In the Senate of the United States, 

January 29, 2009. 

Resolved, That the bill from the House of Representatives (H.R. 2) entitled ‘‘An Act to amend title XXI of the Social Security Act to extend and improve the Children’s Health 

Insurance Program, and for other purposes.’’, do pass with 

the following 

AMENDMENT: 

Strike all after the enacting clause and insert the 

following: 

1 SECTION 1. SHORT TITLE; AMENDMENTS TO SOCIAL SECU2 RITY ACT; REFERENCES; TABLE OF CON3 TENTS. 

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

5 ‘‘Children’s Health Insurance Program Reauthorization 

6 Act of 2009’’. 

7 (b) AMENDMENTS TO SOCIAL SECURITY ACT.—Except 

8 as otherwise specifically provided, whenever in this Act an 

9 amendment is expressed in terms of an amendment to or 
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1 repeal of a section or other provision, the reference shall 

2 be considered to be made to that section or other provision 

3 of the Social Security Act. 

4 (c) REFERENCES TO CHIP; MEDICAID; SECRETARY.— 

5 In this Act: 

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

7 Children’s Health Insurance Program established 

8 under title XXI of the Social Security Act (42 U.S.C. 

9 1397aa et seq.). 

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

11 program for medical assistance established under title 

12 XIX of the Social Security Act (42 U.S.C. 1396 et 

13 seq.). 

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

15 the Secretary of Health and Human Services. 

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

17 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. 

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. 
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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 

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. 
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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. 

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 and 

3 stable funding for children’s health insurance under titles 
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1 XXI and XIX of the Social Security Act in order to enroll 

2 all six million uninsured children who are eligible, but not 

3 enrolled, for coverage today through such titles. 

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

5 LEGISLATION; CONTINGENT EFFECTIVE 

6 DATE; RELIANCE ON LAW. 

7 (a) GENERAL EFFECTIVE DATE.—Unless otherwise 

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

9 this Act (and the amendments made by this Act) shall take 

10 effect on April 1, 2009, and shall apply to child health as11 sistance and medical assistance provided on or after that 

12 date. 

13 (b) EXCEPTION FOR STATE LEGISLATION.—In the case 

14 of a State plan under title XIX or State child health plan 

15 under XXI of the Social Security Act, which the Secretary 

16 of Health and Human Services determines requires State 

17 legislation in order for the respective plan to meet one or 

18 more additional requirements imposed by amendments 

19 made by this Act, the respective plan shall not be regarded 

20 as failing to comply with the requirements of such title sole21 ly on the basis of its failure to meet such an additional 

22 requirement before the first day of the first calendar quarter 

23 beginning after the close of the first regular session of the 

24 State legislature that begins after the date of enactment of 

25 this Act. For purposes of the previous sentence, in the case 
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1 of a State that has a 2-year legislative session, each year 

2 of the session shall be considered to be a separate regular 

3 session of the State legislature. 

4 (c) COORDINATION OF CHIP FUNDING FOR FISCAL

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

6 insofar as funds have been appropriated under section 

7 2104(a)(11), 2104(k), or 2104(l) of the Social Security Act, 

8 as amended by section 201 of Public Law 110–173, to pro9 vide allotments to States under CHIP for fiscal year 

10 2009— 

11 (1) any amounts that are so appropriated that 

12 are not so allotted and obligated before April 1, 2009 

13 are rescinded; and 

14 (2) any amount provided for CHIP allotments to 

15 a State under this Act (and the amendments made by 

16 this Act) for such fiscal year shall be reduced by the 

17 amount of such appropriations so allotted and obli18 gated before such date. 

19 (d) RELIANCE ON LAW.—With respect to amendments 

20 made by this Act (other than title VII) that become effective 

21 as of a date— 

22 (1) such amendments are effective as of such date 

23 whether or not regulations implementing such amend24 ments have been issued; and 
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1 (2) Federal financial participation for medical 

2 assistance or child health assistance furnished under 

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

4 Act on or after such date by a State in good faith re5 liance on such amendments before the date of promul6 gation of final regulations, if any, to carry out such 

7 amendments (or before the date of guidance, if any, 

8 regarding the implementation of such amendments) 

9 shall not be denied on the basis of the State’s failure 

10 to comply with such regulations or guidance. 

11 TITLE I—FINANCING 

12 Subtitle A—Funding 

13 SEC. 101. EXTENSION OF CHIP. 

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

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

16 end; 

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

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

19 ‘‘fiscal year 2008’’; and 

20 (3) by adding at the end the following new para21 graphs: 

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

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

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

25 ‘‘(15) for fiscal year 2012, $14,982,000,000; and 
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1 ‘‘(16) for fiscal year 2013, for purposes of mak2 ing 2 semi-annual allotments— 

3 ‘‘(A) $2,850,000,000 for the period begin4 ning on October 1, 2012, and ending on March 

5 31, 2013, and 

6 ‘‘(B) $2,850,000,000 for the period begin7 ning on April 1, 2013, and ending on September 

8 30, 2013.’’. 

9 SEC. 102. ALLOTMENTS FOR STATES AND TERRITORIES FOR 

10 FISCAL YEARS 2009 THROUGH 2013. 

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

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

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

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

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

16 (3) by adding at the end the following new sub17 section: 

18 ‘‘(m) ALLOTMENTS FOR FISCAL YEARS 2009 

19 THROUGH 2013.— 

20 ‘‘(1) FOR FISCAL YEAR 2009.— 

21 ‘‘(A) FOR THE 50 STATES AND THE DIS22 TRICT OF COLUMBIA.—Subject to the succeeding 

23 provisions of this paragraph and paragraph (4), 

24 the Secretary shall allot for fiscal year 2009 

25 from the amount made available under sub-
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1 section (a)(12), to each of the 50 States and the 

2 District of Columbia 110 percent of the highest 

3 of the following amounts for such State or Dis4 trict: 

5 ‘‘(i) The total Federal payments to the 

6 State under this title for fiscal year 2008, 

7 multiplied by the allotment increase factor 

8 determined under paragraph (5) for fiscal 

9 year 2009. 

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

11 for fiscal year 2008 under subsection (b), 

12 multiplied by the allotment increase factor 

13 determined under paragraph (5) for fiscal 

14 year 2009. 

15 ‘‘(iii) The projected total Federal pay16 ments to the State under this title for fiscal 

17 year 2009, as determined on the basis of the 

18 February 2009 projections certified by the 

19 State to the Secretary by not later than 

20 March 31, 2009. 

21 ‘‘(B) FOR THE COMMONWEALTHS AND TER22 RITORIES.—Subject to the succeeding provisions 

23 of this paragraph and paragraph (4), the Sec24 retary shall allot for fiscal year 2009 from the 

25 amount made available under subsection (a)(12) 
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1 to each of the commonwealths and territories de2 scribed in subsection (c)(3) an amount equal to 

3 the highest amount of Federal payments to the 

4 commonwealth or territory under this title for 

5 any fiscal year occurring during the period of 

6 fiscal years 1999 through 2008, multiplied by the 

7 allotment increase factor determined under para8 graph (5) for fiscal year 2009, except that sub9 paragraph (B) thereof shall be applied by sub10 stituting ‘the United States’ for ‘the State’. 

11 ‘‘(C) ADJUSTMENT FOR QUALIFYING

12 STATES.—In the case of a qualifying State de13 scribed in paragraph (2) of section 2105(g), the 

14 Secretary shall permit the State to submit a re15 vised projection described in subparagraph 

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

17 such projections attributable to the application of 

18 paragraph (4) of such section. 

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

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

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

22 under paragraphs (13) through (15) of subsection 

23 (a) for each of fiscal years 2010 through 2012, 

24 respectively, the Secretary shall compute a State 

25 allotment for each State (including the District 
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1 of Columbia and each commonwealth and terri2 tory) for each such fiscal year as follows: 

3 ‘‘(i) GROWTH FACTOR UPDATE FOR

4 FISCAL YEAR 2010.—For fiscal year 2010, 

5 the allotment of the State is equal to the 

6 sum of— 

7 ‘‘(I) the amount of the State allot8 ment under paragraph (1) for fiscal 

9 year 2009; and 

10 ‘‘(II) the amount of any payments 

11 made to the State under subsection (k), 

12 (l), or (n) for fiscal year 2009, 

13 multiplied by the allotment increase factor 

14 under paragraph (5) for fiscal year 2010. 

15 ‘‘(ii) REBASING IN FISCAL YEAR

16 2011.—For fiscal year 2011, the allotment of 

17 the State is equal to the Federal payments 

18 to the State that are attributable to (and 

19 countable towards) the total amount of al20 lotments available under this section to the 

21 State in fiscal year 2010 (including pay22 ments made to the State under subsection 

23 (n) for fiscal year 2010 as well as amounts 

24 redistributed to the State in fiscal year 

25 2010), multiplied by the allotment increase 
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1 factor under paragraph (5) for fiscal year 

2 2011. 

3 ‘‘(iii) GROWTH FACTOR UPDATE FOR

4 FISCAL YEAR 2012.—For fiscal year 2012, 

5 the allotment of the State is equal to the 

6 sum of— 

7 ‘‘(I) the amount of the State allot8 ment under clause (ii) for fiscal year 

9 2011; and 

10 ‘‘(II) the amount of any payments 

11 made to the State under subsection (n) 

12 for fiscal year 2011, 

13 multiplied by the allotment increase factor 

14 under paragraph (5) for fiscal year 2012. 

15 ‘‘(3) FOR FISCAL YEAR 2013.— 

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

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

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

19 subsection (a) for the semi-annual period de20 scribed in such paragraph, increased by the 

21 amount of the appropriation for such period 

22 under section 108 of the Children’s Health Insur23 ance Program Reauthorization Act of 2009, the 

24 Secretary shall compute a State allotment for 

25 each State (including the District of Columbia 
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1 and each commonwealth and territory) for such 

2 semi-annual period in an amount equal to the 

3 first half ratio (described in subparagraph (D)) 

4 of the amount described in subparagraph (C). 

5 ‘‘(B) SECOND HALF.—Subject to para6 graphs (4) and (6), from the amount made 

7 available under subparagraph (B) of paragraph 

8 (16) of subsection (a) for the semi-annual period 

9 described in such paragraph, the Secretary shall 

10 compute a State allotment for each State (in11 cluding the District of Columbia and each com12 monwealth and territory) for such semi-annual 

13 period in an amount equal to the amount made 

14 available under such subparagraph, multiplied 

15 by the ratio of— 

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

17 such State under subparagraph (A); to 

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

19 the allotments made available under such 

20 subparagraph. 

21 ‘‘(C) FULL YEAR AMOUNT BASED ON

22 REBASED AMOUNT.—The amount described in 

23 this subparagraph for a State is equal to the 

24 Federal payments to the State that are attrib25 utable to (and countable towards) the total 
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1 amount of allotments available under this section 

2 to the State in fiscal year 2012 (including pay3 ments made to the State under subsection (n) for 

4 fiscal year 2012 as well as amounts redistributed 

5 to the State in fiscal year 2012), multiplied by 

6 the allotment increase factor under paragraph 

7 (5) for fiscal year 2013. 

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

9 ratio described in this subparagraph is the ratio 

10 of— 

11 ‘‘(i) the sum of— 

12 ‘‘(I) the amount made available 

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

14 ‘‘(II) the amount of the appro15 priation for such period under section 

16 108 of the Children’s Health Insurance 

17 Program Reauthorization Act of 2009; 

18 to 

19 ‘‘(ii) the sum of the— 

20 ‘‘(I) amount described in clause 

21 (i); and 

22 ‘‘(II) the amount made available 

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

24 ‘‘(4) PRORATION RULE.—If, after the application 

25 of this subsection without regard to this paragraph, 
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1 the sum of the allotments determined under para2 graph (1), (2), or (3) for a fiscal year (or, in the case 

3 of fiscal year 2013, for a semi-annual period in such 

4 fiscal year) exceeds the amount available under sub5 section (a) for such fiscal year or period, the Sec6 retary shall reduce each allotment for any State 

7 under such paragraph for such fiscal year or period 

8 on a proportional basis. 

9 ‘‘(5) ALLOTMENT INCREASE FACTOR.—The allot10 ment increase factor under this paragraph for a fiscal 

11 year is equal to the product of the following: 

12 ‘‘(A) PER CAPITA HEALTH CARE GROWTH

13 FACTOR.—1 plus the percentage increase in the 

14 projected per capita amount of National Health 

15 Expenditures from the calendar year in which 

16 the previous fiscal year ends to the calendar year 

17 in which the fiscal year involved ends, as most 

18 recently published by the Secretary before the be19 ginning of the fiscal year. 

20 ‘‘(B) CHILD POPULATION GROWTH FAC21 TOR.—1 plus the percentage increase (if any) in 

22 the population of children in the State from July 

23 1 in the previous fiscal year to July 1 in the fis24 cal year involved, as determined by the Secretary 

25 based on the most recent published estimates of 
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1 the Bureau of the Census before the beginning of 

2 the fiscal year involved, plus 1 percentage point. 

3 ‘‘(6) INCREASE IN ALLOTMENT TO ACCOUNT FOR

4 APPROVED PROGRAM EXPANSIONS.—In the case of one 

5 of the 50 States or the District of Columbia that— 

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

7 has approved by the Secretary, a State plan 

8 amendment or waiver request relating to an ex9 pansion of eligibility for children or benefits 

10 under this title that becomes effective for a fiscal 

11 year (beginning with fiscal year 2010 and end12 ing with fiscal year 2013); and 

13 ‘‘(B) has submitted to the Secretary, before 

14 the August 31 preceding the beginning of the fis15 cal year, a request for an expansion allotment 

16 adjustment under this paragraph for such fiscal 

17 year that specifies— 

18 ‘‘(i) the additional expenditures that 

19 are attributable to the eligibility or benefit 

20 expansion provided under the amendment 

21 or waiver described in subparagraph (A), as 

22 certified by the State and submitted to the 

23 Secretary by not later than August 31 pre24 ceding the beginning of the fiscal year; 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 the 

4 year, 

5 subject to paragraph (4), the amount of the allotment 

6 of the State or District under this subsection for such 

7 fiscal year shall be increased by the excess amount de8 scribed in subparagraph (B)(i). A State or District 

9 may only obtain an increase under this paragraph 

10 for an allotment for fiscal year 2010 or fiscal year 

11 2012. 

12 ‘‘(7) AVAILABILITY OF AMOUNTS FOR SEMI-AN13 NUAL PERIODS IN FISCAL YEAR 2013.—Each semi-an14 nual allotment made under paragraph (3) for a pe15 riod in fiscal year 2013 shall remain available for ex16 penditure under this title for periods after the end of 

17 such fiscal year in the same manner as if the allot18 ment 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 sec22 tion 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 APPROPRIA10 TIONS.—Subject to subparagraphs (B) and (D), 

11 out of any money in the Treasury of the United 

12 States not otherwise appropriated, there are ap13 propriated 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 semi-an20 nual allotment periods for fiscal year 2013), 

21 such sums as are necessary for making pay22 ments to eligible States for such fiscal year 

23 or period, but not in excess of the aggregate 

24 cap described in subparagraph (B). 
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1 ‘‘(B) AGGREGATE CAP.—The total amount 

2 available for payment from the Fund for each of 

3 fiscal years 2010 through 2012 (and for each of 

4 the semi-annual allotment periods for fiscal year 

5 2013), taking into account deposits made under 

6 subparagraph (C), shall not exceed 20 percent of 

7 the amount made available under subsection (a) 

8 for the fiscal year or period. 

9 ‘‘(C) INVESTMENT OF FUND.—The Secretary 

10 of the Treasury shall invest, in interest bearing 

11 securities of the United States, such currently 

12 available portions of the Fund as are not imme13 diately required for payments from the Fund. 

