parent or caretaker 

3 relative. 

4 ‘‘(F) PRESUMPTIVE ELIGIBILITY FOR

5 CHILDREN.—The State is implementing section 

6 1920A under title XIX as well as, pursuant to 

7 section 2107(e)(1), under this title. 

8 ‘‘(G) EXPRESS LANE.—The State is imple9 menting the option described in section 

10 1902(e)(13) under title XIX as well as, pursu11 ant to section 2107(e)(1), under this title. 

12 ‘‘(H) PREMIUM ASSISTANCE SUBSIDIES.— 

13 The State is implementing the option of pro14 viding premium assistance subsidies under sec15 tion 2105(c)(10) or section 1906A.’’. 

16 SEC. 105. TWO-YEAR INITIAL AVAILABILITY OF CHIP AL17 LOTMENTS. 

18 Section 2104(e) (42 U.S.C. 1397dd(e)) is amended 

19 to read as follows: 

20 ‘‘(e) AVAILABILITY OF AMOUNTS ALLOTTED.— 

21 ‘‘(1) IN GENERAL.—Except as provided in para22 graph (2), amounts allotted to a State pursuant to 

23 this section— 

24 ‘‘(A) for each of fiscal years 1998 through 

25 2008, shall remain available for expenditure by 


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1 the State through the end of the second suc2 ceeding fiscal year; and 

3 ‘‘(B) for fiscal year 2009 and each fiscal 

4 year thereafter, shall remain available for ex5 penditure by the State through the end of the 

6 succeeding fiscal year. 

7 ‘‘(2) AVAILABILITY OF AMOUNTS REDISTRIB8 UTED.—Amounts redistributed to a State under sub9 section (f) shall be available for expenditure by the 

10 State through the end of the fiscal year in which 

11 they are redistributed.’’. 

12 SEC. 106. REDISTRIBUTION OF UNUSED ALLOTMENTS. 

13 (a) BEGINNING WITH FISCAL YEAR 2007.— 

14 (1) IN GENERAL.—Section 2104(f) (42 U.S.C. 

15 1397dd(f)) is amended— 

16 (A) by striking ‘‘The Secretary’’ and in17 serting the following: 

18 ‘‘(1) IN GENERAL.—The Secretary’’; 

19 (B) by striking ‘‘States that have fully ex20 pended the amount of their allotments under 

21 this section.’’ and inserting ‘‘States that the 

22 Secretary determines with respect to the fiscal 

23 year for which unused allotments are available 

24 for redistribution under this subsection, are 

25 shortfall States described in paragraph (2) for 


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1 such fiscal year, but not to exceed the amount 

2 of the shortfall described in paragraph (2)(A) 

3 for each such State (as may be adjusted under 

4 paragraph (2)(C)).’’; and 

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

6 paragraph: 

7 ‘‘(2) SHORTFALL STATES DESCRIBED.— 

8 ‘‘(A) IN GENERAL.—For purposes of para9 graph (1), with respect to a fiscal year, a short10 fall State described in this subparagraph is a 

11 State with a State child health plan approved 

12 under this title for which the Secretary esti13 mates on the basis of the most recent data 

14 available to the Secretary, that the projected ex15 penditures under such plan for the State for the 

16 fiscal year will exceed the sum of— 

17 ‘‘(i) the amount of the State’s allot18 ments for any preceding fiscal years that 

19 remains available for expenditure and that 

20 will not be expended by the end of the im21 mediately preceding fiscal year; 

22 ‘‘(ii) the amount (if any) of the child 

23 enrollment contingency fund payment 

24 under subsection (n); and 


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1 ‘‘(iii) the amount of the State’s allot2 ment for the fiscal year. 

3 ‘‘(B) PRORATION RULE.—If the amounts 

4 available for redistribution under paragraph (1) 

5 for a fiscal year are less than the total amounts 

6 of the estimated shortfalls determined for the 

7 year under subparagraph (A), the amount to be 

8 redistributed under such paragraph for each 

9 shortfall State shall be reduced proportionally. 

10 ‘‘(C) RETROSPECTIVE ADJUSTMENT.—The 

11 Secretary may adjust the estimates and deter12 minations made under paragraph (1) and this 

13 paragraph with respect to a fiscal year as nec14 essary on the basis of the amounts reported by 

15 States not later than November 30 of the suc16 ceeding fiscal year, as approved by the Sec17 retary.’’. 

18 (2) EFFECTIVE DATE.—The amendments made 

19 by paragraph (1) shall apply to redistribution of al20 lotments made for fiscal year 2007 and subsequent 

21 fiscal years. 

22 (b) REDISTRIBUTION OF UNUSED ALLOTMENTS FOR

23 FISCAL YEAR 2006.—Section 2104(k) (42 U.S.C. 

24 1397dd(k)) is amended— 


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1 (1) in the subsection heading, by striking ‘‘THE

2 FIRST 2 QUARTERS OF’’; 

3 (2) in paragraph (1), by striking ‘‘the first 2 

4 quarters of’’; and 

5 (3) in paragraph (6)— 

6 (A) by striking ‘‘the first 2 quarters of’’; 

7 and 

8 (B) by striking ‘‘March 31’’ and inserting 

9 ‘‘September 30’’. 

10 SEC. 107. OPTION FOR QUALIFYING STATES TO RECEIVE 

11 THE ENHANCED PORTION OF THE CHIP 

12 MATCHING RATE FOR MEDICAID COVERAGE 

13 OF CERTAIN CHILDREN. 

14 (a) IN GENERAL.—Section 2105(g) (42 U.S.C. 

15 1397ee(g)) is amended— 

16 (1) in paragraph (1)(A), as amended by section 

17 201(b)(1) of Public Law 110–173— 

18 (A) by inserting ‘‘subject to paragraph 

19 (4),’’ after ‘‘Notwithstanding any other provi20 sion of law,’’; and 

21 (B) by striking ‘‘2008, or 2009’’ and in22 serting ‘‘or 2008’’; and 

23 (2) by adding at the end the following new 

24 paragraph: 


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1 ‘‘(4) OPTION FOR ALLOTMENTS FOR FISCAL

2 YEARS 2009 THROUGH 2013.— 

3 ‘‘(A) PAYMENT OF ENHANCED PORTION OF

4 MATCHING RATE FOR CERTAIN EXPENDI5 TURES.—In the case of expenditures described 

6 in subparagraph (B), a qualifying State (as de7 fined in paragraph (2)) may elect to be paid 

8 from the State’s allotment made under section 

9 2104 for any of fiscal years 2009 through 2013 

10 (insofar as the allotment is available to the 

11 State under subsections (e) and (m) of such 

12 section) an amount each quarter equal to the 

13 additional amount that would have been paid to 

14 the State under title XIX with respect to such 

15 expenditures if the enhanced FMAP (as deter16 mined under subsection (b)) had been sub17 stituted for the Federal medical assistance per18 centage (as defined in section 1905(b)). 

19 ‘‘(B) EXPENDITURES DESCRIBED.—For 

20 purposes of subparagraph (A), the expenditures 

21 described in this subparagraph are expenditures 

22 made after the date of the enactment of this 

23 paragraph and during the period in which funds 

24 are available to the qualifying State for use 

25 under subparagraph (A), for the provision of 


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1 medical assistance to individuals residing in the 

2 State who are eligible for medical assistance 

3 under the State plan under title XIX or under 

4 a waiver of such plan and who have not at5 tained age 19 (or, if a State has so elected 

6 under the State plan under title XIX, age 20 

7 or 21), and whose family income equals or ex8 ceeds 133 percent of the poverty line but does 

9 not exceed the Medicaid applicable income 

10 level.’’. 

11 (b) REPEAL OF LIMITATION ON AVAILABILITY OF

12 FISCAL YEAR 2009 ALLOTMENTS.—Paragraph (2) of sec13 tion 201(b) of the Medicare, Medicaid, and SCHIP Exten14 sion Act of 2007 (Public Law 110-173) is repealed. 

15 SEC. 108. ONE-TIME APPROPRIATION. 

16 There is appropriated to the Secretary, out of any 

17 money in the Treasury not otherwise appropriated, 

18 $11,706,000,000 to accompany the allotment made for the 

19 period beginning on October 1, 2012, and ending on 

20 March 31, 2013, under section 2104(a)(16)(A) of the So21 cial Security Act (42 U.S.C. 1397dd(a)(16)(A)) (as added 

22 by section 101), to remain available until expended. Such 

23 amount shall be used to provide allotments to States under 

24 paragraph (3) of section 2104(m) of the Social Security 

25 Act (42 U.S.C. 1397dd(i)), as added by section 102, for 


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1 the first 6 months of fiscal year 2013 in the same manner 

2 as allotments are provided under subsection (a)(16)(A) of 

3 such section 2104 and subject to the same terms and con4 ditions as apply to the allotments provided from such sub5 section (a)(16)(A). 

6 SEC. 109. IMPROVING FUNDING FOR THE TERRITORIES 

7 UNDER CHIP AND MEDICAID. 

8 Section 1108(g) (42 U.S.C. 1308(g)) is amended by 

9 adding at the end the following new paragraph: 

10 ‘‘(4) EXCLUSION OF CERTAIN EXPENDITURES

11 FROM PAYMENT LIMITS.—With respect to fiscal 

12 years beginning with fiscal year 2009, if Puerto 

13 Rico, the Virgin Islands, Guam, the Northern Mar14 iana Islands, or American Samoa qualify for a pay15 ment under subparagraph (A)(i), (B), or (F) of sec16 tion 1903(a)(3) for a calendar quarter of such fiscal 

17 year, the payment shall not be taken into account in 

18 applying subsection (f) (as increased in accordance 

19 with paragraphs (1), (2), and (3) of this subsection) 

20 to such commonwealth or territory for such fiscal 

21 year.’’. 


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1 Subtitle B—Focus on Low-Income 

2 Children and Pregnant Women 

3 SEC. 111. STATE OPTION TO COVER LOW-INCOME PREG4 NANT WOMEN UNDER CHIP THROUGH A 

5 STATE PLAN AMENDMENT. 

6 (a) IN GENERAL.—Title XXI (42 U.S.C. 1397aa et 

7 seq.), as amended by section 112(a), is amended by adding 

8 at the end the following new section: 

9 ‘‘SEC. 2112. OPTIONAL COVERAGE OF TARGETED LOW-IN10 COME PREGNANT WOMEN THROUGH A STATE 

11 PLAN AMENDMENT. 

12 ‘‘(a) IN GENERAL.—Subject to the succeeding provi13 sions of this section, a State may elect through an amend14 ment to its State child health plan under section 2102 to 

15 provide pregnancy-related assistance under such plan for 

16 targeted low-income pregnant women. 

17 ‘‘(b) CONDITIONS.—A State may only elect the option 

18 under subsection (a) if the following conditions are satis19 fied: 

20 ‘‘(1) MINIMUM INCOME ELIGIBILITY LEVELS

21 FOR PREGNANT WOMEN AND CHILDREN.—The State 

22 has established an income eligibility level— 

23 ‘‘(A) for pregnant women under subsection 

24 (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), or 

25 (l)(1)(A) of section 1902 that is at least 185 


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1 percent (or such higher percent as the State 

2 has in effect with regard to pregnant women 

3 under this title) of the poverty line applicable to 

4 a family of the size involved, but in no case 

5 lower than the percent in effect under any such 

6 subsection as of July 1, 2008; and 

7 ‘‘(B) for children under 19 years of age 

8 under this title (or title XIX) that is at least 

9 200 percent of the poverty line applicable to a 

10 family of the size involved. 

11 ‘‘(2) NO CHIP INCOME ELIGIBILITY LEVEL FOR

12 PREGNANT WOMEN LOWER THAN THE STATE’S MED13 ICAID LEVEL.—The State does not apply an effective 

14 income level for pregnant women under the State 

15 plan amendment that is lower than the effective in16 come level (expressed as a percent of the poverty line 

17 and considering applicable income disregards) speci18 fied under subsection (a)(10)(A)(i)(III), 

19 (a)(10)(A)(i)(IV), or (l)(1)(A) of section 1902, on 

20 the date of enactment of this paragraph to be eligi21 ble for medical assistance as a pregnant woman. 

22 ‘‘(3) NO COVERAGE FOR HIGHER INCOME PREG23 NANT WOMEN WITHOUT COVERING LOWER INCOME

24 PREGNANT WOMEN.—The State does not provide 

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1 come without covering pregnant women with a lower 

2 family income. 

3 ‘‘(4) APPLICATION OF REQUIREMENTS FOR

4 COVERAGE OF TARGETED LOW-INCOME CHILDREN.— 

5 The State provides pregnancy-related assistance for 

6 targeted low-income pregnant women in the same 

7 manner, and subject to the same requirements, as 

8 the State provides child health assistance for tar9 geted low-income children under the State child 

10 health plan, and in addition to providing child health 

11 assistance for such women. 

12 ‘‘(5) NO PREEXISTING CONDITION EXCLUSION

13 OR WAITING PERIOD.—The State does not apply any 

14 exclusion of benefits for pregnancy-related assistance 

15 based on any preexisting condition or any waiting 

16 period (including any waiting period imposed to 

17 carry out section 2102(b)(3)(C)) for receipt of such 

18 assistance. 

19 ‘‘(6) APPLICATION OF COST-SHARING PROTEC20 TION.—The State provides pregnancy-related assist21 ance to a targeted low-income woman consistent 

22 with the cost-sharing protections under section 

23 2103(e) and applies the limitation on total annual 

24 aggregate cost sharing imposed under paragraph 


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1 (3)(B) of such section to the family of such a 

2 woman. 

3 ‘‘(7) NO WAITING LIST FOR CHILDREN.—The 

4 State does not impose, with respect to the enroll5 ment under the State child health plan of targeted 

6 low-income children during the quarter, any enroll7 ment cap or other numerical limitation on enroll8 ment, any waiting list, any procedures designed to 

9 delay the consideration of applications for enroll10 ment, or similar limitation with respect to enroll11 ment. 

12 ‘‘(c) OPTION TO PROVIDE PRESUMPTIVE ELIGI13 BILITY.—A State that elects the option under subsection 

14 (a) and satisfies the conditions described in subsection (b) 

15 may elect to apply section 1920 (relating to presumptive 

16 eligibility for pregnant women) to the State child health 

17 plan in the same manner as such section applies to the 

18 State plan under title XIX. 

19 ‘‘(d) DEFINITIONS.—For purposes of this section: 

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

21 term ‘pregnancy-related assistance’ has the meaning 

22 given the term ‘child health assistance’ in section 

23 2110(a) with respect to an individual during the pe24 riod described in paragraph (2)(A). 


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1 ‘‘(2) TARGETED LOW-INCOME PREGNANT

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

3 woman’ means an individual— 

4 ‘‘(A) during pregnancy and through the 

5 end of the month in which the 60-day period 

6 (beginning on the last day of her pregnancy) 

7 ends; 

8 ‘‘(B) whose family income exceeds 185 per9 cent (or, if higher, the percent applied under 

10 subsection (b)(1)(A)) of the poverty line appli11 cable to a family of the size involved, but does 

12 not exceed the income eligibility level estab13 lished under the State child health plan under 

14 this title for a targeted low-income child; and 

15 ‘‘(C) who satisfies the requirements of 

16 paragraphs (1)(A), (1)(C), (2), and (3) of sec17 tion 2110(b) in the same manner as a child ap18 plying for child health assistance would have to 

19 satisfy such requirements. 

20 ‘‘(e) AUTOMATIC ENROLLMENT FOR CHILDREN

21 BORN TO WOMEN RECEIVING PREGNANCY-RELATED AS22 SISTANCE.—If a child is born to a targeted low-income 

23 pregnant woman who was receiving pregnancy-related as24 sistance under this section on the date of the child’s birth, 

25 the child shall be deemed to have applied for child health 


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1 assistance under the State child health plan and to have 

2 been found eligible for such assistance under such plan 

3 or to have applied for medical assistance under title XIX 

4 and to have been found eligible for such assistance under 

5 such title, as appropriate, on the date of such birth and 

6 to remain eligible for such assistance until the child at7 tains 1 year of age. During the period in which a child 

8 is deemed under the preceding sentence to be eligible for 

9 child health or medical assistance, the child health or med10 ical assistance eligibility identification number of the 

11 mother shall also serve as the identification number of the 

12 child, and all claims shall be submitted and paid under 

13 such number (unless the State issues a separate identifica14 tion number for the child before such period expires). 

15 ‘‘(f) STATES PROVIDING ASSISTANCE THROUGH

16 OTHER OPTIONS.— 

17 ‘‘(1) CONTINUATION OF OTHER OPTIONS FOR

18 PROVIDING ASSISTANCE.—The option to provide as19 sistance in accordance with the preceding sub20 sections of this section shall not limit any other op21 tion for a State to provide— 

22 ‘‘(A) child health assistance through the 

23 application of sections 457.10, 457.350(b)(2), 

24 457.622(c)(5), and 457.626(a)(3) of title 42, 

25 Code of Federal Regulations (as in effect after 


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1 the final rule adopted by the Secretary and set 

2 forth at 67 Fed. Reg. 61956–61974 (October 2, 

3 2002)), or 

4 ‘‘(B) pregnancy-related services through 

5 the application of any waiver authority (as in 

6 effect on June 1, 2008). 

7 ‘‘(2) CLARIFICATION OF AUTHORITY TO PRO8 VIDE POSTPARTUM SERVICES.—Any State that pro9 vides child health assistance under any authority de10 scribed in paragraph (1) may continue to provide 

11 such assistance, as well as postpartum services, 

12 through the end of the month in which the 60-day 

13 period (beginning on the last day of the pregnancy) 

14 ends, in the same manner as such assistance and 

15 postpartum services would be provided if provided 

16 under the State plan under title XIX, but only if the 

17 mother would otherwise satisfy the eligibility re18 quirements that apply under the State child health 

19 plan (other than with respect to age) during such 

20 period. 

21 ‘‘(3) NO INFERENCE.—Nothing in this sub22 section shall be construed— 

23 ‘‘(A) to infer congressional intent regard24 ing the legality or illegality of the content of the 

25 sections specified in paragraph (1)(A); or 


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1 ‘‘(B) to modify the authority to provide 

2 pregnancy-related services under a waiver speci3 fied in paragraph (1)(B).’’. 

4 (b) ADDITIONAL CONFORMING AMENDMENTS.— 

5 (1) NO COST SHARING FOR PREGNANCY-RE6 LATED BENEFITS.—Section 2103(e)(2) (42 U.S.C. 

7 1397cc(e)(2)) is amended— 

8 (A) in the heading, by inserting ‘‘OR

9 PREGNANCY-RELATED ASSISTANCE’’ after 

10 ‘‘PREVENTIVE SERVICES’’; and 

11 (B) by inserting before the period at the 

12 end the following: ‘‘or for pregnancy-related as13 sistance’’. 

14 (2) NO WAITING PERIOD.—Section 

15 2102(b)(1)(B) (42 U.S.C. 1397bb(b)(1)(B)) is 

16 amended— 

17 (A) in clause (i), by striking ‘‘, and’’ at the 

18 end and inserting a semicolon; 

19 (B) in clause (ii), by striking the period at 

20 the end and inserting ‘‘; and’’; and 

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

22 clause: 

23 ‘‘(iii) may not apply a waiting period 

24 (including a waiting period to carry out 

25 paragraph (3)(C)) in the case of a targeted 


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1 low-income pregnant woman provided preg2 nancy-related assistance under section 

3 2112.’’. 

4 SEC. 112. PHASE-OUT OF COVERAGE FOR NONPREGNANT 

5 CHILDLESS ADULTS UNDER CHIP; CONDI6 TIONS FOR COVERAGE OF PARENTS. 

7 (a) PHASE-OUT RULES.— 

8 (1) IN GENERAL.—Title XXI (42 U.S.C. 

9 1397aa et seq.) is amended by adding at the end the 

10 following new section: 

11 ‘‘SEC. 2111. PHASE-OUT OF COVERAGE FOR NONPREGNANT 

12 CHILDLESS ADULTS; CONDITIONS FOR COV13 ERAGE OF PARENTS. 

14 ‘‘(a) TERMINATION OF COVERAGE FOR NONPREG15 NANT CHILDLESS ADULTS.— 

16 ‘‘(1) NO NEW CHIP WAIVERS; AUTOMATIC EX17 TENSIONS AT STATE OPTION THROUGH 2009.—Not18 withstanding section 1115 or any other provision of 

19 this title, except as provided in this subsection— 

20 ‘‘(A) the Secretary shall not on or after the 

21 date of the enactment of the Children’s Health 

22 Insurance Program Reauthorization Act of 

23 2009, approve or renew a waiver, experimental, 

24 pilot, or demonstration project that would allow 

25 funds made available under this title to be used 


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1 to provide child health assistance or other 

2 health benefits coverage to a nonpregnant child3 less adult; and 

4 ‘‘(B) notwithstanding the terms and condi5 tions of an applicable existing waiver, the provi6 sions of paragraph (2) shall apply for purposes 

7 of any period beginning on or after January 1, 

8 2010, in determining the period to which the 

9 waiver applies, the individuals eligible to be cov10 ered by the waiver, and the amount of the Fed11 eral payment under this title. 

12 ‘‘(2) TERMINATION OF CHIP COVERAGE UNDER

13 APPLICABLE EXISTING WAIVERS AT THE END OF

14 2009.— 

15 ‘‘(A) IN GENERAL.—No funds shall be 

16 available under this title for child health assist17 ance or other health benefits coverage that is 

18 provided to a nonpregnant childless adult under 

19 an applicable existing waiver after December 

20 31, 2009. 

21 ‘‘(B) EXTENSION UPON STATE RE22 QUEST.—If an applicable existing waiver de23 scribed in subparagraph (A) would otherwise 

24 expire before January 1, 2010, notwithstanding 

25 the requirements of subsections (e) and (f) of 


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1 section 1115, a State may submit, not later 

2 than September 30, 2009, a request to the Sec3 retary for an extension of the waiver. The Sec4 retary shall approve a request for an extension 

5 of an applicable existing waiver submitted pur6 suant to this subparagraph, but only through 

7 December 31, 2009. 

8 ‘‘(C) APPLICATION OF ENHANCED FMAP.— 

9 The enhanced FMAP determined under section 

10 2105(b) shall apply to expenditures under an 

11 applicable existing waiver for the provision of 

12 child health assistance or other health benefits 

13 coverage to a nonpregnant childless adult dur14 ing the period beginning on the date of the en15 actment of this subsection and ending on De16 cember 31, 2009. 

17 ‘‘(3) STATE OPTION TO APPLY FOR MEDICAID

18 WAIVER TO CONTINUE COVERAGE FOR NONPREG19 NANT CHILDLESS ADULTS.— 

20 ‘‘(A) IN GENERAL.—Each State for which 

21 coverage under an applicable existing waiver is 

22 terminated under paragraph (2)(A) may sub23 mit, not later than September 30, 2009, an ap24 plication to the Secretary for a waiver under 

25 section 1115 of the State plan under title XIX 


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1 to provide medical assistance to a nonpregnant 

2 childless adult whose coverage is so terminated 

3 (in this subsection referred to as a ‘Medicaid 

4 nonpregnant childless adults waiver’). 

5 ‘‘(B) DEADLINE FOR APPROVAL.—The 

6 Secretary shall make a decision to approve or 

7 deny an application for a Medicaid nonpregnant 

8 childless adults waiver submitted under sub9 paragraph (A) within 90 days of the date of the 

10 submission of the application. If no decision has 

11 been made by the Secretary as of December 31, 

12 2009, on the application of a State for a Med13 icaid nonpregnant childless adults waiver that 

14 was submitted to the Secretary by September 

15 30, 2009, the application shall be deemed ap16 proved. 

17 ‘‘(C) STANDARD FOR BUDGET NEU18 TRALITY.—The budget neutrality requirement 

19 applicable with respect to expenditures for med20 ical assistance under a Medicaid nonpregnant 

21 childless adults waiver shall— 

22 ‘‘(i) in the case of fiscal year 2010, 

23 allow expenditures for medical assistance 

24 under title XIX for all such adults to not 

25 exceed the total amount of payments made 


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1 to the State under paragraph (2)(B) for 

2 fiscal year 2009, increased by the percent3 age increase (if any) in the projected nomi4 nal per capita amount of National Health 

5 Expenditures for 2010 over 2009, as most 

6 recently published by the Secretary; and 

7 ‘‘(ii) in the case of any succeeding fis8 cal year, allow such expenditures to not ex9 ceed the amount in effect under this sub10 paragraph for the preceding fiscal year, in11 creased by the percentage increase (if any) 

12 in the projected nominal per capita amount 

13 of National Health Expenditures for the 

14 calendar year that begins during the year 

15 involved over the preceding calendar year, 

16 as most recently published by the Sec17 retary. 

18 ‘‘(b) RULES AND CONDITIONS FOR COVERAGE OF

19 PARENTS OF TARGETED LOW-INCOME CHILDREN.— 

20 ‘‘(1) TWO-YEAR PERIOD; AUTOMATIC EXTEN21 SION AT STATE OPTION THROUGH FISCAL YEAR

22 2011.— 

23 ‘‘(A) NO NEW CHIP WAIVERS.—Notwith24 standing section 1115 or any other provision of 


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1 this title, except as provided in this sub2 section— 

3 ‘‘(i) the Secretary shall not on or after 

4 the date of the enactment of the Children’s 

5 Health Insurance Program Reauthoriza6 tion Act of 2009 approve or renew a waiv7 er, experimental, pilot, or demonstration 

8 project that would allow funds made avail9 able under this title to be used to provide 

10 child health assistance or other health ben11 efits coverage to a parent of a targeted 

12 low-income child; and 

13 ‘‘(ii) notwithstanding the terms and 

14 conditions of an applicable existing waiver, 

15 the provisions of paragraphs (2) and (3) 

16 shall apply for purposes of any fiscal year 

17 beginning on or after October 1, 2011, in 

18 determining the period to which the waiver 

19 applies, the individuals eligible to be cov20 ered by the waiver, and the amount of the 

21 Federal payment under this title. 

22 ‘‘(B) EXTENSION UPON STATE RE23 QUEST.—If an applicable existing waiver de24 scribed in subparagraph (A) would otherwise 

25 expire before October 1, 2011, and the State 


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1 requests an extension of such waiver, the Sec2 retary shall grant such an extension, but only, 

3 subject to paragraph (2)(A), through Sep4 tember 30, 2011. 

5 ‘‘(C) APPLICATION OF ENHANCED FMAP.— 

6 The enhanced FMAP determined under section 

7 2105(b) shall apply to expenditures under an 

8 applicable existing waiver for the provision of 

9 child health assistance or other health benefits 

10 coverage to a parent of a targeted low-income 

11 child during the third and fourth quarters of 

12 fiscal year 2009 and during fiscal years 2010 

13 and 2011. 

14 ‘‘(2) RULES FOR FISCAL YEARS 2012 THROUGH

15 2013.— 

16 ‘‘(A) PAYMENTS FOR COVERAGE LIMITED

17 TO BLOCK GRANT FUNDED FROM STATE ALLOT18 MENT.—Any State that provides child health 

19 assistance or health benefits coverage under an 

20 applicable existing waiver for a parent of a tar21 geted low-income child may elect to continue to 

22 provide such assistance or coverage through fis23 cal year 2012 or 2013, subject to the same 

24 terms and conditions that applied under the apVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00064 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 plicable existing waiver, unless otherwise modi2 fied in subparagraph (B). 

3 ‘‘(B) TERMS AND CONDITIONS.— 

4 ‘‘(i) BLOCK GRANT SET ASIDE FROM

5 STATE ALLOTMENT.—If the State makes 

6 an election under subparagraph (A), the 

7 Secretary shall set aside for the State for 

8 each such fiscal year an amount equal to 

9 the Federal share of 110 percent of the 

10 State’s projected expenditures under the 

11 applicable existing waiver for providing 

12 child health assistance or health benefits 

13 coverage to all parents of targeted low-in14 come children enrolled under such waiver 

15 for the fiscal year (as certified by the State 

16 and submitted to the Secretary by not 

17 later than August 31 of the preceding fis18 cal year). In the case of fiscal year 2013, 

19 the set aside for any State shall be com20 puted separately for each period described 

21 in subparagraphs (A) and (B) of section 

22 2104(a)(16) and any reduction in the allot23 ment for either such period under section 

24 2104(m)(4) shall be allocated on a pro 

25 rata basis to such set aside. 


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1 ‘‘(ii) PAYMENTS FROM BLOCK

2 GRANT.—The Secretary shall pay the State 

3 from the amount set aside under clause (i) 

4 for the fiscal year, an amount for each 

5 quarter of such fiscal year equal to the ap6 plicable percentage determined under 

7 clause (iii) or (iv) for expenditures in the 

8 quarter for providing child health assist9 ance or other health benefits coverage to a 

10 parent of a targeted low-income child. 

11 ‘‘(iii) ENHANCED FMAP ONLY IN FIS12 CAL YEAR 2012 FOR STATES WITH SIGNIFI13 CANT CHILD OUTREACH OR THAT ACHIEVE

14 CHILD COVERAGE BENCHMARKS; FMAP

15 FOR ANY OTHER STATES.—For purposes 

16 of clause (ii), the applicable percentage for 

17 any quarter of fiscal year 2012 is equal 

18 to— 

19 ‘‘(I) the enhanced FMAP deter20 mined under section 2105(b) in the 

21 case of a State that meets the out22 reach or coverage benchmarks de23 scribed in any of subparagraph (A), 

24 (B), or (C) of paragraph (3) for fiscal 

25 year 2011; or 


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1 ‘‘(II) the Federal medical assist2 ance percentage (as determined under 

3 section 1905(b) without regard to 

4 clause (4) of such section) in the case 

5 of any other State. 

6 ‘‘(iv) AMOUNT OF FEDERAL MATCH7 ING PAYMENT IN 2013.—For purposes of 

8 clause (ii), the applicable percentage for 

9 any quarter of fiscal year 2013 is equal 

10 to— 

11 ‘‘(I) the REMAP percentage if— 

12 ‘‘(aa) the applicable percent13 age for the State under clause 

14 (iii) was the enhanced FMAP for 

15 fiscal year 2012; and 

16 ‘‘(bb) the State met either of 

17 the coverage benchmarks de18 scribed in subparagraph (B) or 

19 (C) of paragraph (3) for fiscal 

20 year 2012; or 

21 ‘‘(II) the Federal medical assist22 ance percentage (as so determined) in 

23 the case of any State to which sub24 clause (I) does not apply. 


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1 For purposes of subclause (I), the REMAP 

2 percentage is the percentage which is the 

3 sum of such Federal medical assistance 

4 percentage and a number of percentage 

5 points equal to one-half of the difference 

6 between such Federal medical assistance 

7 percentage and such enhanced FMAP. 

8 ‘‘(v) NO FEDERAL PAYMENTS OTHER

9 THAN FROM BLOCK GRANT SET ASIDE.— 

10 No payments shall be made to a State for 

11 expenditures described in clause (ii) after 

12 the total amount set aside under clause (i) 

13 for a fiscal year has been paid to the 

14 State. 

15 ‘‘(vi) NO INCREASE IN INCOME ELIGI16 BILITY LEVEL FOR PARENTS.—No pay17 ments shall be made to a State from the 

18 amount set aside under clause (i) for a fis19 cal year for expenditures for providing 

20 child health assistance or health benefits 

21 coverage to a parent of a targeted low-in22 come child whose family income exceeds 

23 the income eligibility level applied under 

24 the applicable existing waiver to parents of 

25 targeted low-income children on the date of 


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1 enactment of the Children’s Health Insur2 ance Program Reauthorization Act of 

3 2009. 

4 ‘‘(3) OUTREACH OR COVERAGE BENCH5 MARKS.—For purposes of paragraph (2), the out6 reach or coverage benchmarks described in this 

7 paragraph are as follows: 

8 ‘‘(A) SIGNIFICANT CHILD OUTREACH CAM9 PAIGN.—The State— 

10 ‘‘(i) was awarded a grant under sec11 tion 2113 for fiscal year 2011; 

12 ‘‘(ii) implemented 1 or more of the en13 rollment and retention provisions described 

14 in section 2105(a)(4) for such fiscal year; 

15 or 

16 ‘‘(iii) has submitted a specific plan for 

17 outreach for such fiscal year. 

18 ‘‘(B) HIGH-PERFORMING STATE.—The 

19 State, on the basis of the most timely and accu20 rate published estimates of the Bureau of the 

Census, ranks in the lowest 1 21 ⁄3 of States in 

22 terms of the State’s percentage of low-income 

23 children without health insurance. 

24 ‘‘(C) STATE INCREASING ENROLLMENT OF

25 LOW-INCOME CHILDREN.—The State qualified 


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1 for a performance bonus payment under section 

2 2105(a)(3)(B) for the most recent fiscal year 

3 applicable under such section. 

4 ‘‘(4) RULES OF CONSTRUCTION.—Nothing in 

5 this subsection shall be construed as prohibiting a 

6 State from submitting an application to the Sec7 retary for a waiver under section 1115 of the State 

8 plan under title XIX to provide medical assistance to 

9 a parent of a targeted low-income child that was 

10 provided child health assistance or health benefits 

11 coverage under an applicable existing waiver. 

12 ‘‘(c) APPLICABLE EXISTING WAIVER.—For purposes 

13 of this section— 

14 ‘‘(1) IN GENERAL.—The term ‘applicable exist15 ing waiver’ means a waiver, experimental, pilot, or 

16 demonstration project under section 1115, grand17 fathered under section 6102(c)(3) of the Deficit Re18 duction Act of 2005, or otherwise conducted under 

19 authority that— 

20 ‘‘(A) would allow funds made available 

21 under this title to be used to provide child 

22 health assistance or other health benefits cov23 erage to— 

24 ‘‘(i) a parent of a targeted low-income 

25 child; 


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1 ‘‘(ii) a nonpregnant childless adult; or 

2 ‘‘(iii) individuals described in both 

3 clauses (i) and (ii); and 

4 ‘‘(B) was in effect during fiscal year 2009. 

5 ‘‘(2) DEFINITIONS.— 

6 ‘‘(A) PARENT.—The term ‘parent’ includes 

7 a caretaker relative (as such term is used in 

8 carrying out section 1931) and a legal guard9 ian. 

10 ‘‘(B) NONPREGNANT CHILDLESS ADULT.— 

11 The term ‘nonpregnant childless adult’ has the 

12 meaning given such term by section 2107(f).’’. 

