I 

108TH CONGRESS 

2D SESSION H. R. 4935

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

ensure that the authority granted to the Secretary of Health and Human 

Services under section 1115 of that Act is used solely to promote the 

objectives of the Medicaid and State children’s health insurance programs, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JULY 22, 2004

Mr. DINGELL (for himself, Mr. BROWN of Ohio, Mr. WAXMAN, and Mrs. 

CAPPS) introduced the following bill; which was referred to the Committee on Energy and Commerce 

A BILL

To amend titles XIX and XXI of the Social Security Act 

to clarify and ensure that the authority granted to the 

Secretary of Health and Human Services under section 

1115 of that Act is used solely to promote the objectives 

of the Medicaid and State children’s health insurance 

programs, 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,
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1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

3 ‘‘Medicaid and CHIP Safety Net Preservation Act of 

4 2004’’. 

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

6 this Act is as follows:

Sec. 1. Short title; table of contents. 

Sec. 2. Findings; purposes; rule of construction. 

Sec. 3. Clarification that Section 1115 authority does not permit a cap on Federal financial participation. 

Sec. 4. Clarification that section 1115 authority does not permit elimination of, 

or modification limiting, individual entitlement. 

Sec. 5. Clarification that section 1115 authority does not permit elimination or 

modification of requirements relating to EPSDT services. 

Sec. 6. Clarification that section 1115 authority does not permit elimination or 

modification of requirements relating to certain safety-net services. 

Sec. 7. Improvement of the process for the development and approval of medicaid and CHIP demonstration projects. 

Sec. 8. Effective date.

7 SEC. 2. FINDINGS; PURPOSES; RULE OF CONSTRUCTION. 

8 (a) FINDINGS.—Congress makes the following find9 ings: 

10 (1) Certain requirements of titles XIX and XXI 

11 of the Social Security Act (42 U.S.C. 1396 et seq., 

12 1397aa et seq.) are central to the overall objectives 

13 of the medicaid and State children’s health insur14 ance programs and are not properly subject to waiv15 er, modification, or disregard under the authority of 

16 section 1115 of the Social Security Act (42 U.S.C. 

17 1315). 

18 (2) Some of the requirements of titles XIX and 

19 XXI of the Social Security Act that promote the 
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1 overall objectives of the medicaid and State chil2 dren’s health insurance programs have been waived, 

3 modified, or otherwise disregarded by the Secretary 

4 of Health and Human Services under such section 

5 1115, despite the explicit requirement in that section 

6 that certain requirements of the medicaid and State 

7 children’s health insurance programs only may be 

8 waived, modified, or disregarded for the purpose of 

9 approving an experimental, pilot, or demonstration 

10 project if the waiver, modification, or disregard ‘‘is 

11 likely to assist in promoting the objectives’’ of those 

12 programs. 

13 (b) PURPOSES.—The purposes of this Act are the fol14 lowing: 

15 (1) To clarify that certain requirements of titles 

16 XIX and XXI of the Social Security Act (42 U.S.C. 

17 1396 et seq., 1397aa et seq.), which are among 

18 those critical to achieving the objectives of the med19 icaid and State children’s health insurance pro20 grams, may not be waived, modified, or otherwise 

21 disregarded by the Secretary of Health and Human 

22 Services under the authority of section 1115 of the 

23 Social Security Act (42 U.S.C. 1315). 

24 (2) To ensure that the authority granted to the 

25 Secretary of Health and Human Services under sec-
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1 tion 1115 of the Social Security Act (42 U.S.C. 

2 1315) with respect to the medicaid and State chil3 dren’s health insurance programs for the purpose of 

4 approving experimental, pilot, or demonstration 

5 projects is not used inappropriately. 

6 (c) RULE OF CONSTRUCTION.—Nothing in this Act 

7 or the amendments made by this Act shall be construed 

8 to—

9 (1) authorize the waiver, modification, or other 

10 disregard of any provision of title XIX or XXI of the 

11 Social Security Act (42 U.S.C. 1396 et seq., 1397aa 

12 et seq.); or 

13 (2) imply congressional approval of any dem14 onstration project affecting the medicaid program 

15 under title XIX of the Social Security Act or the 

16 State children’s health insurance program under 

17 title XXI of such Act that has been approved by the 

18 Secretary of Health and Human Services as of the 

19 date of enactment of this Act. 