14 The income derived from these investments con15 stitutes a part of the Fund. 

16 ‘‘(D) AVAILABILITY OF EXCESS FUNDS FOR

17 PERFORMANCE BONUSES.—Any amounts in ex18 cess of the aggregate cap described in subpara19 graph (B) for a fiscal year or period shall be 

20 made available for purposes of carrying out sec21 tion 2105(a)(3) for any succeeding fiscal year 

22 and the Secretary of the Treasury shall reduce 

23 the amount in the Fund by the amount so made 

24 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 subsection 

11 (f) that is available for expenditure during such 

12 fiscal year or period, but including any carry13 over from a previous fiscal year) and if the aver14 age monthly unduplicated number of children 

15 enrolled under the State plan under this title 

16 (including children receiving health care cov17 erage through funds under this title pursuant to 

18 a waiver under section 1115) during such fiscal 

19 year or period exceeds its target average number 

20 of such enrollees (as determined under subpara21 graph (B)) for that fiscal year or period, subject 

22 to subparagraph (D), the Secretary shall pay to 

23 the State from the Fund an amount equal to the 

24 product of— 
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1 ‘‘(i) the amount by which such average 

2 monthly caseload exceeds such target num3 ber of enrollees; and 

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

6 determined under subparagraph (C) for the 

7 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 the 

15 monthly average unduplicated number of 

16 children enrolled in the State child health 

17 plan under this title (including such chil18 dren receiving health care coverage through 

19 funds under this title pursuant to a waiver 

20 under section 1115) during fiscal year 2008 

21 increased by the population growth for chil22 dren in that State for the year ending on 

23 June 30, 2007 (as estimated by the Bureau 

24 of the Census) plus 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 number 

4 of child enrollees for the State for the pre5 vious fiscal year increased by the child pop6 ulation growth factor described in sub7 section (m)(5)(B) for the State for the prior 

8 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 the 

14 average per capita expenditures (including 

15 both State and Federal financial participa16 tion) under such plan for the targeted low17 income children counted in the average 

18 monthly caseload for purposes of this para19 graph during fiscal year 2008, increased by 

20 the annual percentage increase in the pro21 jected per capita amount of National 

22 Health Expenditures (as estimated by the 

23 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 ex2 penditures under such plan for the previous 

3 fiscal year (as determined under clause (i) 

4 or this clause) increased by the annual per5 centage increase in the projected per capita 

6 amount of National Health Expenditures 

7 (as estimated by the Secretary) for the year 

8 in which such subsequent fiscal year ends. 

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

10 available for payment from the Fund for a fiscal 

11 year or period are less than the total amount of 

12 payments determined under subparagraph (A) 

13 for the fiscal year or period, the amount to be 

14 paid under such subparagraph to each eligible 

15 State shall be reduced proportionally. 

16 ‘‘(E) TIMELY PAYMENT; RECONCILIATION.— 

17 Payment under this paragraph for a fiscal year 

18 or period shall be made before the end of the fis19 cal year or period based upon the most recent 

20 data for expenditures and enrollment and the 

21 provisions of subsection (e) of section 2105 shall 

22 apply to payments under this subsection in the 

23 same manner as they apply to payments under 

24 such section. 
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1 ‘‘(F) CONTINUED REPORTING.—For pur2 poses of this paragraph and subsection (f), the 

3 State shall submit to the Secretary the State’s 

4 projected Federal expenditures, even if the 

5 amount of such expenditures exceeds the total 

6 amount of allotments available to the State in 

7 such fiscal year or period. 

8 ‘‘(G) APPLICATION TO COMMONWEALTHS

9 AND TERRITORIES.—No payment shall be made 

10 under this paragraph to a commonwealth or ter11 ritory described in subsection (c)(3) until such 

12 time as the Secretary determines that there are 

13 in effect methods, satisfactory to the Secretary, 

14 for the collection and reporting of reliable data 

15 regarding the enrollment of children described in 

16 subparagraphs (A) and (B) in order to accu17 rately determine the commonwealth’s or terri18 tory’s eligibility for, and amount of payment, 

19 under this paragraph.’’. 

20 SEC. 104. CHIP PERFORMANCE BONUS PAYMENT TO OFFSET 

21 ADDITIONAL ENROLLMENT COSTS RESULT22 ING FROM ENROLLMENT AND RETENTION EF23 FORTS. 

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

25 adding at the end the following new paragraphs: 
25 

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1 ‘‘(3) PERFORMANCE BONUS PAYMENT TO OFFSET

2 ADDITIONAL MEDICAID AND CHIP CHILD ENROLLMENT

3 COSTS RESULTING FROM ENROLLMENT AND RETEN4 TION EFFORTS.— 

5 ‘‘(A) IN GENERAL.—In addition to the pay6 ments made under paragraph (1), for each fiscal 

7 year (beginning with fiscal year 2009 and end8 ing with fiscal year 2013), the Secretary shall 

9 pay from amounts made available under sub10 paragraph (E), to each State that meets the con11 dition under paragraph (4) for the fiscal year, 

12 an amount equal to the amount described in sub13 paragraph (B) for the State and fiscal year. The 

14 payment under this paragraph shall be made, to 

15 a State for a fiscal year, as a single payment not 

16 later than the last day of the first calendar quar17 ter of the following fiscal year. 

18 ‘‘(B) AMOUNT FOR ABOVE BASELINE MED19 ICAID CHILD ENROLLMENT COSTS.—Subject to 

20 subparagraph (E), the amount described in this 

21 subparagraph for a State for a fiscal year is 

22 equal to the sum of the following amounts: 

23 ‘‘(i) FIRST TIER ABOVE BASELINE

24 MEDICAID ENROLLEES.—An amount equal 

25 to the number of first tier above baseline 
26 

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1 child enrollees (as determined under sub2 paragraph (C)(i)) under title XIX for the 

3 State and fiscal year, multiplied by 15 per4 cent of the projected per capita State Med5 icaid expenditures (as determined under 

6 subparagraph (D)) for the State and fiscal 

7 year under title XIX. 

8 ‘‘(ii) SECOND TIER ABOVE BASELINE

9 MEDICAID ENROLLEES.—An amount equal 

10 to the number of second tier above baseline 

11 child enrollees (as determined under sub12 paragraph (C)(ii)) under title XIX for the 

13 State and fiscal year, multiplied by 62.5 

14 percent of the projected per capita State 

15 Medicaid expenditures (as determined under 

16 subparagraph (D)) for the State and fiscal 

17 year under title XIX. 

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

19 ABOVE BASELINE CHILD ENROLLEES; BASELINE

20 NUMBER OF CHILD ENROLLEES.—For purposes 

21 of this paragraph: 

22 ‘‘(i) FIRST TIER ABOVE BASELINE

23 CHILD ENROLLEES.—The number of first 

24 tier above baseline child enrollees for a 

25 State for a fiscal year under title XIX is 
27 

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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 the State plan under title XIX, 

8 respectively; exceeds 

9 ‘‘(II) the baseline number of en10 rollees described in clause (iii) for the 

11 State and fiscal year under title XIX, 

12 respectively; 

13 but not to exceed 10 percent of the baseline 

14 number of enrollees described in subclause 

15 (II). 

16 ‘‘(ii) SECOND TIER ABOVE BASELINE

17 CHILD ENROLLEES.—The number of second 

18 tier above baseline child enrollees for a 

19 State for a fiscal year under title XIX is 

20 equal to the number (if any, as determined 

21 by the Secretary) by which— 

22 ‘‘(I) the monthly average 

23 unduplicated number of qualifying 

24 children (as defined in subparagraph 

25 (F)) enrolled during the fiscal year 
28 

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1 under title XIX as described in clause 

2 (i)(I); exceeds 

3 ‘‘(II) the sum of the baseline num4 ber of child enrollees described in 

5 clause (iii) for the State and fiscal 

6 year under title XIX, as described in 

7 clause (i)(II), and the maximum num8 ber of first tier above baseline child en9 rollees for the State and fiscal year 

10 under title XIX, as determined under 

11 clause (i). 

12 ‘‘(iii) BASELINE NUMBER OF CHILD

13 ENROLLEES.—Subject to subparagraph (H), 

14 the baseline number of child enrollees for a 

15 State under title XIX— 

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

17 to the monthly average unduplicated 

18 number of qualifying children enrolled 

19 in the State plan under title XIX dur20 ing fiscal year 2007 increased by the 

21 population growth for children in that 

22 State from 2007 to 2008 (as estimated 

23 by the Bureau of the Census) plus 4 

24 percentage points, and further in25 creased by the population growth for 
29 

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1 children in that State from 2008 to 

2 2009 (as estimated by the Bureau of 

3 the Census) plus 4 percentage points; 

4 ‘‘(II) for each of fiscal years 2010, 

5 2011, and 2012, is equal to the base6 line number of child enrollees for the 

7 State for the previous fiscal year under 

8 title XIX, increased by the population 

9 growth for children in that State from 

10 the calendar year in which the respec11 tive fiscal year begins to the succeeding 

12 calendar year (as estimated by the Bu13 reau of the Census) plus 3.5 percentage 

14 points; 

15 ‘‘(III) for each of fiscal years 

16 2013, 2014, and 2015, is equal to the 

17 baseline number of child enrollees for 

18 the State for the previous fiscal year 

19 under title XIX, increased by the popu20 lation growth for children in that State 

21 from the calendar year in which the re22 spective fiscal year begins to the suc23 ceeding calendar year (as estimated by 

24 the Bureau of the Census) plus 3 per25 centage points; and 
30 

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1 ‘‘(IV) for a subsequent fiscal year 

2 is equal to the baseline number of child 

3 enrollees for the State for the previous 

4 fiscal year under title XIX, increased 

5 by the population growth for children 

6 in that State from the calendar year in 

7 which the fiscal year involved begins to 

8 the succeeding calendar year (as esti9 mated by the Bureau of the Census) 

10 plus 2 percentage points. 

11 ‘‘(D) PROJECTED PER CAPITA STATE MED12 ICAID EXPENDITURES.—For purposes of sub13 paragraph (B), the projected per capita State 

14 Medicaid expenditures for a State and fiscal 

15 year under title XIX is equal to the average per 

16 capita expenditures (including both State and 

17 Federal financial participation) for children 

18 under the State plan under such title, including 

19 under waivers but not including such children 

20 eligible for assistance by virtue of the receipt of 

21 benefits under title XVI, for the most recent fiscal 

22 year for which actual data are available (as de23 termined by the Secretary), increased (for each 

24 subsequent fiscal year up to and including the 

25 fiscal year involved) by the annual percentage 
31 

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1 increase in per capita amount of National 

2 Health Expenditures (as estimated by the Sec3 retary) for the calendar year in which the respec4 tive subsequent fiscal year ends and multiplied 

5 by a State matching percentage equal to 100 per6 cent minus the Federal medical assistance per7 centage (as defined in section 1905(b)) for the 

8 fiscal year involved. 

9 ‘‘(E) AMOUNTS AVAILABLE FOR PAY10 MENTS.— 

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

12 any money in the Treasury not otherwise 

13 appropriated, there are appropriated 

14 $3,225,000,000 for fiscal year 2009 for mak15 ing payments under this paragraph, to be 

16 available until expended. 

17 ‘‘(ii) TRANSFERS.—Notwithstanding 

18 any other provision of this title, the fol19 lowing amounts shall also be available, 

20 without fiscal year limitation, for making 

21 payments under this paragraph: 

22 ‘‘(I) UNOBLIGATED NATIONAL AL23 LOTMENT.— 

24 ‘‘(aa) FISCAL YEARS 2009

25 THROUGH 2012.—As of December 
32 

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1 31 of fiscal year 2009, and as of 

2 December 31 of each succeeding 

3 fiscal year through fiscal year 

4 2012, the portion, if any, of the 

5 amount appropriated under sub6 section (a) for such fiscal year 

7 that is unobligated for allotment 

8 to a State under subsection (m) 

9 for such fiscal year or set aside 

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

11 of section 2111 for such fiscal 

12 year. 

13 ‘‘(bb) FIRST HALF OF FISCAL

14 YEAR 2013.—As of December 31 of 

15 fiscal year 2013, the portion, if 

16 any, of the sum of the amounts 

17 appropriated under subsection 

18 (a)(16)(A) and under section 108 

19 of the Children’s Health Insurance 

20 Reauthorization Act of 2009 for 

21 the period beginning on October 1, 

22 2012, and ending on March 31, 

23 2013, that is unobligated for allot24 ment to a State under subsection 

25 (m) for such fiscal year or set 
33 

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1 aside under subsection (b)(2) of 

2 section 2111 for such fiscal year. 

3 ‘‘(cc) SECOND HALF OF FIS4 CAL YEAR 2013.—As of June 30 of 

5 fiscal year 2013, the portion, if 

6 any, of the amount appropriated 

7 under subsection (a)(16)(B) for 

8 the period beginning on April 1, 

9 2013, and ending on September 

10 30, 2013, that is unobligated for 

11 allotment to a State under sub12 section (m) for such fiscal year or 

13 set aside under subsection (b)(2) 

14 of section 2111 for such fiscal 

15 year. 

16 ‘‘(II) UNEXPENDED ALLOTMENTS

17 NOT USED FOR REDISTRIBUTION.—As 

18 of November 15 of each of fiscal years 

19 2010 through 2013, the total amount of 

20 allotments made to States under sec21 tion 2104 for the second preceding fis22 cal year (third preceding fiscal year in 

23 the case of the fiscal year 2006, 2007, 

24 and 2008 allotments) that is not ex25 pended or redistributed under section 
34 

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1 2104(f) during the period in which 

2 such allotments are available for obli3 gation. 

4 ‘‘(III) EXCESS CHILD ENROLL5 MENT CONTINGENCY FUNDS.—As of Oc6 tober 1 of each of fiscal years 2010 

7 through 2013, any amount in excess of 

8 the aggregate cap applicable to the 

9 Child Enrollment Contingency Fund 

10 for the fiscal year under section 

11 2104(n). 

12 ‘‘(IV) UNEXPENDED TRANSI13 TIONAL COVERAGE BLOCK GRANT FOR

14 NONPREGNANT CHILDLESS ADULTS.— 

15 As of October 1, 2011, any amounts set 

16 aside under section 2111(a)(3) that are 

17 not expended by September 30, 2011. 

18 ‘‘(iii) PROPORTIONAL REDUCTION.—If 

19 the sum of the amounts otherwise payable 

20 under this paragraph for a fiscal year ex21 ceeds the amount available for the fiscal 

22 year under this subparagraph, the amount 

23 to be paid under this paragraph to each 

24 State shall be reduced proportionally. 

25 ‘‘(F) QUALIFYING CHILDREN DEFINED.— 
35 

† HR 2 EAS 

1 ‘‘(i) IN GENERAL.—For purposes of 

2 this subsection, subject to clauses (ii) and 

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

4 children who meet the eligibility criteria 

5 (including income, categorical eligibility, 

6 age, and immigration status criteria) in ef7 fect as of July 1, 2008, for enrollment under 

8 title XIX, taking into account criteria ap9 plied as of such date under title XIX pursu10 ant to a waiver under section 1115. 

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

12 in clause (i) who is provided medical assist13 ance during a presumptive eligibility period 

14 under section 1920A shall be considered to 

15 be a ‘qualifying child’ only if the child is 

16 determined to be eligible for medical assist17 ance under title XIX. 

18 ‘‘(iii) EXCLUSION.—Such term does 

19 not include any children for whom the State 

20 has made an election to provide medical as21 sistance under paragraph (4) of section 

22 1903(v). 

23 ‘‘(G) APPLICATION TO COMMONWEALTHS

24 AND TERRITORIES.—The provisions of subpara25 graph (G) of section 2104(n)(3) shall apply with 
36 

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1 respect to payment under this paragraph in the 

2 same manner as such provisions apply to pay3 ment under such section. 