13 (2) CONFORMING AMENDMENTS.— 

14 (A) Section 2107(f) (42 U.S.C. 1397gg(f)) 

15 is amended— 

16 (i) by striking ‘‘, the Secretary’’ and 

17 inserting ‘‘: 

18 ‘‘(1) The Secretary’’; 

19 (ii) in the first sentence, by inserting 

20 ‘‘or a parent (as defined in section 

21 2111(c)(2)(A)), who is not pregnant, of a 

22 targeted low-income child’’ before the pe23 riod; 

24 (iii) by striking the second sentence; 

25 and 


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1 (iv) by adding at the end the following 

2 new paragraph: 

3 ‘‘(2) The Secretary may not approve, extend, 

4 renew, or amend a waiver, experimental, pilot, or 

5 demonstration project with respect to a State after 

6 the date of enactment of the Children’s Health In7 surance Program Reauthorization Act of 2009 that 

8 would waive or modify the requirements of section 

9 2111.’’. 

10 (B) Section 6102(c) of the Deficit Reduc11 tion Act of 2005 (Public Law 109–171; 120 

12 Stat. 131) is amended by striking ‘‘Nothing’’ 

13 and inserting ‘‘Subject to section 2111 of the 

14 Social Security Act, as added by section 112 of 

15 the Children’s Health Insurance Program Re16 authorization Act of 2009, nothing’’. 

17 (b) GAO STUDY AND REPORT.— 

18 (1) IN GENERAL.—The Comptroller General of 

19 the United States shall conduct a study of wheth20 er— 

21 (A) the coverage of a parent, a caretaker 

22 relative (as such term is used in carrying out 

23 section 1931), or a legal guardian of a targeted 

24 low-income child under a State health plan 

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1 creases the enrollment of, or the quality of care 

2 for, children, and 

3 (B) such parents, relatives, and legal 

4 guardians who enroll in such a plan are more 

5 likely to enroll their children in such a plan or 

6 in a State plan under title XIX of such Act. 

7 (2) REPORT.—Not later than 2 years after the 

8 date of the enactment of this Act, the Comptroller 

9 General shall report the results of the study to the 

10 Committee on Finance of the Senate and the Com11 mittee on Energy and Commerce of the House of 

12 Representatives, including recommendations (if any) 

13 for changes in legislation. 

14 SEC. 113. ELIMINATION OF COUNTING MEDICAID CHILD 

15 PRESUMPTIVE ELIGIBILITY COSTS AGAINST 

16 TITLE XXI ALLOTMENT. 

17 (a) IN GENERAL.—Section 2105(a)(1) (42 U.S.C. 

18 1397ee(a)(1)) is amended— 

19 (1) in the matter preceding subparagraph (A), 

20 by striking ‘‘(or, in the case of expenditures de21 scribed in subparagraph (B), the Federal medical 

22 assistance percentage (as defined in the first sen23 tence of section 1905(b)))’’; and 

24 (2) by striking subparagraph (B) and inserting 

25 the following new subparagraph: 


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1 ‘‘(B) [reserved]’’. 

2 (b) AMENDMENTS TO MEDICAID.— 

3 (1) ELIGIBILITY OF A NEWBORN.—Section 

4 1902(e)(4) (42 U.S.C. 1396a(e)(4)) is amended in 

5 the first sentence by striking ‘‘so long as the child 

6 is a member of the woman’s household and the 

7 woman remains (or would remain if pregnant) eligi8 ble for such assistance’’. 

9 (2) APPLICATION OF QUALIFIED ENTITIES TO

10 PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN

11 UNDER MEDICAID.—Section 1920(b) (42 U.S.C. 

12 1396r–1(b)) is amended by adding after paragraph 

13 (2) the following flush sentence: 

14 ‘‘The term ‘qualified provider’ also includes a qualified en15 tity, as defined in section 1920A(b)(3).’’. 

16 SEC. 114. LIMITATION ON MATCHING RATE FOR STATES 

17 THAT PROPOSE TO COVER CHILDREN WITH 

18 EFFECTIVE FAMILY INCOME THAT EXCEEDS 

19 300 PERCENT OF THE POVERTY LINE. 

20 (a) FMAP APPLIED TO EXPENDITURES.—Section 

21 2105(c) (42 U.S.C. 1397ee(c)) is amended by adding at 

22 the end the following new paragraph: 

23 ‘‘(8) LIMITATION ON MATCHING RATE FOR EX24 PENDITURES FOR CHILD HEALTH ASSISTANCE PRO25 VIDED TO CHILDREN WHOSE EFFECTIVE FAMILY INVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00074 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 COME EXCEEDS 300 PERCENT OF THE POVERTY

2 LINE.— 

3 ‘‘(A) FMAP APPLIED TO EXPENDI4 TURES.—Except as provided in subparagraph 

5 (B), for fiscal years beginning with fiscal year 

6 2009, the Federal medical assistance percent7 age (as determined under section 1905(b) with8 out regard to clause (4) of such section) shall 

9 be substituted for the enhanced FMAP under 

10 subsection (a)(1) with respect to any expendi11 tures for providing child health assistance or 

12 health benefits coverage for a targeted low-in13 come child whose effective family income would 

14 exceed 300 percent of the poverty line but for 

15 the application of a general exclusion of a block 

16 of income that is not determined by type of ex17 pense or type of income. 

18 ‘‘(B) EXCEPTION.—Subparagraph (A) 

19 shall not apply to any State that, on the date 

20 of enactment of the Children’s Health Insur21 ance Program Reauthorization Act of 2009, has 

22 an approved State plan amendment or waiver to 

23 provide, or has enacted a State law to submit 

24 a State plan amendment to provide, expendiVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00075 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 tures described in such subparagraph under the 

2 State child health plan.’’. 

3 (b) RULE OF CONSTRUCTION.—Nothing in the 

4 amendments made by this section shall be construed as— 

5 (1) changing any income eligibility level for chil6 dren under title XXI of the Social Security Act; or 

7 (2) changing the flexibility provided States 

8 under such title to establish the income eligibility 

9 level for targeted low-income children under a State 

10 child health plan and the methodologies used by the 

11 State to determine income or assets under such 

12 plan. 

13 SEC. 115. STATE AUTHORITY UNDER MEDICAID. 

14 Notwithstanding any other provision of law, including 

15 the fourth sentence of subsection (b) of section 1905 of 

16 the Social Security Act (42 U.S.C. 1396d) or subsection 

17 (u) of such section, at State option, the Secretary shall 

18 provide the State with the Federal medical assistance per19 centage determined for the State for Medicaid with respect 

20 to expenditures described in section 1905(u)(2)(A) of such 

21 Act or otherwise made to provide medical assistance under 

22 Medicaid to a child who could be covered by the State 

23 under CHIP. 


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1 TITLE II—OUTREACH AND 

2 ENROLLMENT 

3 Subtitle A—Outreach and 

4 Enrollment Activities 

5 SEC. 201. GRANTS AND ENHANCED ADMINISTRATIVE FUND6 ING FOR OUTREACH AND ENROLLMENT. 

7 (a) GRANTS.—Title XXI (42 U.S.C. 1397aa et seq.), 

8 as amended by section 111, is amended by adding at the 

9 end the following: 

10 ‘‘SEC. 2113. GRANTS TO IMPROVE OUTREACH AND ENROLL11 MENT. 

12 ‘‘(a) OUTREACH AND ENROLLMENT GRANTS; NA13 TIONAL CAMPAIGN.— 

14 ‘‘(1) IN GENERAL.—From the amounts appro15 priated under subsection (g), subject to paragraph 

16 (2), the Secretary shall award grants to eligible enti17 ties during the period of fiscal years 2009 through 

18 2013 to conduct outreach and enrollment efforts 

19 that are designed to increase the enrollment and 

20 participation of eligible children under this title and 

21 title XIX. 

22 ‘‘(2) TEN PERCENT SET ASIDE FOR NATIONAL

23 ENROLLMENT CAMPAIGN.—An amount equal to 10 

24 percent of such amounts shall be used by the Sec25 retary for expenditures during such period to carry 


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1 out a national enrollment campaign in accordance 

2 with subsection (h). 

3 ‘‘(b) PRIORITY FOR AWARD OF GRANTS.— 

4 ‘‘(1) IN GENERAL.—In awarding grants under 

5 subsection (a), the Secretary shall give priority to el6 igible entities that— 

7 ‘‘(A) propose to target geographic areas 

8 with high rates of— 

9 ‘‘(i) eligible but unenrolled children, 

10 including such children who reside in rural 

11 areas; or 

12 ‘‘(ii) racial and ethnic minorities and 

13 health disparity populations, including 

14 those proposals that address cultural and 

15 linguistic barriers to enrollment; and 

16 ‘‘(B) submit the most demonstrable evi17 dence required under paragraphs (1) and (2) of 

18 subsection (c). 

19 ‘‘(2) TEN PERCENT SET ASIDE FOR OUTREACH

20 TO INDIAN CHILDREN.—An amount equal to 10 per21 cent of the funds appropriated under subsection (g) 

22 shall be used by the Secretary to award grants to 

23 Indian Health Service providers and urban Indian 

24 organizations receiving funds under title V of the In25 dian Health Care Improvement Act (25 U.S.C. 1651 


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1 et seq.) for outreach to, and enrollment of, children 

2 who are Indians. 

3 ‘‘(c) APPLICATION.—An eligible entity that desires to 

4 receive a grant under subsection (a) shall submit an appli5 cation to the Secretary in such form and manner, and con6 taining such information, as the Secretary may decide. 

7 Such application shall include— 

8 ‘‘(1) evidence demonstrating that the entity in9 cludes members who have access to, and credibility 

10 with, ethnic or low-income populations in the com11 munities in which activities funded under the grant 

12 are to be conducted; 

13 ‘‘(2) evidence demonstrating that the entity has 

14 the ability to address barriers to enrollment, such as 

15 lack of awareness of eligibility, stigma concerns and 

16 punitive fears associated with receipt of benefits, 

17 and other cultural barriers to applying for and re18 ceiving child health assistance or medical assistance; 

19 ‘‘(3) specific quality or outcomes performance 

20 measures to evaluate the effectiveness of activities 

21 funded by a grant awarded under this section; and 

22 ‘‘(4) an assurance that the eligible entity 

23 shall— 


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1 ‘‘(A) conduct an assessment of the effec2 tiveness of such activities against the perform3 ance measures; 

4 ‘‘(B) cooperate with the collection and re5 porting of enrollment data and other informa6 tion in order for the Secretary to conduct such 

7 assessments; and 

8 ‘‘(C) in the case of an eligible entity that 

9 is not the State, provide the State with enroll10 ment data and other information as necessary 

11 for the State to make necessary projections of 

12 eligible children and pregnant women. 

13 ‘‘(d) DISSEMINATION OF ENROLLMENT DATA AND

14 INFORMATION DETERMINED FROM EFFECTIVENESS AS15 SESSMENTS; ANNUAL REPORT.—The Secretary shall— 

16 ‘‘(1) make publicly available the enrollment 

17 data and information collected and reported in ac18 cordance with subsection (c)(4)(B); and 

19 ‘‘(2) submit an annual report to Congress on 

20 the outreach and enrollment activities conducted 

21 with funds appropriated under this section. 

22 ‘‘(e) MAINTENANCE OF EFFORT FOR STATES

23 AWARDED GRANTS; NO STATE MATCH REQUIRED.—In 

24 the case of a State that is awarded a grant under this 

25 section— 


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1 ‘‘(1) the State share of funds expended for out2 reach and enrollment activities under the State child 

3 health plan shall not be less than the State share of 

4 such funds expended in the fiscal year preceding the 

5 first fiscal year for which the grant is awarded; and 

6 ‘‘(2) no State matching funds shall be required 

7 for the State to receive a grant under this section. 

8 ‘‘(f) DEFINITIONS.—In this section: 

9 ‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible en10 tity’ means any of the following: 

11 ‘‘(A) A State with an approved child health 

12 plan under this title. 

13 ‘‘(B) A local government. 

14 ‘‘(C) An Indian tribe or tribal consortium, 

15 a tribal organization, an urban Indian organiza16 tion receiving funds under title V of the Indian 

17 Health Care Improvement Act (25 U.S.C. 1651 

18 et seq.), or an Indian Health Service provider. 

19 ‘‘(D) A Federal health safety net organiza20 tion. 

21 ‘‘(E) A national, State, local, or commu22 nity-based public or nonprofit private organiza23 tion, including organizations that use commu24 nity health workers or community-based doula 

25 programs. 


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1 ‘‘(F) A faith-based organization or con2 sortia, to the extent that a grant awarded to 

3 such an entity is consistent with the require4 ments of section 1955 of the Public Health 

5 Service Act (42 U.S.C. 300x–65) relating to a 

6 grant award to nongovernmental entities. 

7 ‘‘(G) An elementary or secondary school. 

8 ‘‘(2) FEDERAL HEALTH SAFETY NET ORGANI9 ZATION.—The term ‘Federal health safety net orga10 nization’ means— 

11 ‘‘(A) a Federally-qualified health center (as 

12 defined in section 1905(l)(2)(B)); 

13 ‘‘(B) a hospital defined as a dispropor14 tionate share hospital for purposes of section 

15 1923; 

16 ‘‘(C) a covered entity described in section 

17 340B(a)(4) of the Public Health Service Act 

18 (42 U.S.C. 256b(a)(4)); and 

19 ‘‘(D) any other entity or consortium that 

20 serves children under a federally funded pro21 gram, including the special supplemental nutri22 tion program for women, infants, and children 

23 (WIC) established under section 17 of the Child 

24 Nutrition Act of 1966 (42 U.S.C. 1786), the 

25 Head Start and Early Head Start programs 


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1 under the Head Start Act (42 U.S.C. 9801 et 

2 seq.), the school lunch program established 

3 under the Richard B. Russell National School 

4 Lunch Act, and an elementary or secondary 

5 school. 

6 ‘‘(3) INDIANS; INDIAN TRIBE; TRIBAL ORGANI7 ZATION; URBAN INDIAN ORGANIZATION.—The terms 

8 ‘Indian’, ‘Indian tribe’, ‘tribal organization’, and 

9 ‘urban Indian organization’ have the meanings given 

10 such terms in section 4 of the Indian Health Care 

11 Improvement Act (25 U.S.C. 1603). 

12 ‘‘(4) COMMUNITY HEALTH WORKER.—The term 

13 ‘community health worker’ means an individual who 

14 promotes health or nutrition within the community 

15 in which the individual resides— 

16 ‘‘(A) by serving as a liaison between com17 munities and health care agencies; 

18 ‘‘(B) by providing guidance and social as19 sistance to community residents; 

20 ‘‘(C) by enhancing community residents’ 

21 ability to effectively communicate with health 

22 care providers; 

23 ‘‘(D) by providing culturally and linguis24 tically appropriate health or nutrition edu25 cation; 


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1 ‘‘(E) by advocating for individual and com2 munity health or nutrition needs; and 

3 ‘‘(F) by providing referral and followup 

4 services. 

5 ‘‘(g) APPROPRIATION.—There is appropriated, out of 

6 any money in the Treasury not otherwise appropriated, 

7 $100,000,000 for the period of fiscal years 2009 through 

8 2013, for the purpose of awarding grants under this sec9 tion. Amounts appropriated and paid under the authority 

10 of this section shall be in addition to amounts appro11 priated under section 2104 and paid to States in accord12 ance with section 2105, including with respect to expendi13 tures for outreach activities in accordance with subsections 

14 (a)(1)(D)(iii) and (c)(2)(C) of that section. 

15 ‘‘(h) NATIONAL ENROLLMENT CAMPAIGN.—From 

16 the amounts made available under subsection (a)(2), the 

17 Secretary shall develop and implement a national enroll18 ment campaign to improve the enrollment of underserved 

19 child populations in the programs established under this 

20 title and title XIX. Such campaign may include— 

21 ‘‘(1) the establishment of partnerships with the 

22 Secretary of Education and the Secretary of Agri23 culture to develop national campaigns to link the eli24 gibility and enrollment systems for the assistance 


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1 programs each Secretary administers that often 

2 serve the same children; 

3 ‘‘(2) the integration of information about the 

4 programs established under this title and title XIX 

5 in public health awareness campaigns administered 

6 by the Secretary; 

7 ‘‘(3) increased financial and technical support 

8 for enrollment hotlines maintained by the Secretary 

9 to ensure that all States participate in such hotlines; 

10 ‘‘(4) the establishment of joint public awareness 

11 outreach initiatives with the Secretary of Education 

12 and the Secretary of Labor regarding the impor13 tance of health insurance to building strong commu14 nities and the economy; 

15 ‘‘(5) the development of special outreach mate16 rials for Native Americans or for individuals with 

17 limited English proficiency; and 

18 ‘‘(6) such other outreach initiatives as the Sec19 retary determines would increase public awareness of 

20 the programs under this title and title XIX.’’. 

21 (b) ENHANCED ADMINISTRATIVE FUNDING FOR

22 TRANSLATION OR INTERPRETATION SERVICES UNDER

23 CHIP AND MEDICAID.— 


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1 (1) CHIP.—Section 2105(a)(1) (42 U.S.C. 

2 1397ee(a)(1)), as amended by section 113, is 

3 amended— 

4 (A) in the matter preceding subparagraph 

5 (A), by inserting ‘‘(or, in the case of expendi6 tures described in subparagraph (D)(iv), the 

7 higher of 75 percent or the sum of the en8 hanced FMAP plus 5 percentage points)’’ after 

9 ‘‘enhanced FMAP’’; and 

10 (B) in subparagraph (D)— 

11 (i) in clause (iii), by striking ‘‘and’’ at 

12 the end; 

13 (ii) by redesignating clause (iv) as 

14 clause (v); and 

15 (iii) by inserting after clause (iii) the 

16 following new clause: 

17 ‘‘(iv) for translation or interpretation 

18 services in connection with the enrollment 

19 of, retention of, and use of services under 

20 this title by, individuals for whom English 

21 is not their primary language (as found 

22 necessary by the Secretary for the proper 

23 and efficient administration of the State 

24 plan); and’’. 

25 (2) MEDICAID.— 


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1 (A) USE OF MEDICAID FUNDS.—Section 

2 1903(a)(2) (42 U.S.C. 1396b(a)(2)) is amended 

3 by adding at the end the following new sub4 paragraph: 

5 ‘‘(E) an amount equal to 75 percent of so much 

6 of the sums expended during such quarter (as found 

7 necessary by the Secretary for the proper and effi8 cient administration of the State plan) as are attrib9 utable to translation or interpretation services in 

10 connection with the enrollment of, retention of, and 

11 use of services under this title by, children of fami12 lies for whom English is not the primary language; 

13 plus’’. 

14 (B) USE OF COMMUNITY HEALTH WORK15 ERS FOR OUTREACH ACTIVITIES.— 

16 (i) IN GENERAL.—Section 2102(c)(1) 

17 of such Act (42 U.S.C. 1397bb(c)(1)) is 

18 amended by inserting ‘‘(through commu19 nity health workers and others)’’ after 

20 ‘‘Outreach’’. 

21 (ii) IN FEDERAL EVALUATION.—Sec22 tion 2108(c)(3)(B) of such Act (42 U.S.C. 

23 1397hh(c)(3)(B)) is amended by inserting 

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1 ers and others)’’ after ‘‘including prac2 tices’’. 

3 SEC. 202. INCREASED OUTREACH AND ENROLLMENT OF IN4 DIANS. 

5 (a) IN GENERAL.—Section 1139 (42 U.S.C. 1320b– 

6 9) is amended to read as follows: 

7 ‘‘SEC. 1139. IMPROVED ACCESS TO, AND DELIVERY OF, 

8 HEALTH CARE FOR INDIANS UNDER TITLES 

9 XIX AND XXI. 

10 ‘‘(a) AGREEMENTS WITH STATES FOR MEDICAID

11 AND CHIP OUTREACH ON OR NEAR RESERVATIONS TO

12 INCREASE THE ENROLLMENT OF INDIANS IN THOSE

13 PROGRAMS.— 

14 ‘‘(1) IN GENERAL.—In order to improve the ac15 cess of Indians residing on or near a reservation to 

16 obtain benefits under the Medicaid and State chil17 dren’s health insurance programs established under 

18 titles XIX and XXI, the Secretary shall encourage 

19 the State to take steps to provide for enrollment on 

20 or near the reservation. Such steps may include out21 reach efforts such as the outstationing of eligibility 

22 workers, entering into agreements with the Indian 

23 Health Service, Indian Tribes, Tribal Organizations, 

24 and Urban Indian Organizations to provide out25 reach, education regarding eligibility and benefits, 


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1 enrollment, and translation services when such serv2 ices are appropriate. 

3 ‘‘(2) CONSTRUCTION.—Nothing in paragraph 

4 (1) shall be construed as affecting arrangements en5 tered into between States and the Indian Health 

6 Service, Indian Tribes, Tribal Organizations, or 

7 Urban Indian Organizations for such Service, 

8 Tribes, or Organizations to conduct administrative 

9 activities under such titles. 

10 ‘‘(b) REQUIREMENT TO FACILITATE COOPERA11 TION.—The Secretary, acting through the Centers for 

12 Medicare & Medicaid Services, shall take such steps as are 

13 necessary to facilitate cooperation with, and agreements 

14 between, States and the Indian Health Service, Indian 

15 Tribes, Tribal Organizations, or Urban Indian Organiza16 tions with respect to the provision of health care items 

17 and services to Indians under the programs established 

18 under title XIX or XXI. 

19 ‘‘(c) DEFINITION OF INDIAN; INDIAN TRIBE; INDIAN

20 HEALTH PROGRAM; TRIBAL ORGANIZATION; URBAN IN21 DIAN ORGANIZATION.—In this section, the terms ‘Indian’, 

22 ‘Indian Tribe’, ‘Indian Health Program’, ‘Tribal Organi23 zation’, and ‘Urban Indian Organization’ have the mean24 ings given those terms in section 4 of the Indian Health 

25 Care Improvement Act.’’. 


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1 (b) NONAPPLICATION OF 10 PERCENT LIMIT ON

2 OUTREACH AND CERTAIN OTHER EXPENDITURES.—Sec3 tion 2105(c)(2) (42 U.S.C. 1397ee(c)(2)) is amended by 

4 adding at the end the following: 

5 ‘‘(C) NONAPPLICATION TO CERTAIN EX6 PENDITURES.—The limitation under subpara7 graph (A) shall not apply with respect to the 

8 following expenditures: 

9 ‘‘(i) EXPENDITURES TO INCREASE

10 OUTREACH TO, AND THE ENROLLMENT OF, 

11 INDIAN CHILDREN UNDER THIS TITLE AND

12 TITLE xix.—Expenditures for outreach ac13 tivities to families of Indian children likely 

14 to be eligible for child health assistance 

15 under the plan or medical assistance under 

16 the State plan under title XIX (or under 

17 a waiver of such plan), to inform such 

18 families of the availability of, and to assist 

19 them in enrolling their children in, such 

20 plans, including such activities conducted 

21 under grants, contracts, or agreements en22 tered into under section 1139(a).’’. 


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1 SEC. 203. STATE OPTION TO RELY ON FINDINGS FROM AN 

2 EXPRESS LANE AGENCY TO CONDUCT SIM3 PLIFIED ELIGIBILITY DETERMINATIONS. 

4 (a) APPLICATION UNDER MEDICAID AND CHIP PRO5 GRAMS.— 

6 (1) MEDICAID.—Section 1902(e) (42 U.S.C. 

7 1396a(e)) is amended by adding at the end the fol8 lowing: 

9 ‘‘(13) EXPRESS LANE OPTION.— 

10 ‘‘(A) IN GENERAL.— 

11 ‘‘(i) OPTION TO USE A FINDING FROM AN

12 EXPRESS LANE AGENCY.—At the option of the 

13 State, the State plan may provide that in deter14 mining eligibility under this title for a child (as 

15 defined in subparagraph (G)), the State may 

16 rely on a finding made within a reasonable pe17 riod (as determined by the State) from an Ex18 press Lane agency (as defined in subparagraph 

19 (F)) when it determines whether a child satis20 fies one or more components of eligibility for 

21 medical assistance under this title. The State 

22 may rely on a finding from an Express Lane 

23 agency notwithstanding sections 

24 1902(a)(46)(B) and 1137(d) or any differences 

25 in budget unit, disregard, deeming or other 


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1 methodology, if the following requirements are 

2 met: 

3 ‘‘(I) PROHIBITION ON DETERMINING

4 CHILDREN INELIGIBLE FOR COVERAGE.— 

5 If a finding from an Express Lane agency 

6 would result in a determination that a 

7 child does not satisfy an eligibility require8 ment for medical assistance under this title 

9 and for child health assistance under title 

10 XXI, the State shall determine eligibility 

11 for assistance using its regular procedures. 

12 ‘‘(II) NOTICE REQUIREMENT.—For 

13 any child who is found eligible for medical 

14 assistance under the State plan under this 

15 title or child health assistance under title 

16 XXI and who is subject to premiums based 

17 on an Express Lane agency’s finding of 

18 such child’s income level, the State shall 

19 provide notice that the child may qualify 

20 for lower premium payments if evaluated 

21 by the State using its regular policies and 

22 of the procedures for requesting such an 

23 evaluation. 

24 ‘‘(III) COMPLIANCE WITH SCREEN

25 AND ENROLL REQUIREMENT.—The State 


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1 shall satisfy the requirements under sub2 paragraphs (A) and (B) of section 

3 2102(b)(3) (relating to screen and enroll) 

4 before enrolling a child in child health as5 sistance under title XXI. At its option, the 

6 State may fulfill such requirements in ac7 cordance with either option provided under 

8 subparagraph (C) of this paragraph. 

9 ‘‘(IV) VERIFICATION OF CITIZENSHIP

10 OR NATIONALITY STATUS.—The State shall 

11 satisfy the requirements of section 

12 1902(a)(46)(B) or 2105(c)(9), as applica13 ble for verifications of citizenship or na14 tionality status. 

15 ‘‘(V) CODING.—The State meets the 

16 requirements of subparagraph (E). 

17 ‘‘(ii) OPTION TO APPLY TO RENEWALS AND

18 REDETERMINATIONS.—The State may apply the 

19 provisions of this paragraph when conducting 

20 initial determinations of eligibility, redetermina21 tions of eligibility, or both, as described in the 

22 State plan. 

23 ‘‘(B) RULES OF CONSTRUCTION.—Nothing in 

24 this paragraph shall be construed— 


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1 ‘‘(i) to limit or prohibit a State from tak2 ing any actions otherwise permitted under this 

3 title or title XXI in determining eligibility for 

4 or enrolling children into medical assistance 

5 under this title or child health assistance under 

6 title XXI; or 

7 ‘‘(ii) to modify the limitations in section 

8 1902(a)(5) concerning the agencies that may 

9 make a determination of eligibility for medical 

10 assistance under this title. 

11 ‘‘(C) OPTIONS FOR SATISFYING THE SCREEN

12 AND ENROLL REQUIREMENT.— 

13 ‘‘(i) IN GENERAL.—With respect to a child 

14 whose eligibility for medical assistance under 

15 this title or for child health assistance under 

16 title XXI has been evaluated by a State agency 

17 using an income finding from an Express Lane 

18 agency, a State may carry out its duties under 

19 subparagraphs (A) and (B) of section 

20 2102(b)(3) (relating to screen and enroll) in ac21 cordance with either clause (ii) or clause (iii). 

22 ‘‘(ii) ESTABLISHING A SCREENING

23 THRESHOLD.— 

24 ‘‘(I) IN GENERAL.—Under this clause, 

25 the State establishes a screening threshold 


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1 set as a percentage of the Federal poverty 

2 level that exceeds the highest income 

3 threshold applicable under this title to the 

4 child by a minimum of 30 percentage 

5 points or, at State option, a higher number 

6 of percentage points that reflects the value 

7 (as determined by the State and described 

8 in the State plan) of any differences be9 tween income methodologies used by the 

10 program administered by the Express Lane 

11 agency and the methodologies used by the 

12 State in determining eligibility for medical 

13 assistance under this title. 

14 ‘‘(II) CHILDREN WITH INCOME NOT

15 ABOVE THRESHOLD.—If the income of a 

16 child does not exceed the screening thresh17 old, the child is deemed to satisfy the in18 come eligibility criteria for medical assist19 ance under this title regardless of whether 

20 such child would otherwise satisfy such cri21 teria. 

22 ‘‘(III) CHILDREN WITH INCOME

23 ABOVE THRESHOLD.—If the income of a 

24 child exceeds the screening threshold, the 

25 child shall be considered to have an income 


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1 above the Medicaid applicable income level 

2 described in section 2110(b)(4) and to sat3 isfy the requirement under section 

4 2110(b)(1)(C) (relating to the requirement 

5 that CHIP matching funds be used only 

6 for children not eligible for Medicaid). If 

7 such a child is enrolled in child health as8 sistance under title XXI, the State shall 

9 provide the parent, guardian, or custodial 

10 relative with the following: 

11 ‘‘(aa) Notice that the child may 

12 be eligible to receive medical assist13 ance under the State plan under this 

14 title if evaluated for such assistance 

15 under the State’s regular procedures 

16 and notice of the process through 

17 which a parent, guardian, or custodial 

18 relative can request that the State 

19 evaluate the child’s eligibility for med20 ical assistance under this title using 

21 such regular procedures. 

22 ‘‘(bb) A description of differences 

23 between the medical assistance pro24 vided under this title and child health 

25 assistance under title XXI, including 


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1 differences in cost-sharing require2 ments and covered benefits. 

3 ‘‘(iii) TEMPORARY ENROLLMENT IN CHIP

4 PENDING SCREEN AND ENROLL.— 

5 ‘‘(I) IN GENERAL.—Under this clause, 

6 a State enrolls a child in child health as7 sistance under title XXI for a temporary 

8 period if the child appears eligible for such 

9 assistance based on an income finding by 

10 an Express Lane agency. 

11 ‘‘(II) DETERMINATION OF ELIGI12 BILITY.—During such temporary enroll13 ment period, the State shall determine the 

14 child’s eligibility for child health assistance 

15 under title XXI or for medical assistance 

16 under this title in accordance with this 

17 clause. 

18 ‘‘(III) PROMPT FOLLOW UP.—In mak19 ing such a determination, the State shall 

20 take prompt action to determine whether 

21 the child should be enrolled in medical as22 sistance under this title or child health as23 sistance under title XXI pursuant to sub24 paragraphs (A) and (B) of section 

25 2102(b)(3) (relating to screen and enroll). 


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1 ‘‘(IV) REQUIREMENT FOR SIMPLIFIED

2 DETERMINATION.—In making such a de3 termination, the State shall use procedures 

4 that, to the maximum feasible extent, re5 duce the burden imposed on the individual 

6 of such determination. Such procedures 

7 may not require the child’s parent, guard8 ian, or custodial relative to provide or 

9 verify information that already has been 

10 provided to the State agency by an Ex11 press Lane agency or another source of in12 formation unless the State agency has rea13 son to believe the information is erroneous. 

14 ‘‘(V) AVAILABILITY OF CHIP MATCH15 ING FUNDS DURING TEMPORARY ENROLL16 MENT PERIOD.—Medical assistance for 

17 items and services that are provided to a 

18 child enrolled in title XXI during a tem19 porary enrollment period under this clause 

20 shall be treated as child health assistance 

21 under such title. 

22 ‘‘(D) OPTION FOR AUTOMATIC ENROLLMENT.— 

23 ‘‘(i) IN GENERAL.—The State may initiate 

24 and determine eligibility for medical assistance 

25 under the State Medicaid plan or for child 


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1 health assistance under the State CHIP plan 

2 without a program application from, or on be3 half of, the child based on data obtained from 

4 sources other than the child (or the child’s fam5 ily), but a child can only be automatically en6 rolled in the State Medicaid plan or the State 

7 CHIP plan if the child or the family affirma8 tively consents to being enrolled through affir9 mation and signature on an Express Lane 

10 agency application, if the requirement of clause 

11 (ii) is met. 

12 ‘‘(ii) INFORMATION REQUIREMENT.—The 

13 requirement of this clause is that the State in14 forms the parent, guardian, or custodial relative 

15 of the child of the services that will be covered, 

16 appropriate methods for using such services, 

17 premium or other cost sharing charges (if any) 

18 that apply, medical support obligations (under 

19 section 1912(a)) created by enrollment (if appli20 cable), and the actions the parent, guardian, or 

21 relative must take to maintain enrollment and 

22 renew coverage. 

23 ‘‘(E) CODING; APPLICATION TO ENROLLMENT

24 ERROR RATES.— 


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1 ‘‘(i) IN GENERAL.—For purposes of sub2 paragraph (A)(iv), the requirement of this sub3 paragraph for a State is that the State agrees 

4 to— 

5 ‘‘(I) assign such codes as the Sec6 retary shall require to the children who are 

7 enrolled in the State Medicaid plan or the 

8 State CHIP plan through reliance on a 

9 finding made by an Express Lane agency 

10 for the duration of the State’s election 

11 under this paragraph; 

12 ‘‘(II) annually provide the Secretary 

13 with a statistically valid sample (that is ap14 proved by Secretary) of the children en15 rolled in such plans through reliance on 

16 such a finding by conducting a full Med17 icaid eligibility review of the children iden18 tified for such sample for purposes of de19 termining an eligibility error rate (as de20 scribed in clause (iv)) with respect to the 

21 enrollment of such children (and shall not 

22 include such children in any data or sam23 ples used for purposes of complying with a 

24 Medicaid Eligibility Quality Control 


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1 (MEQC) review or a payment error rate 

2 measurement (PERM) requirement); 

3 ‘‘(III) submit the error rate deter4 mined under subclause (II) to the Sec5 retary; 

6 ‘‘(IV) if such error rate exceeds 3 per7 cent for either of the first 2 fiscal years in 

8 which the State elects to apply this para9 graph, demonstrate to the satisfaction of 

10 the Secretary the specific corrective actions 

11 implemented by the State to improve upon 

12 such error rate; and 

13 ‘‘(V) if such error rate exceeds 3 per14 cent for any fiscal year in which the State 

15 elects to apply this paragraph, a reduction 

16 in the amount otherwise payable to the 

17 State under section 1903(a) for quarters 

18 for that fiscal year, equal to the total 

19 amount of erroneous excess payments de20 termined for the fiscal year only with re21 spect to the children included in the sam22 ple for the fiscal year that are in excess of 

23 a 3 percent error rate with respect to such 

24 children. 