20 SEC. 3. CLARIFICATION THAT SECTION 1115 AUTHORITY 

21 DOES NOT PERMIT A CAP ON FEDERAL FI22 NANCIAL PARTICIPATION. 

23 Title XIX of the Social Security Act is amended by 

24 inserting after section 1925 the following: 
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1 ‘‘CLARIFICATIONS OF AUTHORITY UNDER SECTION 1115

2 ‘‘SEC. 1926. (a) CLARIFICATION THAT SECTION

3 1115 AUTHORITY DOES NOT PERMIT A CAP ON FEDERAL

4 FINANCIAL PARTICIPATION.—The Secretary may not im5 pose or approve under the authority of section 1115 a cap, 

6 limitation, or other restriction on payment under section 

7 1903(a) to a State for amounts expended as medical as8 sistance in accordance with the requirements of this 

9 title.’’. 

10 SEC. 4. CLARIFICATION THAT SECTION 1115 AUTHORITY 

11 DOES NOT PERMIT ELIMINATION OF, OR 

12 MODIFICATION LIMITING, INDIVIDUAL ENTI13 TLEMENT. 

14 Section 1926 of the Social Security Act, as added by 

15 section 3, is amended by adding at the end the following: 

16 ‘‘(b) CLARIFICATION THAT SECTION 1115 AUTHOR17 ITY DOES NOT PERMIT ELIMINATION OF, OR MODIFICA18 TION LIMITING, INDIVIDUAL ENTITLEMENT.—The Sec19 retary may not approve or impose under the authority of 

20 section 1115 an elimination of, or modification limiting, 

21 the entitlement (established under section 1902(a), 

22 1905(a), or otherwise) of an individual to receive any med23 ical assistance for which Federal financial participation is 

24 claimed under this title.’’. 
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1 SEC. 5. CLARIFICATION THAT SECTION 1115 AUTHORITY 

2 DOES NOT PERMIT ELIMINATION OR MODI3 FICATION OF REQUIREMENTS RELATING TO 

4 EPSDT SERVICES. 

5 Section 1926 of the Social Security Act, as added by 

6 section 3 and amended by section 4, is amended by adding 

7 at the end the following: 

8 ‘‘(c) CLARIFICATION THAT SECTION 1115 AUTHOR9 ITY DOES NOT PERMIT ELIMINATION OR MODIFICATION

10 OF REQUIREMENTS RELATING TO EPSDT SERVICES.—

11 The Secretary may not impose or approve under the au12 thority of section 1115 an elimination or modification of 

13 the amount, duration, or scope of the services described 

14 in section 1905(a)(4)(B) (relating to early and periodic 

15 screening, diagnostic, and treatment services (as defined 

16 in section 1905(r))) or of the requirements of subpara17 graphs (A) through (C) of section 1902(a)(43).’’. 

18 SEC. 6. CLARIFICATION THAT SECTION 1115 AUTHORITY 

19 DOES NOT PERMIT ELIMINATION OR MODI20 FICATION OF REQUIREMENTS RELATING TO 

21 CERTAIN SAFETY-NET SERVICES. 

22 Section 1926 of the Social Security Act, as added by 

23 section 3 and amended by sections 4 and 5, is amended 

24 by adding at the end the following: 

25 ‘‘(d) CLARIFICATION THAT SECTION 1115 AUTHOR26 ITY DOES NOT PERMIT ELIMINATION OR MODIFICATION
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1 OF REQUIREMENTS RELATING TO CERTAIN SAFETY-NET

2 SERVICES.—The Secretary may not impose or approve 

3 under the authority of section 1115 an elimination or 

4 modification of the amount, duration, or scope of the serv5 ices described in subparagraphs (B) and (C) of section 

6 1905(a)(2) (relating to services provided by a rural health 

7 clinic (as defined in section 1905(l)(1)) and services pro8 vided by a Federally-qualified health center (as defined in 

9 section 1905(l)(2))) or of the requirements of section 

10 1902(bb) (relating to payment for such services).’’. 