4 ‘‘(H) APPLICATION TO STATES THAT IMPLE5 MENT A MEDICAID EXPANSION FOR CHILDREN

6 AFTER FISCAL YEAR 2008.—In the case of a State 

7 that provides coverage under section 115 of the 

8 Children’s Health Insurance Program Reauthor9 ization Act of 2009 for any fiscal year after fis10 cal year 2008— 

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

12 plan under title XIX through the applica13 tion of such an election shall be disregarded 

14 from the determination for the State of the 

15 monthly average unduplicated number of 

16 qualifying children enrolled in such plan 

17 during the first 3 fiscal years in which such 

18 an election is in effect; and 

19 ‘‘(ii) in determining the baseline num20 ber of child enrollees for the State for any 

21 fiscal year subsequent to such first 3 fiscal 

22 years, the baseline number of child enrollees 

23 for the State under title XIX for the third 

24 of such fiscal years shall be the monthly av25 erage unduplicated number of qualifying 
37 

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1 children enrolled in the State plan under 

2 title XIX for such third fiscal year. 

3 ‘‘(4) ENROLLMENT AND RETENTION PROVISIONS

4 FOR CHILDREN.—For purposes of paragraph (3)(A), 

5 a State meets the condition of this paragraph for a 

6 fiscal year if it is implementing at least 5 of the fol7 lowing enrollment and retention provisions (treating 

8 each subparagraph as a separate enrollment and re9 tention provision) throughout the entire fiscal year: 

10 ‘‘(A) CONTINUOUS ELIGIBILITY.—The State 

11 has elected the option of continuous eligibility for 

12 a full 12 months for all children described in sec13 tion 1902(e)(12) under title XIX under 19 years 

14 of age, as well as applying such policy under its 

15 State child health plan under this title. 

16 ‘‘(B) LIBERALIZATION OF ASSET REQUIRE17 MENTS.—The State meets the requirement speci18 fied in either of the following clauses: 

19 ‘‘(i) ELIMINATION OF ASSET TEST.— 

20 The State does not apply any asset or re21 source test for eligibility for children under 

22 title XIX or this title. 

23 ‘‘(ii) ADMINISTRATIVE VERIFICATION

24 OF ASSETS.—The State— 
38 

† HR 2 EAS 

1 ‘‘(I) permits a parent or caretaker 

2 relative who is applying on behalf of a 

3 child for medical assistance under title 

4 XIX or child health assistance under 

5 this title to declare and certify by sig6 nature under penalty of perjury infor7 mation relating to family assets for 

8 purposes of determining and redeter9 mining financial eligibility; and 

10 ‘‘(II) takes steps to verify assets 

11 through means other than by requiring 

12 documentation from parents and ap13 plicants except in individual cases of 

14 discrepancies or where otherwise justi15 fied. 

16 ‘‘(C) ELIMINATION OF IN-PERSON INTER17 VIEW REQUIREMENT.—The State does not require 

18 an application of a child for medical assistance 

19 under title XIX (or for child health assistance 

20 under this title), including an application for re21 newal of such assistance, to be made in person 

22 nor does the State require a face-to-face inter23 view, unless there are discrepancies or individual 

24 circumstances justifying an in-person applica25 tion or face-to-face interview. 
39 

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1 ‘‘(D) USE OF JOINT APPLICATION FOR MED2 ICAID AND CHIP.—The application form and 

3 supplemental forms (if any) and information 

4 verification process is the same for purposes of 

5 establishing and renewing eligibility for children 

6 for medical assistance under title XIX and child 

7 health assistance under this title. 

8 ‘‘(E) AUTOMATIC RENEWAL (USE OF ADMIN9 ISTRATIVE RENEWAL).— 

10 ‘‘(i) IN GENERAL.—The State provides, 

11 in the case of renewal of a child’s eligibility 

12 for medical assistance under title XIX or 

13 child health assistance under this title, a 

14 pre-printed form completed by the State 

15 based on the information available to the 

16 State and notice to the parent or caretaker 

17 relative of the child that eligibility of the 

18 child will be renewed and continued based 

19 on such information unless the State is pro20 vided other information. Nothing in this 

21 clause shall be construed as preventing a 

22 State from verifying, through electronic and 

23 other means, the information so provided. 

24 ‘‘(ii) SATISFACTION THROUGH DEM25 ONSTRATED USE OF EX PARTE PROCESS.— 
40 

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1 A State shall be treated as satisfying the re2 quirement of clause (i) if renewal of eligi3 bility of children under title XIX or this 

4 title is determined without any requirement 

5 for an in-person interview, unless sufficient 

6 information is not in the State’s possession 

7 and cannot be acquired from other sources 

8 (including other State agencies) without the 

9 participation of the applicant or the appli10 cant’s parent or caretaker relative. 

11 ‘‘(F) PRESUMPTIVE ELIGIBILITY FOR CHIL12 DREN.—The State is implementing section 

13 1920A under title XIX as well as, pursuant to 

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

15 ‘‘(G) EXPRESS LANE.—The State is imple16 menting the option described in section 

17 1902(e)(13) under title XIX as well as, pursuant 

18 to section 2107(e)(1), under this title. 

19 ‘‘(H) PREMIUM ASSISTANCE SUBSIDIES.— 

20 The State is implementing the option of pro21 viding premium assistance subsidies under sec22 tion 2105(c)(10) or section 1906A.’’. 
41 

† HR 2 EAS 

1 SEC. 105. TWO-YEAR INITIAL AVAILABILITY OF CHIP ALLOT2 MENTS. 

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

4 read as follows: 

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

6 ‘‘(1) IN GENERAL.—Except as provided in para7 graph (2), amounts allotted to a State pursuant to 

8 this section— 

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

10 2008, shall remain available for expenditure by 

11 the State through the end of the second suc12 ceeding fiscal year; and 

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

14 year thereafter, shall remain available for ex15 penditure by the State through the end of the 

16 succeeding fiscal year. 

17 ‘‘(2) AVAILABILITY OF AMOUNTS REDISTRIB18 UTED.—Amounts redistributed to a State under sub19 section (f) shall be available for expenditure by the 

20 State through the end of the fiscal year in which they 

21 are redistributed.’’. 

22 SEC. 106. REDISTRIBUTION OF UNUSED ALLOTMENTS. 

23 (a) BEGINNING WITH FISCAL YEAR 2007.— 

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

25 1397dd(f)) is amended— 
42 

† HR 2 EAS 

1 (A) by striking ‘‘The Secretary’’ and insert2 ing the following: 

3 ‘‘(1) IN GENERAL.—The Secretary’’; 

4 (B) by striking ‘‘States that have fully ex5 pended the amount of their allotments under this 

6 section.’’ and inserting ‘‘States that the Sec7 retary determines with respect to the fiscal year 

8 for which unused allotments are available for re9 distribution under this subsection, are shortfall 

10 States described in paragraph (2) for such fiscal 

11 year, but not to exceed the amount of the short12 fall described in paragraph (2)(A) for each such 

13 State (as may be adjusted under paragraph 

14 (2)(C)).’’; and 

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

16 paragraph: 

17 ‘‘(2) SHORTFALL STATES DESCRIBED.— 

18 ‘‘(A) IN GENERAL.—For purposes of para19 graph (1), with respect to a fiscal year, a short20 fall State described in this subparagraph is a 

21 State with a State child health plan approved 

22 under this title for which the Secretary estimates 

23 on the basis of the most recent data available to 

24 the Secretary, that the projected expenditures 
43 

† HR 2 EAS 

1 under such plan for the State for the fiscal year 

2 will exceed the sum of— 

3 ‘‘(i) the amount of the State’s allot4 ments for any preceding fiscal years that 

5 remains available for expenditure and that 

6 will not be expended by the end of the im7 mediately preceding fiscal year; 

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

9 enrollment contingency fund payment under 

10 subsection (n); and 

11 ‘‘(iii) the amount of the State’s allot12 ment for the fiscal year. 

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

14 available for redistribution under paragraph (1) 

15 for a fiscal year are less than the total amounts 

16 of the estimated shortfalls determined for the 

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

18 redistributed under such paragraph for each 

19 shortfall State shall be reduced proportionally. 

20 ‘‘(C) RETROSPECTIVE ADJUSTMENT.—The 

21 Secretary may adjust the estimates and deter22 minations made under paragraph (1) and this 

23 paragraph with respect to a fiscal year as nec24 essary on the basis of the amounts reported by 

25 States not later than November 30 of the suc-
44 

† HR 2 EAS 

1 ceeding fiscal year, as approved by the Sec2 retary.’’. 

3 (2) EFFECTIVE DATE.—The amendments made 

4 by paragraph (1) shall apply to redistribution of al5 lotments made for fiscal year 2007 and subsequent 

6 fiscal years. 

7 (b) REDISTRIBUTION OF UNUSED ALLOTMENTS FOR

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

9 1397dd(k)) is amended— 

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

11 FIRST 2 QUARTERS OF’’; 

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

13 quarters of’’; and 

14 (3) in paragraph (6)— 

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

16 and 

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

18 ‘‘September 30’’. 

19 SEC. 107. OPTION FOR QUALIFYING STATES TO RECEIVE 

20 THE ENHANCED PORTION OF THE CHIP 

21 MATCHING RATE FOR MEDICAID COVERAGE 

22 OF CERTAIN CHILDREN. 

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

24 1397ee(g)) is amended— 
45 

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

2 201(b)(1) of Public Law 110–173— 

3 (A) by inserting ‘‘subject to paragraph (4),’’ 

4 after ‘‘Notwithstanding any other provision of 

5 law,’’; and 

6 (B) by striking ‘‘2008, or 2009’’ and insert7 ing ‘‘or 2008’’; and 

8 (2) by adding at the end the following new para9 graph: 

10 ‘‘(4) OPTION FOR ALLOTMENTS FOR FISCAL

11 YEARS 2009 THROUGH 2013.— 

12 ‘‘(A) PAYMENT OF ENHANCED PORTION OF

13 MATCHING RATE FOR CERTAIN EXPENDITURES.— 

14 In the case of expenditures described in subpara15 graph (B), a qualifying State (as defined in 

16 paragraph (2)) may elect to be paid from the 

17 State’s allotment made under section 2104 for 

18 any of fiscal years 2009 through 2013 (insofar as 

19 the allotment is available to the State under sub20 sections (e) and (m) of such section) an amount 

21 each quarter equal to the additional amount that 

22 would have been paid to the State under title 

23 XIX with respect to such expenditures if the en24 hanced FMAP (as determined under subsection 

25 (b)) had been substituted for the Federal medical 
46 

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1 assistance percentage (as defined in section 

2 1905(b)). 

3 ‘‘(B) EXPENDITURES DESCRIBED.—For 

4 purposes of subparagraph (A), the expenditures 

5 described in this subparagraph are expenditures 

6 made after the date of the enactment of this 

7 paragraph and during the period in which funds 

8 are available to the qualifying State for use 

9 under subparagraph (A), for the provision of 

10 medical assistance to individuals residing in the 

11 State who are eligible for medical assistance 

12 under the State plan under title XIX or under 

13 a waiver of such plan and who have not attained 

14 age 19 (or, if a State has so elected under the 

15 State plan under title XIX, age 20 or 21), and 

16 whose family income equals or exceeds 133 per17 cent of the poverty line but does not exceed the 

18 Medicaid applicable income level.’’. 

19 (b) REPEAL OF LIMITATION ON AVAILABILITY OF FIS20 CAL YEAR 2009 ALLOTMENTS.—Paragraph (2) of section 

21 201(b) of the Medicare, Medicaid, and SCHIP Extension 

22 Act of 2007 (Public Law 110–173) is repealed. 

23 SEC. 108. ONE-TIME APPROPRIATION. 

24 There is appropriated to the Secretary, out of any 

25 money in the Treasury not otherwise appropriated, 
47 

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1 $11,706,000,000 to accompany the allotment made for the 

2 period beginning on October 1, 2012, and ending on March 

3 31, 2013, under section 2104(a)(16)(A) of the Social Secu4 rity Act (42 U.S.C. 1397dd(a)(16)(A)) (as added by section 

5 101), to remain available until expended. Such amount 

6 shall be used to provide allotments to States under para7 graph (3) of section 2104(m) of the Social Security Act (42 

8 U.S.C. 1397dd(i)), as added by section 102, for the first 

9 6 months of fiscal year 2013 in the same manner as allot10 ments are provided under subsection (a)(16)(A) of such sec11 tion 2104 and subject to the same terms and conditions as 

12 apply to the allotments provided from such subsection 

13 (a)(16)(A). 

14 SEC. 109. IMPROVING FUNDING FOR THE TERRITORIES 

15 UNDER CHIP AND MEDICAID. 

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

17 adding at the end the following new paragraph: 

18 ‘‘(4) EXCLUSION OF CERTAIN EXPENDITURES

19 FROM PAYMENT LIMITS.—With respect to fiscal years 

20 beginning with fiscal year 2009, if Puerto Rico, the 

21 Virgin Islands, Guam, the Northern Mariana Islands, 

22 or American Samoa qualify for a payment under 

23 subparagraph (A)(i), (B), or (F) of section 1903(a)(3) 

24 for a calendar quarter of such fiscal year, the pay25 ment shall not be taken into account in applying sub-
48 

† HR 2 EAS 

1 section (f) (as increased in accordance with para2 graphs (1), (2), and (3) of this subsection) to such 

3 commonwealth or territory for such fiscal year.’’. 

4 Subtitle B—Focus on Low-Income 

5 Children and Pregnant Women 

6 SEC. 111. STATE OPTION TO COVER LOW-INCOME PREG7 NANT WOMEN UNDER CHIP THROUGH A 

8 STATE PLAN AMENDMENT. 

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

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

11 at the end the following new section: 

12 ‘‘SEC. 2112. OPTIONAL COVERAGE OF TARGETED LOW-IN13 COME PREGNANT WOMEN THROUGH A STATE 

14 PLAN AMENDMENT. 

15 ‘‘(a) IN GENERAL.—Subject to the succeeding provi16 sions of this section, a State may elect through an amend17 ment to its State child health plan under section 2102 to 

18 provide pregnancy-related assistance under such plan for 

19 targeted low-income pregnant women. 

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

21 under subsection (a) if the following conditions are satis22 fied: 

23 ‘‘(1) MINIMUM INCOME ELIGIBILITY LEVELS FOR

24 PREGNANT WOMEN AND CHILDREN.—The State has es25 tablished an income eligibility level— 
49 

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1 ‘‘(A) for pregnant women under subsection 

2 (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), or (l)(1)(A) 

3 of section 1902 that is at least 185 percent (or 

4 such higher percent as the State has in effect 

5 with regard to pregnant women under this title) 

6 of the poverty line applicable to a family of the 

7 size involved, but in no case lower than the per8 cent in effect under any such subsection as of 

9 July 1, 2008; and 

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

11 under this title (or title XIX) that is at least 200 

12 percent of the poverty line applicable to a family 

13 of the size involved. 

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

15 PREGNANT WOMEN LOWER THAN THE STATE’S MED16 ICAID LEVEL.—The State does not apply an effective 

17 income level for pregnant women under the State 

18 plan amendment that is lower than the effective in19 come level (expressed as a percent of the poverty line 

20 and considering applicable income disregards) speci21 fied under subsection (a)(10)(A)(i)(III), 

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

23 date of enactment of this paragraph to be eligible for 

24 medical assistance as a pregnant woman. 
50 

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1 ‘‘(3) NO COVERAGE FOR HIGHER INCOME PREG2 NANT WOMEN WITHOUT COVERING LOWER INCOME

3 PREGNANT WOMEN.—The State does not provide cov4 erage for pregnant women with higher family income 

5 without covering pregnant women with a lower fam6 ily income. 