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1 ‘‘(ii) NO PUNITIVE ACTION BASED ON

2 ERROR RATE.—The Secretary shall not apply 

3 the error rate derived from the sample under 

4 clause (i) to the entire population of children 

5 enrolled in the State Medicaid plan or the State 

6 CHIP plan through reliance on a finding made 

7 by an Express Lane agency, or to the popu8 lation of children enrolled in such plans on the 

9 basis of the State’s regular procedures for de10 termining eligibility, or penalize the State on 

11 the basis of such error rate in any manner 

12 other than the reduction of payments provided 

13 for under clause (i)(V). 

14 ‘‘(iii) RULE OF CONSTRUCTION.—Nothing 

15 in this paragraph shall be construed as relieving 

16 a State that elects to apply this paragraph from 

17 being subject to a penalty under section 

18 1903(u), for payments made under the State 

19 Medicaid plan with respect to ineligible individ20 uals and families that are determined to exceed 

21 the error rate permitted under that section (as 

22 determined without regard to the error rate de23 termined under clause (i)(II)). 

24 ‘‘(iv) ERROR RATE DEFINED.—In this sub25 paragraph, the term ‘error rate’ means the rate 


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1 of erroneous excess payments for medical as2 sistance (as defined in section 1903(u)(1)(D)) 

3 for the period involved, except that such pay4 ments shall be limited to individuals for which 

5 eligibility determinations are made under this 

6 paragraph and except that in applying this 

7 paragraph under title XXI, there shall be sub8 stituted for references to provisions of this title 

9 corresponding provisions within title XXI. 

10 ‘‘(F) EXPRESS LANE AGENCY.— 

11 ‘‘(i) IN GENERAL.—In this paragraph, the 

12 term ‘Express Lane agency’ means a public 

13 agency that— 

14 ‘‘(I) is determined by the State Med15 icaid agency or the State CHIP agency (as 

16 applicable) to be capable of making the de17 terminations of one or more eligibility re18 quirements described in subparagraph 

19 (A)(i); 

20 ‘‘(II) is identified in the State Med21 icaid plan or the State CHIP plan; and 

22 ‘‘(III) notifies the child’s family— 

23 ‘‘(aa) of the information which 

24 shall be disclosed in accordance with 

25 this paragraph; 


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1 ‘‘(bb) that the information dis2 closed will be used solely for purposes 

3 of determining eligibility for medical 

4 assistance under the State Medicaid 

5 plan or for child health assistance 

6 under the State CHIP plan; and 

7 ‘‘(cc) that the family may elect to 

8 not have the information disclosed for 

9 such purposes; and 

10 ‘‘(IV) enters into, or is subject to, an 

11 interagency agreement to limit the disclo12 sure and use of the information disclosed. 

13 ‘‘(ii) INCLUSION OF SPECIFIC PUBLIC

14 AGENCIES.—Such term includes the following: 

15 ‘‘(I) A public agency that determines 

16 eligibility for assistance under any of the 

17 following: 

18 ‘‘(aa) The temporary assistance 

19 for needy families program funded 

20 under part A of title IV. 

21 ‘‘(bb) A State program funded 

22 under part D of title IV. 

23 ‘‘(cc) The State Medicaid plan. 

24 ‘‘(dd) The State CHIP plan. 


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1 ‘‘(ee) The Food and Nutrition 

2 Act of 2008 (7 U.S.C. 2011 et seq.). 

3 ‘‘(ff) The Head Start Act (42 

4 U.S.C. 9801 et seq.). 

5 ‘‘(gg) The Richard B. Russell 

6 National School Lunch Act (42 

7 U.S.C. 1751 et seq.). 

8 ‘‘(hh) The Child Nutrition Act of 

9 1966 (42 U.S.C. 1771 et seq.). 

10 ‘‘(ii) The Child Care and Devel11 opment Block Grant Act of 1990 (42 

12 U.S.C. 9858 et seq.). 

13 ‘‘(jj) The Stewart B. McKinney 

14 Homeless Assistance Act (42 U.S.C. 

15 11301 et seq.). 

16 ‘‘(kk) The United States Housing 

17 Act of 1937 (42 U.S.C. 1437 et seq.). 

18 ‘‘(ll) The Native American Hous19 ing Assistance and Self-Determination 

20 Act of 1996 (25 U.S.C. 4101 et seq.). 

21 ‘‘(II) A State-specified governmental 

22 agency that has fiscal liability or legal re23 sponsibility for the accuracy of the eligi24 bility determination findings relied on by 

25 the State. 


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1 ‘‘(III) A public agency that is subject 

2 to an interagency agreement limiting the 

3 disclosure and use of the information dis4 closed for purposes of determining eligi5 bility under the State Medicaid plan or the 

6 State CHIP plan. 

7 ‘‘(iii) EXCLUSIONS.—Such term does not 

8 include an agency that determines eligibility for 

9 a program established under the Social Services 

10 Block Grant established under title XX or a 

11 private, for-profit organization. 

12 ‘‘(iv) RULES OF CONSTRUCTION.—Nothing 

13 in this paragraph shall be construed as— 

14 ‘‘(I) exempting a State Medicaid 

15 agency from complying with the require16 ments of section 1902(a)(4) relating to 

17 merit-based personnel standards for em18 ployees of the State Medicaid agency and 

19 safeguards against conflicts of interest); or 

20 ‘‘(II) authorizing a State Medicaid 

21 agency that elects to use Express Lane 

22 agencies under this subparagraph to use 

23 the Express Lane option to avoid com24 plying with such requirements for purposes 


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1 of making eligibility determinations under 

2 the State Medicaid plan. 

3 ‘‘(v) ADDITIONAL DEFINITIONS.—In this 

4 paragraph: 

5 ‘‘(I) STATE.—The term ‘State’ means 

6 1 of the 50 States or the District of Co7 lumbia. 

8 ‘‘(II) STATE CHIP AGENCY.—The 

9 term ‘State CHIP agency’ means the State 

10 agency responsible for administering the 

11 State CHIP plan. 

12 ‘‘(III) STATE CHIP PLAN.—The term 

13 ‘State CHIP plan’ means the State child 

14 health plan established under title XXI 

15 and includes any waiver of such plan. 

16 ‘‘(IV) STATE MEDICAID AGENCY.— 

17 The term ‘State Medicaid agency’ means 

18 the State agency responsible for admin19 istering the State Medicaid plan. 

20 ‘‘(V) STATE MEDICAID PLAN.—The 

21 term ‘State Medicaid plan’ means the 

22 State plan established under title XIX and 

23 includes any waiver of such plan. 

24 ‘‘(G) CHILD DEFINED.—For purposes of this 

25 paragraph, the term ‘child’ means an individual 


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1 under 19 years of age, or, at the option of a State, 

2 such higher age, not to exceed 21 years of age, as 

3 the State may elect. 

4 ‘‘(H) APPLICATION.—This paragraph shall not 

5 apply with respect to eligibility determinations made 

6 after September 30, 2013.’’. 

7 (2) CHIP.—Section 2107(e)(1) (42 U.S.C. 

8 1397gg(e)(1)) is amended by redesignating subpara9 graphs (B), (C), and (D) as subparagraphs (C), (D), 

10 and (E), respectively, and by inserting after sub11 paragraph (A) the following new subparagraph: 

12 ‘‘(B) Section 1902(e)(13) (relating to the 

13 State option to rely on findings from an Ex14 press Lane agency to help evaluate a child’s eli15 gibility for medical assistance).’’. 

16 (b) EVALUATION AND REPORT.— 

17 (1) EVALUATION.—The Secretary shall con18 duct, by grant, contract, or interagency agreement, 

19 a comprehensive, independent evaluation of the op20 tion provided under the amendments made by sub21 section (a). Such evaluation shall include an analysis 

22 of the effectiveness of the option, and shall include— 

23 (A) obtaining a statistically valid sample of 

24 the children who were enrolled in the State 

25 Medicaid plan or the State CHIP plan through 


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1 reliance on a finding made by an Express Lane 

2 agency and determining the percentage of chil3 dren who were erroneously enrolled in such 

4 plans; 

5 (B) determining whether enrolling children 

6 in such plans through reliance on a finding 

7 made by an Express Lane agency improves the 

8 ability of a State to identify and enroll low-in9 come, uninsured children who are eligible but 

10 not enrolled in such plans; 

11 (C) evaluating the administrative costs or 

12 savings related to identifying and enrolling chil13 dren in such plans through reliance on such 

14 findings, and the extent to which such costs dif15 fer from the costs that the State otherwise 

16 would have incurred to identify and enroll low17 income, uninsured children who are eligible but 

18 not enrolled in such plans; and 

19 (D) any recommendations for legislative or 

20 administrative changes that would improve the 

21 effectiveness of enrolling children in such plans 

22 through reliance on such findings. 

23 (2) REPORT TO CONGRESS.—Not later than 

24 September 30, 2012, the Secretary shall submit a 


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1 report to Congress on the results of the evaluation 

2 under paragraph (1). 

3 (3) FUNDING.— 

4 (A) IN GENERAL.—Out of any funds in the 

5 Treasury not otherwise appropriated, there is 

6 appropriated to the Secretary to carry out the 

7 evaluation under this subsection $5,000,000 for 

8 the period of fiscal years 2009 through 2012. 

9 (B) BUDGET AUTHORITY.—Subparagraph 

10 (A) constitutes budget authority in advance of 

11 appropriations Act and represents the obliga12 tion of the Federal Government to provide for 

13 the payment of such amount to conduct the 

14 evaluation under this subsection. 

15 (c) ELECTRONIC TRANSMISSION OF INFORMATION.— 

16 Section 1902 (42 U.S.C. 1396a) is amended by adding 

17 at the end the following new subsection: 

18 ‘‘(dd) ELECTRONIC TRANSMISSION OF INFORMA19 TION.—If the State agency determining eligibility for med20 ical assistance under this title or child health assistance 

21 under title XXI verifies an element of eligibility based on 

22 information from an Express Lane Agency (as defined in 

23 subsection (e)(13)(F)), or from another public agency, 

24 then the applicant’s signature under penalty of perjury 

25 shall not be required as to such element. Any signature 


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1 requirement for an application for medical assistance may 

2 be satisfied through an electronic signature, as defined in 

3 section 1710(1) of the Government Paperwork Elimi4 nation Act (44 U.S.C. 3504 note). The requirements of 

5 subparagraphs (A) and (B) of section 1137(d)(2) may be 

6 met through evidence in digital or electronic form.’’. 

7 (d) AUTHORIZATION OF INFORMATION DISCLO8 SURE.— 

9 (1) IN GENERAL.—Title XIX is amended by 

10 adding at the end the following new section: 

11 ‘‘SEC. 1942. AUTHORIZATION TO RECEIVE RELEVANT IN12 FORMATION. 

13 ‘‘(a) IN GENERAL.—Notwithstanding any other pro14 vision of law, a Federal or State agency or private entity 

15 in possession of the sources of data directly relevant to 

16 eligibility determinations under this title (including eligi17 bility files maintained by Express Lane agencies described 

18 in section 1902(e)(13)(F), information described in para19 graph (2) or (3) of section 1137(a), vital records informa20 tion about births in any State, and information described 

21 in sections 453(i) and 1902(a)(25)(I)) is authorized to 

22 convey such data or information to the State agency ad23 ministering the State plan under this title, to the extent 

24 such conveyance meets the requirements of subsection (b). 


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1 ‘‘(b) REQUIREMENTS FOR CONVEYANCE.—Data or 

2 information may be conveyed pursuant to subsection (a) 

3 only if the following requirements are met: 

4 ‘‘(1) The individual whose circumstances are 

5 described in the data or information (or such indi6 vidual’s parent, guardian, caretaker relative, or au7 thorized representative) has either provided advance 

8 consent to disclosure or has not objected to disclo9 sure after receiving advance notice of disclosure and 

10 a reasonable opportunity to object. 

11 ‘‘(2) Such data or information are used solely 

12 for the purposes of— 

13 ‘‘(A) identifying individuals who are eligi14 ble or potentially eligible for medical assistance 

15 under this title and enrolling or attempting to 

16 enroll such individuals in the State plan; and 

17 ‘‘(B) verifying the eligibility of individuals 

18 for medical assistance under the State plan. 

19 ‘‘(3) An interagency or other agreement, con20 sistent with standards developed by the Secretary— 

21 ‘‘(A) prevents the unauthorized use, disclo22 sure, or modification of such data and other23 wise meets applicable Federal requirements 

24 safeguarding privacy and data security; and 


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1 ‘‘(B) requires the State agency admin2 istering the State plan to use the data and in3 formation obtained under this section to seek to 

4 enroll individuals in the plan. 

5 ‘‘(c) PENALTIES FOR IMPROPER DISCLOSURE.— 

6 ‘‘(1) CIVIL MONEY PENALTY.—A private entity 

7 described in the subsection (a) that publishes, dis8 closes, or makes known in any manner, or to any ex9 tent not authorized by Federal law, any information 

10 obtained under this section is subject to a civil 

11 money penalty in an amount equal to $10,000 for 

12 each such unauthorized publication or disclosure. 

13 The provisions of section 1128A (other than sub14 sections (a) and (b) and the second sentence of sub15 section (f)) shall apply to a civil money penalty 

16 under this paragraph in the same manner as such 

17 provisions apply to a penalty or proceeding under 

18 section 1128A(a). 

19 ‘‘(2) CRIMINAL PENALTY.—A private entity de20 scribed in the subsection (a) that willfully publishes, 

21 discloses, or makes known in any manner, or to any 

22 extent not authorized by Federal law, any informa23 tion obtained under this section shall be fined not 

24 more than $10,000 or imprisoned not more than 1 


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1 year, or both, for each such unauthorized publication 

2 or disclosure. 

3 ‘‘(d) RULE OF CONSTRUCTION.—The limitations and 

4 requirements that apply to disclosure pursuant to this sec5 tion shall not be construed to prohibit the conveyance or 

6 disclosure of data or information otherwise permitted 

7 under Federal law (without regard to this section).’’. 

8 (2) CONFORMING AMENDMENT TO TITLE XXI.— 

9 Section 2107(e)(1) (42 U.S.C. 1397gg(e)(1)), as 

10 amended by subsection (a)(2), is amended by adding 

11 at the end the following new subparagraph: 

12 ‘‘(F) Section 1942 (relating to authoriza13 tion to receive data directly relevant to eligi14 bility determinations).’’. 

15 (3) CONFORMING AMENDMENT TO PROVIDE AC16 CESS TO DATA ABOUT ENROLLMENT IN INSURANCE

17 FOR PURPOSES OF EVALUATING APPLICATIONS AND

18 FOR CHIP.—Section 1902(a)(25)(I)(i) (42 U.S.C. 

19 1396a(a)(25)(I)(i)) is amended— 

20 (A) by inserting ‘‘(and, at State option, in21 dividuals who apply or whose eligibility for med22 ical assistance is being evaluated in accordance 

23 with section 1902(e)(13)(D))’’ after ‘‘with re24 spect to individuals who are eligible’’; and 


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1 (B) by inserting ‘‘under this title (and, at 

2 State option, child health assistance under title 

3 XXI)’’ after ‘‘the State plan’’. 

4 (e) AUTHORIZATION FOR STATES ELECTING EX5 PRESS LANE OPTION TO RECEIVE CERTAIN DATA DI6 RECTLY RELEVANT TO DETERMINING ELIGIBILITY AND

7 CORRECT AMOUNT OF ASSISTANCE.—The Secretary shall 

8 enter into such agreements as are necessary to permit a 

9 State that elects the Express Lane option under section 

10 1902(e)(13) of the Social Security Act to receive data di11 rectly relevant to eligibility determinations and deter12 mining the correct amount of benefits under a State child 

13 health plan under CHIP or a State plan under Medicaid 

14 from the following: 

15 (1) The National Directory of New Hires estab16 lished under section 453(i) of the Social Security 

17 Act (42 U.S.C. 653(i)). 

18 (2) Data regarding enrollment in insurance that 

19 may help to facilitate outreach and enrollment under 

20 the State Medicaid plan, the State CHIP plan, and 

21 such other programs as the Secretary may specify. 

22 (f) EFFECTIVE DATE.—The amendments made by 

23 this section are effective on the date of the enactment of 

24 this Act. 


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1 Subtitle B—Reducing Barriers to 

2 Enrollment 

3 SEC. 211. VERIFICATION OF DECLARATION OF CITIZENSHIP 

4 OR NATIONALITY FOR PURPOSES OF ELIGI5 BILITY FOR MEDICAID AND CHIP. 

6 (a) ALTERNATIVE STATE PROCESS FOR

7 VERIFICATION OF DECLARATION OF CITIZENSHIP OR NA8 TIONALITY FOR PURPOSES OF ELIGIBILITY FOR MED9 ICAID.— 

10 (1) ALTERNATIVE TO DOCUMENTATION RE11 QUIREMENT.— 

12 (A) IN GENERAL.—Section 1902 (42 

13 U.S.C. 1396a), as amended by section 203(c), 

14 is amended— 

15 (i) in subsection (a)(46)— 

16 (I) by inserting ‘‘(A)’’ after 

17 ‘‘(46)’’; 

18 (II) by adding ‘‘and’’ after the 

19 semicolon; and 

20 (III) by adding at the end the 

21 following new subparagraph: 

22 ‘‘(B) provide, with respect to an individual de23 claring to be a citizen or national of the United 

24 States for purposes of establishing eligibility under 


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1 this title, that the State shall satisfy the require2 ments of— 

3 ‘‘(i) section 1903(x); or 

4 ‘‘(ii) subsection (ee);’’; and 

5 (ii) by adding at the end the following 

6 new subsection: 

7 ‘‘(ee)(1) For purposes of subsection (a)(46)(B)(ii), 

8 the requirements of this subsection with respect to an indi9 vidual declaring to be a citizen or national of the United 

10 States for purposes of establishing eligibility under this 

11 title, are, in lieu of requiring the individual to present sat12 isfactory documentary evidence of citizenship or nation13 ality under section 1903(x) (if the individual is not de14 scribed in paragraph (2) of that section), as follows: 

15 ‘‘(A) The State submits the name and social se16 curity number of the individual to the Commissioner 

17 of Social Security as part of the program established 

18 under paragraph (2). 

19 ‘‘(B) If the State receives notice from the Com20 missioner of Social Security that the name or social 

21 security number, or the declaration of citizenship or 

22 nationality, of the individual is inconsistent with in23 formation in the records maintained by the Commis24 sioner— 


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1 ‘‘(i) the State makes a reasonable effort to 

2 identify and address the causes of such incon3 sistency, including through typographical or 

4 other clerical errors, by contacting the indi5 vidual to confirm the accuracy of the name or 

6 social security number submitted or declaration 

7 of citizenship or nationality and by taking such 

8 additional actions as the Secretary, through 

9 regulation or other guidance, or the State may 

10 identify, and continues to provide the individual 

11 with medical assistance while making such ef12 fort; and 

13 ‘‘(ii) in the case such inconsistency is not 

14 resolved under clause (i), the State— 

15 ‘‘(I) notifies the individual of such 

16 fact; 

17 ‘‘(II) provides the individual with a 

18 period of 90 days from the date on which 

19 the notice required under subclause (I) is 

20 received by the individual to either present 

21 satisfactory documentary evidence of citi22 zenship or nationality (as defined in sec23 tion 1903(x)(3)) or resolve the inconsist24 ency with the Commissioner of Social Se25 curity (and continues to provide the indiVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00118 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 vidual with medical assistance during such 

2 90-day period); and 

3 ‘‘(III) disenrolls the individual from 

4 the State plan under this title within 30 

5 days after the end of such 90-day period if 

6 no such documentary evidence is presented 

7 or if such inconsistency is not resolved. 

8 ‘‘(2)(A) Each State electing to satisfy the require9 ments of this subsection for purposes of section 

10 1902(a)(46)(B) shall establish a program under which the 

11 State submits at least monthly to the Commissioner of So12 cial Security for comparison of the name and social secu13 rity number, of each individual newly enrolled in the State 

14 plan under this title that month who is not described in 

15 section 1903(x)(2) and who declares to be a United States 

16 citizen or national, with information in records maintained 

17 by the Commissioner. 

18 ‘‘(B) In establishing the State program under this 

19 paragraph, the State may enter into an agreement with 

20 the Commissioner of Social Security— 

21 ‘‘(i) to provide, through an on-line system or 

22 otherwise, for the electronic submission of, and re23 sponse to, the information submitted under subpara24 graph (A) for an individual enrolled in the State 


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1 plan under this title who declares to be citizen or na2 tional on at least a monthly basis; or 

3 ‘‘(ii) to provide for a determination of the con4 sistency of the information submitted with the infor5 mation maintained in the records of the Commis6 sioner through such other method as agreed to by 

7 the State and the Commissioner and approved by 

8 the Secretary, provided that such method is no more 

9 burdensome for individuals to comply with than any 

10 burdens that may apply under a method described in 

11 clause (i). 

12 ‘‘(C) The program established under this paragraph 

13 shall provide that, in the case of any individual who is 

14 required to submit a social security number to the State 

15 under subparagraph (A) and who is unable to provide the 

16 State with such number, shall be provided with at least 

17 the reasonable opportunity to present satisfactory docu18 mentary evidence of citizenship or nationality (as defined 

19 in section 1903(x)(3)) as is provided under clauses (i) and 

20 (ii) of section 1137(d)(4)(A) to an individual for the sub21 mittal to the State of evidence indicating a satisfactory 

22 immigration status. 

23 ‘‘(3)(A) The State agency implementing the plan ap24 proved under this title shall, at such times and in such 

25 form as the Secretary may specify, provide information on 


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1 the percentage each month that the inconsistent submis2 sions bears to the total submissions made for comparison 

3 for such month. For purposes of this subparagraph, a 

4 name, social security number, or declaration of citizenship 

5 or nationality of an individual shall be treated as incon6 sistent and included in the determination of such percent7 age only if— 

8 ‘‘(i) the information submitted by the individual 

9 is not consistent with information in records main10 tained by the Commissioner of Social Security; 

11 ‘‘(ii) the inconsistency is not resolved by the 

12 State; 

13 ‘‘(iii) the individual was provided with a reason14 able period of time to resolve the inconsistency with 

15 the Commissioner of Social Security or provide satis16 factory documentation of citizenship status and did 

17 not successfully resolve such inconsistency; and 

18 ‘‘(iv) payment has been made for an item or 

19 service furnished to the individual under this title. 

20 ‘‘(B) If, for any fiscal year, the average monthly per21 centage determined under subparagraph (A) is greater 

22 than 3 percent— 

23 ‘‘(i) the State shall develop and adopt a correc24 tive plan to review its procedures for verifying the 

25 identities of individuals seeking to enroll in the State 


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1 plan under this title and to identify and implement 

2 changes in such procedures to improve their accu3 racy; and 

4 ‘‘(ii) pay to the Secretary an amount equal to 

5 the amount which bears the same ratio to the total 

6 payments under the State plan for the fiscal year for 

7 providing medical assistance to individuals who pro8 vided inconsistent information as the number of in9 dividuals with inconsistent information in excess of 

10 3 percent of such total submitted bears to the total 

11 number of individuals with inconsistent information. 

12 ‘‘(C) The Secretary may waive, in certain limited 

13 cases, all or part of the payment under subparagraph 

14 (B)(ii) if the State is unable to reach the allowable error 

15 rate despite a good faith effort by such State. 

16 ‘‘(D) Subparagraphs (A) and (B) shall not apply to 

17 a State for a fiscal year if there is an agreement described 

18 in paragraph (2)(B) in effect as of the close of the fiscal 

19 year that provides for the submission on a real-time basis 

20 of the information described in such paragraph. 

21 ‘‘(4) Nothing in this subsection shall affect the rights 

22 of any individual under this title to appeal any 

23 disenrollment from a State plan.’’. 


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1 (B) COSTS OF IMPLEMENTING AND MAIN2 TAINING SYSTEM.—Section 1903(a)(3) (42 

3 U.S.C. 1396b(a)(3)) is amended— 

4 (i) by striking ‘‘plus’’ at the end of 

5 subparagraph (E) and inserting ‘‘and’’, 

6 and 

7 (ii) by adding at the end the following 

8 new subparagraph: 

9 ‘‘(F)(i) 90 percent of the sums expended 

10 during the quarter as are attributable to the de11 sign, development, or installation of such 

12 mechanized verification and information re13 trieval systems as the Secretary determines are 

14 necessary to implement section 1902(ee) (in15 cluding a system described in paragraph (2)(B) 

16 thereof), and 

17 ‘‘(ii) 75 percent of the sums expended dur18 ing the quarter as are attributable to the oper19 ation of systems to which clause (i) applies, 

20 plus’’. 

21 (2) LIMITATION ON WAIVER AUTHORITY.—Not22 withstanding any provision of section 1115 of the 

23 Social Security Act (42 U.S.C. 1315), or any other 

24 provision of law, the Secretary may not waive the re25 quirements of section 1902(a)(46)(B) of such Act 


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1 (42 U.S.C. 1396a(a)(46)(B)) with respect to a 

2 State. 

3 (3) CONFORMING AMENDMENTS.—Section 1903 

4 (42 U.S.C. 1396b) is amended— 

5 (A) in subsection (i)(22), by striking ‘‘sub6 section (x)’’ and inserting ‘‘section 

7 1902(a)(46)(B)’’; and 

8 (B) in subsection (x)(1), by striking ‘‘sub9 section (i)(22)’’ and inserting ‘‘section 

10 1902(a)(46)(B)(i)’’. 

11 (4) APPROPRIATION.—Out of any money in the 

12 Treasury of the United States not otherwise appro13 priated, there are appropriated to the Commissioner 

14 of Social Security $5,000,000 to remain available 

15 until expended to carry out the Commissioner’s re16 sponsibilities under section 1902(ee) of the Social 

17 Security Act, as added by subsection (a). 

18 (b) CLARIFICATION OF REQUIREMENTS RELATING

19 TO PRESENTATION OF SATISFACTORY DOCUMENTARY

20 EVIDENCE OF CITIZENSHIP OR NATIONALITY.— 

21 (1) ACCEPTANCE OF DOCUMENTARY EVIDENCE

22 ISSUED BY A FEDERALLY RECOGNIZED INDIAN

23 TRIBE.—Section 1903(x)(3)(B) (42 U.S.C. 

24 1396b(x)(3)(B)) is amended— 


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1 (A) by redesignating clause (v) as clause 

2 (vi); and 

3 (B) by inserting after clause (iv), the fol4 lowing new clause: 

5 ‘‘(v)(I) Except as provided in subclause (II), a 

6 document issued by a federally recognized Indian 

7 tribe evidencing membership or enrollment in, or af8 filiation with, such tribe (such as a tribal enrollment 

9 card or certificate of degree of Indian blood). 

10 ‘‘(II) With respect to those federally recognized 

11 Indian tribes located within States having an inter12 national border whose membership includes individ13 uals who are not citizens of the United States, the 

14 Secretary shall, after consulting with such tribes, 

15 issue regulations authorizing the presentation of 

16 such other forms of documentation (including tribal 

17 documentation, if appropriate) that the Secretary 

18 determines to be satisfactory documentary evidence 

19 of citizenship or nationality for purposes of satis20 fying the requirement of this subsection.’’. 

21 (2) REQUIREMENT TO PROVIDE REASONABLE

22 OPPORTUNITY TO PRESENT SATISFACTORY DOCU23 MENTARY EVIDENCE.—Section 1903(x) (42 U.S.C. 

24 1396b(x)) is amended by adding at the end the fol25 lowing new paragraph: 


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1 ‘‘(4) In the case of an individual declaring to be a 

2 citizen or national of the United States with respect to 

3 whom a State requires the presentation of satisfactory 

4 documentary evidence of citizenship or nationality under 

5 section 1902(a)(46)(B)(i), the individual shall be provided 

6 at least the reasonable opportunity to present satisfactory 

7 documentary evidence of citizenship or nationality under 

8 this subsection as is provided under clauses (i) and (ii) 

9 of section 1137(d)(4)(A) to an individual for the submittal 

10 to the State of evidence indicating a satisfactory immigra11 tion status.’’. 

12 (3) CHILDREN BORN IN THE UNITED STATES

13 TO MOTHERS ELIGIBLE FOR MEDICAID.— 

14 (A) CLARIFICATION OF RULES.—Section 

15 1903(x) (42 U.S.C. 1396b(x)), as amended by 

16 paragraph (2), is amended— 

17 (i) in paragraph (2)— 

18 (I) in subparagraph (C), by strik19 ing ‘‘or’’ at the end; 

20 (II) by redesignating subpara21 graph (D) as subparagraph (E); and 

22 (III) by inserting after subpara23 graph (C) the following new subpara24 graph: 


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1 ‘‘(D) pursuant to the application of section 

2 1902(e)(4) (and, in the case of an individual who is 

3 eligible for medical assistance on such basis, the in4 dividual shall be deemed to have provided satisfac5 tory documentary evidence of citizenship or nation6 ality and shall not be required to provide further 

7 documentary evidence on any date that occurs dur8 ing or after the period in which the individual is eli9 gible for medical assistance on such basis); or’’; and 

10 (ii) by adding at the end the following 

11 new paragraph: 

12 ‘‘(5) Nothing in subparagraph (A) or (B) of section 

13 1902(a)(46), the preceding paragraphs of this subsection, 

14 or the Deficit Reduction Act of 2005, including section 

15 6036 of such Act, shall be construed as changing the re16 quirement of section 1902(e)(4) that a child born in the 

17 United States to an alien mother for whom medical assist18 ance for the delivery of such child is available as treatment 

19 of an emergency medical condition pursuant to subsection 

20 (v) shall be deemed eligible for medical assistance during 

21 the first year of such child’s life.’’. 

22 (B) STATE REQUIREMENT TO ISSUE SEPA23 RATE IDENTIFICATION NUMBER.—Section 

24 1902(e)(4) (42 U.S.C. 1396a(e)(4)) is amended 

25 by adding at the end the following new senVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00127 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 tence: ‘‘Notwithstanding the preceding sentence, 

2 in the case of a child who is born in the United 

3 States to an alien mother for whom medical as4 sistance for the delivery of the child is made 

5 available pursuant to section 1903(v), the State 

6 immediately shall issue a separate identification 

7 number for the child upon notification by the 

8 facility at which such delivery occurred of the 

9 child’s birth.’’. 

10 (4) TECHNICAL AMENDMENTS.—Section 

11 1903(x)(2) (42 U.S.C. 1396b(x)) is amended— 

12 (A) in subparagraph (B)— 

13 (i) by realigning the left margin of the 

14 matter preceding clause (i) 2 ems to the 

15 left; and 

16 (ii) by realigning the left margins of 

17 clauses (i) and (ii), respectively, 2 ems to 

18 the left; and 

19 (B) in subparagraph (C)— 

20 (i) by realigning the left margin of the 

21 matter preceding clause (i) 2 ems to the 

22 left; and 

23 (ii) by realigning the left margins of 

24 clauses (i) and (ii), respectively, 2 ems to 

25 the left. 


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1 (c) APPLICATION OF DOCUMENTATION SYSTEM TO

2 CHIP.— 

3 (1) IN GENERAL.—Section 2105(c) (42 U.S.C. 

4 1397ee(c)), as amended by section 114(a), is amend5 ed by adding at the end the following new para6 graph: 

7 ‘‘(9) CITIZENSHIP DOCUMENTATION REQUIRE8 MENTS.— 

9 ‘‘(A) IN GENERAL.—No payment may be 

10 made under this section with respect to an indi11 vidual who has, or is, declared to be a citizen 

12 or national of the United States for purposes of 

13 establishing eligibility under this title unless the 

14 State meets the requirements of section 

15 1902(a)(46)(B) with respect to the individual. 

16 ‘‘(B) ENHANCED PAYMENTS.—Notwith17 standing subsection (b), the enhanced FMAP 

18 with respect to payments under subsection (a) 

19 for expenditures described in clause (i) or (ii) of 

20 section 1903(a)(3)(F) necessary to comply with 

21 subparagraph (A) shall in no event be less than 

22 90 percent and 75 percent, respectively.’’. 

23 (2) NONAPPLICATION OF ADMINISTRATIVE EX24 PENDITURES CAP.—Section 2105(c)(2)(C) (42 

25 U.S.C. 1397ee(c)(2)(C)), as amended by section 


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1 202(b), is amended by adding at the end the fol2 lowing: 

3 ‘‘(ii) EXPENDITURES TO COMPLY

4 WITH CITIZENSHIP OR NATIONALITY

5 VERIFICATION REQUIREMENTS.—Expendi6 tures necessary for the State to comply 

7 with paragraph (9)(A).’’. 

8 (d) EFFECTIVE DATE.— 

9 (1) IN GENERAL.— 

10 (A) IN GENERAL.—Except as provided in 

11 subparagraph (B), the amendments made by 

12 this section shall take effect on January 1, 

13 2010. 

14 (B) TECHNICAL AMENDMENTS.—The 

15 amendments made by— 

16 (i) paragraphs (1), (2), and (3) of 

17 subsection (b) shall take effect as if in18 cluded in the enactment of section 6036 of 

19 the Deficit Reduction Act of 2005 (Public 

20 Law 109–171; 120 Stat. 80); and 

21 (ii) paragraph (4) of subsection (b) 

22 shall take effect as if included in the enact23 ment of section 405 of division B of the 

24 Tax Relief and Health Care Act of 2006 

25 (Public Law 109–432; 120 Stat. 2996). 


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1 (2) RESTORATION OF ELIGIBILITY.—In the 

2 case of an individual who, during the period that 

3 began on July 1, 2006, and ends on October 1, 

4 2009, was determined to be ineligible for medical as5 sistance under a State Medicaid plan, including any 

6 waiver of such plan, solely as a result of the applica7 tion of subsections (i)(22) and (x) of section 1903 

8 of the Social Security Act (as in effect during such 

9 period), but who would have been determined eligible 

10 for such assistance if such subsections, as amended 

11 by subsection (b), had applied to the individual, a 

12 State may deem the individual to be eligible for such 

13 assistance as of the date that the individual was de14 termined to be ineligible for such medical assistance 

15 on such basis. 

16 (3) SPECIAL TRANSITION RULE FOR INDIANS.— 

17 During the period that begins on July 1, 2006, and 

18 ends on the effective date of final regulations issued 

19 under subclause (II) of section 1903(x)(3)(B)(v) of 

20 the Social Security Act (42 U.S.C. 