11 SEC. 7. IMPROVEMENT OF THE PROCESS FOR THE DEVEL12 OPMENT AND APPROVAL OF MEDICAID AND 

13 CHIP DEMONSTRATION PROJECTS. 

14 Section 1115 of the Social Security Act (42 U.S.C. 

15 1315) is amended by inserting after subsection (c) the fol16 lowing: 

17 ‘‘(d) In the case of any experimental, pilot, or dem18 onstration project under subsection (a) to assist in pro19 moting the objectives of title XIX or XXI in a State that 

20 would result in a substantive change in eligibility, enroll21 ment, benefits, financing, or cost-sharing (to the extent 

22 permitted under section 1916(f)) with respect to a State 

23 program under title XIX or XXI (in this subsection re24 ferred to as a ‘demonstration project’) the following shall 

25 apply: 
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1 ‘‘(1) The Secretary may not approve a proposal 

2 for a demonstration project, or for an amendment of 

3 a demonstration project, submitted by a State on or 

4 after the date of enactment of this subsection, unless 

5 the State requesting approval certifies that the State 

6 provided reasonable public notice and a reasonable 

7 opportunity for receipt and consideration of public 

8 comment on the proposal prior to submission of the 

9 proposal to the Secretary. Such notice shall in10 clude—

11 ‘‘(A) the proposal; 

12 ‘‘(B) the methodologies underlying the pro13 posal; 

14 ‘‘(C) the justifications for the proposal; 

15 ‘‘(D) the State’s projections regarding the 

16 likely effect and impact of the proposal on indi17 viduals eligible for assistance and providers or 

18 suppliers of items or services under title XIX or 

19 XXI (including under any demonstration 

20 project conducted in conjunction with either of 

21 those titles); and 

22 ‘‘(E) the State’s assumptions on which the 

23 projections described in subparagraph (D) are 

24 based. 
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1 ‘‘(2) With respect to any proposal for a dem2 onstration project, or for an amendment or exten3 sion of a demonstration project, which has not been 

4 approved or disapproved by the Secretary as of the 

5 date of enactment of this subsection, the Secretary 

6 shall—

7 ‘‘(A) provide public notice in the Federal 

8 Register and on the Internet website of the 

9 Centers for Medicare Medicaid Services of the 

10 proposal, any revisions of the proposal, and any 

11 conditions for the financing or approval of the 

12 proposal; 

13 ‘‘(B) provide adequate opportunity for 

14 public comment on the proposal, any revisions 

15 of the proposal, and any such conditions; 

16 ‘‘(C) approve such proposal, any revisions 

17 of the proposal, and any such conditions only if, 

18 after consideration of the public comments re19 ceived, the Secretary determines that the pro20 posal, any revisions of the proposal, and any 

21 such conditions are likely to assist in promoting 

22 the objectives of title XIX or XXI and identifies 

23 in writing the basis for such determination; and 

24 ‘‘(D) publish on such website all docu25 mentation relating to the proposal (including 
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1 the written determination required under sub2 paragraph (C)), any revisions of the proposal, 

3 and any such conditions, including if the pro4 posal, any revisions of the proposal, and any 

5 such conditions are approved—

6 ‘‘(i) the final terms and conditions for 

7 the demonstration project; and 

8 ‘‘(ii) a list identifying each provision 

9 of title XIX or XXI, and each regulation 

10 relating to either such title, with which 

11 compliance is waived, modified, or other12 wise disregarded or for which costs that 

13 would otherwise not be permitted under 

14 such title will be allowed.’’. 

15 SEC. 8. EFFECTIVE DATE. 

16 (a) IN GENERAL.—Except as provided in subsection 

17 (b), the amendments made by sections 3 through 6 shall 

18 apply to the approval on or after the date of enactment 

19 of this Act of—

20 (1) a waiver, experimental, pilot, or demonstra21 tion project under section 1115 of the Social Secu22 rity Act (42 U.S.C. 1315); and 

23 (2) an amendment or extension of such a 

24 project. 
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1 (b) EXCEPTION.—The amendment made by section 

2 5 shall not apply with respect to any extension of approval 

3 of a waiver, experimental, pilot, or demonstration project 

4 with respect to title XIX of the Social Security Act that 

5 was first approved before 1994 and that provides a com6 prehensive and preventive child health program under 

7 such project that includes screening, diagnosis, and treat8 ment of children who have not attained age 21.

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