7 ‘‘(4) APPLICATION OF REQUIREMENTS FOR COV8 ERAGE OF TARGETED LOW-INCOME CHILDREN.—The 

9 State provides pregnancy-related assistance for tar10 geted low-income pregnant women in the same man11 ner, and subject to the same requirements, as the 

12 State provides child health assistance for targeted 

13 low-income children under the State child health 

14 plan, and in addition to providing child health as15 sistance for such women. 

16 ‘‘(5) NO PREEXISTING CONDITION EXCLUSION OR

17 WAITING PERIOD.—The State does not apply any ex18 clusion of benefits for pregnancy-related assistance 

19 based on any preexisting condition or any waiting 

20 period (including any waiting period imposed to 

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

22 assistance. 

23 ‘‘(6) APPLICATION OF COST-SHARING PROTEC24 TION.—The State provides pregnancy-related assist25 ance to a targeted low-income woman consistent with 
51 

† HR 2 EAS 

1 the cost-sharing protections under section 2103(e) and 

2 applies the limitation on total annual aggregate cost 

3 sharing imposed under paragraph (3)(B) of such sec4 tion to the family of such a woman. 

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

6 State does not impose, with respect to the enrollment 

7 under the State child health plan of targeted low-in8 come children during the quarter, any enrollment cap 

9 or other numerical limitation on enrollment, any 

10 waiting list, any procedures designed to delay the 

11 consideration of applications for enrollment, or simi12 lar limitation with respect to enrollment. 

13 ‘‘(c) OPTION TO PROVIDE PRESUMPTIVE ELIGI14 BILITY.—A State that elects the option under subsection (a) 

15 and satisfies the conditions described in subsection (b) may 

16 elect to apply section 1920 (relating to presumptive eligi17 bility for pregnant women) to the State child health plan 

18 in the same manner as such section applies to the State 

19 plan under title XIX. 

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

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

22 term ‘pregnancy-related assistance’ has the meaning 

23 given the term ‘child health assistance’ in section 

24 2110(a) with respect to an individual during the pe25 riod described in paragraph (2)(A). 
52 

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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 end 

5 of the month in which the 60-day period (begin6 ning on the last day of her pregnancy) ends; 

7 ‘‘(B) whose family income exceeds 185 per8 cent (or, if higher, the percent applied under sub9 section (b)(1)(A)) of the poverty line applicable 

10 to a family of the size involved, but does not ex11 ceed the income eligibility level established under 

12 the State child health plan under this title for a 

13 targeted low-income child; and 

14 ‘‘(C) who satisfies the requirements of para15 graphs (1)(A), (1)(C), (2), and (3) of section 

16 2110(b) in the same manner as a child applying 

17 for child health assistance would have to satisfy 

18 such requirements. 

19 ‘‘(e) AUTOMATIC ENROLLMENT FOR CHILDREN BORN

20 TO WOMEN RECEIVING PREGNANCY-RELATED ASSIST21 ANCE.—If a child is born to a targeted low-income pregnant 

22 woman who was receiving pregnancy-related assistance 

23 under this section on the date of the child’s birth, the child 

24 shall be deemed to have applied for child health assistance 

25 under the State child health plan and to have been found 
53 

† HR 2 EAS 

1 eligible for such assistance under such plan or to have ap2 plied for medical assistance under title XIX and to have 

3 been found eligible for such assistance under such title, as 

4 appropriate, on the date of such birth and to remain eligible 

5 for such assistance until the child attains 1 year of age. 

6 During the period in which a child is deemed under the 

7 preceding sentence to be eligible for child health or medical 

8 assistance, the child health or medical assistance eligibility 

9 identification number of the mother shall also serve as the 

10 identification number of the child, and all claims shall be 

11 submitted and paid under such number (unless the State 

12 issues a separate identification number for the child before 

13 such period expires). 

14 ‘‘(f) STATES PROVIDING ASSISTANCE THROUGH

15 OTHER OPTIONS.— 

16 ‘‘(1) CONTINUATION OF OTHER OPTIONS FOR

17 PROVIDING ASSISTANCE.—The option to provide as18 sistance in accordance with the preceding subsections 

19 of this section shall not limit any other option for a 

20 State to provide— 

21 ‘‘(A) child health assistance through the ap22 plication of sections 457.10, 457.350(b)(2), 

23 457.622(c)(5), and 457.626(a)(3) of title 42, 

24 Code of Federal Regulations (as in effect after 

25 the final rule adopted by the Secretary and set 
54 

† HR 2 EAS 

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

2 2002)), or 

3 ‘‘(B) pregnancy-related services through the 

4 application of any waiver authority (as in effect 

5 on June 1, 2008). 

6 ‘‘(2) CLARIFICATION OF AUTHORITY TO PROVIDE

7 POSTPARTUM SERVICES.—Any State that provides 

8 child health assistance under any authority described 

9 in paragraph (1) may continue to provide such as10 sistance, as well as postpartum services, through the 

11 end of the month in which the 60-day period (begin12 ning on the last day of the pregnancy) ends, in the 

13 same manner as such assistance and postpartum serv14 ices would be provided if provided under the State 

15 plan under title XIX, but only if the mother would 

16 otherwise satisfy the eligibility requirements that 

17 apply under the State child health plan (other than 

18 with respect to age) during such period. 

19 ‘‘(3) NO INFERENCE.—Nothing in this subsection 

20 shall be construed— 

21 ‘‘(A) to infer congressional intent regarding 

22 the legality or illegality of the content of the sec23 tions specified in paragraph (1)(A); or 
55 

† HR 2 EAS 

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-RELATED

6 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 end 

12 the following: ‘‘or for pregnancy-related assist13 ance’’. 

14 (2) NO WAITING PERIOD.—Section 2102(b)(1)(B) 

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

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

17 end and inserting a semicolon; 

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

19 the end and inserting ‘‘; and’’; and 

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

21 clause: 

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

23 (including a waiting period to carry out 

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

25 low-income pregnant woman provided preg-
56 

† HR 2 EAS 

1 nancy-related assistance under section 

2 2112.’’. 

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

4 CHILDLESS ADULTS UNDER CHIP; CONDI5 TIONS FOR COVERAGE OF PARENTS. 

6 (a) PHASE-OUT RULES.— 

7 (1) IN GENERAL.—Title XXI (42 U.S.C. 1397aa 

8 et seq.) is amended by adding at the end the following 

9 new section: 

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

11 CHILDLESS ADULTS; CONDITIONS FOR COV12 ERAGE OF PARENTS. 

13 ‘‘(a) TERMINATION OF COVERAGE FOR NONPREGNANT

14 CHILDLESS ADULTS.— 

15 ‘‘(1) NO NEW CHIP WAIVERS; AUTOMATIC EXTEN16 SIONS AT STATE OPTION THROUGH 2009.—Notwith17 standing section 1115 or any other provision of this 

18 title, except as provided in this subsection— 

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

20 date of the enactment of the Children’s Health 

21 Insurance Program Reauthorization Act of 2009, 

22 approve or renew a waiver, experimental, pilot, 

23 or demonstration project that would allow funds 

24 made available under this title to be used to pro25 vide child health assistance or other health bene-
57 

† HR 2 EAS 

1 fits coverage to a nonpregnant childless adult; 

2 and 

3 ‘‘(B) notwithstanding the terms and condi4 tions of an applicable existing waiver, the provi5 sions of paragraph (2) shall apply for purposes 

6 of any period beginning on or after January 1, 

7 2010, in determining the period to which the 

8 waiver applies, the individuals eligible to be cov9 ered by the waiver, and the amount of the Fed10 eral payment under this title. 

11 ‘‘(2) TERMINATION OF CHIP COVERAGE UNDER

12 APPLICABLE EXISTING WAIVERS AT THE END OF

13 2009.— 

14 ‘‘(A) IN GENERAL.—No funds shall be avail15 able under this title for child health assistance or 

16 other health benefits coverage that is provided to 

17 a nonpregnant childless adult under an applica18 ble existing waiver after December 31, 2009. 

19 ‘‘(B) EXTENSION UPON STATE REQUEST.— 

20 If an applicable existing waiver described in 

21 subparagraph (A) would otherwise expire before 

22 January 1, 2010, notwithstanding the require23 ments of subsections (e) and (f) of section 1115, 

24 a State may submit, not later than September 

25 30, 2009, a request to the Secretary for an exten-
58 

† HR 2 EAS 

1 sion of the waiver. The Secretary shall approve 

2 a request for an extension of an applicable exist3 ing waiver submitted pursuant to this subpara4 graph, but only through December 31, 2009. 

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 nonpregnant childless adult during 

11 the period beginning on the date of the enact12 ment of this subsection and ending on December 

13 31, 2009. 

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

15 WAIVER TO CONTINUE COVERAGE FOR NONPREGNANT

16 CHILDLESS ADULTS.— 

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

18 coverage under an applicable existing waiver is 

19 terminated under paragraph (2)(A) may submit, 

20 not later than September 30, 2009, an applica21 tion to the Secretary for a waiver under section 

22 1115 of the State plan under title XIX to provide 

23 medical assistance to a nonpregnant childless 

24 adult whose coverage is so terminated (in this 
59 

† HR 2 EAS 

1 subsection referred to as a ‘Medicaid nonpreg2 nant childless adults waiver’). 

3 ‘‘(B) DEADLINE FOR APPROVAL.—The Sec4 retary shall make a decision to approve or deny 

5 an application for a Medicaid nonpregnant 

6 childless adults waiver submitted under subpara7 graph (A) within 90 days of the date of the sub8 mission of the application. If no decision has 

9 been made by the Secretary as of December 31, 

10 2009, on the application of a State for a Med11 icaid nonpregnant childless adults waiver that 

12 was submitted to the Secretary by September 30, 

13 2009, the application shall be deemed approved. 

14 ‘‘(C) STANDARD FOR BUDGET NEU15 TRALITY.—The budget neutrality requirement 

16 applicable with respect to expenditures for med17 ical assistance under a Medicaid nonpregnant 

18 childless adults waiver shall— 

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

20 allow expenditures for medical assistance 

21 under title XIX for all such adults to not 

22 exceed the total amount of payments made 

23 to the State under paragraph (2)(B) for fis24 cal year 2009, increased by the percentage 

25 increase (if any) in the projected nominal 
60 

† HR 2 EAS 

1 per capita amount of National Health Ex2 penditures for 2010 over 2009, as most re3 cently published by the Secretary; and 

4 ‘‘(ii) in the case of any succeeding fis5 cal year, allow such expenditures to not ex6 ceed the amount in effect under this sub7 paragraph for the preceding fiscal year, in8 creased by the percentage increase (if any) 

9 in the projected nominal per capita amount 

10 of National Health Expenditures for the 

11 calendar year that begins during the year 

12 involved over the preceding calendar year, 

13 as most recently published by the Secretary. 

14 ‘‘(b) RULES AND CONDITIONS FOR COVERAGE OF PAR15 ENTS OF TARGETED LOW-INCOME CHILDREN.— 

16 ‘‘(1) TWO-YEAR PERIOD; AUTOMATIC EXTENSION

17 AT STATE OPTION THROUGH FISCAL YEAR 2011.— 

18 ‘‘(A) NO NEW CHIP WAIVERS.—Notwith19 standing section 1115 or any other provision of 

20 this title, except as provided in this subsection— 

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

22 the date of the enactment of the Children’s 

23 Health Insurance Program Reauthorization 

24 Act of 2009 approve or renew a waiver, ex25 perimental, pilot, or demonstration project 
61 

† HR 2 EAS 

1 that would allow funds made available 

2 under this title to be used to provide child 

3 health assistance or other health benefits 

4 coverage to a parent of a targeted low-in5 come child; and 

6 ‘‘(ii) notwithstanding the terms and 

7 conditions of an applicable existing waiver, 

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

9 shall apply for purposes of any fiscal year 

10 beginning on or after October 1, 2011, in 

11 determining the period to which the waiver 

12 applies, the individuals eligible to be cov13 ered by the waiver, and the amount of the 

14 Federal payment under this title. 

15 ‘‘(B) EXTENSION UPON STATE REQUEST.— 

16 If an applicable existing waiver described in 

17 subparagraph (A) would otherwise expire before 

18 October 1, 2011, and the State requests an exten19 sion of such waiver, the Secretary shall grant 

20 such an extension, but only, subject to paragraph 

21 (2)(A), through September 30, 2011. 

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

23 The enhanced FMAP determined under section 

24 2105(b) shall apply to expenditures under an 

25 applicable existing waiver for the provision of 
62 

† HR 2 EAS 

1 child health assistance or other health benefits 

2 coverage to a parent of a targeted low-income 

3 child during the third and fourth quarters of fis4 cal year 2009 and during fiscal years 2010 and 

5 2011. 

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

7 2013.— 

8 ‘‘(A) PAYMENTS FOR COVERAGE LIMITED TO

9 BLOCK GRANT FUNDED FROM STATE ALLOT10 MENT.—Any State that provides child health as11 sistance or health benefits coverage under an ap12 plicable existing waiver for a parent of a tar13 geted low-income child may elect to continue to 

14 provide such assistance or coverage through fiscal 

15 year 2012 or 2013, subject to the same terms and 

16 conditions that applied under the applicable ex17 isting waiver, unless otherwise modified in sub18 paragraph (B). 

19 ‘‘(B) TERMS AND CONDITIONS.— 

20 ‘‘(i) BLOCK GRANT SET ASIDE FROM

21 STATE ALLOTMENT.—If the State makes an 

22 election under subparagraph (A), the Sec23 retary shall set aside for the State for each 

24 such fiscal year an amount equal to the 

25 Federal share of 110 percent of the State’s 
63 

† HR 2 EAS 

1 projected expenditures under the applicable 

2 existing waiver for providing child health 

3 assistance or health benefits coverage to all 

4 parents of targeted low-income children en5 rolled under such waiver for the fiscal year 

6 (as certified by the State and submitted to 

7 the Secretary by not later than August 31 

8 of the preceding fiscal year). In the case of 

9 fiscal year 2013, the set aside for any State 

10 shall be computed separately for each period 

11 described in subparagraphs (A) and (B) of 

12 section 2104(a)(16) and any reduction in 

13 the allotment for either such period under 

14 section 2104(m)(4) shall be allocated on a 

15 pro rata basis to such set aside. 

16 ‘‘(ii) PAYMENTS FROM BLOCK

17 GRANT.—The Secretary shall pay the State 

18 from the amount set aside under clause (i) 

19 for the fiscal year, an amount for each 

20 quarter of such fiscal year equal to the ap21 plicable percentage determined under clause 

22 (iii) or (iv) for expenditures in the quarter 

23 for providing child health assistance or 

24 other health benefits coverage to a parent of 

25 a targeted low-income child. 
64 

† HR 2 EAS 

1 ‘‘(iii) ENHANCED FMAP ONLY IN FIS2 CAL YEAR 2012 FOR STATES WITH SIGNIFI3 CANT CHILD OUTREACH OR THAT ACHIEVE

4 CHILD COVERAGE BENCHMARKS; FMAP FOR

5 ANY OTHER STATES.—For purposes of 

6 clause (ii), the applicable percentage for 

7 any quarter of fiscal year 2012 is equal 

8 to— 

9 ‘‘(I) the enhanced FMAP deter10 mined under section 2105(b) in the 

11 case of a State that meets the outreach 

12 or coverage benchmarks described in 

13 any of subparagraph (A), (B), or (C) 

14 of paragraph (3) for fiscal year 2011; 

15 or 

16 ‘‘(II) the Federal medical assist17 ance percentage (as determined under 

18 section 1905(b) without regard to 

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

20 of any other State. 