21 1396b(x)(3)(B)(v)) (as added by subsection 

22 (b)(1)(B)), an individual who is a member of a fed23 erally-recognized Indian tribe described in subclause 

24 (II) of that section who presents a document de25 scribed in subclause (I) of such section that is issued 


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1 by such Indian tribe, shall be deemed to have pre2 sented satisfactory evidence of citizenship or nation3 ality for purposes of satisfying the requirement of 

4 subsection (x) of section 1903 of such Act. 

5 SEC. 212. REDUCING ADMINISTRATIVE BARRIERS TO EN6 ROLLMENT. 

7 Section 2102(b) (42 U.S.C. 1397bb(b)) is amended— 

8 (1) by redesignating paragraph (4) as para9 graph (5); and 

10 (2) by inserting after paragraph (3) the fol11 lowing new paragraph: 

12 ‘‘(4) REDUCTION OF ADMINISTRATIVE BAR13 RIERS TO ENROLLMENT.— 

14 ‘‘(A) IN GENERAL.—Subject to subpara15 graph (B), the plan shall include a description 

16 of the procedures used to reduce administrative 

17 barriers to the enrollment of children and preg18 nant women who are eligible for medical assist19 ance under title XIX or for child health assist20 ance or health benefits coverage under this title. 

21 Such procedures shall be established and re22 vised as often as the State determines appro23 priate to take into account the most recent in24 formation available to the State identifying 

25 such barriers. 


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1 ‘‘(B) DEEMED COMPLIANCE IF JOINT AP2 PLICATION AND RENEWAL PROCESS THAT PER3 MITS APPLICATION OTHER THAN IN PERSON.— 

4 A State shall be deemed to comply with sub5 paragraph (A) if the State’s application and re6 newal forms and supplemental forms (if any) 

7 and information verification process is the same 

8 for purposes of establishing and renewing eligi9 bility for children and pregnant women for 

10 medical assistance under title XIX and child 

11 health assistance under this title, and such 

12 process does not require an application to be 

13 made in person or a face-to-face interview.’’. 

14 SEC. 213. MODEL OF INTERSTATE COORDINATED ENROLL15 MENT AND COVERAGE PROCESS. 

16 (a) IN GENERAL.—In order to assure continuity of 

17 coverage of low-income children under the Medicaid pro18 gram and the State Children’s Health Insurance Program 

19 (CHIP), not later than 18 months after the date of the 

20 enactment of this Act, the Secretary of Health and 

21 Human Services, in consultation with State Medicaid and 

22 CHIP directors and organizations representing program 

23 beneficiaries, shall develop a model process for the coordi24 nation of the enrollment, retention, and coverage under 

25 such programs of children who, because of migration of 


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1 families, emergency evacuations, natural or other disas2 ters, public health emergencies, educational needs, or oth3 erwise, frequently change their State of residency or other4 wise are temporarily located outside of the State of their 

5 residency. 

6 (b) REPORT TO CONGRESS.—After development of 

7 such model process, the Secretary of Health and Human 

8 Services shall submit to Congress a report describing addi9 tional steps or authority needed to make further improve10 ments to coordinate the enrollment, retention, and cov11 erage under CHIP and Medicaid of children described in 

12 subsection (a). 

13 SEC. 214. PERMITTING STATES TO ENSURE COVERAGE 

14 WITHOUT A 5-YEAR DELAY OF CERTAIN CHIL15 DREN AND PREGNANT WOMEN UNDER THE 

16 MEDICAID PROGRAM AND CHIP. 

17 (a) MEDICAID PROGRAM.—Section 1903(v) (42 

18 U.S.C. 1396b(v)) is amended— 

19 (1) in paragraph (1), by striking ‘‘paragraph 

20 (2)’’ and inserting ‘‘paragraphs (2) and (4)’’; and 

21 (2) by adding at the end the following new 

22 paragraph: 

23 ‘‘(4)(A) A State may elect (in a plan amendment 

24 under this title) to provide medical assistance under this 

25 title, notwithstanding sections 401(a), 402(b), 403, and 


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1 421 of the Personal Responsibility and Work Opportunity 

2 Reconciliation Act of 1996, to children and pregnant 

3 women who are lawfully residing in the United States (in4 cluding battered individuals described in section 431(c) of 

5 such Act) and who are otherwise eligible for such assist6 ance, within either or both of the following eligibility cat7 egories: 

8 ‘‘(i) PREGNANT WOMEN.—Women during preg9 nancy (and during the 60-day period beginning on 

10 the last day of the pregnancy). 

11 ‘‘(ii) CHILDREN.—Individuals under 21 years of 

12 age, including optional targeted low-income children 

13 described in section 1905(u)(2)(B). 

14 ‘‘(B) In the case of a State that has elected to provide 

15 medical assistance to a category of aliens under subpara16 graph (A), no debt shall accrue under an affidavit of sup17 port against any sponsor of such an alien on the basis 

18 of provision of assistance to such category and the cost 

19 of such assistance shall not be considered as an unreim20 bursed cost. 

21 ‘‘(C) A State shall demonstrate that the State re22 quires an individual provided medical assistance as a re23 sult of an election by the State under subparagraph (A), 

24 to provide the State, as part of the State’s ongoing eligi25 bility redetermination requirements and procedures, with 


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1 documentation or other evidence that the individual is law2 fully residing in the United States.’’. 

3 (b) CHIP.—Section 2107(e)(1) (42 U.S.C. 

4 1397gg(e)(1)), as amended by sections 203(a)(2) and 

5 203(d)(2), is amended by redesignating subparagraphs 

6 (E) and (F) as subparagraphs (F) and (G), respectively 

7 and by inserting after subparagraph (D) the following new 

8 subparagraph: 

9 ‘‘(E) Paragraph (4) of section 1903(v) (re10 lating to optional coverage of categories of law11 fully residing immigrant children or pregnant 

12 women), but only if the State has elected to 

13 apply such paragraph with respect to such cat14 egory of children or pregnant women under title 

15 XIX.’’. 

16 TITLE III—REDUCING BARRIERS 

17 TO PROVIDING PREMIUM AS18 SISTANCE 

19 Subtitle A—Additional State Op20 tion for Providing Premium As21 sistance 

22 SEC. 301. ADDITIONAL STATE OPTION FOR PROVIDING 

23 PREMIUM ASSISTANCE. 

24 (a) CHIP.— 


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1 (1) IN GENERAL.—Section 2105(c) (42 U.S.C. 

2 1397ee(c)), as amended by sections 114(a) and 

3 211(c), is amended by adding at the end the fol4 lowing: 

5 ‘‘(10) STATE OPTION TO OFFER PREMIUM AS6 SISTANCE.— 

7 ‘‘(A) IN GENERAL.—A State may elect to 

8 offer a premium assistance subsidy (as defined 

9 in subparagraph (C)) for qualified employer10 sponsored coverage (as defined in subparagraph 

11 (B)) to all targeted low-income children who are 

12 eligible for child health assistance under the 

13 plan and have access to such coverage in ac14 cordance with the requirements of this para15 graph. No subsidy shall be provided to a tar16 geted low-income child under this paragraph 

17 unless the child (or the child’s parent) volun18 tarily elects to receive such a subsidy. A State 

19 may not require such an election as a condition 

20 of receipt of child health assistance. 

21 ‘‘(B) QUALIFIED EMPLOYER-SPONSORED

22 COVERAGE.— 

23 ‘‘(i) IN GENERAL.—Subject to clause 

24 (ii), in this paragraph, the term ‘qualified 

25 employer-sponsored coverage’ means a 


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1 group health plan or health insurance cov2 erage offered through an employer— 

3 ‘‘(I) that qualifies as creditable 

4 coverage as a group health plan under 

5 section 2701(c)(1) of the Public 

6 Health Service Act; 

7 ‘‘(II) for which the employer con8 tribution toward any premium for 

9 such coverage is at least 40 percent; 

10 and 

11 ‘‘(III) that is offered to all indi12 viduals in a manner that would be 

13 considered a nondiscriminatory eligi14 bility classification for purposes of 

15 paragraph (3)(A)(ii) of section 105(h) 

16 of the Internal Revenue Code of 1986 

17 (but determined without regard to 

18 clause (i) of subparagraph (B) of such 

19 paragraph). 

20 ‘‘(ii) EXCEPTION.—Such term does 

21 not include coverage consisting of— 

22 ‘‘(I) benefits provided under a 

23 health flexible spending arrangement 

24 (as defined in section 106(c)(2) of the 

25 Internal Revenue Code of 1986); or 


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1 ‘‘(II) a high deductible health 

2 plan (as defined in section 223(c)(2) 

3 of such Code), without regard to 

4 whether the plan is purchased in con5 junction with a health savings account 

6 (as defined under section 223(d) of 

7 such Code). 

8 ‘‘(C) PREMIUM ASSISTANCE SUBSIDY.— 

9 ‘‘(i) IN GENERAL.—In this paragraph, 

10 the term ‘premium assistance subsidy’ 

11 means, with respect to a targeted low-in12 come child, the amount equal to the dif13 ference between the employee contribution 

14 required for enrollment only of the em15 ployee under qualified employer-sponsored 

16 coverage and the employee contribution re17 quired for enrollment of the employee and 

18 the child in such coverage, less any appli19 cable premium cost-sharing applied under 

20 the State child health plan (subject to the 

21 limitations imposed under section 2103(e), 

22 including the requirement to count the 

23 total amount of the employee contribution 

24 required for enrollment of the employee 

25 and the child in such coverage toward the 


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1 annual aggregate cost-sharing limit applied 

2 under paragraph (3)(B) of such section). 

3 ‘‘(ii) STATE PAYMENT OPTION.—A 

4 State may provide a premium assistance 

5 subsidy either as reimbursement to an em6 ployee for out-of-pocket expenditures or, 

7 subject to clause (iii), directly to the em8 ployee’s employer. 

9 ‘‘(iii) EMPLOYER OPT-OUT.—An em10 ployer may notify a State that it elects to 

11 opt-out of being directly paid a premium 

12 assistance subsidy on behalf of an em13 ployee. In the event of such a notification, 

14 an employer shall withhold the total 

15 amount of the employee contribution re16 quired for enrollment of the employee and 

17 the child in the qualified employer-spon18 sored coverage and the State shall pay the 

19 premium assistance subsidy directly to the 

20 employee. 

21 ‘‘(iv) TREATMENT AS CHILD HEALTH

22 ASSISTANCE.—Expenditures for the provi23 sion of premium assistance subsidies shall 

24 be considered child health assistance de25 scribed in paragraph (1)(C) of subsection 


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1 (a) for purposes of making payments 

2 under that subsection. 

3 ‘‘(D) APPLICATION OF SECONDARY PAYOR

4 RULES.—The State shall be a secondary payor 

5 for any items or services provided under the 

6 qualified employer-sponsored coverage for which 

7 the State provides child health assistance under 

8 the State child health plan. 

9 ‘‘(E) REQUIREMENT TO PROVIDE SUPPLE10 MENTAL COVERAGE FOR BENEFITS AND COST11 SHARING PROTECTION PROVIDED UNDER THE

12 STATE CHILD HEALTH PLAN.— 

13 ‘‘(i) IN GENERAL.—Notwithstanding 

14 section 2110(b)(1)(C), the State shall pro15 vide for each targeted low-income child en16 rolled in qualified employer-sponsored cov17 erage, supplemental coverage consisting 

18 of— 

19 ‘‘(I) items or services that are 

20 not covered, or are only partially cov21 ered, under the qualified employer22 sponsored coverage; and 

23 ‘‘(II) cost-sharing protection con24 sistent with section 2103(e). 


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1 ‘‘(ii) RECORD KEEPING REQUIRE2 MENTS.—For purposes of carrying out 

3 clause (i), a State may elect to directly pay 

4 out-of-pocket expenditures for cost-sharing 

5 imposed under the qualified employer-spon6 sored coverage and collect or not collect all 

7 or any portion of such expenditures from 

8 the parent of the child. 

9 ‘‘(F) APPLICATION OF WAITING PERIOD

10 IMPOSED UNDER THE STATE.—Any waiting pe11 riod imposed under the State child health plan 

12 prior to the provision of child health assistance 

13 to a targeted low-income child under the State 

14 plan shall apply to the same extent to the provi15 sion of a premium assistance subsidy for the 

16 child under this paragraph. 

17 ‘‘(G) OPT-OUT PERMITTED FOR ANY

18 MONTH.—A State shall establish a process for 

19 permitting the parent of a targeted low-income 

20 child receiving a premium assistance subsidy to 

21 disenroll the child from the qualified employer22 sponsored coverage and enroll the child in, and 

23 receive child health assistance under, the State 

24 child health plan, effective on the first day of 

25 any month for which the child is eligible for 


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1 such assistance and in a manner that ensures 

2 continuity of coverage for the child. 

3 ‘‘(H) APPLICATION TO PARENTS.—If a 

4 State provides child health assistance or health 

5 benefits coverage to parents of a targeted low6 income child in accordance with section 

7 2111(b), the State may elect to offer a pre8 mium assistance subsidy to a parent of a tar9 geted low-income child who is eligible for such 

10 a subsidy under this paragraph in the same 

11 manner as the State offers such a subsidy for 

12 the enrollment of the child in qualified em13 ployer-sponsored coverage, except that— 

14 ‘‘(i) the amount of the premium as15 sistance subsidy shall be increased to take 

16 into account the cost of the enrollment of 

17 the parent in the qualified employer-spon18 sored coverage or, at the option of the 

19 State if the State determines it cost-effec20 tive, the cost of the enrollment of the 

21 child’s family in such coverage; and 

22 ‘‘(ii) any reference in this paragraph 

23 to a child is deemed to include a reference 

24 to the parent or, if applicable under clause 

25 (i), the family of the child. 


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1 ‘‘(I) ADDITIONAL STATE OPTION FOR PRO2 VIDING PREMIUM ASSISTANCE.— 

3 ‘‘(i) IN GENERAL.—A State may es4 tablish an employer-family premium assist5 ance purchasing pool for employers with 

6 less than 250 employees who have at least 

7 1 employee who is a pregnant woman eligi8 ble for assistance under the State child 

9 health plan (including through the applica10 tion of an option described in section 

11 2112(f)) or a member of a family with at 

12 least 1 targeted low-income child and to 

13 provide a premium assistance subsidy 

14 under this paragraph for enrollment in 

15 coverage made available through such pool. 

16 ‘‘(ii) ACCESS TO CHOICE OF COV17 ERAGE.—A State that elects the option 

18 under clause (i) shall identify and offer ac19 cess to not less than 2 private health plans 

20 that are health benefits coverage that is 

21 equivalent to the benefits coverage in a 

22 benchmark benefit package described in 

23 section 2103(b) or benchmark-equivalent 

24 coverage that meets the requirements of 


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1 section 2103(a)(2) for employees described 

2 in clause (i). 

3 ‘‘(iii) CLARIFICATION OF PAYMENT

4 FOR ADMINISTRATIVE EXPENDITURES.— 

5 Nothing in this subparagraph shall be con6 strued as permitting payment under this 

7 section for administrative expenditures at8 tributable to the establishment or oper9 ation of such pool, except to the extent 

10 that such payment would otherwise be per11 mitted under this title. 

12 ‘‘(J) NO EFFECT ON PREMIUM ASSISTANCE

13 WAIVER PROGRAMS.—Nothing in this para14 graph shall be construed as limiting the author15 ity of a State to offer premium assistance under 

16 section 1906 or 1906A, a waiver described in 

17 paragraph (2)(B) or (3), a waiver approved 

18 under section 1115, or other authority in effect 

19 prior to the date of enactment of the Children’s 

20 Health Insurance Program Reauthorization Act 

21 of 2009. 

22 ‘‘(K) NOTICE OF AVAILABILITY.—If a 

23 State elects to provide premium assistance sub24 sidies in accordance with this paragraph, the 

25 State shall— 


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1 ‘‘(i) include on any application or en2 rollment form for child health assistance a 

3 notice of the availability of premium assist4 ance subsidies for the enrollment of tar5 geted low-income children in qualified em6 ployer-sponsored coverage; 

7 ‘‘(ii) provide, as part of the applica8 tion and enrollment process under the 

9 State child health plan, information de10 scribing the availability of such subsidies 

11 and how to elect to obtain such a subsidy; 

12 and 

13 ‘‘(iii) establish such other procedures 

14 as the State determines necessary to en15 sure that parents are fully informed of the 

16 choices for receiving child health assistance 

17 under the State child health plan or 

18 through the receipt of premium assistance 

19 subsidies. 

20 ‘‘(L) APPLICATION TO QUALIFIED EM21 PLOYER-SPONSORED BENCHMARK COVERAGE.— 

22 If a group health plan or health insurance cov23 erage offered through an employer is certified 

24 by an actuary as health benefits coverage that 

25 is equivalent to the benefits coverage in a 


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1 benchmark benefit package described in section 

2 2103(b) or benchmark-equivalent coverage that 

3 meets the requirements of section 2103(a)(2), 

4 the State may provide premium assistance sub5 sidies for enrollment of targeted low-income 

6 children in such group health plan or health in7 surance coverage in the same manner as such 

8 subsidies are provided under this paragraph for 

9 enrollment in qualified employer-sponsored cov10 erage, but without regard to the requirement to 

11 provide supplemental coverage for benefits and 

12 cost-sharing protection provided under the 

13 State child health plan under subparagraph 

14 (E). 

15 ‘‘(M) SATISFACTION OF COST-EFFECTIVE16 NESS TEST.—Premium assistance subsidies for 

17 qualified employer-sponsored coverage offered 

18 under this paragraph shall be deemed to meet 

19 the requirement of subparagraph (A) of para20 graph (3). 

21 ‘‘(N) COORDINATION WITH MEDICAID.—In 

22 the case of a targeted low-income child who re23 ceives child health assistance through a State 

24 plan under title XIX and who voluntarily elects 

25 to receive a premium assistance subsidy under 


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1 this section, the provisions of section 1906A 

2 shall apply and shall supersede any other provi3 sions of this paragraph that are inconsistent 

4 with such section.’’. 

5 (2) DETERMINATION OF COST-EFFECTIVENESS

6 FOR PREMIUM ASSISTANCE OR PURCHASE OF FAM7 ILY COVERAGE.— 

8 (A) IN GENERAL.—Section 2105(c)(3)(A) 

9 (42 U.S.C. 1397ee(c)(3)(A)) is amended by 

10 striking ‘‘relative to’’ and all that follows 

11 through the comma and inserting ‘‘relative to 

12 ‘‘(i) the amount of expenditures under 

13 the State child health plan, including ad14 ministrative expenditures, that the State 

15 would have made to provide comparable 

16 coverage of the targeted low-income child 

17 involved or the family involved (as applica18 ble); or 

19 ‘‘(ii) the aggregate amount of expendi20 tures that the State would have made 

21 under the State child health plan, includ22 ing administrative expenditures, for pro23 viding coverage under such plan for all 

24 such children or families.’’. 


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1 (B) NONAPPLICATION TO PREVIOUSLY AP2 PROVED COVERAGE.—The amendment made by 

3 subparagraph (A) shall not apply to coverage 

4 the purchase of which has been approved by the 

5 Secretary under section 2105(c)(3) of the Social 

6 Security Act prior to the date of enactment of 

7 this Act. 

8 (b) MEDICAID.—Title XIX is amended by inserting 

9 after section 1906 the following new section: 

10 ‘‘PREMIUM ASSISTANCE OPTION FOR CHILDREN

11 ‘‘SEC. 1906A. (a) IN GENERAL.—A State may elect 

12 to offer a premium assistance subsidy (as defined in sub13 section (c)) for qualified employer-sponsored coverage (as 

14 defined in subsection (b)) to all individuals under age 19 

15 who are entitled to medical assistance under this title (and 

16 to the parent of such an individual) who have access to 

17 such coverage if the State meets the requirements of this 

18 section. 

19 ‘‘(b) QUALIFIED EMPLOYER-SPONSORED COV20 ERAGE.— 

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

22 in this paragraph, the term ‘qualified employer-spon23 sored coverage’ means a group health plan or health 

24 insurance coverage offered through an employer— 


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1 ‘‘(A) that qualifies as creditable coverage 

2 as a group health plan under section 2701(c)(1) 

3 of the Public Health Service Act; 

4 ‘‘(B) for which the employer contribution 

5 toward any premium for such coverage is at 

6 least 40 percent; and 

7 ‘‘(C) that is offered to all individuals in a 

8 manner that would be considered a nondiscrim9 inatory eligibility classification for purposes of 

10 paragraph (3)(A)(ii) of section 105(h) of the 

11 Internal Revenue Code of 1986 (but determined 

12 without regard to clause (i) of subparagraph 

13 (B) of such paragraph). 

14 ‘‘(2) EXCEPTION.—Such term does not include 

15 coverage consisting of— 

16 ‘‘(A) benefits provided under a health flexi17 ble spending arrangement (as defined in section 

18 106(c)(2) of the Internal Revenue Code of 

19 1986); or 

20 ‘‘(B) a high deductible health plan (as de21 fined in section 223(c)(2) of such Code), with22 out regard to whether the plan is purchased in 

23 conjunction with a health savings account (as 

24 defined under section 223(d) of such Code). 


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1 ‘‘(3) TREATMENT AS THIRD PARTY LIABIL2 ITY.—The State shall treat the coverage provided 

3 under qualified employer-sponsored coverage as a 

4 third party liability under section 1902(a)(25). 

5 ‘‘(c) PREMIUM ASSISTANCE SUBSIDY.—In this sec6 tion, the term ‘premium assistance subsidy’ means the 

7 amount of the employee contribution for enrollment in the 

8 qualified employer-sponsored coverage by the individual 

9 under age 19 or by the individual’s family. Premium as10 sistance subsidies under this section shall be considered, 

11 for purposes of section 1903(a), to be a payment for med12 ical assistance. 

13 ‘‘(d) VOLUNTARY PARTICIPATION.— 

14 ‘‘(1) EMPLOYERS.—Participation by an em15 ployer in a premium assistance subsidy offered by a 

16 State under this section shall be voluntary. An em17 ployer may notify a State that it elects to opt-out of 

18 being directly paid a premium assistance subsidy on 

19 behalf of an employee. 

20 ‘‘(2) BENEFICIARIES.—No subsidy shall be pro21 vided to an individual under age 19 under this sec22 tion unless the individual (or the individual’s parent) 

23 voluntarily elects to receive such a subsidy. A State 

24 may not require such an election as a condition of 

25 receipt of medical assistance. State may not require, 


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1 as a condition of an individual under age 19 (or the 

2 individual’s parent) being or remaining eligible for 

3 medical assistance under this title, apply for enroll4 ment in qualified employer-sponsored coverage under 

5 this section. 

6 ‘‘(3) OPT-OUT PERMITTED FOR ANY MONTH.— 

7 A State shall establish a process for permitting the 

8 parent of an individual under age 19 receiving a pre9 mium assistance subsidy to disenroll the individual 

10 from the qualified employer-sponsored coverage. 

11 ‘‘(e) REQUIREMENT TO PAY PREMIUMS AND COST12 SHARING AND PROVIDE SUPPLEMENTAL COVERAGE.—In 

13 the case of the participation of an individual under age 

14 19 (or the individual’s parent) in a premium assistance 

15 subsidy under this section for qualified employer-spon16 sored coverage, the State shall provide for payment of all 

17 enrollee premiums for enrollment in such coverage and all 

18 deductibles, coinsurance, and other cost-sharing obliga19 tions for items and services otherwise covered under the 

20 State plan under this title (exceeding the amount other21 wise permitted under section 1916 or, if applicable, section 

22 1916A). The fact that an individual under age 19 (or a 

23 parent) elects to enroll in qualified employer-sponsored 

24 coverage under this section shall not change the individ25 ual’s (or parent’s) eligibility for medical assistance under 


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1 the State plan, except insofar as section 1902(a)(25) pro2 vides that payments for such assistance shall first be made 

3 under such coverage.’’. 

4 (c) GAO STUDY AND REPORT.—Not later than Janu5 ary 1, 2010, the Comptroller General of the United States 

6 shall study cost and coverage issues relating to any State 

7 premium assistance programs for which Federal matching 

8 payments are made under title XIX or XXI of the Social 

9 Security Act, including under waiver authority, and shall 

10 submit a report to the Committee on Finance of the Sen11 ate and the Committee on Energy and Commerce of the 

12 House of Representatives on the results of such study. 

13 SEC. 302. OUTREACH, EDUCATION, AND ENROLLMENT AS14 SISTANCE. 

15 (a) REQUIREMENT TO INCLUDE DESCRIPTION OF

16 OUTREACH, EDUCATION, AND ENROLLMENT EFFORTS

17 RELATED TO PREMIUM ASSISTANCE SUBSIDIES IN STATE

18 CHILD HEALTH PLAN.—Section 2102(c) (42 U.S.C. 

19 1397bb(c)) is amended by adding at the end the following 

20 new paragraph: 

21 ‘‘(3) PREMIUM ASSISTANCE SUBSIDIES.—In the 

22 case of a State that provides for premium assistance 

23 subsidies under the State child health plan in ac24 cordance with paragraph (2)(B), (3), or (10) of sec25 tion 2105(c), or a waiver approved under section 


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1 1115, outreach, education, and enrollment assistance 

2 for families of children likely to be eligible for such 

3 subsidies, to inform such families of the availability 

4 of, and to assist them in enrolling their children in, 

5 such subsidies, and for employers likely to provide 

6 coverage that is eligible for such subsidies, including 

7 the specific, significant resources the State intends 

8 to apply to educate employers about the availability 

9 of premium assistance subsidies under the State 

10 child health plan.’’. 

11 (b) NONAPPLICATION OF 10 PERCENT LIMIT ON

12 OUTREACH AND CERTAIN OTHER EXPENDITURES.—Sec13 tion 2105(c)(2)(C) (42 U.S.C. 1397ee(c)(2)(C)), as 

14 amended by section 211(c)(2), is amended by adding at 

15 the end the following new clause: 

16 ‘‘(iii) EXPENDITURES FOR OUTREACH

17 TO INCREASE THE ENROLLMENT OF CHIL18 DREN UNDER THIS TITLE AND TITLE xix 

19 THROUGH PREMIUM ASSISTANCE SUB20 SIDIES.—Expenditures for outreach activi21 ties to families of children likely to be eligi22 ble for premium assistance subsidies in ac23 cordance with paragraph (2)(B), (3), or 

24 (10), or a waiver approved under section 

25 1115, to inform such families of the availVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00154 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 ability of, and to assist them in enrolling 

2 their children in, such subsidies, and to 

3 employers likely to provide qualified em4 ployer-sponsored coverage (as defined in 

5 subparagraph (B) of such paragraph), but 

6 not to exceed an amount equal to 1.25 per7 cent of the maximum amount permitted to 

8 be expended under subparagraph (A) for 

9 items described in subsection (a)(1)(D).’’. 

10 Subtitle B—Coordinating Premium 

11 Assistance With Private Coverage 

12 SEC. 311. SPECIAL ENROLLMENT PERIOD UNDER GROUP 

13 HEALTH PLANS IN CASE OF TERMINATION OF 

14 MEDICAID OR CHIP COVERAGE OR ELIGI15 BILITY FOR ASSISTANCE IN PURCHASE OF 

16 EMPLOYMENT-BASED COVERAGE; COORDINA17 TION OF COVERAGE. 

18 (a) AMENDMENTS TO INTERNAL REVENUE CODE OF

19 1986.—Section 9801(f) of the Internal Revenue Code of 

20 1986 (relating to special enrollment periods) is amended 

21 by adding at the end the following new paragraph: 

22 ‘‘(3) SPECIAL RULES RELATING TO MEDICAID

23 AND CHIP.— 

24 ‘‘(A) IN GENERAL.—A group health plan 

25 shall permit an employee who is eligible, but 


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1 not enrolled, for coverage under the terms of 

2 the plan (or a dependent of such an employee 

3 if the dependent is eligible, but not enrolled, for 

4 coverage under such terms) to enroll for cov5 erage under the terms of the plan if either of 

6 the following conditions is met: 

7 ‘‘(i) TERMINATION OF MEDICAID OR

8 CHIP COVERAGE.—The employee or de9 pendent is covered under a Medicaid plan 

10 under title XIX of the Social Security Act 

11 or under a State child health plan under 

12 title XXI of such Act and coverage of the 

13 employee or dependent under such a plan 

14 is terminated as a result of loss of eligi15 bility for such coverage and the employee 

16 requests coverage under the group health 

17 plan not later than 60 days after the date 

18 of termination of such coverage. 

19 ‘‘(ii) ELIGIBILITY FOR EMPLOYMENT

20 ASSISTANCE UNDER MEDICAID OR CHIP.— 

21 The employee or dependent becomes eligi22 ble for assistance, with respect to coverage 

23 under the group health plan under such 

24 Medicaid plan or State child health plan 

25 (including under any waiver or demonstraVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00156 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 tion project conducted under or in relation 

2 to such a plan), if the employee requests 

3 coverage under the group health plan not 

4 later than 60 days after the date the em5 ployee or dependent is determined to be el6 igible for such assistance. 

7 ‘‘(B) EMPLOYEE OUTREACH AND DISCLO8 SURE.— 

9 ‘‘(i) OUTREACH TO EMPLOYEES RE10 GARDING AVAILABILITY OF MEDICAID AND

11 CHIP COVERAGE.— 

12 ‘‘(I) IN GENERAL.—Each em13 ployer that maintains a group health 

14 plan in a State that provides medical 

15 assistance under a State Medicaid 

16 plan under title XIX of the Social Se17 curity Act, or child health assistance 

18 under a State child health plan under 

19 title XXI of such Act, in the form of 

20 premium assistance for the purchase 

21 of coverage under a group health 

22 plan, shall provide to each employee a 

23 written notice informing the employee 

24 of potential opportunities then cur25 rently available in the State in which 


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1 the employee resides for premium as2 sistance under such plans for health 

3 coverage of the employee or the em4 ployee’s dependents. For purposes of 

5 compliance with this clause, the em6 ployer may use any State-specific 

7 model notice developed in accordance 

8 with section 701(f)(3)(B)(i)(II) of the 

9 Employee Retirement Income Security 

10 Act of 1974 (29 U.S.C. 

11 1181(f)(3)(B)(i)(II)). 

12 ‘‘(II) OPTION TO PROVIDE CON13 CURRENT WITH PROVISION OF PLAN

14 MATERIALS TO EMPLOYEE.—An em15 ployer may provide the model notice 

16 applicable to the State in which an 

17 employee resides concurrent with the 

18 furnishing of materials notifying the 

19 employee of health plan eligibility, 

20 concurrent with materials provided to 

21 the employee in connection with an 

22 open season or election process con23 ducted under the plan, or concurrent 

24 with the furnishing of the summary 

25 plan description as provided in section 


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1 104(b) of the Employee Retirement 

2 Income Security Act of 1974 (29 

3 U.S.C. 1024). 

4 ‘‘(ii) DISCLOSURE ABOUT GROUP

5 HEALTH PLAN BENEFITS TO STATES FOR

6 MEDICAID AND CHIP ELIGIBLE INDIVID7 UALS.—In the case of a participant or ben8 eficiary of a group health plan who is cov9 ered under a Medicaid plan of a State 

10 under title XIX of the Social Security Act 

11 or under a State child health plan under 

12 title XXI of such Act, the plan adminis13 trator of the group health plan shall dis14 close to the State, upon request, informa15 tion about the benefits available under the 

16 group health plan in sufficient specificity, 

17 as determined under regulations of the 

18 Secretary of Health and Human Services 

19 in consultation with the Secretary that re20 quire use of the model coverage coordina21 tion disclosure form developed under sec22 tion 311(b)(1)(C) of the Children’s Health 

23 Insurance Program Reauthorization Act of 

24 2009, so as to permit the State to make a 

25 determination (under paragraph (2)(B), 


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1 (3), or (10) of section 2105(c) of the So2 cial Security Act or otherwise) concerning 

3 the cost-effectiveness of the State pro4 viding medical or child health assistance 

5 through premium assistance for the pur6 chase of coverage under such group health 

7 plan and in order for the State to provide 

8 supplemental benefits required under para9 graph (10)(E) of such section or other au10 thority.’’. 

11 (b) CONFORMING AMENDMENTS.— 

12 (1) AMENDMENTS TO EMPLOYEE RETIREMENT

13 INCOME SECURITY ACT.— 

14 (A) IN GENERAL.—Section 701(f) of the 

15 Employee Retirement Income Security Act of 

16 1974 (29 U.S.C. 1181(f)) is amended by adding 

17 at the end the following new paragraph: 

18 ‘‘(3) SPECIAL RULES FOR APPLICATION IN CASE

19 OF MEDICAID AND CHIP.— 

20 ‘‘(A) IN GENERAL.—A group health plan, 

21 and a health insurance issuer offering group 

22 health insurance coverage in connection with a 

23 group health plan, shall permit an employee 

24 who is eligible, but not enrolled, for coverage 

25 under the terms of the plan (or a dependent of 


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1 such an employee if the dependent is eligible, 

2 but not enrolled, for coverage under such 

3 terms) to enroll for coverage under the terms of 

4 the plan if either of the following conditions is 

5 met: 

6 ‘‘(i) TERMINATION OF MEDICAID OR

7 CHIP COVERAGE.—The employee or de8 pendent is covered under a Medicaid plan 

9 under title XIX of the Social Security Act 

10 or under a State child health plan under 

11 title XXI of such Act and coverage of the 

12 employee or dependent under such a plan 

13 is terminated as a result of loss of eligi14 bility for such coverage and the employee 

15 requests coverage under the group health 

16 plan (or health insurance coverage) not 

17 later than 60 days after the date of termi18 nation of such coverage. 

19 ‘‘(ii) ELIGIBILITY FOR EMPLOYMENT

20 ASSISTANCE UNDER MEDICAID OR CHIP.— 

21 The employee or dependent becomes eligi22 ble for assistance, with respect to coverage 

23 under the group health plan or health in24 surance coverage, under such Medicaid 

25 plan or State child health plan (including 


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1 under any waiver or demonstration project 

2 conducted under or in relation to such a 

3 plan), if the employee requests coverage 

4 under the group health plan or health in5 surance coverage not later than 60 days 

6 after the date the employee or dependent is 

7 determined to be eligible for such assist8 ance. 