21 ‘‘(iv) AMOUNT OF FEDERAL MATCHING

22 PAYMENT IN 2013.—For purposes of clause 

23 (ii), the applicable percentage for any quar24 ter of fiscal year 2013 is equal to— 

25 ‘‘(I) the REMAP percentage if— 
65 

† HR 2 EAS 

1 ‘‘(aa) the applicable percent2 age for the State under clause 

3 (iii) was the enhanced FMAP for 

4 fiscal year 2012; and 

5 ‘‘(bb) the State met either of 

6 the coverage benchmarks described 

7 in subparagraph (B) or (C) of 

8 paragraph (3) for fiscal year 

9 2012; or 

10 ‘‘(II) the Federal medical assist11 ance percentage (as so determined) in 

12 the case of any State to which sub13 clause (I) does not apply. 

14 For purposes of subclause (I), the REMAP 

15 percentage is the percentage which is the 

16 sum of such Federal medical assistance per17 centage and a number of percentage points 

18 equal to one-half of the difference between 

19 such Federal medical assistance percentage 

20 and such enhanced FMAP. 

21 ‘‘(v) NO FEDERAL PAYMENTS OTHER

22 THAN FROM BLOCK GRANT SET ASIDE.—No 

23 payments shall be made to a State for ex24 penditures described in clause (ii) after the 
66 

† HR 2 EAS 

1 total amount set aside under clause (i) for 

2 a fiscal year has been paid to the State. 

3 ‘‘(vi) NO INCREASE IN INCOME ELIGI4 BILITY LEVEL FOR PARENTS.—No payments 

5 shall be made to a State from the amount 

6 set aside under clause (i) for a fiscal year 

7 for expenditures for providing child health 

8 assistance or health benefits coverage to a 

9 parent of a targeted low-income child whose 

10 family income exceeds the income eligibility 

11 level applied under the applicable existing 

12 waiver to parents of targeted low-income 

13 children on the date of enactment of the 

14 Children’s Health Insurance Program Re15 authorization Act of 2009. 

16 ‘‘(3) OUTREACH OR COVERAGE BENCHMARKS.— 

17 For purposes of paragraph (2), the outreach or cov18 erage benchmarks described in this paragraph are as 

19 follows: 

20 ‘‘(A) SIGNIFICANT CHILD OUTREACH CAM21 PAIGN.—The State— 

22 ‘‘(i) was awarded a grant under sec23 tion 2113 for fiscal year 2011; 
67 

† HR 2 EAS 

1 ‘‘(ii) implemented 1 or more of the en2 rollment and retention provisions described 

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

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

5 outreach for such fiscal year. 

6 ‘‘(B) HIGH-PERFORMING STATE.—The 

7 State, on the basis of the most timely and accu8 rate published estimates of the Bureau of the 

Census, ranks in the lowest 1 9 ⁄3 of States in terms 

10 of the State’s percentage of low-income children 

11 without health insurance. 

12 ‘‘(C) STATE INCREASING ENROLLMENT OF

13 LOW-INCOME CHILDREN.—The State qualified for 

14 a performance bonus payment under section 

15 2105(a)(3)(B) for the most recent fiscal year ap16 plicable under such section. 

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

18 subsection shall be construed as prohibiting a State 

19 from submitting an application to the Secretary for 

20 a waiver under section 1115 of the State plan under 

21 title XIX to provide medical assistance to a parent of 

22 a targeted low-income child that was provided child 

23 health assistance or health benefits coverage under an 

24 applicable existing waiver. 
68 

† HR 2 EAS 

1 ‘‘(c) APPLICABLE EXISTING WAIVER.—For purposes of 

2 this section— 

3 ‘‘(1) IN GENERAL.—The term ‘applicable existing 

4 waiver’ means a waiver, experimental, pilot, or dem5 onstration project under section 1115, grandfathered 

6 under section 6102(c)(3) of the Deficit Reduction Act 

7 of 2005, or otherwise conducted under authority 

8 that— 

9 ‘‘(A) would allow funds made available 

10 under this title to be used to provide child health 

11 assistance or other health benefits coverage to— 

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

13 child; 

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

15 ‘‘(iii) individuals described in both 

16 clauses (i) and (ii); and 

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

18 ‘‘(2) DEFINITIONS.— 

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

20 a caretaker relative (as such term is used in car21 rying out section 1931) and a legal guardian. 

22 ‘‘(B) NONPREGNANT CHILDLESS ADULT.— 

23 The term ‘nonpregnant childless adult’ has the 

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

25 (2) CONFORMING AMENDMENTS.— 
69 

† HR 2 EAS 

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

2 amended— 

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

4 inserting ‘‘: 

5 ‘‘(1) The Secretary’’; 

6 (ii) in the first sentence, by inserting 

7 ‘‘or a parent (as defined in section 

8 2111(c)(2)(A)), who is not pregnant, of a 

9 targeted low-income child’’ before the period; 

10 (iii) by striking the second sentence; 

11 and 

12 (iv) by adding at the end the following 

13 new paragraph: 

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

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

16 demonstration project with respect to a State after the 

17 date of enactment of the Children’s Health Insurance 

18 Program Reauthorization Act of 2009 that would 

19 waive or modify the requirements of section 2111.’’. 

20 (B) Section 6102(c) of the Deficit Reduction 

21 Act of 2005 (Public Law 109–171; 120 Stat. 

22 131) is amended by striking ‘‘Nothing’’ and in23 serting ‘‘Subject to section 2111 of the Social Se24 curity Act, as added by section 112 of the Chil-
70 

† HR 2 EAS 

1 dren’s Health Insurance Program Reauthoriza2 tion Act of 2009, nothing’’. 

3 (b) GAO STUDY AND REPORT.— 

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

5 the United States shall conduct a study of whether— 

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

7 relative (as such term is used in carrying out 

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

9 low-income child under a State health plan 

10 under title XXI of the Social Security Act in11 creases the enrollment of, or the quality of care 

12 for, children, and 

13 (B) such parents, relatives, and legal guard14 ians who enroll in such a plan are more likely 

15 to enroll their children in such a plan or in a 

16 State plan under title XIX of such Act. 

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

18 date of the enactment of this Act, the Comptroller 

19 General shall report the results of the study to the 

20 Committee on Finance of the Senate and the Com21 mittee on Energy and Commerce of the House of Rep22 resentatives, including recommendations (if any) for 

23 changes in legislation. 
71 

† HR 2 EAS 

1 SEC. 113. ELIMINATION OF COUNTING MEDICAID CHILD 

2 PRESUMPTIVE ELIGIBILITY COSTS AGAINST 

3 TITLE XXI ALLOTMENT. 

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

5 1397ee(a)(1)) is amended— 

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

7 by striking ‘‘(or, in the case of expenditures described 

8 in subparagraph (B), the Federal medical assistance 

9 percentage (as defined in the first sentence of section 

10 1905(b)))’’; and 

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

12 the following new subparagraph: 

13 ‘‘(B) [reserved]’’. 

14 (b) AMENDMENTS TO MEDICAID.— 

15 (1) ELIGIBILITY OF A NEWBORN.—Section 

16 1902(e)(4) (42 U.S.C. 1396a(e)(4)) is amended in the 

17 first sentence by striking ‘‘so long as the child is a 

18 member of the woman’s household and the woman re19 mains (or would remain if pregnant) eligible for such 

20 assistance’’. 

21 (2) APPLICATION OF QUALIFIED ENTITIES TO

22 PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN

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

24 1396r–1(b)) is amended by adding after paragraph 

25 (2) the following flush sentence: 
72 

† HR 2 EAS 

1 ‘‘The term ‘qualified provider’ also includes a qualified en2 tity, as defined in section 1920A(b)(3).’’. 

3 SEC. 114. LIMITATION ON MATCHING RATE FOR STATES 

4 THAT PROPOSE TO COVER CHILDREN WITH 

5 EFFECTIVE FAMILY INCOME THAT EXCEEDS 

6 300 PERCENT OF THE POVERTY LINE. 

7 (a) FMAP APPLIED TO EXPENDITURES.—Section 

8 2105(c) (42 U.S.C. 1397ee(c)) is amended by adding at the 

9 end the following new paragraph: 

10 ‘‘(8) LIMITATION ON MATCHING RATE FOR EX11 PENDITURES FOR CHILD HEALTH ASSISTANCE PRO12 VIDED TO CHILDREN WHOSE EFFECTIVE FAMILY IN13 COME EXCEEDS 300 PERCENT OF THE POVERTY

14 LINE.— 

15 ‘‘(A) FMAP APPLIED TO EXPENDITURES.— 

16 Except as provided in subparagraph (B), for fis17 cal years beginning with fiscal year 2009, the 

18 Federal medical assistance percentage (as deter19 mined under section 1905(b) without regard to 

20 clause (4) of such section) shall be substituted for 

21 the enhanced FMAP under subsection (a)(1) with 

22 respect to any expenditures for providing child 

23 health assistance or health benefits coverage for a 

24 targeted low-income child whose effective family 

25 income would exceed 300 percent of the poverty 
73 

† HR 2 EAS 

1 line but for the application of a general exclu2 sion of a block of income that is not determined 

3 by type of expense or type of income. 

4 ‘‘(B) EXCEPTION.—Subparagraph (A) shall 

5 not apply to any State that, on the date of en6 actment of the Children’s Health Insurance Pro7 gram Reauthorization Act of 2009, has an ap8 proved State plan amendment or waiver to pro9 vide, or has enacted a State law to submit a 

10 State plan amendment to provide, expenditures 

11 described in such subparagraph under the State 

12 child health plan.’’. 

13 (b) RULE OF CONSTRUCTION.—Nothing in the amend14 ments made by this section shall be construed as— 

15 (1) changing any income eligibility level for chil16 dren under title XXI of the Social Security Act; or 

17 (2) changing the flexibility provided States 

18 under such title to establish the income eligibility 

19 level for targeted low-income children under a State 

20 child health plan and the methodologies used by the 

21 State to determine income or assets under such plan. 

22 SEC. 115. STATE AUTHORITY UNDER MEDICAID. 

23 Notwithstanding any other provision of law, including 

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

25 Social Security Act (42 U.S.C. 1396d) or subsection (u) of 
74 

† HR 2 EAS 

1 such section, at State option, the Secretary shall provide 

2 the State with the Federal medical assistance percentage de3 termined for the State for Medicaid with respect to expendi4 tures described in section 1905(u)(2)(A) of such Act or oth5 erwise made to provide medical assistance under Medicaid 

6 to a child who could be covered by the State under CHIP. 

7 TITLE II—OUTREACH AND 

8 ENROLLMENT 

9 Subtitle A—Outreach and 

10 Enrollment Activities 

11 SEC. 201. GRANTS AND ENHANCED ADMINISTRATIVE FUND12 ING FOR OUTREACH AND ENROLLMENT. 

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

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

15 end the following: 

16 ‘‘SEC. 2113. GRANTS TO IMPROVE OUTREACH AND ENROLL17 MENT. 

18 ‘‘(a) OUTREACH AND ENROLLMENT GRANTS; NA19 TIONAL CAMPAIGN.— 

20 ‘‘(1) IN GENERAL.—From the amounts appro21 priated under subsection (g), subject to paragraph 

22 (2), the Secretary shall award grants to eligible enti23 ties during the period of fiscal years 2009 through 

24 2013 to conduct outreach and enrollment efforts that 
75 

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1 are designed to increase the enrollment and participa2 tion of eligible children under this title and title XIX. 

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

4 ENROLLMENT CAMPAIGN.—An amount equal to 10 

5 percent of such amounts shall be used by the Sec6 retary for expenditures during such period to carry 

7 out a national enrollment campaign in accordance 

8 with subsection (h). 

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

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

11 subsection (a), the Secretary shall give priority to eli12 gible entities that— 

13 ‘‘(A) propose to target geographic areas 

14 with high rates of— 

15 ‘‘(i) eligible but unenrolled children, 

16 including such children who reside in rural 

17 areas; or 

18 ‘‘(ii) racial and ethnic minorities and 

19 health disparity populations, including 

20 those proposals that address cultural and 

21 linguistic barriers to enrollment; and 

22 ‘‘(B) submit the most demonstrable evidence 

23 required under paragraphs (1) and (2) of sub24 section (c). 
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1 ‘‘(2) TEN PERCENT SET ASIDE FOR OUTREACH

2 TO INDIAN CHILDREN.—An amount equal to 10 per3 cent of the funds appropriated under subsection (g) 

4 shall be used by the Secretary to award grants to In5 dian Health Service providers and urban Indian or6 ganizations receiving funds under title V of the In7 dian Health Care Improvement Act (25 U.S.C. 1651 

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

9 who are Indians. 

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

11 receive a grant under subsection (a) shall submit an appli12 cation to the Secretary in such form and manner, and con13 taining such information, as the Secretary may decide. 

14 Such application shall include— 

15 ‘‘(1) evidence demonstrating that the entity in16 cludes members who have access to, and credibility 

17 with, ethnic or low-income populations in the commu18 nities in which activities funded under the grant are 

19 to be conducted; 

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

21 the ability to address barriers to enrollment, such as 

22 lack of awareness of eligibility, stigma concerns and 

23 punitive fears associated with receipt of benefits, and 

24 other cultural barriers to applying for and receiving 

25 child health assistance or medical assistance; 
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1 ‘‘(3) specific quality or outcomes performance 

2 measures to evaluate the effectiveness of activities 

3 funded by a grant awarded under this section; and 

4 ‘‘(4) an assurance that the eligible entity shall— 

5 ‘‘(A) conduct an assessment of the effective6 ness of such activities against the performance 

7 measures; 

8 ‘‘(B) cooperate with the collection and re9 porting of enrollment data and other informa10 tion in order for the Secretary to conduct such 

11 assessments; and 

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

13 not the State, provide the State with enrollment 

14 data and other information as necessary for the 

15 State to make necessary projections of eligible 

16 children and pregnant women. 

17 ‘‘(d) DISSEMINATION OF ENROLLMENT DATA AND IN18 FORMATION DETERMINED FROM EFFECTIVENESS ASSESS19 MENTS; ANNUAL REPORT.—The Secretary shall— 

20 ‘‘(1) make publicly available the enrollment data 

21 and information collected and reported in accordance 

22 with subsection (c)(4)(B); and 

23 ‘‘(2) submit an annual report to Congress on the 

24 outreach and enrollment activities conducted with 

25 funds appropriated under this section. 
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1 ‘‘(e) MAINTENANCE OF EFFORT FOR STATES AWARDED

2 GRANTS; NO MATCH REQUIRED FOR ANY ELIGIBLE ENTITY

3 AWARDED A GRANT.— 

4 ‘‘(1) STATE MAINTENANCE OF EFFORT.—In the 

5 case of a State that is awarded a grant under this 

6 section, the State share of funds expended for outreach 

7 and enrollment activities under the State child health 

8 plan shall not be less than the State share of such 

9 funds expended in the fiscal year preceding the first 

10 fiscal year for which the grant is awarded. 

11 ‘‘(2) NO MATCHING REQUIREMENT.—No eligible 

12 entity awarded a grant under subsection (a) shall be 

13 required to provide any matching funds as a condi14 tion for receiving the grant. 

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

16 ‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible enti17 ty’ means any of the following: 

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

19 plan under this title. 

20 ‘‘(B) A local government. 

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

22 a tribal organization, an urban Indian organi23 zation receiving funds under title V of the In24 dian Health Care Improvement Act (25 U.S.C. 
79 

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1 1651 et seq.), or an Indian Health Service pro2 vider. 

3 ‘‘(D) A Federal health safety net organiza4 tion. 

5 ‘‘(E) A national, State, local, or commu6 nity-based public or nonprofit private organiza7 tion, including organizations that use commu8 nity health workers or community-based doula 

9 programs. 

10 ‘‘(F) A faith-based organization or con11 sortia, to the extent that a grant awarded to such 

12 an entity is consistent with the requirements of 

13 section 1955 of the Public Health Service Act (42 

14 U.S.C. 300x–65) relating to a grant award to 

15 nongovernmental entities. 

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

17 ‘‘(2) FEDERAL HEALTH SAFETY NET ORGANIZA18 TION.—The term ‘Federal health safety net organiza19 tion’ means— 

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

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

22 ‘‘(B) a hospital defined as a dispropor23 tionate share hospital for purposes of section 

24 1923; 
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1 ‘‘(C) a covered entity described in section 

2 340B(a)(4) of the Public Health Service Act (42 

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

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

5 serves children under a federally funded pro6 gram, including the special supplemental nutri7 tion program for women, infants, and children 

8 (WIC) established under section 17 of the Child 

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

10 Head Start and Early Head Start programs 

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

12 seq.), the school lunch program established under 

13 the Richard B. Russell National School Lunch 

14 Act, and an elementary or secondary school. 

15 ‘‘(3) INDIANS; INDIAN TRIBE; TRIBAL ORGANIZA16 TION; URBAN INDIAN ORGANIZATION.—The terms ‘In17 dian’, ‘Indian tribe’, ‘tribal organization’, and ‘urban 

18 Indian organization’ have the meanings given such 

19 terms in section 4 of the Indian Health Care Im20 provement Act (25 U.S.C. 1603). 

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

22 ‘community health worker’ means an individual who 

23 promotes health or nutrition within the community 

24 in which the individual resides— 
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1 ‘‘(A) by serving as a liaison between com2 munities and health care agencies; 

3 ‘‘(B) by providing guidance and social as4 sistance to community residents; 

5 ‘‘(C) by enhancing community residents’ 

6 ability to effectively communicate with health 

7 care providers; 

8 ‘‘(D) by providing culturally and linguis9 tically appropriate health or nutrition edu10 cation; 

11 ‘‘(E) by advocating for individual and com12 munity health or nutrition needs; and 

13 ‘‘(F) by providing referral and followup 

14 services. 

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

16 any money in the Treasury not otherwise appropriated, 

17 $100,000,000 for the period of fiscal years 2009 through 

18 2013, for the purpose of awarding grants under this section. 

19 Amounts appropriated and paid under the authority of this 

20 section shall be in addition to amounts appropriated under 

21 section 2104 and paid to States in accordance with section 

22 2105, including with respect to expenditures for outreach 

23 activities in accordance with subsections (a)(1)(D)(iii) and 

24 (c)(2)(C) of that section. 
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1 ‘‘(h) NATIONAL ENROLLMENT CAMPAIGN.—From the 

2 amounts made available under subsection (a)(2), the Sec3 retary shall develop and implement a national enrollment 

4 campaign to improve the enrollment of underserved child 

5 populations in the programs established under this title and 

6 title XIX. Such campaign may include— 

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

8 Secretary of Education and the Secretary of Agri9 culture to develop national campaigns to link the eli10 gibility and enrollment systems for the assistance pro11 grams each Secretary administers that often serve the 

12 same children; 

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

14 programs established under this title and title XIX in 

15 public health awareness campaigns administered by 

16 the Secretary; 

17 ‘‘(3) increased financial and technical support 

18 for enrollment hotlines maintained by the Secretary 

19 to ensure that all States participate in such hotlines; 

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

21 outreach initiatives with the Secretary of Education 

22 and the Secretary of Labor regarding the importance 

23 of health insurance to building strong communities 

24 and the economy; 
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1 ‘‘(5) the development of special outreach mate2 rials for Native Americans or for individuals with 

3 limited English proficiency; and 

4 ‘‘(6) such other outreach initiatives as the Sec5 retary determines would increase public awareness of 

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

7 (b) ENHANCED ADMINISTRATIVE FUNDING FOR

8 TRANSLATION OR INTERPRETATION SERVICES UNDER

9 CHIP AND MEDICAID.— 

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

11 1397ee(a)(1)), as amended by section 113, is amend12 ed— 

13 (A) in the matter preceding subparagraph 

14 (A), by inserting ‘‘(or, in the case of expenditures 

15 described in subparagraph (D)(iv), the higher of 

16 75 percent or the sum of the enhanced FMAP 

17 plus 5 percentage points)’’ after ‘‘enhanced 

18 FMAP’’; and 

19 (B) in subparagraph (D)— 

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

21 the end; 

22 (ii) by redesignating clause (iv) as 

23 clause (v); and 

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

25 following new clause: 
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1 ‘‘(iv) for translation or interpretation 

2 services in connection with the enrollment 

3 of, retention of, and use of services under 

4 this title by, individuals for whom English 

5 is not their primary language (as found 

6 necessary by the Secretary for the proper 

7 and efficient administration of the State 

8 plan); and’’. 

9 (2) MEDICAID.— 

10 (A) USE OF MEDICAID FUNDS.—Section 

11 1903(a)(2) (42 U.S.C. 1396b(a)(2)) is amended 

12 by adding at the end the following new subpara13 graph: 

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

15 of the sums expended during such quarter (as found 

16 necessary by the Secretary for the proper and efficient 

17 administration of the State plan) as are attributable 

18 to translation or interpretation services in connection 

19 with the enrollment of, retention of, and use of serv20 ices under this title by, children of families for whom 

21 English is not the primary language; plus’’. 

22 (B) USE OF COMMUNITY HEALTH WORKERS

23 FOR OUTREACH ACTIVITIES.— 

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

25 of such Act (42 U.S.C. 1397bb(c)(1)) is 
85 

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1 amended by inserting ‘‘(through community 

2 health workers and others)’’ after ‘‘Out3 reach’’. 

4 (ii) IN FEDERAL EVALUATION.—Sec5 tion 2108(c)(3)(B) of such Act (42 U.S.C. 

6 1397hh(c)(3)(B)) is amended by inserting 

7 ‘‘(such as through community health work8 ers and others)’’ after ‘‘including practices’’. 

9 SEC. 202. INCREASED OUTREACH AND ENROLLMENT OF IN10 DIANS. 

11 (a) IN GENERAL.—Section 1139 (42 U.S.C. 1320b–9) 

12 is amended to read as follows: 

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

14 HEALTH CARE FOR INDIANS UNDER TITLES 

15 XIX AND XXI. 

16 ‘‘(a) AGREEMENTS WITH STATES FOR MEDICAID AND

17 CHIP OUTREACH ON OR NEAR RESERVATIONS TO IN18 CREASE THE ENROLLMENT OF INDIANS IN THOSE PRO19 GRAMS.— 

20 ‘‘(1) IN GENERAL.—In order to improve the ac21 cess of Indians residing on or near a reservation to 

22 obtain benefits under the Medicaid and State chil23 dren’s health insurance programs established under 

24 titles XIX and XXI, the Secretary shall encourage the 

25 State to take steps to provide for enrollment on or 
86 

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1 near the reservation. Such steps may include outreach 

2 efforts such as the outstationing of eligibility workers, 

3 entering into agreements with the Indian Health 

4 Service, Indian Tribes, Tribal Organizations, and 

5 Urban Indian Organizations to provide outreach, 

6 education regarding eligibility and benefits, enroll7 ment, and translation services when such services are 

8 appropriate. 

9 ‘‘(2) CONSTRUCTION.—Nothing in paragraph (1) 

10 shall be construed as affecting arrangements entered 

11 into between States and the Indian Health Service, 

12 Indian Tribes, Tribal Organizations, or Urban In13 dian Organizations for such Service, Tribes, or Orga14 nizations to conduct administrative activities under 

15 such titles. 

16 ‘‘(b) REQUIREMENT TO FACILITATE COOPERATION.— 

17 The Secretary, acting through the Centers for Medicare & 

18 Medicaid Services, shall take such steps as are necessary 

19 to facilitate cooperation with, and agreements between, 

20 States and the Indian Health Service, Indian Tribes, Trib21 al Organizations, or Urban Indian Organizations with re22 spect to the provision of health care items and services to 

23 Indians under the programs established under title XIX or 

24 XXI. 
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1 ‘‘(c) DEFINITION OF INDIAN; INDIAN TRIBE; INDIAN

2 HEALTH PROGRAM; TRIBAL ORGANIZATION; URBAN INDIAN

3 ORGANIZATION.—In this section, the terms ‘Indian’, ‘In4 dian Tribe’, ‘Indian Health Program’, ‘Tribal Organiza5 tion’, and ‘Urban Indian Organization’ have the meanings 

6 given those terms in section 4 of the Indian Health Care 

7 Improvement Act.’’. 

8 (b) NONAPPLICATION OF 10 PERCENT LIMIT ON OUT9 REACH AND CERTAIN OTHER EXPENDITURES.—Section 

10 2105(c)(2) (42 U.S.C. 1397ee(c)(2)) is amended by adding 

11 at the end the following: 

12 ‘‘(C) NONAPPLICATION TO CERTAIN EX13 PENDITURES.—The limitation under subpara14 graph (A) shall not apply with respect to the fol15 lowing expenditures: 

16 ‘‘(i) EXPENDITURES TO INCREASE

17 OUTREACH TO, AND THE ENROLLMENT OF, 

18 INDIAN CHILDREN UNDER THIS TITLE AND

19 TITLE xix.—Expenditures for outreach ac20 tivities to families of Indian children likely 

21 to be eligible for child health assistance 

22 under the plan or medical assistance under 

23 the State plan under title XIX (or under a 

24 waiver of such plan), to inform such fami25 lies of the availability of, and to assist them 
88 

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1 in enrolling their children in, such plans, 

2 including such activities conducted under 

3 grants, contracts, or agreements entered into 

4 under section 1139(a).’’. 

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

6 EXPRESS LANE AGENCY TO CONDUCT SIM7 PLIFIED ELIGIBILITY DETERMINATIONS. 

8 (a) APPLICATION UNDER MEDICAID AND CHIP PRO9 GRAMS.— 

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

11 1396a(e)) is amended by adding at the end the fol12 lowing: 

13 ‘‘(13) EXPRESS LANE OPTION.— 

14 ‘‘(A) IN GENERAL.— 

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

16 EXPRESS LANE AGENCY.—At the option of the 

17 State, the State plan may provide that in deter18 mining eligibility under this title for a child (as 

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

20 rely on a finding made within a reasonable pe21 riod (as determined by the State) from an Ex22 press Lane agency (as defined in subparagraph 

23 (F)) when it determines whether a child satisfies 

24 one or more components of eligibility for medical 

25 assistance under this title. The State may rely 
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1 on a finding from an Express Lane agency not2 withstanding sections 1902(a)(46)(B) and 

3 1137(d) or any differences in budget unit, dis4 regard, deeming or other methodology, if the fol5 lowing requirements are met: 

6 ‘‘(I) PROHIBITION ON DETERMINING

7 CHILDREN INELIGIBLE FOR COVERAGE.—If 

8 a finding from an Express Lane agency 

9 would result in a determination that a 

10 child does not satisfy an eligibility require11 ment for medical assistance under this title 

12 and for child health assistance under title 

13 XXI, the State shall determine eligibility for 

14 assistance using its regular procedures. 

15 ‘‘(II) NOTICE REQUIREMENT.—For 

16 any child who is found eligible for medical 

17 assistance under the State plan under this 

18 title or child health assistance under title 

19 XXI and who is subject to premiums based 

20 on an Express Lane agency’s finding of 

21 such child’s income level, the State shall 

22 provide notice that the child may qualify 

23 for lower premium payments if evaluated 

24 by the State using its regular policies and 
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1 of the procedures for requesting such an 

2 evaluation. 

3 ‘‘(III) COMPLIANCE WITH SCREEN AND

4 ENROLL REQUIREMENT.—The State shall 

5 satisfy the requirements under subpara6 graphs (A) and (B) of section 2102(b)(3) 

7 (relating to screen and enroll) before enroll8 ing a child in child health assistance under 

9 title XXI. At its option, the State may ful10 fill such requirements in accordance with 

11 either option provided under subparagraph 

12 (C) of this paragraph. 

13 ‘‘(IV) VERIFICATION OF CITIZENSHIP

14 OR NATIONALITY STATUS.—The State shall 

15 satisfy the requirements of section 

16 1902(a)(46)(B) or 2105(c)(9), as applicable 

17 for verifications of citizenship or nation18 ality status. 

19 ‘‘(V) CODING.—The State meets the re20 quirements of subparagraph (E). 

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

22 REDETERMINATIONS.—The State may apply the 

23 provisions of this paragraph when conducting 

24 initial determinations of eligibility, redetermina-
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1 tions of eligibility, or both, as described in the 

2 State plan. 

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

4 this paragraph shall be construed— 

5 ‘‘(i) to limit or prohibit a State from taking 

6 any actions otherwise permitted under this title 

7 or title XXI in determining eligibility for or en8 rolling children into medical assistance under 

9 this title or child health assistance under title 

10 XXI; or 

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

12 1902(a)(5) concerning the agencies that may 

13 make a determination of eligibility for medical 

14 assistance under this title. 

15 ‘‘(C) OPTIONS FOR SATISFYING THE SCREEN AND

16 ENROLL REQUIREMENT.— 

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

18 whose eligibility for medical assistance under 

19 this title or for child health assistance under title 

20 XXI has been evaluated by a State agency using 

21 an income finding from an Express Lane agen22 cy, a State may carry out its duties under sub23 paragraphs (A) and (B) of section 2102(b)(3) 

24 (relating to screen and enroll) in accordance 

25 with either clause (ii) or clause (iii). 
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1 ‘‘(ii) ESTABLISHING A SCREENING THRESH2 OLD.— 

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

4 the State establishes a screening threshold 

5 set as a percentage of the Federal poverty 

6 level that exceeds the highest income thresh7 old applicable under this title to the child 

8 by a minimum of 30 percentage points or, 

9 at State option, a higher number of percent10 age points that reflects the value (as deter11 mined by the State and described in the 

12 State plan) of any differences between in13 come methodologies used by the program ad14 ministered by the Express Lane agency and 

15 the methodologies used by the State in deter16 mining eligibility for medical assistance 

17 under this title. 

18 ‘‘(II) CHILDREN WITH INCOME NOT

19 ABOVE THRESHOLD.—If the income of a 

20 child does not exceed the screening threshold, 

21 the child is deemed to satisfy the income eli22 gibility criteria for medical assistance 

23 under this title regardless of whether such 

24 child would otherwise satisfy such criteria. 
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1 ‘‘(III) CHILDREN WITH INCOME ABOVE

2 THRESHOLD.—If the income of a child ex3 ceeds the screening threshold, the child shall 

4 be considered to have an income above the 

5 Medicaid applicable income level described 

6 in section 2110(b)(4) and to satisfy the re7 quirement under section 2110(b)(1)(C) (re8 lating to the requirement that CHIP match9 ing funds be used only for children not eli10 gible for Medicaid). If such a child is en11 rolled in child health assistance under title 

12 XXI, the State shall provide the parent, 

13 guardian, or custodial relative with the fol14 lowing: 

15 ‘‘(aa) Notice that the child may be 

16 eligible to receive medical assistance 

17 under the State plan under this title if 

18 evaluated for such assistance under the 

19 State’s regular procedures and notice 

20 of the process through which a parent, 

21 guardian, or custodial relative can re22 quest that the State evaluate the child’s 

23 eligibility for medical assistance under 

24 this title using such regular procedures. 
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1 ‘‘(bb) A description of differences 

2 between the medical assistance pro3 vided under this title and child health 

4 assistance under title XXI, including 

5 differences in cost-sharing requirements 

6 and covered benefits. 

7 ‘‘(iii) TEMPORARY ENROLLMENT IN CHIP

8 PENDING SCREEN AND ENROLL.— 

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

10 a State enrolls a child in child health as11 sistance under title XXI for a temporary 

12 period if the child appears eligible for such 

13 assistance based on an income finding by 

14 an Express Lane agency. 

15 ‘‘(II) DETERMINATION OF ELIGI16 BILITY.—During such temporary enrollment 

17 period, the State shall determine the child’s 

18 eligibility for child health assistance under 

19 title XXI or for medical assistance under 

20 this title in accordance with this clause. 