9 ‘‘(B) COORDINATION WITH MEDICAID AND

10 CHIP.— 

11 ‘‘(i) OUTREACH TO EMPLOYEES RE12 GARDING AVAILABILITY OF MEDICAID AND

13 CHIP COVERAGE.— 

14 ‘‘(I) IN GENERAL.—Each em15 ployer that maintains a group health 

16 plan in a State that provides medical 

17 assistance under a State Medicaid 

18 plan under title XIX of the Social Se19 curity Act, or child health assistance 

20 under a State child health plan under 

21 title XXI of such Act, in the form of 

22 premium assistance for the purchase 

23 of coverage under a group health 

24 plan, shall provide to each employee a 

25 written notice informing the employee 


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1 of potential opportunities then cur2 rently available in the State in which 

3 the employee resides for premium as4 sistance under such plans for health 

5 coverage of the employee or the em6 ployee’s dependents. 

7 ‘‘(II) MODEL NOTICE.—Not later 

8 than 1 year after the date of enact9 ment of the Children’s Health Insur10 ance Program Reauthorization Act of 

11 2009, the Secretary and the Secretary 

12 of Health and Human Services, in 

13 consultation with Directors of State 

14 Medicaid agencies under title XIX of 

15 the Social Security Act and Directors 

16 of State CHIP agencies under title 

17 XXI of such Act, shall jointly develop 

18 national and State-specific model no19 tices for purposes of subparagraph 

20 (A). The Secretary shall provide em21 ployers with such model notices so as 

22 to enable employers to timely comply 

23 with the requirements of subpara24 graph (A). Such model notices shall 

25 include information regarding how an 


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1 employee may contact the State in 

2 which the employee resides for addi3 tional information regarding potential 

4 opportunities for such premium assist5 ance, including how to apply for such 

6 assistance. 

7 ‘‘(III) OPTION TO PROVIDE CON8 CURRENT WITH PROVISION OF PLAN

9 MATERIALS TO EMPLOYEE.—An em10 ployer may provide the model notice 

11 applicable to the State in which an 

12 employee resides concurrent with the 

13 furnishing of materials notifying the 

14 employee of health plan eligibility, 

15 concurrent with materials provided to 

16 the employee in connection with an 

17 open season or election process con18 ducted under the plan, or concurrent 

19 with the furnishing of the summary 

20 plan description as provided in section 

21 104(b). 

22 ‘‘(ii) DISCLOSURE ABOUT GROUP

23 HEALTH PLAN BENEFITS TO STATES FOR

24 MEDICAID AND CHIP ELIGIBLE INDIVID25 UALS.—In the case of a participant or benVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00164 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 eficiary of a group health plan who is cov2 ered under a Medicaid plan of a State 

3 under title XIX of the Social Security Act 

4 or under a State child health plan under 

5 title XXI of such Act, the plan adminis6 trator of the group health plan shall dis7 close to the State, upon request, informa8 tion about the benefits available under the 

9 group health plan in sufficient specificity, 

10 as determined under regulations of the 

11 Secretary of Health and Human Services 

12 in consultation with the Secretary that re13 quire use of the model coverage coordina14 tion disclosure form developed under sec15 tion 311(b)(1)(C) of the Children’s Health 

16 Insurance Program Reauthorization Act of 

17 2009, so as to permit the State to make a 

18 determination (under paragraph (2)(B), 

19 (3), or (10) of section 2105(c) of the So20 cial Security Act or otherwise) concerning 

21 the cost-effectiveness of the State pro22 viding medical or child health assistance 

23 through premium assistance for the pur24 chase of coverage under such group health 

25 plan and in order for the State to provide 


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1 supplemental benefits required under para2 graph (10)(E) of such section or other au3 thority.’’. 

4 (B) CONFORMING AMENDMENT.—Section 

5 102(b) of the Employee Retirement Income Se6 curity Act of 1974 (29 U.S.C. 1022(b)) is 

7 amended— 

8 (i) by striking ‘‘and the remedies’’ 

9 and inserting ‘‘, the remedies’’; and 

10 (ii) by inserting before the period the 

11 following: ‘‘, and if the employer so elects 

12 for purposes of complying with section 

13 701(f)(3)(B)(i), the model notice applicable 

14 to the State in which the participants and 

15 beneficiaries reside’’. 

16 (C) WORKING GROUP TO DEVELOP MODEL

17 COVERAGE COORDINATION DISCLOSURE

18 FORM.— 

19 (i) MEDICAID, CHIP, AND EMPLOYER20 SPONSORED COVERAGE COORDINATION

21 WORKING GROUP.— 

22 (I) IN GENERAL.—Not later than 

23 60 days after the date of enactment of 

24 this Act, the Secretary of Health and 

25 Human Services and the Secretary of 


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1 Labor shall jointly establish a Med2 icaid, CHIP, and Employer-Sponsored 

3 Coverage Coordination Working 

4 Group (in this subparagraph referred 

5 to as the ‘‘Working Group’’). The 

6 purpose of the Working Group shall 

7 be to develop the model coverage co8 ordination disclosure form described 

9 in subclause (II) and to identify the 

10 impediments to the effective coordina11 tion of coverage available to families 

12 that include employees of employers 

13 that maintain group health plans and 

14 members who are eligible for medical 

15 assistance under title XIX of the So16 cial Security Act or child health as17 sistance or other health benefits cov18 erage under title XXI of such Act. 

19 (II) MODEL COVERAGE COORDI20 NATION DISCLOSURE FORM DE21 SCRIBED.—The model form described 

22 in this subclause is a form for plan 

23 administrators of group health plans 

24 to complete for purposes of permitting 

25 a State to determine the availability 


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1 and cost-effectiveness of the coverage 

2 available under such plans to employ3 ees who have family members who are 

4 eligible for premium assistance offered 

5 under a State plan under title XIX or 

6 XXI of such Act and to allow for co7 ordination of coverage for enrollees of 

8 such plans. Such form shall provide 

9 the following information in addition 

10 to such other information as the 

11 Working Group determines appro12 priate: 

13 (aa) A determination of 

14 whether the employee is eligible 

15 for coverage under the group 

16 health plan. 

17 (bb) The name and contract 

18 information of the plan adminis19 trator of the group health plan. 

20 (cc) The benefits offered 

21 under the plan. 

22 (dd) The premiums and 

23 cost-sharing required under the 

24 plan. 


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1 (ee) Any other information 

2 relevant to coverage under the 

3 plan. 

4 (ii) MEMBERSHIP.—The Working 

5 Group shall consist of not more than 30 

6 members and shall be composed of rep7 resentatives of— 

8 (I) the Department of Labor; 

9 (II) the Department of Health 

10 and Human Services; 

11 (III) State directors of the Med12 icaid program under title XIX of the 

13 Social Security Act; 

14 (IV) State directors of the State 

15 Children’s Health Insurance Program 

16 under title XXI of the Social Security 

17 Act; 

18 (V) employers, including owners 

19 of small businesses and their trade or 

20 industry representatives and certified 

21 human resource and payroll profes22 sionals; 

23 (VI) plan administrators and 

24 plan sponsors of group health plans 

25 (as defined in section 607(1) of the 


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1 Employee Retirement Income Security 

2 Act of 1974); 

3 (VII) health insurance issuers; 

4 and 

5 (VIII) children and other bene6 ficiaries of medical assistance under 

7 title XIX of the Social Security Act or 

8 child health assistance or other health 

9 benefits coverage under title XXI of 

10 such Act. 

11 (iii) COMPENSATION.—The members 

12 of the Working Group shall serve without 

13 compensation. 

14 (iv) ADMINISTRATIVE SUPPORT.—The 

15 Department of Health and Human Serv16 ices and the Department of Labor shall 

17 jointly provide appropriate administrative 

18 support to the Working Group, including 

19 technical assistance. The Working Group 

20 may use the services and facilities of either 

21 such Department, with or without reim22 bursement, as jointly determined by such 

23 Departments. 

24 (v) REPORT.— 


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1 (I) REPORT BY WORKING GROUP

2 TO THE SECRETARIES.—Not later 

3 than 18 months after the date of the 

4 enactment of this Act, the Working 

5 Group shall submit to the Secretary of 

6 Labor and the Secretary of Health 

7 and Human Services the model form 

8 described in clause (i)(II) along with a 

9 report containing recommendations 

10 for appropriate measures to address 

11 the impediments to the effective co12 ordination of coverage between group 

13 health plans and the State plans 

14 under titles XIX and XXI of the So15 cial Security Act. 

16 (II) REPORT BY SECRETARIES TO

17 THE CONGRESS.—Not later than 2 

18 months after receipt of the report 

19 pursuant to subclause (I), the Secre20 taries shall jointly submit a report to 

21 each House of the Congress regarding 

22 the recommendations contained in the 

23 report under such subclause. 

24 (vi) TERMINATION.—The Working 

25 Group shall terminate 30 days after the 


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1 date of the issuance of its report under 

2 clause (v). 

3 (D) EFFECTIVE DATES.—The Secretary of 

4 Labor and the Secretary of Health and Human 

5 Services shall develop the initial model notices 

6 under section 701(f)(3)(B)(i)(II) of the Em7 ployee Retirement Income Security Act of 1974, 

8 and the Secretary of Labor shall provide such 

9 notices to employers, not later than the date 

10 that is 1 year after the date of enactment of 

11 this Act, and each employer shall provide the 

12 initial annual notices to such employer’s em13 ployees beginning with the first plan year that 

14 begins after the date on which such initial 

15 model notices are first issued. The model cov16 erage coordination disclosure form developed 

17 under subparagraph (C) shall apply with re18 spect to requests made by States beginning 

19 with the first plan year that begins after the 

20 date on which such model coverage coordination 

21 disclosure form is first issued. 

22 (E) ENFORCEMENT.—Section 502 of the 

23 Employee Retirement Income Security Act of 

24 1974 (29 U.S.C. 1132) is amended— 


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1 (i) in subsection (a)(6), by striking 

2 ‘‘or (8)’’ and inserting ‘‘(8), or (9)’’; and 

3 (ii) in subsection (c), by redesignating 

4 paragraph (9) as paragraph (10), and by 

5 inserting after paragraph (8) the following: 

6 ‘‘(9)(A) The Secretary may assess a civil penalty 

7 against any employer of up to $100 a day from the date 

8 of the employer’s failure to meet the notice requirement 

9 of section 701(f)(3)(B)(i)(I). For purposes of this sub10 paragraph, each violation with respect to any single em11 ployee shall be treated as a separate violation. 

12 ‘‘(B) The Secretary may assess a civil penalty against 

13 any plan administrator of up to $100 a day from the date 

14 of the plan administrator’s failure to timely provide to any 

15 State the information required to be disclosed under sec16 tion 701(f)(3)(B)(ii). For purposes of this subparagraph, 

17 each violation with respect to any single participant or 

18 beneficiary shall be treated as a separate violation.’’. 

19 (2) AMENDMENTS TO PUBLIC HEALTH SERVICE

20 ACT.—Section 2701(f) of the Public Health Service 

21 Act (42 U.S.C. 300gg(f)) is amended by adding at 

22 the end the following new paragraph: 

23 ‘‘(3) SPECIAL RULES FOR APPLICATION IN CASE

24 OF MEDICAID AND CHIP.— 


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1 ‘‘(A) IN GENERAL.—A group health plan, 

2 and a health insurance issuer offering group 

3 health insurance coverage in connection with a 

4 group health plan, shall permit an employee 

5 who is eligible, but not enrolled, for coverage 

6 under the terms of the plan (or a dependent of 

7 such an employee if the dependent is eligible, 

8 but not enrolled, for coverage under such 

9 terms) to enroll for coverage under the terms of 

10 the plan if either of the following conditions is 

11 met: 

12 ‘‘(i) TERMINATION OF MEDICAID OR

13 CHIP COVERAGE.—The employee or de14 pendent is covered under a Medicaid plan 

15 under title XIX of the Social Security Act 

16 or under a State child health plan under 

17 title XXI of such Act and coverage of the 

18 employee or dependent under such a plan 

19 is terminated as a result of loss of eligi20 bility for such coverage and the employee 

21 requests coverage under the group health 

22 plan (or health insurance coverage) not 

23 later than 60 days after the date of termi24 nation of such coverage. 


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1 ‘‘(ii) ELIGIBILITY FOR EMPLOYMENT

2 ASSISTANCE UNDER MEDICAID OR CHIP.— 

3 The employee or dependent becomes eligi4 ble for assistance, with respect to coverage 

5 under the group health plan or health in6 surance coverage, under such Medicaid 

7 plan or State child health plan (including 

8 under any waiver or demonstration project 

9 conducted under or in relation to such a 

10 plan), if the employee requests coverage 

11 under the group health plan or health in12 surance coverage not later than 60 days 

13 after the date the employee or dependent is 

14 determined to be eligible for such assist15 ance. 

16 ‘‘(B) COORDINATION WITH MEDICAID AND

17 CHIP.— 

18 ‘‘(i) OUTREACH TO EMPLOYEES RE19 GARDING AVAILABILITY OF MEDICAID AND

20 CHIP COVERAGE.— 

21 ‘‘(I) IN GENERAL.—Each em22 ployer that maintains a group health 

23 plan in a State that provides medical 

24 assistance under a State Medicaid 

25 plan under title XIX of the Social SeVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00175 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 curity Act, or child health assistance 

2 under a State child health plan under 

3 title XXI of such Act, in the form of 

4 premium assistance for the purchase 

5 of coverage under a group health 

6 plan, shall provide to each employee a 

7 written notice informing the employee 

8 of potential opportunities then cur9 rently available in the State in which 

10 the employee resides for premium as11 sistance under such plans for health 

12 coverage of the employee or the em13 ployee’s dependents. For purposes of 

14 compliance with this subclause, the 

15 employer may use any State-specific 

16 model notice developed in accordance 

17 with section 701(f)(3)(B)(i)(II) of the 

18 Employee Retirement Income Security 

19 Act of 1974 (29 U.S.C. 

20 1181(f)(3)(B)(i)(II)). 

21 ‘‘(II) OPTION TO PROVIDE CON22 CURRENT WITH PROVISION OF PLAN

23 MATERIALS TO EMPLOYEE.—An em24 ployer may provide the model notice 

25 applicable to the State in which an 


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1 employee resides concurrent with the 

2 furnishing of materials notifying the 

3 employee of health plan eligibility, 

4 concurrent with materials provided to 

5 the employee in connection with an 

6 open season or election process con7 ducted under the plan, or concurrent 

8 with the furnishing of the summary 

9 plan description as provided in section 

10 104(b) of the Employee Retirement 

11 Income Security Act of 1974. 

12 ‘‘(ii) DISCLOSURE ABOUT GROUP

13 HEALTH PLAN BENEFITS TO STATES FOR

14 MEDICAID AND CHIP ELIGIBLE INDIVID15 UALS.—In the case of an enrollee in a 

16 group health plan who is covered under a 

17 Medicaid plan of a State under title XIX 

18 of the Social Security Act or under a State 

19 child health plan under title XXI of such 

20 Act, the plan administrator of the group 

21 health plan shall disclose to the State, 

22 upon request, information about the bene23 fits available under the group health plan 

24 in sufficient specificity, as determined 

25 under regulations of the Secretary of 


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1 Health and Human Services in consulta2 tion with the Secretary that require use of 

3 the model coverage coordination disclosure 

4 form developed under section 311(b)(1)(C) 

5 of the Children’s Health Insurance Reau6 thorization Act of 2009, so as to permit 

7 the State to make a determination (under 

8 paragraph (2)(B), (3), or (10) of section 

9 2105(c) of the Social Security Act or oth10 erwise) concerning the cost-effectiveness of 

11 the State providing medical or child health 

12 assistance through premium assistance for 

13 the purchase of coverage under such group 

14 health plan and in order for the State to 

15 provide supplemental benefits required 

16 under paragraph (10)(E) of such section 

17 or other authority.’’. 

18 TITLE IV—STRENGTHENING 

19 QUALITY OF CARE AND 

20 HEALTH OUTCOMES 

21 SEC. 401. CHILD HEALTH QUALITY IMPROVEMENT ACTIVI22 TIES FOR CHILDREN ENROLLED IN MED23 ICAID OR CHIP. 

24 (a) DEVELOPMENT OF CHILD HEALTH QUALITY

25 MEASURES FOR CHILDREN ENROLLED IN MEDICAID OR


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1 CHIP.—Title XI (42 U.S.C. 1301 et seq.) is amended by 

2 inserting after section 1139 the following new section: 

3 ‘‘SEC. 1139A. CHILD HEALTH QUALITY MEASURES. 

4 ‘‘(a) DEVELOPMENT OF AN INITIAL CORE SET OF

5 HEALTH CARE QUALITY MEASURES FOR CHILDREN EN6 ROLLED IN MEDICAID OR CHIP.— 

7 ‘‘(1) IN GENERAL.—Not later than January 1, 

8 2010, the Secretary shall identify and publish for 

9 general comment an initial, recommended core set of 

10 child health quality measures for use by State pro11 grams administered under titles XIX and XXI, 

12 health insurance issuers and managed care entities 

13 that enter into contracts with such programs, and 

14 providers of items and services under such pro15 grams. 

16 ‘‘(2) IDENTIFICATION OF INITIAL CORE MEAS17 URES.—In consultation with the individuals and en18 tities described in subsection (b)(3), the Secretary 

19 shall identify existing quality of care measures for 

20 children that are in use under public and privately 

21 sponsored health care coverage arrangements, or 

22 that are part of reporting systems that measure both 

23 the presence and duration of health insurance cov24 erage over time. 


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1 ‘‘(3) RECOMMENDATIONS AND DISSEMINA2 TION.—Based on such existing and identified meas3 ures, the Secretary shall publish an initial core set 

4 of child health quality measures that includes (but 

5 is not limited to) the following: 

6 ‘‘(A) The duration of children’s health in7 surance coverage over a 12-month time period. 

8 ‘‘(B) The availability and effectiveness of a 

9 full range of— 

10 ‘‘(i) preventive services, treatments, 

11 and services for acute conditions, including 

12 services to promote healthy birth, prevent 

13 and treat premature birth, and detect the 

14 presence or risk of physical or mental con15 ditions that could adversely affect growth 

16 and development; and 

17 ‘‘(ii) treatments to correct or amelio18 rate the effects of physical and mental con19 ditions, including chronic conditions, in in20 fants, young children, school-age children, 

21 and adolescents. 

22 ‘‘(C) The availability of care in a range of 

23 ambulatory and inpatient health care settings 

24 in which such care is furnished. 


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1 ‘‘(D) The types of measures that, taken to2 gether, can be used to estimate the overall na3 tional quality of health care for children, includ4 ing children with special needs, and to perform 

5 comparative analyses of pediatric health care 

6 quality and racial, ethnic, and socioeconomic 

7 disparities in child health and health care for 

8 children. 

9 ‘‘(4) ENCOURAGE VOLUNTARY AND STANDARD10 IZED REPORTING.—Not later than 2 years after the 

11 date of enactment of the Children’s Health Insur12 ance Program Reauthorization Act of 2009, the Sec13 retary, in consultation with States, shall develop a 

14 standardized format for reporting information and 

15 procedures and approaches that encourage States to 

16 use the initial core measurement set to voluntarily 

17 report information regarding the quality of pediatric 

18 health care under titles XIX and XXI. 

19 ‘‘(5) ADOPTION OF BEST PRACTICES IN IMPLE20 MENTING QUALITY PROGRAMS.—The Secretary shall 

21 disseminate information to States regarding best 

22 practices among States with respect to measuring 

23 and reporting on the quality of health care for chil24 dren, and shall facilitate the adoption of such best 

25 practices. In developing best practices approaches, 


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1 the Secretary shall give particular attention to State 

2 measurement techniques that ensure the timeliness 

3 and accuracy of provider reporting, encourage pro4 vider reporting compliance, encourage successful 

5 quality improvement strategies, and improve effi6 ciency in data collection using health information 

7 technology. 

8 ‘‘(6) REPORTS TO CONGRESS.—Not later than 

9 January 1, 2011, and every 3 years thereafter, the 

10 Secretary shall report to Congress on— 

11 ‘‘(A) the status of the Secretary’s efforts 

12 to improve— 

13 ‘‘(i) quality related to the duration 

14 and stability of health insurance coverage 

15 for children under titles XIX and XXI; 

16 ‘‘(ii) the quality of children’s health 

17 care under such titles, including preventive 

18 health services, health care for acute condi19 tions, chronic health care, and health serv20 ices to ameliorate the effects of physical 

21 and mental conditions and to aid in growth 

22 and development of infants, young chil23 dren, school-age children, and adolescents 

24 with special health care needs; and 


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1 ‘‘(iii) the quality of children’s health 

2 care under such titles across the domains 

3 of quality, including clinical quality, health 

4 care safety, family experience with health 

5 care, health care in the most integrated 

6 setting, and elimination of racial, ethnic, 

7 and socioeconomic disparities in health and 

8 health care; 

9 ‘‘(B) the status of voluntary reporting by 

10 States under titles XIX and XXI, utilizing the 

11 initial core quality measurement set; and 

12 ‘‘(C) any recommendations for legislative 

13 changes needed to improve the quality of care 

14 provided to children under titles XIX and XXI, 

15 including recommendations for quality reporting 

16 by States. 

17 ‘‘(7) TECHNICAL ASSISTANCE.—The Secretary 

18 shall provide technical assistance to States to assist 

19 them in adopting and utilizing core child health 

20 quality measures in administering the State plans 

21 under titles XIX and XXI. 

22 ‘‘(8) DEFINITION OF CORE SET.—In this sec23 tion, the term ‘core set’ means a group of valid, reli24 able, and evidence-based quality measures that, 

25 taken together— 


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1 ‘‘(A) provide information regarding the 

2 quality of health coverage and health care for 

3 children; 

4 ‘‘(B) address the needs of children 

5 throughout the developmental age span; and 

6 ‘‘(C) allow purchasers, families, and health 

7 care providers to understand the quality of care 

8 in relation to the preventive needs of children, 

9 treatments aimed at managing and resolving 

10 acute conditions, and diagnostic and treatment 

11 services whose purpose is to correct or amelio12 rate physical, mental, or developmental condi13 tions that could, if untreated or poorly treated, 

14 become chronic. 

15 ‘‘(b) ADVANCING AND IMPROVING PEDIATRIC QUAL16 ITY MEASURES.— 

17 ‘‘(1) ESTABLISHMENT OF PEDIATRIC QUALITY

18 MEASURES PROGRAM.—Not later than January 1, 

19 2011, the Secretary shall establish a pediatric qual20 ity measures program to— 

21 ‘‘(A) improve and strengthen the initial 

22 core child health care quality measures estab23 lished by the Secretary under subsection (a); 

24 ‘‘(B) expand on existing pediatric quality 

25 measures used by public and private health care 


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1 purchasers and advance the development of 

2 such new and emerging quality measures; and 

3 ‘‘(C) increase the portfolio of evidence4 based, consensus pediatric quality measures 

5 available to public and private purchasers of 

6 children’s health care services, providers, and 

7 consumers. 

8 ‘‘(2) EVIDENCE-BASED MEASURES.—The meas9 ures developed under the pediatric quality measures 

10 program shall, at a minimum, be— 

11 ‘‘(A) evidence-based and, where appro12 priate, risk adjusted; 

13 ‘‘(B) designed to identify and eliminate ra14 cial and ethnic disparities in child health and 

15 the provision of health care; 

16 ‘‘(C) designed to ensure that the data re17 quired for such measures is collected and re18 ported in a standard format that permits com19 parison of quality and data at a State, plan, 

20 and provider level; 

21 ‘‘(D) periodically updated; and 

22 ‘‘(E) responsive to the child health needs, 

23 services, and domains of health care quality de24 scribed in clauses (i), (ii), and (iii) of subsection 

25 (a)(6)(A). 


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1 ‘‘(3) PROCESS FOR PEDIATRIC QUALITY MEAS2 URES PROGRAM.—In identifying gaps in existing pe3 diatric quality measures and establishing priorities 

4 for development and advancement of such measures, 

5 the Secretary shall consult with— 

6 ‘‘(A) States; 

7 ‘‘(B) pediatricians, children’s hospitals, 

8 and other primary and specialized pediatric 

9 health care professionals (including members of 

10 the allied health professions) who specialize in 

11 the care and treatment of children, particularly 

12 children with special physical, mental, and de13 velopmental health care needs; 

14 ‘‘(C) dental professionals, including pedi15 atric dental professionals; 

16 ‘‘(D) health care providers that furnish 

17 primary health care to children and families 

18 who live in urban and rural medically under19 served communities or who are members of dis20 tinct population sub-groups at heightened risk 

21 for poor health outcomes; 

22 ‘‘(E) national organizations representing 

23 children, including children with disabilities and 

24 children with chronic conditions; 


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1 ‘‘(F) national organizations representing 

2 consumers and purchasers of children’s health 

3 care; 

4 ‘‘(G) national organizations and individuals 

5 with expertise in pediatric health quality meas6 urement; and 

7 ‘‘(H) voluntary consensus standards set8 ting organizations and other organizations in9 volved in the advancement of evidence-based 

10 measures of health care. 

11 ‘‘(4) DEVELOPING, VALIDATING, AND TESTING

12 A PORTFOLIO OF PEDIATRIC QUALITY MEASURES.— 

13 As part of the program to advance pediatric quality 

14 measures, the Secretary shall— 

15 ‘‘(A) award grants and contracts for the 

16 development, testing, and validation of new, 

17 emerging, and innovative evidence-based meas18 ures for children’s health care services across 

19 the domains of quality described in clauses (i), 

20 (ii), and (iii) of subsection (a)(6)(A); and 

21 ‘‘(B) award grants and contracts for— 

22 ‘‘(i) the development of consensus on 

23 evidence-based measures for children’s 

24 health care services; 


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1 ‘‘(ii) the dissemination of such meas2 ures to public and private purchasers of 

3 health care for children; and 

4 ‘‘(iii) the updating of such measures 

5 as necessary. 

6 ‘‘(5) REVISING, STRENGTHENING, AND IMPROV7 ING INITIAL CORE MEASURES.—Beginning no later 

8 than January 1, 2013, and annually thereafter, the 

9 Secretary shall publish recommended changes to the 

10 core measures described in subsection (a) that shall 

11 reflect the testing, validation, and consensus process 

12 for the development of pediatric quality measures 

13 described in subsection paragraphs (1) through (4). 

14 ‘‘(6) DEFINITION OF PEDIATRIC QUALITY

15 MEASURE.—In this subsection, the term ‘pediatric 

16 quality measure’ means a measurement of clinical 

17 care that is capable of being examined through the 

18 collection and analysis of relevant information, that 

19 is developed in order to assess 1 or more aspects of 

20 pediatric health care quality in various institutional 

21 and ambulatory health care settings, including the 

22 structure of the clinical care system, the process of 

23 care, the outcome of care, or patient experiences in 

24 care. 


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1 ‘‘(7) CONSTRUCTION.—Nothing in this section 

2 shall be construed as supporting the restriction of 

3 coverage, under title XIX or XXI or otherwise, to 

4 only those services that are evidence-based. 

5 ‘‘(c) ANNUAL STATE REPORTS REGARDING STATE6 SPECIFIC QUALITY OF CARE MEASURES APPLIED UNDER

7 MEDICAID OR CHIP.— 

8 ‘‘(1) ANNUAL STATE REPORTS.—Each State 

9 with a State plan approved under title XIX or a 

10 State child health plan approved under title XXI 

11 shall annually report to the Secretary on the— 

12 ‘‘(A) State-specific child health quality 

13 measures applied by the States under such 

14 plans, including measures described in subpara15 graphs (A) and (B) of subsection (a)(6); and 

16 ‘‘(B) State-specific information on the 

17 quality of health care furnished to children 

18 under such plans, including information col19 lected through external quality reviews of man20 aged care organizations under section 1932 of 

21 the Social Security Act (42 U.S.C. 1396u–4) 

22 and benchmark plans under sections 1937 and 

23 2103 of such Act (42 U.S.C. 1396u–7, 1397cc). 

24 ‘‘(2) PUBLICATION.—Not later than September 

25 30, 2010, and annually thereafter, the Secretary 


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1 shall collect, analyze, and make publicly available the 

2 information reported by States under paragraph (1). 

3 ‘‘(d) DEMONSTRATION PROJECTS FOR IMPROVING

4 THE QUALITY OF CHILDREN’S HEALTH CARE AND THE

5 USE OF HEALTH INFORMATION TECHNOLOGY.— 

6 ‘‘(1) IN GENERAL.—During the period of fiscal 

7 years 2009 through 2013, the Secretary shall award 

8 not more than 10 grants to States and child health 

9 providers to conduct demonstration projects to 

10 evaluate promising ideas for improving the quality of 

11 children’s health care provided under title XIX or 

12 XXI, including projects to— 

13 ‘‘(A) experiment with, and evaluate the use 

14 of, new measures of the quality of children’s 

15 health care under such titles (including testing 

16 the validity and suitability for reporting of such 

17 measures); 

18 ‘‘(B) promote the use of health information 

19 technology in care delivery for children under 

20 such titles; 

21 ‘‘(C) evaluate provider-based models which 

22 improve the delivery of children’s health care 

23 services under such titles, including care man24 agement for children with chronic conditions 

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1 prove the effectiveness, safety, and efficiency of 

2 health care services for children; or 

3 ‘‘(D) demonstrate the impact of the model 

4 electronic health record format for children de5 veloped and disseminated under subsection (f) 

6 on improving pediatric health, including the ef7 fects of chronic childhood health conditions, and 

8 pediatric health care quality as well as reducing 

9 health care costs. 

10 ‘‘(2) REQUIREMENTS.—In awarding grants 

11 under this subsection, the Secretary shall ensure 

12 that— 

13 ‘‘(A) only 1 demonstration project funded 

14 under a grant awarded under this subsection 

15 shall be conducted in a State; and 

16 ‘‘(B) demonstration projects funded under 

17 grants awarded under this subsection shall be 

18 conducted evenly between States with large 

19 urban areas and States with large rural areas. 

20 ‘‘(3) AUTHORITY FOR MULTISTATE

21 PROJECTS.—A demonstration project conducted with 

22 a grant awarded under this subsection may be con23 ducted on a multistate basis, as needed. 


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1 ‘‘(4) FUNDING.—$20,000,000 of the amount 

2 appropriated under subsection (i) for a fiscal year 

3 shall be used to carry out this subsection. 

4 ‘‘(e) CHILDHOOD OBESITY DEMONSTRATION

5 PROJECT.— 

6 ‘‘(1) AUTHORITY TO CONDUCT DEMONSTRA7 TION.—The Secretary, in consultation with the Ad8 ministrator of the Centers for Medicare & Medicaid 

9 Services, shall conduct a demonstration project to 

10 develop a comprehensive and systematic model for 

11 reducing childhood obesity by awarding grants to eli12 gible entities to carry out such project. Such model 

13 shall— 

14 ‘‘(A) identify, through self-assessment, be15 havioral risk factors for obesity among children; 

16 ‘‘(B) identify, through self-assessment, 

17 needed clinical preventive and screening benefits 

18 among those children identified as target indi19 viduals on the basis of such risk factors; 

20 ‘‘(C) provide ongoing support to such tar21 get individuals and their families to reduce risk 

22 factors and promote the appropriate use of pre23 ventive and screening benefits; and 

24 ‘‘(D) be designed to improve health out25 comes, satisfaction, quality of life, and approVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00192 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 priate use of items and services for which med2 ical assistance is available under title XIX or 

3 child health assistance is available under title 

4 XXI among such target individuals. 

5 ‘‘(2) ELIGIBILITY ENTITIES.—For purposes of 

6 this subsection, an eligible entity is any of the fol7 lowing: 

8 ‘‘(A) A city, county, or Indian tribe. 

9 ‘‘(B) A local or tribal educational agency. 

10 ‘‘(C) An accredited university, college, or 

11 community college. 

12 ‘‘(D) A Federally-qualified health center. 

13 ‘‘(E) A local health department. 

14 ‘‘(F) A health care provider. 

15 ‘‘(G) A community-based organization. 

16 ‘‘(H) Any other entity determined appro17 priate by the Secretary, including a consortia or 

18 partnership of entities described in any of sub19 paragraphs (A) through (G). 

20 ‘‘(3) USE OF FUNDS.—An eligible entity award21 ed a grant under this subsection shall use the funds 

22 made available under the grant to— 

23 ‘‘(A) carry out community-based activities 

24 related to reducing childhood obesity, including 

25 by— 


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1 ‘‘(i) forming partnerships with enti2 ties, including schools and other facilities 

3 providing recreational services, to establish 

4 programs for after school and weekend 

5 community activities that are designed to 

6 reduce childhood obesity; 

7 ‘‘(ii) forming partnerships with 

8 daycare facilities to establish programs 

9 that promote healthy eating behaviors and 

10 physical activity; and 

11 ‘‘(iii) developing and evaluating com12 munity educational activities targeting 

13 good nutrition and promoting healthy eat14 ing behaviors; 

15 ‘‘(B) carry out age-appropriate school16 based activities that are designed to reduce 

17 childhood obesity, including by— 

18 ‘‘(i) developing and testing edu19 cational curricula and intervention pro20 grams designed to promote healthy eating 

21 behaviors and habits in youth, which may 

22 include— 

23 ‘‘(I) after hours physical activity 

24 programs; and 


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1 ‘‘(II) science-based interventions 

2 with multiple components to prevent 

3 eating disorders including nutritional 

4 content, understanding and respond5 ing to hunger and satiety, positive 

6 body image development, positive self7 esteem development, and learning life 

8 skills (such as stress management, 

9 communication skills, problemsolving 

10 and decisionmaking skills), as well as 

11 consideration of cultural and develop12 mental issues, and the role of family, 

13 school, and community; 

14 ‘‘(ii) providing education and training 

15 to educational professionals regarding how 

16 to promote a healthy lifestyle and a 

17 healthy school environment for children; 

18 ‘‘(iii) planning and implementing a 

19 healthy lifestyle curriculum or program 

20 with an emphasis on healthy eating behav21 iors and physical activity; and 

22 ‘‘(iv) planning and implementing 

23 healthy lifestyle classes or programs for 

24 parents or guardians, with an emphasis on 


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1 healthy eating behaviors and physical ac2 tivity for children; 

3 ‘‘(C) carry out educational, counseling, 

4 promotional, and training activities through the 

5 local health care delivery systems including 

6 by— 

7 ‘‘(i) promoting healthy eating behav8 iors and physical activity services to treat 

9 or prevent eating disorders, being over10 weight, and obesity; 

11 ‘‘(ii) providing patient education and 

12 counseling to increase physical activity and 

13 promote healthy eating behaviors; 

14 ‘‘(iii) training health professionals on 

15 how to identify and treat obese and over16 weight individuals which may include nu17 trition and physical activity counseling; 

18 and 

19 ‘‘(iv) providing community education 

20 by a health professional on good nutrition 

21 and physical activity to develop a better 

22 understanding of the relationship between 

23 diet, physical activity, and eating disorders, 

24 obesity, or being overweight; and 


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1 ‘‘(D) provide, through qualified health pro2 fessionals, training and supervision for commu3 nity health workers to— 

4 ‘‘(i) educate families regarding the re5 lationship between nutrition, eating habits, 

6 physical activity, and obesity; 

7 ‘‘(ii) educate families about effective 

8 strategies to improve nutrition, establish 

9 healthy eating patterns, and establish ap10 propriate levels of physical activity; and 

11 ‘‘(iii) educate and guide parents re12 garding the ability to model and commu13 nicate positive health behaviors. 