21 ‘‘(III) PROMPT FOLLOW UP.—In mak22 ing such a determination, the State shall 

23 take prompt action to determine whether the 

24 child should be enrolled in medical assist25 ance under this title or child health assist-
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† HR 2 EAS 

1 ance under title XXI pursuant to subpara2 graphs (A) and (B) of section 2102(b)(3) 

3 (relating to screen and enroll). 

4 ‘‘(IV) REQUIREMENT FOR SIMPLIFIED

5 DETERMINATION.—In making such a deter6 mination, the State shall use procedures 

7 that, to the maximum feasible extent, reduce 

8 the burden imposed on the individual of 

9 such determination. Such procedures may 

10 not require the child’s parent, guardian, or 

11 custodial relative to provide or verify infor12 mation that already has been provided to 

13 the State agency by an Express Lane agen14 cy or another source of information unless 

15 the State agency has reason to believe the 

16 information is erroneous. 

17 ‘‘(V) AVAILABILITY OF CHIP MATCHING

18 FUNDS DURING TEMPORARY ENROLLMENT

19 PERIOD.—Medical assistance for items and 

20 services that are provided to a child enrolled 

21 in title XXI during a temporary enrollment 

22 period under this clause shall be treated as 

23 child health assistance under such title. 

24 ‘‘(D) OPTION FOR AUTOMATIC ENROLLMENT.— 
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1 ‘‘(i) IN GENERAL.—The State may initiate 

2 and determine eligibility for medical assistance 

3 under the State Medicaid plan or for child 

4 health assistance under the State CHIP plan 

5 without a program application from, or on be6 half of, the child based on data obtained from 

7 sources other than the child (or the child’s fam8 ily), but a child can only be automatically en9 rolled in the State Medicaid plan or the State 

10 CHIP plan if the child or the family affirma11 tively consents to being enrolled through affirma12 tion in writing, by telephone, orally, through 

13 electronic signature, or through any other means 

14 specified by the Secretary or by signature on an 

15 Express Lane agency application, if the require16 ment of clause (ii) is met. 

17 ‘‘(ii) INFORMATION REQUIREMENT.—The re18 quirement of this clause is that the State informs 

19 the parent, guardian, or custodial relative of the 

20 child of the services that will be covered, appro21 priate methods for using such services, premium 

22 or other cost sharing charges (if any) that apply, 

23 medical support obligations (under section 

24 1912(a)) created by enrollment (if applicable), 

25 and the actions the parent, guardian, or relative 
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1 must take to maintain enrollment and renew 

2 coverage. 

3 ‘‘(E) CODING; APPLICATION TO ENROLLMENT

4 ERROR RATES.— 

5 ‘‘(i) IN GENERAL.—For purposes of sub6 paragraph (A)(iv), the requirement of this sub7 paragraph for a State is that the State agrees 

8 to— 

9 ‘‘(I) assign such codes as the Secretary 

10 shall require to the children who are en11 rolled in the State Medicaid plan or the 

12 State CHIP plan through reliance on a 

13 finding made by an Express Lane agency 

14 for the duration of the State’s election under 

15 this paragraph; 

16 ‘‘(II) annually provide the Secretary 

17 with a statistically valid sample (that is 

18 approved by Secretary) of the children en19 rolled in such plans through reliance on 

20 such a finding by conducting a full Med21 icaid eligibility review of the children iden22 tified for such sample for purposes of deter23 mining an eligibility error rate (as de24 scribed in clause (iv)) with respect to the 

25 enrollment of such children (and shall not 
98 

† HR 2 EAS 

1 include such children in any data or sam2 ples used for purposes of complying with a 

3 Medicaid Eligibility Quality Control 

4 (MEQC) review or a payment error rate 

5 measurement (PERM) requirement); 

6 ‘‘(III) submit the error rate determined 

7 under subclause (II) to the Secretary; 

8 ‘‘(IV) if such error rate exceeds 3 per9 cent for either of the first 2 fiscal years in 

10 which the State elects to apply this para11 graph, demonstrate to the satisfaction of the 

12 Secretary the specific corrective actions im13 plemented by the State to improve upon 

14 such error rate; and 

15 ‘‘(V) if such error rate exceeds 3 per16 cent for any fiscal year in which the State 

17 elects to apply this paragraph, a reduction 

18 in the amount otherwise payable to the 

19 State under section 1903(a) for quarters for 

20 that fiscal year, equal to the total amount 

21 of erroneous excess payments determined for 

22 the fiscal year only with respect to the chil23 dren included in the sample for the fiscal 

24 year that are in excess of a 3 percent error 

25 rate with respect to such children. 
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1 ‘‘(ii) NO PUNITIVE ACTION BASED ON

2 ERROR RATE.—The Secretary shall not apply the 

3 error rate derived from the sample under clause 

4 (i) to the entire population of children enrolled 

5 in the State Medicaid plan or the State CHIP 

6 plan through reliance on a finding made by an 

7 Express Lane agency, or to the population of 

8 children enrolled in such plans on the basis of 

9 the State’s regular procedures for determining 

10 eligibility, or penalize the State on the basis of 

11 such error rate in any manner other than the re12 duction of payments provided for under clause 

13 (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 1903(u), 

18 for payments made under the State Medicaid 

19 plan with respect to ineligible individuals and 

20 families that are determined to exceed the error 

21 rate permitted under that section (as determined 

22 without regard to the error rate determined 

23 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 assist2 ance (as defined in section 1903(u)(1)(D)) for 

3 the period involved, except that such payments 

4 shall be limited to individuals for which eligi5 bility determinations are made under this para6 graph and except that in applying this para7 graph under title XXI, there shall be substituted 

8 for references to provisions of this title cor9 responding 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 AGEN14 CIES.—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 Act 

2 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 Na6 tional School Lunch Act (42 U.S.C. 

7 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 Develop11 ment 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 eligibility 

5 under the State Medicaid plan or the State 

6 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 pri11 vate, for-profit organization. 

12 ‘‘(iv) RULES OF CONSTRUCTION.—Nothing 

13 in this paragraph shall be construed as— 

14 ‘‘(I) exempting a State Medicaid agen15 cy from complying with the requirements of 

16 section 1902(a)(4) relating to merit-based 

17 personnel standards for employees of the 

18 State Medicaid agency and safeguards 

19 against conflicts of interest); or 

20 ‘‘(II) authorizing a State Medicaid 

21 agency that elects to use Express Lane agen22 cies under this subparagraph to use the Ex23 press Lane option to avoid complying with 

24 such requirements for purposes of making 
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1 eligibility determinations under the State 

2 Medicaid plan. 

3 ‘‘(v) ADDITIONAL DEFINITIONS.—In this 

4 paragraph: 

5 ‘‘(I) STATE.—The term ‘State’ means 1 

6 of the 50 States or the District of Columbia. 

7 ‘‘(II) STATE CHIP AGENCY.—The term 

8 ‘State CHIP agency’ means the State agen9 cy responsible for administering the State 

10 CHIP plan. 

11 ‘‘(III) STATE CHIP PLAN.—The term 

12 ‘State CHIP plan’ means the State child 

13 health plan established under title XXI and 

14 includes any waiver of such plan. 

15 ‘‘(IV) STATE MEDICAID AGENCY.—The 

16 term ‘State Medicaid agency’ means the 

17 State agency responsible for administering 

18 the State Medicaid plan. 

19 ‘‘(V) STATE MEDICAID PLAN.—The 

20 term ‘State Medicaid plan’ means the State 

21 plan established under title XIX and in22 cludes any waiver of such plan. 

23 ‘‘(G) CHILD DEFINED.—For purposes of this 

24 paragraph, the term ‘child’ means an individual 

25 under 19 years of age, or, at the option of a State, 
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1 such higher age, not to exceed 21 years of age, as the 

2 State may elect. 

3 ‘‘(H) STATE OPTION TO RELY ON STATE INCOME

4 TAX DATA OR RETURN.—At the option of the State, a 

5 finding from an Express Lane agency may include 

6 gross income or adjusted gross income shown by State 

7 income tax records or returns. 

8 ‘‘(I) APPLICATION.—This paragraph shall not 

9 apply with respect to eligibility determinations made 

10 after September 30, 2013.’’. 

11 (2) CHIP.—Section 2107(e)(1) (42 U.S.C. 

12 1397gg(e)(1)) is amended by redesignating subpara13 graphs (B), (C), and (D) as subparagraphs (C), (D), 

14 and (E), respectively, and by inserting after subpara15 graph (A) the following new subparagraph: 

16 ‘‘(B) Section 1902(e)(13) (relating to the 

17 State option to rely on findings from an Express 

18 Lane agency to help evaluate a child’s eligibility 

19 for medical assistance).’’. 

20 (b) EVALUATION AND REPORT.— 

21 (1) EVALUATION.—The Secretary shall conduct, 

22 by grant, contract, or interagency agreement, a com23 prehensive, independent evaluation of the option pro24 vided under the amendments made by subsection (a). 
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1 Such evaluation shall include an analysis of the effec2 tiveness of the option, and shall include— 

3 (A) obtaining a statistically valid sample of 

4 the children who were enrolled in the State Med5 icaid plan or the State CHIP plan through reli6 ance on a finding made by an Express Lane 

7 agency and determining the percentage of chil8 dren who were erroneously enrolled in such 

9 plans; 

10 (B) determining whether enrolling children 

11 in such plans through reliance on a finding 

12 made by an Express Lane agency improves the 

13 ability of a State to identify and enroll low-in14 come, uninsured children who are eligible but 

15 not enrolled in such plans; 

16 (C) evaluating the administrative costs or 

17 savings related to identifying and enrolling chil18 dren in such plans through reliance on such 

19 findings, and the extent to which such costs differ 

20 from the costs that the State otherwise would 

21 have incurred to identify and enroll low-income, 

22 uninsured children who are eligible but not en23 rolled in such plans; and 

24 (D) any recommendations for legislative or 

25 administrative changes that would improve the 
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1 effectiveness of enrolling children in such plans 

2 through reliance on such findings. 

3 (2) REPORT TO CONGRESS.—Not later than Sep4 tember 30, 2012, the Secretary shall submit a report 

5 to Congress on the results of the evaluation under 

6 paragraph (1). 

7 (3) FUNDING.— 

8 (A) IN GENERAL.—Out of any funds in the 

9 Treasury not otherwise appropriated, there is 

10 appropriated to the Secretary to carry out the 

11 evaluation under this subsection $5,000,000 for 

12 the period of fiscal years 2009 through 2012. 

13 (B) BUDGET AUTHORITY.—Subparagraph 

14 (A) constitutes budget authority in advance of 

15 appropriations Act and represents the obligation 

16 of the Federal Government to provide for the 

17 payment of such amount to conduct the evalua18 tion under this subsection. 

19 (c) ELECTRONIC TRANSMISSION OF INFORMATION.— 

20 Section 1902 (42 U.S.C. 1396a) is amended by adding at 

21 the end the following new subsection: 

22 ‘‘(dd) ELECTRONIC TRANSMISSION OF INFORMA23 TION.—If the State agency determining eligibility for med24 ical assistance under this title or child health assistance 

25 under title XXI verifies an element of eligibility based on 
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1 information from an Express Lane Agency (as defined in 

2 subsection (e)(13)(F)), or from another public agency, then 

3 the applicant’s signature under penalty of perjury shall not 

4 be required as to such element. Any signature requirement 

5 for an application for medical assistance may be satisfied 

6 through an electronic signature, as defined in section 

7 1710(1) of the Government Paperwork Elimination Act (44 

8 U.S.C. 3504 note). The requirements of subparagraphs (A) 

9 and (B) of section 1137(d)(2) may be met through evidence 

10 in digital or electronic form.’’. 

11 (d) AUTHORIZATION OF INFORMATION DISCLOSURE.— 

12 (1) IN GENERAL.—Title XIX is amended by add13 ing at the end the following new section: 

14 ‘‘SEC. 1942. AUTHORIZATION TO RECEIVE RELEVANT IN15 FORMATION. 

16 ‘‘(a) IN GENERAL.—Notwithstanding any other provi17 sion of law, a Federal or State agency or private entity 

18 in possession of the sources of data directly relevant to eligi19 bility determinations under this title (including eligibility 

20 files maintained by Express Lane agencies described in sec21 tion 1902(e)(13)(F), information described in paragraph 

22 (2) or (3) of section 1137(a), vital records information 

23 about births in any State, and information described in 

24 sections 453(i) and 1902(a)(25)(I)) is authorized to convey 

25 such data or information to the State agency administering 
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1 the State plan under this title, to the extent such conveyance 

2 meets the requirements of subsection (b). 

3 ‘‘(b) REQUIREMENTS FOR CONVEYANCE.—Data or in4 formation may be conveyed pursuant to subsection (a) only 

5 if the following requirements are met: 

6 ‘‘(1) The individual whose circumstances are de7 scribed in the data or information (or such individ8 ual’s parent, guardian, caretaker relative, or author9 ized representative) has either provided advance con10 sent to disclosure or has not objected to disclosure 

11 after receiving advance notice of disclosure and a rea12 sonable opportunity to object. 

13 ‘‘(2) Such data or information are used solely for 

14 the purposes of— 

15 ‘‘(A) identifying individuals who are eligi16 ble or potentially eligible for medical assistance 

17 under this title and enrolling or attempting to 

18 enroll such individuals in the State plan; and 

19 ‘‘(B) verifying the eligibility of individuals 

20 for medical assistance under the State plan. 

21 ‘‘(3) An interagency or other agreement, con22 sistent with standards developed by the Secretary— 

23 ‘‘(A) prevents the unauthorized use, disclo24 sure, or modification of such data and otherwise 
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1 meets applicable Federal requirements safe2 guarding privacy and data security; and 

3 ‘‘(B) requires the State agency admin4 istering the State plan to use the data and infor5 mation obtained under this section to seek to en6 roll individuals in the plan. 

7 ‘‘(c) PENALTIES FOR IMPROPER DISCLOSURE.— 

8 ‘‘(1) CIVIL MONEY PENALTY.—A private entity 

9 described in the subsection (a) that publishes, dis10 closes, or makes known in any manner, or to any ex11 tent not authorized by Federal law, any information 

12 obtained under this section is subject to a civil money 

13 penalty in an amount equal to $10,000 for each such 

14 unauthorized publication or disclosure. The provisions 

15 of section 1128A (other than subsections (a) and (b) 

16 and the second sentence of subsection (f)) shall apply 

17 to a civil money penalty under this paragraph in the 

18 same manner as such provisions apply to a penalty 

19 or proceeding under section 1128A(a). 

20 ‘‘(2) CRIMINAL PENALTY.—A private entity de21 scribed in the subsection (a) that willfully publishes, 

22 discloses, or makes known in any manner, or to any 

23 extent not authorized by Federal law, any informa24 tion obtained under this section shall be fined not 

25 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 under 

7 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 authorization 

13 to receive data directly relevant to eligibility de14 terminations).’’. 

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 respect 

24 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 EXPRESS

5 LANE OPTION TO RECEIVE CERTAIN DATA DIRECTLY REL6 EVANT TO DETERMINING ELIGIBILITY AND CORRECT

7 AMOUNT OF ASSISTANCE.—The Secretary shall enter into 

8 such agreements as are necessary to permit a State that 

9 elects the Express Lane option under section 1902(e)(13) 

10 of the Social Security Act to receive data directly relevant 

11 to eligibility determinations and determining the correct 

12 amount of benefits under a State child health plan under 

13 CHIP or a State plan under Medicaid from the following: 

14 (1) The National Directory of New Hires estab15 lished under section 453(i) of the Social Security Act 

16 (42 U.S.C. 653(i)). 

17 (2) Data regarding enrollment in insurance that 

18 may help to facilitate outreach and enrollment under 

19 the State Medicaid plan, the State CHIP plan, and 

20 such other programs as the Secretary may specify. 