14 ‘‘(4) PRIORITY.—In awarding grants under 

15 paragraph (1), the Secretary shall give priority to 

16 awarding grants to eligible entities— 

17 ‘‘(A) that demonstrate that they have pre18 viously applied successfully for funds to carry 

19 out activities that seek to promote individual 

20 and community health and to prevent the inci21 dence of chronic disease and that can cite pub22 lished and peer-reviewed research dem23 onstrating that the activities that the entities 

24 propose to carry out with funds made available 

25 under the grant are effective; 


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1 ‘‘(B) that will carry out programs or ac2 tivities that seek to accomplish a goal or goals 

3 set by the State in the Healthy People 2010 

4 plan of the State; 

5 ‘‘(C) that provide non-Federal contribu6 tions, either in cash or in-kind, to the costs of 

7 funding activities under the grants; 

8 ‘‘(D) that develop comprehensive plans 

9 that include a strategy for extending program 

10 activities developed under grants in the years 

11 following the fiscal years for which they receive 

12 grants under this subsection; 

13 ‘‘(E) located in communities that are medi14 cally underserved, as determined by the Sec15 retary; 

16 ‘‘(F) located in areas in which the average 

17 poverty rate is at least 150 percent or higher of 

18 the average poverty rate in the State involved, 

19 as determined by the Secretary; and 

20 ‘‘(G) that submit plans that exhibit multi21 sectoral, cooperative conduct that includes the 

22 involvement of a broad range of stakeholders, 

23 including— 

24 ‘‘(i) community-based organizations; 

25 ‘‘(ii) local governments; 


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1 ‘‘(iii) local educational agencies; 

2 ‘‘(iv) the private sector; 

3 ‘‘(v) State or local departments of 

4 health; 

5 ‘‘(vi) accredited colleges, universities, 

6 and community colleges; 

7 ‘‘(vii) health care providers; 

8 ‘‘(viii) State and local departments of 

9 transportation and city planning; and 

10 ‘‘(ix) other entities determined appro11 priate by the Secretary. 

12 ‘‘(5) PROGRAM DESIGN.— 

13 ‘‘(A) INITIAL DESIGN.—Not later than 1 

14 year after the date of enactment of the Chil15 dren’s Health Insurance Program Reauthoriza16 tion Act of 2009, the Secretary shall design the 

17 demonstration project. The demonstration 

18 should draw upon promising, innovative models 

19 and incentives to reduce behavioral risk factors. 

20 The Administrator of the Centers for Medicare 

21 & Medicaid Services shall consult with the Di22 rector of the Centers for Disease Control and 

23 Prevention, the Director of the Office of Minor24 ity Health, the heads of other agencies in the 

25 Department of Health and Human Services, 


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1 and such professional organizations, as the Sec2 retary determines to be appropriate, on the de3 sign, conduct, and evaluation of the demonstra4 tion. 

5 ‘‘(B) NUMBER AND PROJECT AREAS.—Not 

6 later than 2 years after the date of enactment 

7 of the Children’s Health Insurance Program 

8 Reauthorization Act of 2009, the Secretary 

9 shall award 1 grant that is specifically designed 

10 to determine whether programs similar to pro11 grams to be conducted by other grantees under 

12 this subsection should be implemented with re13 spect to the general population of children who 

14 are eligible for child health assistance under 

15 State child health plans under title XXI in 

16 order to reduce the incidence of childhood obe17 sity among such population. 

18 ‘‘(6) REPORT TO CONGRESS.—Not later than 3 

19 years after the date the Secretary implements the 

20 demonstration project under this subsection, the 

21 Secretary shall submit to Congress a report that de22 scribes the project, evaluates the effectiveness and 

23 cost effectiveness of the project, evaluates the bene24 ficiary satisfaction under the project, and includes 


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1 any such other information as the Secretary deter2 mines to be appropriate. 

3 ‘‘(7) DEFINITIONS.—In this subsection: 

4 ‘‘(A) FEDERALLY-QUALIFIED HEALTH

5 CENTER.—The term ‘Federally-qualified health 

6 center’ has the meaning given that term in sec7 tion 1905(l)(2)(B). 

8 ‘‘(B) INDIAN TRIBE.—The term ‘Indian 

9 tribe’ has the meaning given that term in sec10 tion 4 of the Indian Health Care Improvement 

11 Act (25 U.S.C. 1603). 

12 ‘‘(C) SELF-ASSESSMENT.—The term ‘self13 assessment’ means a form that— 

14 ‘‘(i) includes questions regarding— 

15 ‘‘(I) behavioral risk factors; 

16 ‘‘(II) needed preventive and 

17 screening services; and 

18 ‘‘(III) target individuals’ pref19 erences for receiving follow-up infor20 mation; 

21 ‘‘(ii) is assessed using such computer 

22 generated assessment programs; and 

23 ‘‘(iii) allows for the provision of such 

24 ongoing support to the individual as the 

25 Secretary determines appropriate. 


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1 ‘‘(D) ONGOING SUPPORT.—The term ‘on2 going support’ means— 

3 ‘‘(i) to provide any target individual 

4 with information, feedback, health coach5 ing, and recommendations regarding— 

6 ‘‘(I) the results of a self-assess7 ment given to the individual; 

8 ‘‘(II) behavior modification based 

9 on the self-assessment; and 

10 ‘‘(III) any need for clinical pre11 ventive and screening services or 

12 treatment including medical nutrition 

13 therapy; 

14 ‘‘(ii) to provide any target individual 

15 with referrals to community resources and 

16 programs available to assist the target in17 dividual in reducing health risks; and 

18 ‘‘(iii) to provide the information de19 scribed in clause (i) to a health care pro20 vider, if designated by the target individual 

21 to receive such information. 

22 ‘‘(8) AUTHORIZATION OF APPROPRIATIONS.— 

23 There is authorized to be appropriated to carry out 

24 this subsection, $25,000,000 for the period of fiscal 

25 years 2009 through 2013. 


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1 ‘‘(f) DEVELOPMENT OF MODEL ELECTRONIC

2 HEALTH RECORD FORMAT FOR CHILDREN ENROLLED IN

3 MEDICAID OR CHIP.— 

4 ‘‘(1) IN GENERAL.—Not later than January 1, 

5 2010, the Secretary shall establish a program to en6 courage the development and dissemination of a 

7 model electronic health record format for children 

8 enrolled in the State plan under title XIX or the 

9 State child health plan under title XXI that is— 

10 ‘‘(A) subject to State laws, accessible to 

11 parents, caregivers, and other consumers for 

12 the sole purpose of demonstrating compliance 

13 with school or leisure activity requirements, 

14 such as appropriate immunizations or physicals; 

15 ‘‘(B) designed to allow interoperable ex16 changes that conform with Federal and State 

17 privacy and security requirements; 

18 ‘‘(C) structured in a manner that permits 

19 parents and caregivers to view and understand 

20 the extent to which the care their children re21 ceive is clinically appropriate and of high qual22 ity; and 

23 ‘‘(D) capable of being incorporated into, 

24 and otherwise compatible with, other standards 

25 developed for electronic health records. 


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1 ‘‘(2) FUNDING.—$5,000,000 of the amount ap2 propriated under subsection (i) for a fiscal year shall 

3 be used to carry out this subsection. 

4 ‘‘(g) STUDY OF PEDIATRIC HEALTH AND HEALTH

5 CARE QUALITY MEASURES.— 

6 ‘‘(1) IN GENERAL.—Not later than July 1, 

7 2010, the Institute of Medicine shall study and re8 port to Congress on the extent and quality of efforts 

9 to measure child health status and the quality of 

10 health care for children across the age span and in 

11 relation to preventive care, treatments for acute con12 ditions, and treatments aimed at ameliorating or 

13 correcting physical, mental, and developmental con14 ditions in children. In conducting such study and 

15 preparing such report, the Institute of Medicine 

16 shall— 

17 ‘‘(A) consider all of the major national 

18 population-based reporting systems sponsored 

19 by the Federal Government that are currently 

20 in place, including reporting requirements 

21 under Federal grant programs and national 

22 population surveys and estimates conducted di23 rectly by the Federal Government; 

24 ‘‘(B) identify the information regarding 

25 child health and health care quality that each 


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1 system is designed to capture and generate, the 

2 study and reporting periods covered by each 

3 system, and the extent to which the information 

4 so generated is made widely available through 

5 publication; 

6 ‘‘(C) identify gaps in knowledge related to 

7 children’s health status, health disparities 

8 among subgroups of children, the effects of so9 cial conditions on children’s health status and 

10 use and effectiveness of health care, and the re11 lationship between child health status and fam12 ily income, family stability and preservation, 

13 and children’s school readiness and educational 

14 achievement and attainment; and 

15 ‘‘(D) make recommendations regarding im16 proving and strengthening the timeliness, qual17 ity, and public transparency and accessibility of 

18 information about child health and health care 

19 quality. 

20 ‘‘(2) FUNDING.—Up to $1,000,000 of the 

21 amount appropriated under subsection (i) for a fis22 cal year shall be used to carry out this subsection. 

23 ‘‘(h) RULE OF CONSTRUCTION.—Notwithstanding 

24 any other provision in this section, no evidence based qual25 ity measure developed, published, or used as a basis of 


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1 measurement or reporting under this section may be used 

2 to establish an irrebuttable presumption regarding either 

3 the medical necessity of care or the maximum permissible 

4 coverage for any individual child who is eligible for and 

5 receiving medical assistance under title XIX or child 

6 health assistance under title XXI. 

7 ‘‘(i) APPROPRIATION.—Out of any funds in the 

8 Treasury not otherwise appropriated, there is appro9 priated for each of fiscal years 2009 through 2013, 

10 $45,000,000 for the purpose of carrying out this section 

11 (other than subsection (e)). Funds appropriated under 

12 this subsection shall remain available until expended.’’. 

13 (b) INCREASED MATCHING RATE FOR COLLECTING

14 AND REPORTING ON CHILD HEALTH MEASURES.—Sec15 tion 1903(a)(3)(A) (42 U.S.C. 1396b(a)(3)(A)), is amend16 ed— 

17 (1) by striking ‘‘and’’ at the end of clause (i); 

18 and 

19 (2) by adding at the end the following new 

20 clause: 

21 ‘‘(iii) an amount equal to the Federal med22 ical assistance percentage (as defined in section 

23 1905(b)) of so much of the sums expended dur24 ing such quarter (as found necessary by the 

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1 tration of the State plan) as are attributable to 

2 such developments or modifications of systems 

3 of the type described in clause (i) as are nec4 essary for the efficient collection and reporting 

5 on child health measures; and’’. 

6 SEC. 402. IMPROVED AVAILABILITY OF PUBLIC INFORMA7 TION REGARDING ENROLLMENT OF CHIL8 DREN IN CHIP AND MEDICAID. 

9 (a) INCLUSION OF PROCESS AND ACCESS MEASURES

10 IN ANNUAL STATE REPORTS.—Section 2108 (42 U.S.C. 

11 1397hh) is amended— 

12 (1) in subsection (a), in the matter preceding 

13 paragraph (1), by striking ‘‘The State’’ and insert14 ing ‘‘Subject to subsection (e), the State’’; and 

15 (2) by adding at the end the following new sub16 section: 

17 ‘‘(e) INFORMATION REQUIRED FOR INCLUSION IN

18 STATE ANNUAL REPORT.—The State shall include the fol19 lowing information in the annual report required under 

20 subsection (a): 

21 ‘‘(1) Eligibility criteria, enrollment, and reten22 tion data (including data with respect to continuity 

23 of coverage or duration of benefits). 

24 ‘‘(2) Data regarding the extent to which the 

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1 mining the eligibility of children under the State 

2 child health plan, including measures such as 12- 

3 month continuous eligibility, self-declaration of in4 come for applications or renewals, or presumptive 

5 eligibility. 

6 ‘‘(3) Data regarding denials of eligibility and 

7 redeterminations of eligibility. 

8 ‘‘(4) Data regarding access to primary and spe9 cialty services, access to networks of care, and care 

10 coordination provided under the State child health 

11 plan, using quality care and consumer satisfaction 

12 measures included in the Consumer Assessment of 

13 Healthcare Providers and Systems (CAHPS) survey. 

14 ‘‘(5) If the State provides child health assist15 ance in the form of premium assistance for the pur16 chase of coverage under a group health plan, data 

17 regarding the provision of such assistance, including 

18 the extent to which employer-sponsored health insur19 ance coverage is available for children eligible for 

20 child health assistance under the State child health 

21 plan, the range of the monthly amount of such as22 sistance provided on behalf of a child or family, the 

23 number of children or families provided such assist24 ance on a monthly basis, the income of the children 

25 or families provided such assistance, the benefits 


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1 and cost-sharing protection provided under the State 

2 child health plan to supplement the coverage pur3 chased with such premium assistance, the effective 

4 strategies the State engages in to reduce any admin5 istrative barriers to the provision of such assistance, 

6 and, the effects, if any, of the provision of such as7 sistance on preventing the coverage provided under 

8 the State child health plan from substituting for cov9 erage provided under employer-sponsored health in10 surance offered in the State. 

11 ‘‘(6) To the extent applicable, a description of 

12 any State activities that are designed to reduce the 

13 number of uncovered children in the State, including 

14 through a State health insurance connector program 

15 or support for innovative private health coverage ini16 tiatives.’’. 

17 (b) STANDARDIZED REPORTING FORMAT.— 

18 (1) IN GENERAL.—Not later than 1 year after 

19 the date of enactment of this Act, the Secretary 

20 shall specify a standardized format for States to use 

21 for reporting the information required under section 

22 2108(e) of the Social Security Act, as added by sub23 section (a)(2). 

24 (2) TRANSITION PERIOD FOR STATES.—Each 

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1 section (a) of section 2108 of the Social Security Act 

2 that includes the information required under sub3 section (e) of such section may use up to 3 reporting 

4 periods to transition to the reporting of such infor5 mation in accordance with the standardized format 

6 specified by the Secretary under paragraph (1). 

7 (c) ADDITIONAL FUNDING FOR THE SECRETARY TO

8 IMPROVE TIMELINESS OF DATA REPORTING AND ANAL9 YSIS FOR PURPOSES OF DETERMINING ENROLLMENT IN10 CREASES UNDER MEDICAID AND CHIP.— 

11 (1) APPROPRIATION.—There is appropriated, 

12 out of any money in the Treasury not otherwise ap13 propriated, $5,000,000 to the Secretary for fiscal 

14 year 2009 for the purpose of improving the timeli15 ness of the data reported and analyzed from the 

16 Medicaid Statistical Information System (MSIS) for 

17 purposes of providing more timely data on enroll18 ment and eligibility of children under Medicaid and 

19 CHIP and to provide guidance to States with re20 spect to any new reporting requirements related to 

21 such improvements. Amounts appropriated under 

22 this paragraph shall remain available until expended. 

23 (2) REQUIREMENTS.—The improvements made 

24 by the Secretary under paragraph (1) shall be de25 signed and implemented (including with respect to 


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1 any necessary guidance for States to report such in2 formation in a complete and expeditious manner) so 

3 that, beginning no later than October 1, 2009, data 

4 regarding the enrollment of low-income children (as 

5 defined in section 2110(c)(4) of the Social Security 

6 Act (42 U.S.C. 1397jj(c)(4)) of a State enrolled in 

7 the State plan under Medicaid or the State child 

8 health plan under CHIP with respect to a fiscal year 

9 shall be collected and analyzed by the Secretary 

10 within 6 months of submission. 

11 (d) GAO STUDY AND REPORT ON ACCESS TO PRI12 MARY AND SPECIALITY SERVICES.— 

13 (1) IN GENERAL.—The Comptroller General of 

14 the United States shall conduct a study of children’s 

15 access to primary and specialty services under Med16 icaid and CHIP, including— 

17 (A) the extent to which providers are will18 ing to treat children eligible for such programs; 

19 (B) information on such children’s access 

20 to networks of care; 

21 (C) geographic availability of primary and 

22 specialty services under such programs; 

23 (D) the extent to which care coordination 

24 is provided for children’s care under Medicaid 

25 and CHIP; and 


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1 (E) as appropriate, information on the de2 gree of availability of services for children under 

3 such programs. 

4 (2) REPORT.—Not later than 2 years after the 

5 date of enactment of this Act, the Comptroller Gen6 eral shall submit a report to the Committee on Fi7 nance of the Senate and the Committee on Energy 

8 and Commerce of the House of Representatives on 

9 the study conducted under paragraph (1) that in10 cludes recommendations for such Federal and State 

11 legislative and administrative changes as the Comp12 troller General determines are necessary to address 

13 any barriers to access to children’s care under Med14 icaid and CHIP that may exist. 

15 SEC. 403. APPLICATION OF CERTAIN MANAGED CARE 

16 QUALITY SAFEGUARDS TO CHIP. 

17 (a) IN GENERAL.—Section 2103(f) of Social Security 

18 Act (42 U.S.C. 1397bb(f)) is amended by adding at the 

19 end the following new paragraph: 

20 ‘‘(3) COMPLIANCE WITH MANAGED CARE RE21 QUIREMENTS.—The State child health plan shall 

22 provide for the application of subsections (a)(4), 

23 (a)(5), (b), (c), (d), and (e) of section 1932 (relating 

24 to requirements for managed care) to coverage, 

25 State agencies, enrollment brokers, managed care 


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1 entities, and managed care organizations under this 

2 title in the same manner as such subsections apply 

3 to coverage and such entities and organizations 

4 under title XIX.’’. 

5 (b) EFFECTIVE DATE.—The amendment made by 

6 subsection (a) shall apply to contract years for health 

7 plans beginning on or after July 1, 2009. 

8 TITLE V—IMPROVING ACCESS 

9 TO BENEFITS 

10 SEC. 501. DENTAL BENEFITS. 

11 (a) COVERAGE.— 

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

13 1397cc) is amended— 

14 (A) in subsection (a)— 

15 (i) in the matter before paragraph 

16 (1), by striking ‘‘subsection (c)(5)’’ and in17 serting ‘‘paragraphs (5) and (7) of sub18 section (c)’’; and 

19 (ii) in paragraph (1), by inserting ‘‘at 

20 least’’ after ‘‘that is’’; and 

21 (B) in subsection (c)— 

22 (i) by redesignating paragraph (5) as 

23 paragraph (7); and 

24 (ii) by inserting after paragraph (4), 

25 the following: 


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1 ‘‘(5) DENTAL BENEFITS.— 

2 ‘‘(A) IN GENERAL.—The child health as3 sistance provided to a targeted low-income child 

4 shall include coverage of dental services nec5 essary to prevent disease and promote oral 

6 health, restore oral structures to health and 

7 function, and treat emergency conditions. 

8 ‘‘(B) PERMITTING USE OF DENTAL

9 BENCHMARK PLANS BY CERTAIN STATES.—A 

10 State may elect to meet the requirement of sub11 paragraph (A) through dental coverage that is 

12 equivalent to a benchmark dental benefit pack13 age described in subparagraph (C). 

14 ‘‘(C) BENCHMARK DENTAL BENEFIT PACK15 AGES.—The benchmark dental benefit packages 

16 are as follows: 

17 ‘‘(i) FEHBP CHILDREN’S DENTAL

18 COVERAGE.—A dental benefits plan under 

19 chapter 89A of title 5, United States Code, 

20 that has been selected most frequently by 

21 employees seeking dependent coverage, 

22 among such plans that provide such de23 pendent coverage, in either of the previous 

24 2 plan years. 


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1 ‘‘(ii) STATE EMPLOYEE DEPENDENT

2 DENTAL COVERAGE.—A dental benefits 

3 plan that is offered and generally available 

4 to State employees in the State involved 

5 and that has been selected most frequently 

6 by employees seeking dependent coverage, 

7 among such plans that provide such de8 pendent coverage, in either of the previous 

9 2 plan years. 

10 ‘‘(iii) COVERAGE OFFERED THROUGH

11 COMMERCIAL DENTAL PLAN.—A dental 

12 benefits plan that has the largest insured 

13 commercial, non-medicaid enrollment of 

14 dependent covered lives of such plans that 

15 is offered in the State involved.’’. 

16 (2) ASSURING ACCESS TO CARE.—Section 

17 2102(a)(7)(B) (42 U.S.C. 1397bb(c)(2)) is amended 

18 by inserting ‘‘and services described in section 

19 2103(c)(5)’’ after ‘‘emergency services’’. 

20 (3) EFFECTIVE DATE.—The amendments made 

21 by paragraphs (1) and (2) shall apply to coverage of 

22 items and services furnished on or after October 1, 

23 2009. 

24 (b) STATE OPTION TO PROVIDE DENTAL-ONLY SUP25 PLEMENTAL COVERAGE.— 


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1 (1) IN GENERAL.——Section 2110(b) (42 

2 U.S.C. 1397jj(b)) is amended— 

3 (A) in paragraph (1)(C), by inserting ‘‘, 

4 subject to paragraph (5),’’ after ‘‘under title 

5 XIX or’’; and 

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

7 paragraph: 

8 ‘‘(5) STATE OPTION TO PROVIDE DENTAL-ONLY

9 SUPPLEMENTAL COVERAGE.— 

10 ‘‘(A) IN GENERAL.—Subject to subpara11 graphs (B) and (C), in the case of any child 

12 who is enrolled in a group health plan or health 

13 insurance coverage offered through an employer 

14 who would, but for the application of paragraph 

15 (1)(C), satisfy the requirements for being a tar16 geted low-income child under the State child 

17 health plan, a State may waive the application 

18 of such paragraph to the child in order to pro19 vide— 

20 ‘‘(i) dental coverage consistent with 

21 the requirements of subsection (c)(5) of 

22 section 2103; or 

23 ‘‘(ii) cost-sharing protection for dental 

24 coverage consistent with such requirements 


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1 and the requirements of subsection 

2 (e)(3)(B) of such section. 

3 ‘‘(B) LIMITATION.—A State may limit the 

4 application of a waiver of paragraph (1)(C) to 

5 children whose family income does not exceed a 

6 level specified by the State, so long as the level 

7 so specified does not exceed the maximum in8 come level otherwise established for other chil9 dren under the State child health plan. 

10 ‘‘(C) CONDITIONS.—A State may not offer 

11 dental-only supplemental coverage under this 

12 paragraph unless the State satisfies the fol13 lowing conditions: 

14 ‘‘(i) INCOME ELIGIBILITY.—The State 

15 child health plan (whether implemented 

16 under title XIX or this title)— 

17 ‘‘(I) has the highest income eligi18 bility standard permitted under this 

19 title (or a waiver) as of January 1, 

20 2009; 

21 ‘‘(II) does not limit the accept22 ance of applications for children or 

23 impose any numerical limitation, wait24 ing list, or similar limitation on the 

25 eligibility of such children for child 


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1 health assistance under such State 

2 plan; and 

3 ‘‘(III) provides benefits to all 

4 children in the State who apply for 

5 and meet eligibility standards. 

6 ‘‘(ii) NO MORE FAVORABLE TREAT7 MENT.—The State child health plan may 

8 not provide more favorable dental coverage 

9 or cost-sharing protection for dental cov10 erage to children provided dental-only sup11 plemental coverage under this paragraph 

12 than the dental coverage and cost-sharing 

13 protection for dental coverage provided to 

14 targeted low-income children who are eligi15 ble for the full range of child health assist16 ance provided under the State child health 

17 plan.’’. 

18 (2) STATE OPTION TO WAIVE WAITING PE19 RIOD.—Section 2102(b)(1)(B) (42 U.S.C. 

20 1397bb(b)(1)(B)), as amended by section 111(b)(2), 

21 is amended— 

22 (A) in clause (ii), by striking ‘‘and’’ at the 

23 end; 

24 (B) in clause (iii), by striking the period 

25 and inserting ‘‘; and’’; and 


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

2 clause: 

3 ‘‘(iv) at State option, may not apply a 

4 waiting period in the case of a child pro5 vided dental-only supplemental coverage 

6 under section 2110(b)(5).’’. 

7 (3) APPLICATION OF ENHANCED MATCH UNDER

8 MEDICAID.—Section 1905 (42 U.S.C. 1396d) is 

9 amended— 

10 (A) in subsection (b), in the fourth sen11 tence, by striking ‘‘or subsection (u)(3)’’ and 

12 inserting ‘‘, (u)(3), or (u)(4)’’; and 

13 (B) in subsection (u)— 

14 (i) by redesignating paragraph (4) as 

15 paragraph (5); and 

16 (ii) by inserting after paragraph (3) 

17 the following new paragraph: 

18 ‘‘(4) For purposes of subsection (b), the ex19 penditures described in this paragraph are expendi20 tures for dental-only supplemental coverage for chil21 dren described in section 2110(b)(5).’’. 

22 (c) DENTAL EDUCATION FOR PARENTS OF

23 NEWBORNS.—The Secretary shall develop and implement, 

24 through entities that fund or provide perinatal care serv25 ices to targeted low-income children under a State child 


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1 health plan under title XXI of the Social Security Act, 

2 a program to deliver oral health educational materials that 

3 inform new parents about risks for, and prevention of, 

4 early childhood caries and the need for a dental visit with5 in their newborn’s first year of life. 

6 (d) PROVISION OF DENTAL SERVICES THROUGH

7 FQHCS.— 

8 (1) MEDICAID.—Section 1902(a) (42 U.S.C. 

9 1396a(a)) is amended— 

10 (A) by striking ‘‘and’’ at the end of para11 graph (70); 

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

13 paragraph (71) and inserting ‘‘; and’’; and 

14 (C) by inserting after paragraph (71) the 

15 following new paragraph: 

16 ‘‘(72) provide that the State will not prevent a 

17 Federally-qualified health center from entering into 

18 contractual relationships with private practice dental 

19 providers in the provision of Federally-qualified 

20 health center services.’’. 

21 (2) CHIP.—Section 2107(e)(1) (42 U.S.C. 

22 1397g(e)(1)), as amended by subsections (a)(2) and 

23 (d)(2) of section 203, is amended by inserting after 

24 subparagraph (B) the following new subparagraph 


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1 (and redesignating the succeeding subparagraphs ac2 cordingly): 

3 ‘‘(C) Section 1902(a)(72) (relating to lim4 iting FQHC contracting for provision of dental 

5 services).’’. 

6 (3) EFFECTIVE DATE.—The amendments made 

7 by this subsection shall take effect on January 1, 

8 2009. 

9 (e) REPORTING INFORMATION ON DENTAL

10 HEALTH.— 

11 (1) MEDICAID.—Section 1902(a)(43)(D)(iii) 

12 (42 U.S.C. 1396a(a)(43)(D)(iii)) is amended by in13 serting ‘‘and other information relating to the provi14 sion of dental services to such children described in 

15 section 2108(e)’’ after ‘‘receiving dental services,’’. 

16 (2) CHIP.—Section 2108 (42 U.S.C. 1397hh) 

17 is amended by adding at the end the following new 

18 subsection: 

19 ‘‘(e) INFORMATION ON DENTAL CARE FOR CHIL20 DREN.— 

21 ‘‘(1) IN GENERAL.—Each annual report under 

22 subsection (a) shall include the following information 

23 with respect to care and services described in section 

24 1905(r)(3) provided to targeted low-income children 


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1 enrolled in the State child health plan under this 

2 title at any time during the year involved: 

3 ‘‘(A) The number of enrolled children by 

4 age grouping used for reporting purposes under 

5 section 1902(a)(43). 

6 ‘‘(B) For children within each such age 

7 grouping, information of the type contained in 

8 questions 12(a)–(c) of CMS Form 416 (that 

9 consists of the number of enrolled targeted low 

10 income children who receive any, preventive, or 

11 restorative dental care under the State plan). 

12 ‘‘(C) For the age grouping that includes 

13 children 8 years of age, the number of such 

14 children who have received a protective sealant 

15 on at least one permanent molar tooth. 

16 ‘‘(2) INCLUSION OF INFORMATION ON ENROLL17 EES IN MANAGED CARE PLANS.—The information 

18 under paragraph (1) shall include information on 

19 children who are enrolled in managed care plans and 

20 other private health plans and contracts with such 

21 plans under this title shall provide for the reporting 

22 of such information by such plans to the State.’’. 

23 (3) EFFECTIVE DATE.—The amendments made 

24 by this subsection shall be effective for annual reVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00222 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 ports submitted for years beginning after date of en2 actment. 

3 (f) IMPROVED ACCESSIBILITY OF DENTAL PROVIDER

4 INFORMATION TO ENROLLEES UNDER MEDICAID AND

5 CHIP.—The Secretary shall— 

6 (1) work with States, pediatric dentists, and 

7 other dental providers (including providers that are, 

8 or are affiliated with, a school of dentistry) to in9 clude, not later than 6 months after the date of the 

10 enactment of this Act, on the Insure Kids Now 

11 website (http://www.insurekidsnow.gov/) and hotline 

12 (1–877–KIDS–NOW) (or on any successor websites 

13 or hotlines) a current and accurate list of all such 

14 dentists and providers within each State that provide 

15 dental services to children enrolled in the State plan 

16 (or waiver) under Medicaid or the State child health 

17 plan (or waiver) under CHIP, and shall ensure that 

18 such list is updated at least quarterly; and 

19 (2) work with States to include, not later than 

20 6 months after the date of the enactment of this 

21 Act, a description of the dental services provided 

22 under each State plan (or waiver) under Medicaid 

23 and each State child health plan (or waiver) under 

24 CHIP on such Insure Kids Now website, and shall 

25 ensure that such list is updated at least annually. 


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1 (g) INCLUSION OF STATUS OF EFFORTS TO IMPROVE

2 DENTAL CARE IN REPORTS ON THE QUALITY OF CHIL3 DREN’S HEALTH CARE UNDER MEDICAID AND CHIP.— 

4 Section 1139A(a), as added by section 401(a), is amend5 ed— 

6 (1) in paragraph (3)(B)(ii), by inserting ‘‘and, 

7 with respect to dental care, conditions requiring the 

8 restoration of teeth, relief of pain and infection, and 

9 maintenance of dental health’’ after ‘‘chronic condi10 tions’’; and 

11 (2) in paragraph (6)(A)(ii), by inserting ‘‘dental 

12 care,’’ after ‘‘preventive health services,’’. 

13 (h) GAO STUDY AND REPORT.— 

14 (1) STUDY.—The Comptroller General of the 

15 United States shall provide for a study that exam16 ines— 

17 (A) access to dental services by children in 

18 underserved areas; 

19 (B) children’s access to oral health care, 

20 including preventive and restorative services, 

21 under Medicaid and CHIP, including— 

22 (i) the extent to which dental pro23 viders are willing to treat children eligible 

24 for such programs; 


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1 (ii) information on such children’s ac2 cess to networks of care, including such 

3 networks that serve special needs children; 

4 and 

5 (iii) geographic availability of oral 

6 health care, including preventive and re7 storative services, under such programs; 

8 and 

9 (C) the feasibility and appropriateness of 

10 using qualified mid-level dental health pro11 viders, in coordination with dentists, to improve 

12 access for children to oral health services and 

13 public health overall. 

14 (2) REPORT.—Not later than 18 months year 

15 after the date of the enactment of this Act, the 

16 Comptroller General shall submit to Congress a re17 port on the study conducted under paragraph (1). 

18 The report shall include recommendations for such 

19 Federal and State legislative and administrative 

20 changes as the Comptroller General determines are 

21 necessary to address any barriers to access to oral 

22 health care, including preventive and restorative 

23 services, under Medicaid and CHIP that may exist. 


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1 SEC. 502. MENTAL HEALTH PARITY IN CHIP PLANS. 

2 (a) ASSURANCE OF PARITY.—Section 2103(c) (42 

3 U.S.C. 1397cc(c)), as amended by section 501(a)(1)(B), 

4 is amended by inserting after paragraph (5), the following: 

5 ‘‘(6) MENTAL HEALTH SERVICES PARITY.— 

6 ‘‘(A) IN GENERAL.—In the case of a State 

7 child health plan that provides both medical 

8 and surgical benefits and mental health or sub9 stance use disorder benefits, such plan shall en10 sure that the financial requirements and treat11 ment limitations applicable to such mental 

12 health or substance use disorder benefits com13 ply with the requirements of section 2705(a) of 

14 the Public Health Service Act in the same man15 ner as such requirements apply to a group 

16 health plan. 

17 ‘‘(B) DEEMED COMPLIANCE.—To the ex18 tent that a State child health plan includes cov19 erage with respect to an individual described in 

20 section 1905(a)(4)(B) and covered under the 

21 State plan under section 1902(a)(10)(A) of the 

22 services described in section 1905(a)(4)(B) (re23 lating to early and periodic screening, diag24 nostic, and treatment services defined in section 

25 1905(r)) and provided in accordance with secVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00226 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 tion 1902(a)(43), such plan shall be deemed to 

2 satisfy the requirements of subparagraph (A).’’. 

3 (b) CONFORMING AMENDMENTS.—Section 2103 (42 

4 U.S.C. 1397cc) is amended— 

5 (1) in subsection (a), as amended by section 

6 501(a)(1)(A)(i), in the matter preceding paragraph 

7 (1), by inserting ‘‘, (6),’’ after ‘‘(5)’’; and 

8 (2) in subsection (c)(2), by striking subpara9 graph (B) and redesignating subparagraphs (C) and 

10 (D) as subparagraphs (B) and (C), respectively. 

11 SEC. 503. APPLICATION OF PROSPECTIVE PAYMENT SYS12 TEM FOR SERVICES PROVIDED BY FEDER13 ALLY-QUALIFIED HEALTH CENTERS AND 

14 RURAL HEALTH CLINICS. 

15 (a) APPLICATION OF PROSPECTIVE PAYMENT SYS16 TEM.— 

17 (1) IN GENERAL.—Section 2107(e)(1) (42 

18 U.S.C. 1397gg(e)(1)), as amended by section 

19 501(c)(2) is amended by inserting after subpara20 graph (C) the following new subparagraph (and re21 designating the succeeding subparagraphs accord22 ingly): 

23 ‘‘(D) Section 1902(bb) (relating to pay24 ment for services provided by Federally-quali25 fied health centers and rural health clinics).’’. 


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1 (2) EFFECTIVE DATE.—The amendment made 

2 by paragraph (1) shall apply to services provided on 

3 or after October 1, 2009. 

4 (b) TRANSITION GRANTS.— 

5 (1) APPROPRIATION.—Out of any funds in the 

6 Treasury not otherwise appropriated, there is appro7 priated to the Secretary for fiscal year 2009, 

8 $5,000,000, to remain available until expended, for 

9 the purpose of awarding grants to States with State 

10 child health plans under CHIP that are operated 

11 separately from the State Medicaid plan under title 

12 XIX of the Social Security Act (including any waiver 

13 of such plan), or in combination with the State Med14 icaid plan, for expenditures related to transitioning 

15 to compliance with the requirement of section 

16 2107(e)(1)(D) of the Social Security Act (as added 

17 by subsection (a)) to apply the prospective payment 

18 system established under section 1902(bb) of the 

19 such Act (42 U.S.C. 1396a(bb)) to services provided 

20 by Federally-qualified health centers and rural 

21 health clinics. 

22 (2) MONITORING AND REPORT.—The Secretary 

23 shall monitor the impact of the application of such 

24 prospective payment system on the States described 

25 in paragraph (1) and, not later than October 1, 


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1 2011, shall report to Congress on any effect on ac2 cess to benefits, provider payment rates, or scope of 

3 benefits offered by such States as a result of the ap4 plication of such payment system. 

5 SEC. 504. PREMIUM GRACE PERIOD. 

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

7 1397cc(e)(3)) is amended by adding at the end the fol8 lowing new subparagraph: 

9 ‘‘(C) PREMIUM GRACE PERIOD.—The State 

10 child health plan— 

11 ‘‘(i) shall afford individuals enrolled 

12 under the plan a grace period of at least 

13 30 days from the beginning of a new cov14 erage period to make premium payments 

15 before the individual’s coverage under the 

16 plan may be terminated; and 

17 ‘‘(ii) shall provide to such an indi18 vidual, not later than 7 days after the first 

19 day of such grace period, notice— 

20 ‘‘(I) that failure to make a pre21 mium payment within the grace pe22 riod will result in termination of cov23 erage under the State child health 

24 plan; and 


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1 ‘‘(II) of the individual’s right to 

2 challenge the proposed termination 

3 pursuant to the applicable Federal 

4 regulations. 

5 For purposes of clause (i), the term ‘new cov6 erage period’ means the month immediately fol7 lowing the last month for which the premium 

8 has been paid.’’. 

9 (b) EFFECTIVE DATE.—The amendment made by 

10 subsection (a) shall apply to new coverage periods begin11 ning on or after the date of the enactment of this Act. 

12 SEC. 505. CLARIFICATION OF COVERAGE OF SERVICES 

13 PROVIDED THROUGH SCHOOL-BASED 

14 HEALTH CENTERS. 

15 (a) IN GENERAL.—Section 2103(c) (42 U.S.C. 

16 1397cc(c)), as amended by section 501(a)(1)(B), is 

17 amended by adding at the end the following new para18 graph: 

19 ‘‘(8) AVAILABILITY OF COVERAGE FOR ITEMS

20 AND SERVICES FURNISHED THROUGH SCHOOL21 BASED HEALTH CENTERS.—Nothing in this title 

22 shall be construed as limiting a State’s ability to 

23 provide child health assistance for covered items and 

24 services that are furnished through school-based 

25 health centers (as defined in section 2110(c)(9)).’’. 


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1 (b) DEFINITION.—Section 2110(c) (42 U.S.C. 

2 1397jj) is amended by adding at the end the following: 

3 ‘‘(9) SCHOOL-BASED HEALTH CENTER.— 

4 ‘‘(A) IN GENERAL.—The term ‘school5 based health center’ means a health clinic 

6 that— 

7 ‘‘(i) is located in or near a school fa8 cility of a school district or board or of an 

9 Indian tribe or tribal organization; 

10 ‘‘(ii) is organized through school, com11 munity, and health provider relationships; 

12 ‘‘(iii) is administered by a sponsoring 

13 facility; 

14 ‘‘(iv) provides through health profes15 sionals primary health services to children 

16 in accordance with State and local law, in17 cluding laws relating to licensure and cer18 tification; and 

19 ‘‘(v) satisfies such other requirements 

20 as a State may establish for the operation 

21 of such a clinic. 

22 ‘‘(B) SPONSORING FACILITY.—For pur23 poses of subparagraph (A)(iii), the term ‘spon24 soring facility’ includes any of the following: 

25 ‘‘(i) A hospital. 


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1 ‘‘(ii) A public health department. 

2 ‘‘(iii) A community health center. 

3 ‘‘(iv) A nonprofit health care agency. 

4 ‘‘(v) A school or school system. 

5 ‘‘(vi) A program administered by the 

6 Indian Health Service or the Bureau of In7 dian Affairs or operated by an Indian tribe 

8 or a tribal organization.’’. 

9 SEC. 506. MEDICAID AND CHIP PAYMENT AND ACCESS COM10 MISSION. 

11 (a) IN GENERAL.—Title XIX (42 U.S.C. 1396 et 

12 seq.) is amended by inserting before section 1901 the fol13 lowing new section: 

14 ‘‘MEDICAID AND CHIP PAYMENT AND ACCESS

15 COMMISSION

16 ‘‘SEC. 1900. (a) ESTABLISHMENT.—There is hereby 

17 established the Medicaid and CHIP Payment and Access 

18 Commission (in this section referred to as ‘MACPAC’). 

19 ‘‘(b) DUTIES.— 

20 ‘‘(1) REVIEW OF ACCESS POLICIES AND AN21 NUAL REPORTS.—MACPAC shall— 

22 ‘‘(A) review policies of the Medicaid pro23 gram established under this title (in this section 

24 referred to as ‘Medicaid’) and the State Chil25 dren’s Health Insurance Program established 

26 under title XXI (in this section referred to as 


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1 ‘CHIP’) affecting children’s access to covered 

2 items and services, including topics described in 

3 paragraph (2); 

4 ‘‘(B) make recommendations to Congress 

5 concerning such access policies; 

6 ‘‘(C) by not later than March 1 of each 

7 year (beginning with 2010), submit a report to 

8 Congress containing the results of such reviews 

9 and MACPAC’s recommendations concerning 

10 such policies; and 

11 ‘‘(D) by not later than June 1 of each year 

12 (beginning with 2010), submit a report to Con13 gress containing an examination of issues af14 fecting Medicaid and CHIP, including the im15 plications of changes in health care delivery in 

16 the United States and in the market for health 

17 care services on such programs. 

18 ‘‘(2) SPECIFIC TOPICS TO BE REVIEWED.—Spe19 cifically, MACPAC shall review and assess the fol20 lowing: 

21 ‘‘(A) MEDICAID AND CHIP PAYMENT POLI22 CIES.—Payment policies under Medicaid and 

23 CHIP, including— 

24 ‘‘(i) the factors affecting expenditures 

25 for items and services in different sectors, 


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1 including the process for updating hospital, 

2 skilled nursing facility, physician, Feder3 ally-qualified health center, rural health 

4 center, and other fees; 

5 ‘‘(ii) payment methodologies; and 

6 ‘‘(iii) the relationship of such factors 

7 and methodologies to access and quality of 

8 care for Medicaid and CHIP beneficiaries. 

9 ‘‘(B) INTERACTION OF MEDICAID AND

10 CHIP PAYMENT POLICIES WITH HEALTH CARE

11 DELIVERY GENERALLY.—The effect of Medicaid 

12 and CHIP payment policies on access to items 

13 and services for children and other Medicaid 

14 and CHIP populations other than under this 

15 title or title XXI and the implications of 

16 changes in health care delivery in the United 

17 States and in the general market for health 

18 care items and services on Medicaid and CHIP. 

19 ‘‘(C) OTHER ACCESS POLICIES.—The ef20 fect of other Medicaid and CHIP policies on ac21 cess to covered items and services, including 

22 policies relating to transportation and language 

23 barriers. 

24 ‘‘(3) CREATION OF EARLY-WARNING SYSTEM.— 

25 MACPAC shall create an early-warning system to 


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1 identify provider shortage areas or any other prob2 lems that threaten access to care or the health care 

3 status of Medicaid and CHIP beneficiaries. 

4 ‘‘(4) COMMENTS ON CERTAIN SECRETARIAL RE5 PORTS.—If the Secretary submits to Congress (or a 

6 committee of Congress) a report that is required by 

7 law and that relates to access policies, including with 

8 respect to payment policies, under Medicaid or 

9 CHIP, the Secretary shall transmit a copy of the re10 port to MACPAC. MACPAC shall review the report 

11 and, not later than 6 months after the date of sub12 mittal of the Secretary’s report to Congress, shall 

13 submit to the appropriate committees of Congress 

14 written comments on such report. Such comments 

15 may include such recommendations as MACPAC 

16 deems appropriate. 

17 ‘‘(5) AGENDA AND ADDITIONAL REVIEWS.— 

18 MACPAC shall consult periodically with the chair19 men and ranking minority members of the appro20 priate committees of Congress regarding MACPAC’s 

21 agenda and progress towards achieving the agenda. 

22 MACPAC may conduct additional reviews, and sub23 mit additional reports to the appropriate committees 

24 of Congress, from time to time on such topics relat25 ing to the program under this title or title XXI as 


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1 may be requested by such chairmen and members 

2 and as MACPAC deems appropriate. 

3 ‘‘(6) AVAILABILITY OF REPORTS.—MACPAC 

4 shall transmit to the Secretary a copy of each report 

5 submitted under this subsection and shall make such 

6 reports available to the public. 

7 ‘‘(7) APPROPRIATE COMMITTEE OF CON8 GRESS.—For purposes of this section, the term ‘ap9 propriate committees of Congress’ means the Com10 mittee on Energy and Commerce of the House of 

11 Representatives and the Committee on Finance of 

12 the Senate. 

13 ‘‘(8) VOTING AND REPORTING REQUIRE14 MENTS.—With respect to each recommendation con15 tained in a report submitted under paragraph (1), 

16 each member of MACPAC shall vote on the rec17 ommendation, and MACPAC shall include, by mem18 ber, the results of that vote in the report containing 

19 the recommendation. 

20 ‘‘(9) EXAMINATION OF BUDGET CON21 SEQUENCES.—Before making any recommendations, 

22 MACPAC shall examine the budget consequences of 

23 such recommendations, directly or through consulta24 tion with appropriate expert entities. 

25 ‘‘(c) MEMBERSHIP.— 


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1 ‘‘(1) NUMBER AND APPOINTMENT.—MACPAC 

2 shall be composed of 17 members appointed by the 

3 Comptroller General of the United States. 

4 ‘‘(2) QUALIFICATIONS.— 

5 ‘‘(A) IN GENERAL.—The membership of 

6 MACPAC shall include individuals who have 

7 had direct experience as enrollees or parents of 

8 enrollees in Medicaid or CHIP and individuals 

9 with national recognition for their expertise in 

10 Federal safety net health programs, health fi11 nance and economics, actuarial science, health 

12 facility management, health plans and inte13 grated delivery systems, reimbursement of 

14 health facilities, health information technology, 

15 pediatric physicians, dentists, and other pro16 viders of health services, and other related 

17 fields, who provide a mix of different profes18 sionals, broad geographic representation, and a 

19 balance between urban and rural representa20 tives. 

21 ‘‘(B) INCLUSION.—The membership of 

22 MACPAC shall include (but not be limited to) 

23 physicians and other health professionals, em24 ployers, third-party payers, and individuals with 

25 expertise in the delivery of health services. Such 


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1 membership shall also include consumers rep2 resenting children, pregnant women, the elderly, 

3 and individuals with disabilities, current or 

4 former representatives of State agencies respon5 sible for administering Medicaid, and current or 

6 former representatives of State agencies respon7 sible for administering CHIP. 

8 ‘‘(C) MAJORITY NONPROVIDERS.—Individ9 uals who are directly involved in the provision, 

10 or management of the delivery, of items and 

11 services covered under Medicaid or CHIP shall 

12 not constitute a majority of the membership of 

13 MACPAC. 

14 ‘‘(D) ETHICAL DISCLOSURE.—The Comp15 troller General of the United States shall estab16 lish a system for public disclosure by members 

17 of MACPAC of financial and other potential 

18 conflicts of interest relating to such members. 

19 Members of MACPAC shall be treated as em20 ployees of Congress for purposes of applying 

21 title I of the Ethics in Government Act of 1978 

22 (Public Law 95–521). 

23 ‘‘(3) TERMS.— 

24 ‘‘(A) IN GENERAL.—The terms of mem25 bers of MACPAC shall be for 3 years except 


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1 that the Comptroller General of the United 

2 States shall designate staggered terms for the 

3 members first appointed. 

4 ‘‘(B) VACANCIES.—Any member appointed 

5 to fill a vacancy occurring before the expiration 

6 of the term for which the member’s predecessor 

7 was appointed shall be appointed only for the 

8 remainder of that term. A member may serve 

9 after the expiration of that member’s term until 

10 a successor has taken office. A vacancy in 

11 MACPAC shall be filled in the manner in which 

12 the original appointment was made. 

13 ‘‘(4) COMPENSATION.—While serving on the 

14 business of MACPAC (including travel time), a 

15 member of MACPAC shall be entitled to compensa16 tion at the per diem equivalent of the rate provided 

17 for level IV of the Executive Schedule under section 

18 5315 of title 5, United States Code; and while so 

19 serving away from home and the member’s regular 

20 place of business, a member may be allowed travel 

21 expenses, as authorized by the Chairman of 

22 MACPAC. Physicians serving as personnel of 

23 MACPAC may be provided a physician comparability 

24 allowance by MACPAC in the same manner as Gov25 ernment physicians may be provided such an allowVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00239 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 ance by an agency under section 5948 of title 5, 

2 United States Code, and for such purpose subsection 

3 (i) of such section shall apply to MACPAC in the 

4 same manner as it applies to the Tennessee Valley 

5 Authority. For purposes of pay (other than pay of 

6 members of MACPAC) and employment benefits, 

7 rights, and privileges, all personnel of MACPAC 

8 shall be treated as if they were employees of the 

9 United States Senate. 

10 ‘‘(5) CHAIRMAN; VICE CHAIRMAN.—The Comp11 troller General of the United States shall designate 

12 a member of MACPAC, at the time of appointment 

13 of the member as Chairman and a member as Vice 

14 Chairman for that term of appointment, except that 

15 in the case of vacancy of the Chairmanship or Vice 

16 Chairmanship, the Comptroller General of the 

17 United States may designate another member for 

18 the remainder of that member’s term. 

19 ‘‘(6) MEETINGS.—MACPAC shall meet at the 

20 call of the Chairman. 

21 ‘‘(d) DIRECTOR AND STAFF; EXPERTS AND CON22 SULTANTS.—Subject to such review as the Comptroller 

23 General of the United States deems necessary to assure 

24 the efficient administration of MACPAC, MACPAC 

25 may— 


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1 ‘‘(1) employ and fix the compensation of an Ex2 ecutive Director (subject to the approval of the 

3 Comptroller General of the United States) and such 

4 other personnel as may be necessary to carry out its 

5 duties (without regard to the provisions of title 5, 

6 United States Code, governing appointments in the 

7 competitive service); 

8 ‘‘(2) seek such assistance and support as may 

9 be required in the performance of its duties from ap10 propriate Federal departments and agencies; 

11 ‘‘(3) enter into contracts or make other ar12 rangements, as may be necessary for the conduct of 

13 the work of MACPAC (without regard to section 

14 3709 of the Revised Statutes (41 U.S.C. 5)); 

15 ‘‘(4) make advance, progress, and other pay16 ments which relate to the work of MACPAC; 

17 ‘‘(5) provide transportation and subsistence for 

18 persons serving without compensation; and 

19 ‘‘(6) prescribe such rules and regulations as it 

20 deems necessary with respect to the internal organi21 zation and operation of MACPAC. 

22 ‘‘(e) POWERS.— 

23 ‘‘(1) OBTAINING OFFICIAL DATA.—MACPAC 

24 may secure directly from any department or agency 

25 of the United States information necessary to enable 


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1 it to carry out this section. Upon request of the 

2 Chairman, the head of that department or agency 

3 shall furnish that information to MACPAC on an 

4 agreed upon schedule. 

5 ‘‘(2) DATA COLLECTION.—In order to carry out 

6 its functions, MACPAC shall— 

7 ‘‘(A) utilize existing information, both pub8 lished and unpublished, where possible, collected 

9 and assessed either by its own staff or under 

10 other arrangements made in accordance with 

11 this section; 

12 ‘‘(B) carry out, or award grants or con13 tracts for, original research and experimen14 tation, where existing information is inad15 equate; and 

16 ‘‘(C) adopt procedures allowing any inter17 ested party to submit information for 

18 MACPAC’s use in making reports and rec19 ommendations. 

20 ‘‘(3) ACCESS OF GAO TO INFORMATION.—The 

21 Comptroller General of the United States shall have 

22 unrestricted access to all deliberations, records, and 

23 nonproprietary data of MACPAC, immediately upon 

24 request. 


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1 ‘‘(4) PERIODIC AUDIT.—MACPAC shall be sub2 ject to periodic audit by the Comptroller General of 

3 the United States. 

4 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.— 

5 ‘‘(1) REQUEST FOR APPROPRIATIONS.— 

6 MACPAC shall submit requests for appropriations 

7 in the same manner as the Comptroller General of 

8 the United States submits requests for appropria9 tions, but amounts appropriated for MACPAC shall 

10 be separate from amounts appropriated for the 

11 Comptroller General of the United States. 

12 ‘‘(2) AUTHORIZATION.—There are authorized to 

13 be appropriated such sums as may be necessary to 

14 carry out the provisions of this section.’’. 

15 (b) DEADLINE FOR INITIAL APPOINTMENTS.—Not 

16 later than January 1, 2010, the Comptroller General of 

17 the United States shall appoint the initial members of the 

18 Medicaid and CHIP Payment and Access Commission es19 tablished under section 1900 of the Social Security Act 

20 (as added by subsection (a)). 

21 (c) ANNUAL REPORT ON MEDICAID.—Not later than 

22 January 1, 2010, and annually thereafter, the Secretary, 

23 in consultation with the Secretary of the Treasury, the 

24 Secretary of Labor, and the States (as defined for pur25 poses of Medicaid), shall submit an annual report to ConVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00243 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 gress on the financial status of, enrollment in, and spend2 ing trends for, Medicaid for the fiscal year ending on Sep3 tember 30 of the preceding year. 

4 TITLE VI—PROGRAM INTEGRITY 

5 AND OTHER MISCELLANEOUS 

6 PROVISIONS 

7 Subtitle A—Program Integrity and 

8 Data Collection 

9 SEC. 601. PAYMENT ERROR RATE MEASUREMENT (‘‘PERM’’). 

10 (a) EXPENDITURES RELATED TO COMPLIANCE WITH

11 REQUIREMENTS.— 

12 (1) ENHANCED PAYMENTS.—Section 2105(c) 

13 (42 U.S.C. 1397ee(c)), as amended by section 

14 301(a), is amended by adding at the end the fol15 lowing new paragraph: 

16 ‘‘(11) ENHANCED PAYMENTS.—Notwith17 standing subsection (b), the enhanced FMAP with 

18 respect to payments under subsection (a) for ex19 penditures related to the administration of the pay20 ment error rate measurement (PERM) requirements 

21 applicable to the State child health plan in accord22 ance with the Improper Payments Information Act 

23 of 2002 and parts 431 and 457 of title 42, Code of 

24 Federal Regulations (or any related or successor 


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1 guidance or regulations) shall in no event be less 

2 than 90 percent.’’. 

3 (2) EXCLUSION OF FROM CAP ON ADMINISTRA4 TIVE EXPENDITURES.—Section 2105(c)(2)(C) (42 

5 U.S.C. 1397ee(c)(2)C)), as amended by section 

6 302(b)), is amended by adding at the end the fol7 lowing: 

8 ‘‘(iv) PAYMENT ERROR RATE MEAS9 UREMENT (PERM) EXPENDITURES.—Ex10 penditures related to the administration of 

11 the payment error rate measurement 

12 (PERM) requirements applicable to the 

13 State child health plan in accordance with 

14 the Improper Payments Information Act of 

15 2002 and parts 431 and 457 of title 42, 

16 Code of Federal Regulations (or any re17 lated or successor guidance or regula18 tions).’’. 

19 (b) FINAL RULE REQUIRED TO BE IN EFFECT FOR

20 ALL STATES.—Notwithstanding parts 431 and 457 of 

21 title 42, Code of Federal Regulations (as in effect on the 

22 date of enactment of this Act), the Secretary shall not cal23 culate or publish any national or State-specific error rate 

24 based on the application of the payment error rate meas25 urement (in this section referred to as ‘‘PERM’’) requireVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00245 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 ments to CHIP until after the date that is 6 months after 

2 the date on which a new final rule (in this section referred 

3 to as the ‘‘new final rule’’) promulgated after the date of 

4 the enactment of this Act and implementing such require5 ments in accordance with the requirements of subsection 

6 (c) is in effect for all States. Any calculation of a national 

7 error rate or a State specific error rate after such new 

8 final rule in effect for all States may only be inclusive of 

9 errors, as defined in such new final rule or in guidance 

10 issued within a reasonable time frame after the effective 

11 date for such new final rule that includes detailed guid12 ance for the specific methodology for error determinations. 

13 (c) REQUIREMENTS FOR NEW FINAL RULE.—For 

14 purposes of subsection (b), the requirements of this sub15 section are that the new final rule implementing the 

16 PERM requirements shall— 

17 (1) include— 

18 (A) clearly defined criteria for errors for 

19 both States and providers; 

20 (B) a clearly defined process for appealing 

21 error determinations by— 

22 (i) review contractors; or 

23 (ii) the agency and personnel de24 scribed in section 431.974(a)(2) of title 42, 

25 Code of Federal Regulations, as in effect 


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1 on September 1, 2007, responsible for the 

2 development, direction, implementation, 

3 and evaluation of eligibility reviews and as4 sociated activities; and 

5 (C) clearly defined responsibilities and 

6 deadlines for States in implementing any cor7 rective action plans; and 

8 (2) provide that the payment error rate deter9 mined for a State shall not take into account pay10 ment errors resulting from the State’s verification of 

11 an applicant’s self-declaration or self-certification of 

12 eligibility for, and the correct amount of, medical as13 sistance or child health assistance, if the State proc14 ess for verifying an applicant’s self-declaration or 

15 self-certification satisfies the requirements for such 

16 process applicable under regulations promulgated by 

17 the Secretary or otherwise approved by the Sec18 retary. 

19 (d) OPTION FOR APPLICATION OF DATA FOR STATES

20 IN FIRST APPLICATION CYCLE UNDER THE INTERIM

21 FINAL RULE.—After the new final rule implementing the 

22 PERM requirements in accordance with the requirements 

23 of subsection (c) is in effect for all States, a State for 

24 which the PERM requirements were first in effect under 

25 an interim final rule for fiscal year 2007 or under a final 


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1 rule for fiscal year 2008 may elect to accept any payment 

2 error rate determined in whole or in part for the State 

3 on the basis of data for that fiscal year or may elect to 

4 not have any payment error rate determined on the basis 

5 of such data and, instead, shall be treated as if fiscal year 

6 2010 or fiscal year 2011 were the first fiscal year for 

7 which the PERM requirements apply to the State. 

8 (e) HARMONIZATION OF MEQC AND PERM.— 

9 (1) REDUCTION OF REDUNDANCIES.—The Sec10 retary shall review the Medicaid Eligibility Quality 

11 Control (in this subsection referred to as the 

12 ‘‘MEQC’’) requirements with the PERM require13 ments and coordinate consistent implementation of 

14 both sets of requirements, while reducing 

15 redundancies. 

16 (2) STATE OPTION TO APPLY PERM DATA.—A 

17 State may elect, for purposes of determining the er18 roneous excess payments for medical assistance ratio 

19 applicable to the State for a fiscal year under section 

20 1903(u) of the Social Security Act (42 U.S.C. 

21 1396b(u)) to substitute data resulting from the ap22 plication of the PERM requirements to the State 

23 after the new final rule implementing such require24 ments is in effect for all States for data obtained 


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1 from the application of the MEQC requirements to 

2 the State with respect to a fiscal year. 

3 (3) STATE OPTION TO APPLY MEQC DATA.—For 

4 purposes of satisfying the requirements of subpart Q 

5 of part 431 of title 42, Code of Federal Regulations, 

6 relating to Medicaid eligibility reviews, a State may 

7 elect to substitute data obtained through MEQC re8 views conducted in accordance with section 1903(u) 

9 of the Social Security Act (42 U.S.C. 1396b(u)) for 

10 data required for purposes of PERM requirements, 

11 but only if the State MEQC reviews are based on a 

12 broad, representative sample of Medicaid applicants 

13 or enrollees in the States. 

14 (f) IDENTIFICATION OF IMPROVED STATE-SPECIFIC

15 SAMPLE SIZES.—The Secretary shall establish State-spe16 cific sample sizes for application of the PERM require17 ments with respect to State child health plans for fiscal 

18 years beginning with the first fiscal year that begins on 

19 or after the date on which the new final rule is in effect 

20 for all States, on the basis of such information as the Sec21 retary determines appropriate. In establishing such sam22 ple sizes, the Secretary shall, to the greatest extent prac23 ticable— 

24 (1) minimize the administrative cost burden on 

25 States under Medicaid and CHIP; and 


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1 (2) maintain State flexibility to manage such 

2 programs. 

3 SEC. 602. IMPROVING DATA COLLECTION. 

4 (a) INCREASED APPROPRIATION.—Section 

5 2109(b)(2) (42 U.S.C. 1397ii(b)(2)) is amended by strik6 ing ‘‘$10,000,000 for fiscal year 2000’’ and inserting 

7 ‘‘$20,000,000 for fiscal year 2009’’. 

8 (b) USE OF ADDITIONAL FUNDS.—Section 2109(b) 

9 (42 U.S.C. 1397ii(b)), as amended by subsection (a), is 

10 amended— 

11 (1) by redesignating paragraph (2) as para12 graph (4); and 

13 (2) by inserting after paragraph (1), the fol14 lowing new paragraphs: 

15 ‘‘(2) ADDITIONAL REQUIREMENTS.—In addition 

16 to making the adjustments required to produce the 

17 data described in paragraph (1), with respect to 

18 data collection occurring for fiscal years beginning 

19 with fiscal year 2009, in appropriate consultation 

20 with the Secretary of Health and Human Services, 

21 the Secretary of Commerce shall do the following: 

22 ‘‘(A) Make appropriate adjustments to the 

23 Current Population Survey to develop more ac24 curate State-specific estimates of the number of 


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1 children enrolled in health coverage under title 

2 XIX or this title. 

3 ‘‘(B) Make appropriate adjustments to the 

4 Current Population Survey to improve the sur5 vey estimates used to determine the child popu6 lation growth factor under section 

7 2104(m)(5)(B) and any other data necessary 

8 for carrying out this title. 

9 ‘‘(C) Include health insurance survey infor10 mation in the American Community Survey re11 lated to children. 

12 ‘‘(D) Assess whether American Community 

13 Survey estimates, once such survey data are 

14 first available, produce more reliable estimates 

15 than the Current Population Survey with re16 spect to the purposes described in subparagraph 

17 (B). 

18 ‘‘(E) On the basis of the assessment re19 quired under subparagraph (D), recommend to 

20 the Secretary of Health and Human Services 

21 whether American Community Survey estimates 

22 should be used in lieu of, or in some combina23 tion with, Current Population Survey estimates 

24 for the purposes described in subparagraph (B). 


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1 ‘‘(F) Continue making the adjustments de2 scribed in the last sentence of paragraph (1) 

3 with respect to expansion of the sample size 

4 used in State sampling units, the number of 

5 sampling units in a State, and using an appro6 priate verification element. 

7 ‘‘(3) AUTHORITY FOR THE SECRETARY OF

8 HEALTH AND HUMAN SERVICES TO TRANSITION TO

9 THE USE OF ALL, OR SOME COMBINATION OF, ACS

10 ESTIMATES UPON RECOMMENDATION OF THE SEC11 RETARY OF COMMERCE.—If, on the basis of the as12 sessment required under paragraph (2)(D), the Sec13 retary of Commerce recommends to the Secretary of 

14 Health and Human Services that American Commu15 nity Survey estimates should be used in lieu of, or 

16 in some combination with, Current Population Sur17 vey estimates for the purposes described in para18 graph (2)(B), the Secretary of Health and Human 

19 Services, in consultation with the States, may pro20 vide for a period during which the Secretary may 

21 transition from carrying out such purposes through 

22 the use of Current Population Survey estimates to 

23 the use of American Community Survey estimates 

24 (in lieu of, or in combination with the Current Popu25 lation Survey estimates, as recommended), provided 


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1 that any such transition is implemented in a manner 

2 that is designed to avoid adverse impacts upon 

3 States with approved State child health plans under 

4 this title.’’. 

5 SEC. 603. UPDATED FEDERAL EVALUATION OF CHIP. 

6 Section 2108(c) (42 U.S.C. 1397hh(c)) is amended 

7 by striking paragraph (5) and inserting the following: 

8 ‘‘(5) SUBSEQUENT EVALUATION USING UP9 DATED INFORMATION.— 

10 ‘‘(A) IN GENERAL.—The Secretary, di11 rectly or through contracts or interagency 

12 agreements, shall conduct an independent sub13 sequent evaluation of 10 States with approved 

14 child health plans. 

15 ‘‘(B) SELECTION OF STATES AND MAT16 TERS INCLUDED.—Paragraphs (2) and (3) shall 

17 apply to such subsequent evaluation in the 

18 same manner as such provisions apply to the 

19 evaluation conducted under paragraph (1). 

20 ‘‘(C) SUBMISSION TO CONGRESS.—Not 

21 later than December 31, 2011, the Secretary 

22 shall submit to Congress the results of the eval23 uation conducted under this paragraph. 

24 ‘‘(D) FUNDING.—Out of any money in the 

25 Treasury of the United States not otherwise apVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00253 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 propriated, there are appropriated $10,000,000 

2 for fiscal year 2010 for the purpose of con3 ducting the evaluation authorized under this 

4 paragraph. Amounts appropriated under this 

5 subparagraph shall remain available for expend6 iture through fiscal year 2012.’’. 

7 SEC. 604. ACCESS TO RECORDS FOR IG AND GAO AUDITS 

8 AND EVALUATIONS. 

9 Section 2108(d) (42 U.S.C. 1397hh(d)) is amended 

10 to read as follows: 

11 ‘‘(d) ACCESS TO RECORDS FOR IG AND GAO AUDITS

12 AND EVALUATIONS.—For the purpose of evaluating and 

13 auditing the program established under this title, or title 

14 XIX, the Secretary, the Office of Inspector General, and 

15 the Comptroller General shall have access to any books, 

16 accounts, records, correspondence, and other documents 

17 that are related to the expenditure of Federal funds under 

18 this title and that are in the possession, custody, or control 

19 of States receiving Federal funds under this title or polit20 ical subdivisions thereof, or any grantee or contractor of 

21 such States or political subdivisions.’’. 


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1 SEC. 605. NO FEDERAL FUNDING FOR ILLEGAL ALIENS; DIS2 ALLOWANCE FOR UNAUTHORIZED EXPENDI3 TURES. 

4 Nothing in this Act allows Federal payment for indi5 viduals who are not legal residents. Titles XI, XIX, and 

6 XXI of the Social Security Act provide for the disallow7 ance of Federal financial participation for erroneous ex8 penditures under Medicaid and under CHIP, respectively. 

9 Subtitle B—Miscellaneous Health 

10 Provisions 

11 SEC. 611. DEFICIT REDUCTION ACT TECHNICAL CORREC12 TIONS. 

13 (a) CLARIFICATION OF REQUIREMENT TO PROVIDE

14 EPSDT SERVICES FOR ALL CHILDREN IN BENCHMARK

15 BENEFIT PACKAGES UNDER MEDICAID.—Section 

16 1937(a)(1) (42 U.S.C. 1396u–7(a)(1)), as inserted by sec17 tion 6044(a) of the Deficit Reduction Act of 2005 (Public 

18 Law 109–171, 120 Stat. 88), is amended— 

19 (1) in subparagraph (A)— 

20 (A) in the matter before clause (i)— 

21 (i) by striking ‘‘Notwithstanding any 

22 other provision of this title’’ and inserting 

23 ‘‘Notwithstanding section 1902(a)(1) (re24 lating to statewideness), section 

25 1902(a)(10)(B) (relating to comparability) 

26 and any other provision of this title which 


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1 would be directly contrary to the authority 

2 under this section and subject to sub3 section (E)’’; and 

4 (ii) by striking ‘‘enrollment in cov5 erage that provides’’ and inserting ‘‘cov6 erage that’’; 

7 (B) in clause (i), by inserting ‘‘provides’’ 

8 after ‘‘(i)’’; and 

9 (C) by striking clause (ii) and inserting the 

10 following: 

11 ‘‘(ii) for any individual described in 

12 section 1905(a)(4)(B) who is eligible under 

13 the State plan in accordance with para14 graphs (10) and (17) of section 1902(a), 

15 consists of the items and services described 

16 in section 1905(a)(4)(B) (relating to early 

17 and periodic screening, diagnostic, and 

18 treatment services defined in section 

19 1905(r)) and provided in accordance with 

20 the requirements of section 1902(a)(43).’’; 

21 (2) in subparagraph (C)— 

22 (A) in the heading, by striking ‘‘WRAP23 AROUND’’ and inserting ‘‘ADDITIONAL’’; and 

24 (B) by striking ‘‘wrap-around or’’; and 


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1 (3) by adding at the end the following new sub2 paragraph: 

3 ‘‘(E) RULE OF CONSTRUCTION.—Nothing 

4 in this paragraph shall be construed as— 

5 ‘‘(i) requiring a State to offer all or 

6 any of the items and services required by 

7 subparagraph (A)(ii) through an issuer of 

8 benchmark coverage described in sub9 section (b)(1) or benchmark equivalent 

10 coverage described in subsection (b)(2); 

11 ‘‘(ii) preventing a State from offering 

12 all or any of the items and services re13 quired by subparagraph (A)(ii) through an 

14 issuer of benchmark coverage described in 

15 subsection (b)(1) or benchmark equivalent 

16 coverage described in subsection (b)(2); or 

17 ‘‘(iii) affecting a child’s entitlement to 

18 care and services described in subsections 

19 (a)(4)(B) and (r) of section 1905 and pro20 vided in accordance with section 

21 1902(a)(43) whether provided through 

22 benchmark coverage, benchmark equivalent 

23 coverage, or otherwise.’’. 

24 (b) CORRECTION OF REFERENCE TO CHILDREN IN

25 FOSTER CARE RECEIVING CHILD WELFARE SERVICES.— 


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1 Section 1937(a)(2)(B)(viii) (42 U.S.C. 1396u– 

2 7(a)(2)(B)(viii)), as inserted by section 6044(a) of the 

3 Deficit Reduction Act of 2005, is amended by striking 

4 ‘‘aid or assistance is made available under part B of title 

5 IV to children in foster care and individuals’’ and inserting 

6 ‘‘child welfare services are made available under part B 

7 of title IV on the basis of being a child in foster care or’’. 

8 (c) TRANSPARENCY.—Section 1937 (42 U.S.C. 

9 1396u–7), as inserted by section 6044(a) of the Deficit 

10 Reduction Act of 2005, is amended by adding at the end 

11 the following: 

12 ‘‘(c) PUBLICATION OF PROVISIONS AFFECTED.— 

13 With respect to a State plan amendment to provide bench14 mark benefits in accordance with subsections (a) and (b) 

15 that is approved by the Secretary, the Secretary shall pub16 lish on the Internet website of the Centers for Medicare 

17 & Medicaid Services, a list of the provisions of this title 

18 that the Secretary has determined do not apply in order 

19 to enable the State to carry out the plan amendment and 

20 the reason for each such determination on the date such 

21 approval is made, and shall publish such list in the Fed22 eral Register and not later than 30 days after such date 

23 of approval.’’. 

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

25 subsections (a), (b), and (c) of this section shall take effect 


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1 as if included in the amendment made by section 6044(a) 

2 of the Deficit Reduction Act of 2005. 

3 SEC. 612. REFERENCES TO TITLE XXI. 

4 Section 704 of the Medicare, Medicaid, and SCHIP 

5 Balanced Budget Refinement Act of 1999, as enacted into 

6 law by division B of Public Law 106–113 (113 Stat. 

7 1501A–402) is repealed. 

8 SEC. 613. PROHIBITING INITIATION OF NEW HEALTH OP9 PORTUNITY ACCOUNT DEMONSTRATION PRO10 GRAMS. 

11 After the date of the enactment of this Act, the Sec12 retary of Health and Human Services may not approve 

13 any new demonstration programs under section 1938 of 

14 the Social Security Act (42 U.S.C. 1396u–8). 

15 SEC. 614. ADJUSTMENT IN COMPUTATION OF MEDICAID 

16 FMAP TO DISREGARD AN EXTRAORDINARY 

17 EMPLOYER PENSION CONTRIBUTION. 

18 (a) IN GENERAL.—Only for purposes of computing 

19 the FMAP (as defined in subsection (e)) for a State for 

20 a fiscal year (beginning with fiscal year 2006) and apply21 ing the FMAP under title XIX of the Social Security Act, 

22 any significantly disproportionate employer pension or in23 surance fund contribution described in subsection (b) shall 

24 be disregarded in computing the per capita income of such 

25 State, but shall not be disregarded in computing the per 


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1 capita income for the continental United States (and Alas2 ka) and Hawaii. 

3 (b) SIGNIFICANTLY DISPROPORTIONATE EMPLOYER

4 PENSION AND INSURANCE FUND CONTRIBUTION.— 

5 (1) IN GENERAL.—For purposes of this section, 

6 a significantly disproportionate employer pension 

7 and insurance fund contribution described in this 

8 subsection with respect to a State is any identifiable 

9 employer contribution towards pension or other em10 ployee insurance funds that is estimated to accrue to 

11 residents of such State for a calendar year (begin12 ning with calendar year 2003) if the increase in the 

13 amount so estimated exceeds 25 percent of the total 

14 increase in personal income in that State for the 

15 year involved. 

16 (2) DATA TO BE USED.—For estimating and 

17 adjustment a FMAP already calculated as of the 

18 date of the enactment of this Act for a State with 

19 a significantly disproportionate employer pension 

20 and insurance fund contribution, the Secretary shall 

21 use the personal income data set originally used in 

22 calculating such FMAP. 

23 (3) SPECIAL ADJUSTMENT FOR NEGATIVE

24 GROWTH.—If in any calendar year the total personal 

25 income growth in a State is negative, an employer 


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1 pension and insurance fund contribution for the pur2 poses of calculating the State’s FMAP for a cal3 endar year shall not exceed 125 percent of the 

4 amount of such contribution for the previous cal5 endar year for the State. 

6 (c) HOLD HARMLESS.—No State shall have its 

7 FMAP for a fiscal year reduced as a result of the applica8 tion of this section. 

9 (d) REPORT.—Not later than May 15, 2009, the Sec10 retary shall submit to the Congress a report on the prob11 lems presented by the current treatment of pension and 

12 insurance fund contributions in the use of Bureau of Eco13 nomic Affairs calculations for the FMAP and for Medicaid 

14 and on possible alternative methodologies to mitigate such 

15 problems. 

16 (e) FMAP DEFINED.—For purposes of this section, 

17 the term ‘‘FMAP’’ means the Federal medical assistance 

18 percentage, as defined in section 1905(b) of the Social Se19 curity Act (42 U.S.C. 1396(d)). 

20 SEC. 615. CLARIFICATION TREATMENT OF REGIONAL MED21 ICAL CENTER. 

22 (a) IN GENERAL.—Nothing in section 1903(w) of the 

23 Social Security Act (42 U.S.C. 1396b(w)) shall be con24 strued by the Secretary of Health and Human Services 

25 as prohibiting a State’s use of funds as the non-Federal 


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1 share of expenditures under title XIX of such Act where 

2 such funds are transferred from or certified by a publicly3 owned regional medical center located in another State 

4 and described in subsection (b), so long as the Secretary 

5 determines that such use of funds is proper and in the 

6 interest of the program under title XIX. 

7 (b) CENTER DESCRIBED.—A center described in this 

8 subsection is a publicly-owned regional medical center 

9 that— 

10 (1) provides level 1 trauma and burn care serv11 ices; 

12 (2) provides level 3 neonatal care services; 

13 (3) is obligated to serve all patients, regardless 

14 of ability to pay; 

15 (4) is located within a Standard Metropolitan 

16 Statistical Area (SMSA) that includes at least 3 

17 States; 

18 (5) provides services as a tertiary care provider 

19 for patients residing within a 125-mile radius; and 

20 (6) meets the criteria for a disproportionate 

21 share hospital under section 1923 of such Act (42 

22 U.S.C. 1396r–4) in at least one State other than the 

23 State in which the center is located. 


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1 SEC. 616. EXTENSION OF MEDICAID DSH ALLOTMENTS FOR 

2 TENNESSEE AND HAWAII. 

3 Section 1923(f)(6) (42 U.S.C. 1396r–4(f)(6)), as 

4 amended by section 202 of the Medicare Improvements 

5 for Patients and Providers Act of 2008 (Public Law 110– 

6 275) is amended— 

7 (1) in the paragraph heading, by striking ‘‘2009

8 AND THE FIRST CALENDAR QUARTER OF FISCAL

9 YEAR 2010’’ and inserting ‘‘2011 AND THE FIRST CAL10 ENDAR QUARTER OF FISCAL YEAR 2012’’; 

11 (2) in subparagraph (A)— 

12 (A) in clause (i)— 

13 (i) in the second sentence— 

14 (I) by striking ‘‘and 2009’’ and 

15 inserting ‘‘, 2009, 2010, and 2011’’; 

16 and 

17 (II) by striking ‘‘such portion 

18 of’’; and 

19 (ii) in the third sentence, by striking 

20 ‘‘2010 for the period ending on December 

21 31, 2009’’ and inserting ‘‘2012 for the pe22 riod ending on December 31, 2011’’; 

23 (B) in clause (ii), by striking ‘‘or for a pe24 riod in fiscal year 2010’’ and inserting ‘‘2010, 

25 2011, or for period in fiscal year 2012’’; and 

26 (C) in clause (iv)— 


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1 (i) in the clause heading, by striking 

2 ‘‘2009 AND THE FIRST CALENDAR QUARTER

3 OF FISCAL YEAR 2010’’ and inserting ‘‘2011

4 AND THE FIRST CALENDAR QUARTER OF

5 FISCAL YEAR 2012’’; and 

6 (ii) in each of subclauses (I) and (II), 

7 by striking ‘‘ or for a period in fiscal year 

8 2010’’ and inserting ‘‘2010, 2011, or for a 

9 period in fiscal year 2012’’; and 

10 (3) in subparagraph (B)— 

11 (A) in clause (i)— 

12 (i) in the first sentence, by striking 

13 ‘‘2009’’ and inserting ‘‘2011’’; and 

14 (ii) in the second sentence, by striking 

15 ‘‘2010 for the period ending on December 

16 31, 2009’’ and inserting ‘‘2012 for the pe17 riod ending on December 31, 2011’’. 

18 SEC. 617. GAO REPORT ON MEDICAID MANAGED CARE PAY19 MENT RATES. 

20 Not later than 18 months after the date of the enact21 ment of this Act, the Comptroller General of the United 

22 States shall submit a report to the Committee on Finance 

23 of the Senate and the Committee on Energy and Com24 merce of the House of Representatives analyzing the exVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00264 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 tent to which State payment rates for medicaid managed 

2 care organizations under Medicaid are actuarially sound. 

3 Subtitle C—Other Provisions 

4 SEC. 621. OUTREACH REGARDING HEALTH INSURANCE OP5 TIONS AVAILABLE TO CHILDREN. 

6 (a) DEFINITIONS.—In this section— 

7 (1) the terms ‘‘Administration’’ and ‘‘Adminis8 trator’’ means the Small Business Administration 

9 and the Administrator thereof, respectively; 

10 (2) the term ‘‘certified development company’’ 

11 means a development company participating in the 

12 program under title V of the Small Business Invest13 ment Act of 1958 (15 U.S.C. 695 et seq.); 

14 (3) the term ‘‘Medicaid program’’ means the 

15 program established under title XIX of the Social 

16 Security Act (42 U.S.C. 1396 et seq.); 

17 (4) the term ‘‘Service Corps of Retired Execu18 tives’’ means the Service Corps of Retired Execu19 tives authorized by section 8(b)(1) of the Small 

20 Business Act (15 U.S.C. 637(b)(1)); 

21 (5) the term ‘‘small business concern’’ has the 

22 meaning given that term in section 3 of the Small 

23 Business Act (15 U.S.C. 632); 

24 (6) the term ‘‘small business development cen25 ter’’ means a small business development center deVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00265 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 scribed in section 21 of the Small Business Act (15 

2 U.S.C. 648); 

3 (7) the term ‘‘State’’ has the meaning given 

4 that term for purposes of title XXI of the Social Se5 curity Act (42 U.S.C. 1397aa et seq.); 

6 (8) the term ‘‘State Children’s Health Insur7 ance Program’’ means the State Children’s Health 

8 Insurance Program established under title XXI of 

9 the Social Security Act (42 U.S.C. 1397aa et seq.); 

10 (9) the term ‘‘task force’’ means the task force 

11 established under subsection (b)(1); and 

12 (10) the term ‘‘women’s business center’’ means 

13 a women’s business center described in section 29 of 

14 the Small Business Act (15 U.S.C. 656). 

15 (b) ESTABLISHMENT OF TASK FORCE.— 

16 (1) ESTABLISHMENT.—There is established a 

17 task force to conduct a nationwide campaign of edu18 cation and outreach for small business concerns re19 garding the availability of coverage for children 

20 through private insurance options, the Medicaid pro21 gram, and the State Children’s Health Insurance 

22 Program. 

23 (2) MEMBERSHIP.—The task force shall consist 

24 of the Administrator, the Secretary of Health and 


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1 Human Services, the Secretary of Labor, and the 

2 Secretary of the Treasury. 

3 (3) RESPONSIBILITIES.—The campaign con4 ducted under this subsection shall include— 

5 (A) efforts to educate the owners of small 

6 business concerns about the value of health cov7 erage for children; 

8 (B) information regarding options available 

9 to the owners and employees of small business 

10 concerns to make insurance more affordable, in11 cluding Federal and State tax deductions and 

12 credits for health care-related expenses and 

13 health insurance expenses and Federal tax ex14 clusion for health insurance options available 

15 under employer-sponsored cafeteria plans under 

16 section 125 of the Internal Revenue Code of 

17 1986; 

18 (C) efforts to educate the owners of small 

19 business concerns about assistance available 

20 through public programs; and 

21 (D) efforts to educate the owners and em22 ployees of small business concerns regarding 

23 the availability of the hotline operated as part 

24 of the Insure Kids Now program of the Depart25 ment of Health and Human Services. 


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1 (4) IMPLEMENTATION.—In carrying out this 

2 subsection, the task force may— 

3 (A) use any business partner of the Ad4 ministration, including— 

5 (i) a small business development cen6 ter; 

7 (ii) a certified development company; 

8 (iii) a women’s business center; and 

9 (iv) the Service Corps of Retired Ex10 ecutives; 

11 (B) enter into— 

12 (i) a memorandum of understanding 

13 with a chamber of commerce; and 

14 (ii) a partnership with any appro15 priate small business concern or health ad16 vocacy group; and 

17 (C) designate outreach programs at re18 gional offices of the Department of Health and 

19 Human Services to work with district offices of 

20 the Administration. 

21 (5) WEBSITE.—The Administrator shall ensure 

22 that links to information on the eligibility and enroll23 ment requirements for the Medicaid program and 

24 State Children’s Health Insurance Program of each 


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1 State are prominently displayed on the website of 

2 the Administration. 

3 (6) REPORT.— 

4 (A) IN GENERAL.—Not later than 2 years 

5 after the date of enactment of this Act, and 

6 every 2 years thereafter, the Administrator 

7 shall submit to the Committee on Small Busi8 ness and Entrepreneurship of the Senate and 

9 the Committee on Small Business of the House 

10 of Representatives a report on the status of the 

11 nationwide campaign conducted under para12 graph (1). 

13 (B) CONTENTS.—Each report submitted 

14 under subparagraph (A) shall include a status 

15 update on all efforts made to educate owners 

16 and employees of small business concerns on 

17 options for providing health insurance for chil18 dren through public and private alternatives. 

19 SEC. 622. SENSE OF THE SENATE REGARDING ACCESS TO 

20 AFFORDABLE AND MEANINGFUL HEALTH IN21 SURANCE COVERAGE. 

22 (a) FINDINGS.—The Senate finds the following: 

23 (1) There are approximately 45 million Ameri24 cans currently without health insurance. 


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1 (2) More than half of uninsured workers are 

2 employed by businesses with less than 25 employees 

3 or are self-employed. 

4 (3) Health insurance premiums continue to rise 

5 at more than twice the rate of inflation for all con6 sumer goods. 

7 (4) Individuals in the small group and indi8 vidual health insurance markets usually pay more 

9 for similar coverage than those in the large group 

10 market. 

11 (5) The rapid growth in health insurance costs 

12 over the last few years has forced many employers, 

13 particularly small employers, to increase deductibles 

14 and co-pays or to drop coverage completely. 

15 (b) SENSE OF THE SENATE.—The Senate— 

16 (1) recognizes the necessity to improve afford17 ability and access to health insurance for all Ameri18 cans; 

19 (2) acknowledges the value of building upon the 

20 existing private health insurance market; and 

21 (3) affirms its intent to enact legislation this 

22 year that, with appropriate protection for con23 sumers, improves access to affordable and meaning24 ful health insurance coverage for employees of small 

25 businesses and individuals by— 


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1 (A) facilitating pooling mechanisms, in2 cluding pooling across State lines, and 

3 (B) providing assistance to small busi4 nesses and individuals, including financial as5 sistance and tax incentives, for the purchase of 

6 private insurance coverage. 

7 TITLE VII—REVENUE 

8 PROVISIONS 

9 SEC. 701. INCREASE IN EXCISE TAX RATE ON TOBACCO 

10 PRODUCTS. 

11 (a) CIGARS.—Section 5701(a) of the Internal Rev12 enue Code of 1986 is amended— 

13 (1) by striking ‘‘$1.828 cents per thousand 

14 ($1.594 cents per thousand on cigars removed dur15 ing 2000 or 2001)’’ in paragraph (1) and inserting 

16 ‘‘$50.33 per thousand’’, 

17 (2) by striking ‘‘20.719 percent (18.063 percent 

18 on cigars removed during 2000 or 2001)’’ in para19 graph (2) and inserting ‘‘52.75 percent’’, and 

20 (3) by striking ‘‘$48.75 per thousand ($42.50 

21 per thousand on cigars removed during 2000 or 

22 2001)’’ in paragraph (2) and inserting ‘‘40.26 cents 

23 per cigar’’. 

24 (b) CIGARETTES.—Section 5701(b) of such Code is 

25 amended— 


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1 (1) by striking ‘‘$19.50 per thousand ($17 per 

2 thousand on cigarettes removed during 2000 or 

3 2001)’’ in paragraph (1) and inserting ‘‘$50.33 per 

4 thousand’’, and 

5 (2) by striking ‘‘$40.95 per thousand ($35.70 

6 per thousand on cigarettes removed during 2000 or 

7 2001)’’ in paragraph (2) and inserting ‘‘$105.69 per 

8 thousand’’. 

9 (c) CIGARETTE PAPERS.—Section 5701(c) of such 

10 Code is amended by striking ‘‘1.22 cents (1.06 cents on 

11 cigarette papers removed during 2000 or 2001)’’ and in12 serting ‘‘3.15 cents’’. 

13 (d) CIGARETTE TUBES.—Section 5701(d) of such 

14 Code is amended by striking ‘‘2.44 cents (2.13 cents on 

15 cigarette tubes removed during 2000 or 2001)’’ and in16 serting ‘‘6.30 cents’’. 

17 (e) SMOKELESS TOBACCO.—Section 5701(e) of such 

18 Code is amended— 

19 (1) by striking ‘‘58.5 cents (51 cents on snuff 

20 removed during 2000 or 2001)’’ in paragraph (1) 

21 and inserting ‘‘$1.51’’, and 

22 (2) by striking ‘‘19.5 cents (17 cents on chew23 ing tobacco removed during 2000 or 2001)’’ in para24 graph (2) and inserting ‘‘50.33 cents’’. 


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1 (f) PIPE TOBACCO.—Section 5701(f) of such Code is 

2 amended by striking ‘‘$1.0969 cents (95.67 cents on pipe 

3 tobacco removed during 2000 or 2001)’’ and inserting 

4 ‘‘$2.8311 cents’’. 

5 (g) ROLL-YOUR-OWN TOBACCO.—Section 5701(g) of 

6 such Code is amended by striking ‘‘$1.0969 cents (95.67 

7 cents on roll-your-own tobacco removed during 2000 or 

8 2001)’’ and inserting ‘‘$24.78’’. 

9 (h) FLOOR STOCKS TAXES.— 

10 (1) IMPOSITION OF TAX.—On tobacco products 

11 (other than cigars described in section 5701(a)(2) of 

12 the Internal Revenue Code of 1986) and cigarette 

13 papers and tubes manufactured in or imported into 

14 the United States which are removed before April 1, 

15 2009, and held on such date for sale by any person, 

16 there is hereby imposed a tax in an amount equal 

17 to the excess of— 

18 (A) the tax which would be imposed under 

19 section 5701 of such Code on the article if the 

20 article had been removed on such date, over 

21 (B) the prior tax (if any) imposed under 

22 section 5701 of such Code on such article. 

23 (2) CREDIT AGAINST TAX.—Each person shall 

24 be allowed as a credit against the taxes imposed by 

25 paragraph (1) an amount equal to $500. Such credit 


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1 shall not exceed the amount of taxes imposed by 

2 paragraph (1) on April 1, 2009, for which such per3 son is liable. 

4 (3) LIABILITY FOR TAX AND METHOD OF PAY5 MENT.— 

6 (A) LIABILITY FOR TAX.—A person hold7 ing tobacco products, cigarette papers, or ciga8 rette tubes on April 1, 2009, to which any tax 

9 imposed by paragraph (1) applies shall be liable 

10 for such tax. 

11 (B) METHOD OF PAYMENT.—The tax im12 posed by paragraph (1) shall be paid in such 

13 manner as the Secretary shall prescribe by reg14 ulations. 

15 (C) TIME FOR PAYMENT.—The tax im16 posed by paragraph (1) shall be paid on or be17 fore August 1, 2009. 

18 (4) ARTICLES IN FOREIGN TRADE ZONES.— 

19 Notwithstanding the Act of June 18, 1934 (com20 monly known as the Foreign Trade Zone Act, 48 

21 Stat. 998, 19 U.S.C. 81a et seq.) or any other provi22 sion of law, any article which is located in a foreign 

23 trade zone on April 1, 2009, shall be subject to the 

24 tax imposed by paragraph (1) if— 


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1 (A) internal revenue taxes have been deter2 mined, or customs duties liquidated, with re3 spect to such article before such date pursuant 

4 to a request made under the 1st proviso of sec5 tion 3(a) of such Act, or 

6 (B) such article is held on such date under 

7 the supervision of an officer of the United 

8 States Customs and Border Protection of the 

9 Department of Homeland Security pursuant to 

10 the 2d proviso of such section 3(a). 

11 (5) DEFINITIONS.—For purposes of this sub12 section— 

13 (A) IN GENERAL.—Any term used in this 

14 subsection which is also used in section 5702 of 

15 the Internal Revenue Code of 1986 shall have 

16 the same meaning as such term has in such 

17 section. 

18 (B) SECRETARY.—The term ‘‘Secretary’’ 

19 means the Secretary of the Treasury or the 

20 Secretary’s delegate. 

21 (6) CONTROLLED GROUPS.—Rules similar to 

22 the rules of section 5061(e)(3) of such Code shall 

23 apply for purposes of this subsection. 

24 (7) OTHER LAWS APPLICABLE.—All provisions 

25 of law, including penalties, applicable with respect to 


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1 the taxes imposed by section 5701 of such Code 

2 shall, insofar as applicable and not inconsistent with 

3 the provisions of this subsection, apply to the floor 

4 stocks taxes imposed by paragraph (1), to the same 

5 extent as if such taxes were imposed by such section 

6 5701. The Secretary may treat any person who bore 

7 the ultimate burden of the tax imposed by para8 graph (1) as the person to whom a credit or refund 

9 under such provisions may be allowed or made. 

10 (i) EFFECTIVE DATE.—The amendments made by 

11 this section shall apply to articles removed (as defined in 

12 section 5702(j) of the Internal Revenue Code of 1986) 

13 after March 31, 2009. 

14 SEC. 702. ADMINISTRATIVE IMPROVEMENTS. 

15 (a) PERMIT, INVENTORIES, REPORTS, AND RECORDS

16 REQUIREMENTS FOR MANUFACTURERS AND IMPORTERS

17 OF PROCESSED TOBACCO.— 

18 (1) PERMIT.— 

19 (A) APPLICATION.—Section 5712 of the 

20 Internal Revenue Code of 1986 is amended by 

21 inserting ‘‘or processed tobacco’’ after ‘‘tobacco 

22 products’’. 

23 (B) ISSUANCE.—Section 5713(a) of such 

24 Code is amended by inserting ‘‘or processed to25 bacco’’ after ‘‘tobacco products’’. 


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1 (2) INVENTORIES, REPORTS, AND PACKAGES.— 

2 (A) INVENTORIES.—Section 5721 of such 

3 Code is amended by inserting ‘‘, processed to4 bacco,’’ after ‘‘tobacco products’’. 

5 (B) REPORTS.—Section 5722 of such Code 

6 is amended by inserting ‘‘, processed tobacco,’’ 

7 after ‘‘tobacco products’’. 

8 (C) PACKAGES, MARKS, LABELS, AND NO9 TICES.—Section 5723 of such Code is amended 

10 by inserting ‘‘, processed tobacco,’’ after ‘‘to11 bacco products’’ each place it appears. 

12 (3) RECORDS.—Section 5741 of such Code is 

13 amended by inserting ‘‘, processed tobacco,’’ after 

14 ‘‘tobacco products’’. 

15 (4) MANUFACTURER OF PROCESSED TO16 BACCO.—Section 5702 of such Code is amended by 

17 adding at the end the following new subsection: 

18 ‘‘(p) MANUFACTURER OF PROCESSED TOBACCO.— 

19 ‘‘(1) IN GENERAL.—The term ‘manufacturer of 

20 processed tobacco’ means any person who processes 

21 any tobacco other than tobacco products. 

22 ‘‘(2) PROCESSED TOBACCO.—The processing of 

23 tobacco shall not include the farming or growing of 

24 tobacco or the handling of tobacco solely for sale, 


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1 shipment, or delivery to a manufacturer of tobacco 

2 products or processed tobacco.’’. 

3 (5) CONFORMING AMENDMENTS.— 

4 (A) Section 5702(h) of such Code is 

5 amended by striking ‘‘tobacco products and cig6 arette papers and tubes’’ and inserting ‘‘tobacco 

7 products or cigarette papers or tubes or any 

8 processed tobacco’’. 

9 (B) Sections 5702(j) and 5702(k) of such 

10 Code are each amended by inserting ‘‘, or any 

11 processed tobacco,’’ after ‘‘tobacco products or 

12 cigarette papers or tubes’’. 

13 (6) EFFECTIVE DATE.—The amendments made 

14 by this subsection shall take effect on April 1, 2009. 

15 (b) BASIS FOR DENIAL, SUSPENSION, OR REVOCA16 TION OF PERMITS.— 

17 (1) DENIAL.—Paragraph (3) of section 5712 of 

18 such Code is amended to read as follows: 

19 ‘‘(3) such person (including, in the case of a 

20 corporation, any officer, director, or principal stock21 holder and, in the case of a partnership, a part22 ner)— 

23 ‘‘(A) is, by reason of his business experi24 ence, financial standing, or trade connections or 

25 by reason of previous or current legal proVerDate Nov 24 2008 02:01 Jan 17, 2009 Jkt 079200 PO 00000 Frm 00278 Fmt 6652 Sfmt 6201 E:\BILLS\S275.PCS S275

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1 ceedings involving a felony violation of any 

2 other provision of Federal criminal law relating 

3 to tobacco products, processed tobacco, ciga4 rette paper, or cigarette tubes, not likely to 

5 maintain operations in compliance with this 

6 chapter, 

7 ‘‘(B) has been convicted of a felony viola8 tion of any provision of Federal or State crimi9 nal law relating to tobacco products, processed 

10 tobacco, cigarette paper, or cigarette tubes, or 

11 ‘‘(C) has failed to disclose any material in12 formation required or made any material false 

13 statement in the application therefor.’’. 

14 (2) SUSPENSION OR REVOCATION.—Subsection 

15 (b) of section 5713 of such Code is amended to read 

16 as follows: 

17 ‘‘(b) SUSPENSION OR REVOCATION.— 

18 ‘‘(1) SHOW CAUSE HEARING.—If the Secretary 

19 has reason to believe that any person holding a per20 mit— 

21 ‘‘(A) has not in good faith complied with 

22 this chapter, or with any other provision of this 

23 title involving intent to defraud, 

24 ‘‘(B) has violated the conditions of such 

25 permit, 


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1 ‘‘(C) has failed to disclose any material in2 formation required or made any material false 

3 statement in the application for such permit, 

4 ‘‘(D) has failed to maintain his premises in 

5 such manner as to protect the revenue, 

6 ‘‘(E) is, by reason of previous or current 

7 legal proceedings involving a felony violation of 

8 any other provision of Federal criminal law re9 lating to tobacco products, processed tobacco, 

10 cigarette paper, or cigarette tubes, not likely to 

11 maintain operations in compliance with this 

12 chapter, or 

13 ‘‘(F) has been convicted of a felony viola14 tion of any provision of Federal or State crimi15 nal law relating to tobacco products, processed 

16 tobacco, cigarette paper, or cigarette tubes, 

17 the Secretary shall issue an order, stating the facts 

18 charged, citing such person to show cause why his 

19 permit should not be suspended or revoked. 

20 ‘‘(2) ACTION FOLLOWING HEARING.—If, after 

21 hearing, the Secretary finds that such person has 

22 not shown cause why his permit should not be sus23 pended or revoked, such permit shall be suspended 

24 for such period as the Secretary deems proper or 

25 shall be revoked.’’. 


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1 (3) EFFECTIVE DATE.—The amendments made 

2 by this subsection shall take effect on the date of the 

3 enactment of this Act. 

4 (c) APPLICATION OF INTERNAL REVENUE CODE

5 STATUTE OF LIMITATIONS FOR ALCOHOL AND TOBACCO

6 EXCISE TAXES.— 

7 (1) IN GENERAL.—Section 514(a) of the Tariff 

8 Act of 1930 (19 U.S.C. 1514(a)) is amended by 

9 striking ‘‘and section 520 (relating to refunds)’’ and 

10 inserting ‘‘section 520 (relating to refunds), and sec11 tion 6501 of the Internal Revenue Code of 1986 

12 (but only with respect to taxes imposed under chap13 ters 51 and 52 of such Code)’’. 

14 (2) EFFECTIVE DATE.—The amendment made 

15 by this subsection shall apply to articles imported 

16 after the date of the enactment of this Act. 

17 (d) EXPANSION OF DEFINITION OF ROLL-YOUR-OWN

18 TOBACCO.— 

19 (1) IN GENERAL.—Section 5702(o) of the In20 ternal Revenue Code of 1986 is amended by insert21 ing ‘‘or cigars, or for use as wrappers thereof’’ be22 fore the period at the end. 

23 (2) EFFECTIVE DATE.—The amendment made 

24 by this subsection shall apply to articles removed (as 


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1 defined in section 5702(j) of the Internal Revenue 

2 Code of 1986) after March 31, 2009. 

3 (e) TIME OF TAX FOR UNLAWFULLY MANUFAC4 TURED TOBACCO PRODUCTS.— 

5 (1) IN GENERAL.—Section 5703(b)(2) of such 

6 Code is amended by adding at the end the following 

7 new subparagraph: 

8 ‘‘(F) SPECIAL RULE FOR UNLAWFULLY

9 MANUFACTURED TOBACCO PRODUCTS.—In the 

10 case of any tobacco products, cigarette paper, 

11 or cigarette tubes manufactured in the United 

12 States at any place other than the premises of 

13 a manufacturer of tobacco products, cigarette 

14 paper, or cigarette tubes that has filed the bond 

15 and obtained the permit required under this 

16 chapter, tax shall be due and payable imme17 diately upon manufacture.’’. 

18 (2) EFFECTIVE DATE.—The amendment made 

19 by this subsection shall take effect on the date of the 

20 enactment of this Act. 

21 (f) DISCLOSURE.— 

22 (1) IN GENERAL.—Paragraph (1) of section 

23 6103(o) of such Code is amended by designating the 

24 text as subparagraph (A), moving such text 2 ems 

25 to the right, striking ‘‘Returns’’ and inserting ‘‘(A)


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1 IN GENERAL.—Returns’’, and by inserting after sub2 paragraph (A) (as so redesignated) the following 

3 new subparagraph: 

4 ‘‘(B) USE IN CERTAIN PROCEEDINGS.—Re5 turns and return information disclosed to a 

6 Federal agency under subparagraph (A) may be 

7 used in an action or proceeding (or in prepara8 tion for such action or proceeding) brought 

9 under section 625 of the American Jobs Cre10 ation Act of 2004 for the collection of any un11 paid assessment or penalty arising under such 

12 Act.’’. 

13 (2) CONFORMING AMENDMENT.—Section 

14 6103(p)(4) of such Code is amended by striking 

15 ‘‘(o)(1)’’ both places it appears and inserting 

16 ‘‘(o)(1)(A)’’. 

17 (3) EFFECTIVE DATE.—The amendments made 

18 by this subsection shall apply on or after the date 

19 of the enactment of this Act. 

20 (g) TRANSITIONAL RULE.—Any person who— 

21 (1) on April 1 is engaged in business as a man22 ufacturer of processed tobacco or as an importer of 

23 processed tobacco, and 

24 (2) before the end of the 90-day period begin25 ning on such date, submits an application under 


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1 subchapter B of chapter 52 of such Code to engage 

2 in such business, may, notwithstanding such sub3 chapter B, continue to engage in such business 

4 pending final action on such application. Pending 

5 such final action, all provisions of such chapter 52 

6 shall apply to such applicant in the same manner 

7 and to the same extent as if such applicant were a 

8 holder of a permit under such chapter 52 to engage 

9 in such business. 

10 SEC. 703. TREASURY STUDY CONCERNING MAGNITUDE OF 

11 TOBACCO SMUGGLING IN THE UNITED 

12 STATES. 

13 Not later than one year after the date of the enact14 ment of this Act, the Secretary of the Treasury shall con15 duct a study concerning the magnitude of tobacco smug16 gling in the United States and submit to Congress rec17 ommendations for the most effective steps to reduce to18 bacco smuggling. Such study shall also include a review 

19 of the loss of Federal tax receipts due to illicit tobacco 

20 trade in the United States and the role of imported to21 bacco products in the illicit tobacco trade in the United 

22 States. 


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1 SEC. 704. TIME FOR PAYMENT OF CORPORATE ESTIMATED 

2 TAXES. 

3 The percentage under subparagraph (C) of section 

4 401(1) of the Tax Increase Prevention and Reconciliation 

5 Act of 2005 in effect on the date of the enactment of this 

6 Act is increased by 0.5 percentage point. 


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Calendar No. 17 

111TH CONGRESS 

1ST SESSION S. 275 

A BILL 

To amend title XXI of the Social Security Act to 

ance Program, and for other purposes. extend and improve the Children’s Health InsurJANUARY 16, 2009 

Read twice and placed on the calendar 


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