21 (f) EFFECTIVE DATE.—The amendments made by this 

22 section are effective on the date of the enactment of 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 VERIFICATION

7 OF DECLARATION OF CITIZENSHIP OR NATIONALITY FOR

8 PURPOSES OF ELIGIBILITY FOR MEDICAID.— 

9 (1) ALTERNATIVE TO DOCUMENTATION REQUIRE10 MENT.— 

11 (A) IN GENERAL.—Section 1902 (42 U.S.C. 

12 1396a), as amended by section 203(c), is amend13 ed— 

14 (i) in subsection (a)(46)— 

15 (I) by inserting ‘‘(A)’’ after 

16 ‘‘(46)’’; 

17 (II) by adding ‘‘and’’ after the 

18 semicolon; and 

19 (III) by adding at the end the fol20 lowing new subparagraph: 

21 ‘‘(B) provide, with respect to an individual de22 claring to be a citizen or national of the United 

23 States for purposes of establishing eligibility under 

24 this title, that the State shall satisfy the requirements 

25 of— 
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1 ‘‘(i) section 1903(x); or 

2 ‘‘(ii) subsection (ee);’’; and 

3 (ii) by adding at the end the following 

4 new subsection: 

5 ‘‘(ee)(1) For purposes of subsection (a)(46)(B)(ii), the 

6 requirements of this subsection with respect to an indi7 vidual declaring to be a citizen or national of the United 

8 States for purposes of establishing eligibility under this 

9 title, are, in lieu of requiring the individual to present sat10 isfactory documentary evidence of citizenship or nationality 

11 under section 1903(x) (if the individual is not described in 

12 paragraph (2) of that section), as follows: 

13 ‘‘(A) The State submits the name and social se14 curity number of the individual to the Commissioner 

15 of Social Security as part of the program established 

16 under paragraph (2). 

17 ‘‘(B) If the State receives notice from the Com18 missioner of Social Security that the name or social 

19 security number, or the declaration of citizenship or 

20 nationality, of the individual is inconsistent with in21 formation in the records maintained by the Commis22 sioner— 

23 ‘‘(i) the State makes a reasonable effort to 

24 identify and address the causes of such inconsist25 ency, including through typographical or other 
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1 clerical errors, by contacting the individual to 

2 confirm the accuracy of the name or social secu3 rity number submitted or declaration of citizen4 ship or nationality and by taking such addi5 tional actions as the Secretary, through regula6 tion or other guidance, or the State may iden7 tify, and continues to provide the individual 

8 with medical assistance while making such effort; 

9 and 

10 ‘‘(ii) in the case such inconsistency is not 

11 resolved under clause (i), the State— 

12 ‘‘(I) notifies the individual of such 

13 fact; 

14 ‘‘(II) provides the individual with a 

15 period of 90 days from the date on which 

16 the notice required under subclause (I) is 

17 received by the individual to either present 

18 satisfactory documentary evidence of citi19 zenship or nationality (as defined in section 

20 1903(x)(3)) or resolve the inconsistency with 

21 the Commissioner of Social Security (and 

22 continues to provide the individual with 

23 medical assistance during such 90-day pe24 riod); and 
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1 ‘‘(III) disenrolls the individual from 

2 the State plan under this title within 30 

3 days after the end of such 90-day period if 

4 no such documentary evidence is presented 

5 or if such inconsistency is not resolved. 

6 ‘‘(2)(A) Each State electing to satisfy the requirements 

7 of this subsection for purposes of section 1902(a)(46)(B) 

8 shall establish a program under which the State submits 

9 at least monthly to the Commissioner of Social Security 

10 for comparison of the name and social security number, of 

11 each individual newly enrolled in the State plan under this 

12 title that month who is not described in section 1903(x)(2) 

13 and who declares to be a United States citizen or national, 

14 with information in records maintained by the Commis15 sioner. 

16 ‘‘(B) In establishing the State program under this 

17 paragraph, the State may enter into an agreement with the 

18 Commissioner of Social Security— 

19 ‘‘(i) to provide, through an on-line system or oth20 erwise, for the electronic submission of, and response 

21 to, the information submitted under subparagraph 

22 (A) for an individual enrolled in the State plan 

23 under this title who declares to be citizen or national 

24 on at least a monthly basis; or 
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1 ‘‘(ii) to provide for a determination of the con2 sistency of the information submitted with the infor3 mation maintained in the records of the Commis4 sioner through such other method as agreed to by the 

5 State and the Commissioner and approved by the 

6 Secretary, provided that such method is no more bur7 densome for individuals to comply with than any 

8 burdens that may apply under a method described in 

9 clause (i). 

10 ‘‘(C) The program established under this paragraph 

11 shall provide that, in the case of any individual who is re12 quired to submit a social security number to the State 

13 under subparagraph (A) and who is unable to provide the 

14 State with such number, shall be provided with at least the 

15 reasonable opportunity to present satisfactory documentary 

16 evidence of citizenship or nationality (as defined in section 

17 1903(x)(3)) as is provided under clauses (i) and (ii) of sec18 tion 1137(d)(4)(A) to an individual for the submittal to the 

19 State of evidence indicating a satisfactory immigration sta20 tus. 

21 ‘‘(3)(A) The State agency implementing the plan ap22 proved under this title shall, at such times and in such form 

23 as the Secretary may specify, provide information on the 

24 percentage each month that the inconsistent submissions 

25 bears to the total submissions made for comparison for such 
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1 month. For purposes of this subparagraph, a name, social 

2 security number, or declaration of citizenship or nation3 ality of an individual shall be treated as inconsistent and 

4 included in the determination of such percentage only if— 

5 ‘‘(i) the information submitted by the individual 

6 is not consistent with information in records main7 tained by the Commissioner of Social Security; 

8 ‘‘(ii) the inconsistency is not resolved by the 

9 State; 

10 ‘‘(iii) the individual was provided with a rea11 sonable period of time to resolve the inconsistency 

12 with the Commissioner of Social Security or provide 

13 satisfactory documentation of citizenship status and 

14 did not successfully resolve such inconsistency; and 

15 ‘‘(iv) payment has been made for an item or 

16 service furnished to the individual under this title. 

17 ‘‘(B) If, for any fiscal year, the average monthly per18 centage determined under subparagraph (A) is greater than 

19 3 percent— 

20 ‘‘(i) the State shall develop and adopt a correc21 tive plan to review its procedures for verifying the 

22 identities of individuals seeking to enroll in the State 

23 plan under this title and to identify and implement 

24 changes in such procedures to improve their accuracy; 

25 and 
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† HR 2 EAS 

1 ‘‘(ii) pay to the Secretary an amount equal to 

2 the amount which bears the same ratio to the total 

3 payments under the State plan for the fiscal year for 

4 providing medical assistance to individuals who pro5 vided inconsistent information as the number of indi6 viduals with inconsistent information in excess of 3 

7 percent of such total submitted bears to the total num8 ber of individuals with inconsistent information. 

9 ‘‘(C) The Secretary may waive, in certain limited 

10 cases, all or part of the payment under subparagraph 

11 (B)(ii) if the State is unable to reach the allowable error 

12 rate despite a good faith effort by such State. 

13 ‘‘(D) Subparagraphs (A) and (B) shall not apply to 

14 a State for a fiscal year if there is an agreement described 

15 in paragraph (2)(B) in effect as of the close of the fiscal 

16 year that provides for the submission on a real-time basis 

17 of the information described in such paragraph. 

18 ‘‘(4) Nothing in this subsection shall affect the rights 

19 of any individual under this title to appeal any 

20 disenrollment from a State plan.’’. 

21 (B) COSTS OF IMPLEMENTING AND MAIN22 TAINING SYSTEM.—Section 1903(a)(3) (42 

23 U.S.C. 1396b(a)(3)) is amended— 

24 (i) by striking ‘‘plus’’ at the end of 

25 subparagraph (E) and inserting ‘‘and’’, and 
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1 (ii) by adding at the end the following 

2 new subparagraph: 

3 ‘‘(F)(i) 90 percent of the sums expended 

4 during the quarter as are attributable to the de5 sign, development, or installation of such mecha6 nized verification and information retrieval sys7 tems as the Secretary determines are necessary to 

8 implement section 1902(ee) (including a system 

9 described in paragraph (2)(B) thereof), and 

10 ‘‘(ii) 75 percent of the sums expended dur11 ing the quarter as are attributable to the oper12 ation of systems to which clause (i) applies, 

13 plus’’. 

14 (2) LIMITATION ON WAIVER AUTHORITY.—Not15 withstanding any provision of section 1115 of the So16 cial Security Act (42 U.S.C. 1315), or any other pro17 vision of law, the Secretary may not waive the re18 quirements of section 1902(a)(46)(B) of such Act (42 

19 U.S.C. 1396a(a)(46)(B)) with respect to a State. 

20 (3) CONFORMING AMENDMENTS.—Section 1903 

21 (42 U.S.C. 1396b) is amended— 

22 (A) in subsection (i)(22), by striking ‘‘sub23 section (x)’’ and inserting ‘‘section 

24 1902(a)(46)(B)’’; and 
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1 (B) in subsection (x)(1), by striking ‘‘sub2 section (i)(22)’’ and inserting ‘‘section 

3 1902(a)(46)(B)(i)’’. 

4 (4) APPROPRIATION.—Out of any money in the 

5 Treasury of the United States not otherwise appro6 priated, there are appropriated to the Commissioner 

7 of Social Security $5,000,000 to remain available 

8 until expended to carry out the Commissioner’s re9 sponsibilities under section 1902(ee) of the Social Se10 curity Act, as added by subsection (a). 

11 (b) CLARIFICATION OF REQUIREMENTS RELATING TO

12 PRESENTATION OF SATISFACTORY DOCUMENTARY EVI13 DENCE OF CITIZENSHIP OR NATIONALITY.— 

14 (1) ACCEPTANCE OF DOCUMENTARY EVIDENCE

15 ISSUED BY A FEDERALLY RECOGNIZED INDIAN

16 TRIBE.—Section 1903(x)(3)(B) (42 U.S.C. 

17 1396b(x)(3)(B)) is amended— 

18 (A) by redesignating clause (v) as clause 

19 (vi); and 

20 (B) by inserting after clause (iv), the fol21 lowing new clause: 

22 ‘‘(v)(I) Except as provided in subclause (II), a 

23 document issued by a federally recognized Indian 

24 tribe evidencing membership or enrollment in, or af-
122 

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1 filiation with, such tribe (such as a tribal enrollment 

2 card or certificate of degree of Indian blood). 

3 ‘‘(II) With respect to those federally recognized 

4 Indian tribes located within States having an inter5 national border whose membership includes individ6 uals who are not citizens of the United States, the 

7 Secretary shall, after consulting with such tribes, 

8 issue regulations authorizing the presentation of such 

9 other forms of documentation (including tribal docu10 mentation, if appropriate) that the Secretary deter11 mines to be satisfactory documentary evidence of citi12 zenship or nationality for purposes of satisfying the 

13 requirement of this subsection.’’. 

14 (2) REQUIREMENT TO PROVIDE REASONABLE OP15 PORTUNITY TO PRESENT SATISFACTORY DOCUMEN16 TARY EVIDENCE.—Section 1903(x) (42 U.S.C. 

17 1396b(x)) is amended by adding at the end the fol18 lowing new paragraph: 

19 ‘‘(4) In the case of an individual declaring to be a 

20 citizen or national of the United States with respect to 

21 whom a State requires the presentation of satisfactory docu22 mentary evidence of citizenship or nationality under section 

23 1902(a)(46)(B)(i), the individual shall be provided at least 

24 the reasonable opportunity to present satisfactory documen25 tary evidence of citizenship or nationality under this sub-
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1 section as is provided under clauses (i) and (ii) of section 

2 1137(d)(4)(A) to an individual for the submittal to the 

3 State of evidence indicating a satisfactory immigration sta4 tus.’’. 

5 (3) CHILDREN BORN IN THE UNITED STATES TO

6 MOTHERS ELIGIBLE FOR MEDICAID.— 

7 (A) CLARIFICATION OF RULES.—Section 

8 1903(x) (42 U.S.C. 1396b(x)), as amended by 

9 paragraph (2), is amended— 

10 (i) in paragraph (2)— 

11 (I) in subparagraph (C), by strik12 ing ‘‘or’’ at the end; 

13 (II) by redesignating subpara14 graph (D) as subparagraph (E); and 

15 (III) by inserting after subpara16 graph (C) the following new subpara17 graph: 

18 ‘‘(D) pursuant to the application of section 

19 1902(e)(4) (and, in the case of an individual who is 

20 eligible for medical assistance on such basis, the indi21 vidual shall be deemed to have provided satisfactory 

22 documentary evidence of citizenship or nationality 

23 and shall not be required to provide further documen24 tary evidence on any date that occurs during or after 
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1 the period in which the individual is eligible for med2 ical assistance on such basis); or’’; and 

3 (ii) by adding at the end the following 

4 new paragraph: 

5 ‘‘(5) Nothing in subparagraph (A) or (B) of section 

6 1902(a)(46), the preceding paragraphs of this subsection, 

7 or the Deficit Reduction Act of 2005, including section 6036 

8 of such Act, shall be construed as changing the requirement 

9 of section 1902(e)(4) that a child born in the United States 

10 to an alien mother for whom medical assistance for the de11 livery of such child is available as treatment of an emer12 gency medical condition pursuant to subsection (v) shall be 

13 deemed eligible for medical assistance during the first year 

14 of such child’s life.’’. 

15 (B) STATE REQUIREMENT TO ISSUE SEPA16 RATE IDENTIFICATION NUMBER.—Section 

17 1902(e)(4) (42 U.S.C. 1396a(e)(4)) is amended 

18 by adding at the end the following new sentence: 

19 ‘‘Notwithstanding the preceding sentence, in the 

20 case of a child who is born in the United States 

21 to an alien mother for whom medical assistance 

22 for the delivery of the child is made available 

23 pursuant to section 1903(v), the State imme24 diately shall issue a separate identification num25 ber for the child upon notification by the facility 
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1 at which such delivery occurred of the child’s 

2 birth.’’. 

3 (4) TECHNICAL AMENDMENTS.—Section 

4 1903(x)(2) (42 U.S.C. 1396b(x)) is amended— 

5 (A) in subparagraph (B)— 

6 (i) by realigning the left margin of the 

7 matter preceding clause (i) 2 ems to the left; 

8 and 

9 (ii) by realigning the left margins of 

10 clauses (i) and (ii), respectively, 2 ems to 

11 the left; and 

12 (B) in subparagraph (C)— 

13 (i) by realigning the left margin of the 

14 matter preceding clause (i) 2 ems to the left; 

15 and 

16 (ii) by realigning the left margins of 

17 clauses (i) and (ii), respectively, 2 ems to 

18 the left. 

19 (c) APPLICATION OF DOCUMENTATION SYSTEM TO

20 CHIP.— 

21 (1) IN GENERAL.—Section 2105(c) (42 U.S.C. 

22 1397ee(c)), as amended by section 114(a), is amended 

23 by adding at the end the following new paragraph: 

24 ‘‘(9) CITIZENSHIP DOCUMENTATION REQUIRE25 MENTS.— 
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1 ‘‘(A) IN GENERAL.—No payment may be 

2 made under this section with respect to an indi3 vidual who has, or is, declared to be a citizen or 

4 national of the United States for purposes of es5 tablishing eligibility under this title unless the 

6 State meets the requirements of section 

7 1902(a)(46)(B) with respect to the individual. 

8 ‘‘(B) ENHANCED PAYMENTS.—Notwith9 standing subsection (b), the enhanced FMAP 

10 with respect to payments under subsection (a) 

11 for expenditures described in clause (i) or (ii) of 

12 section 1903(a)(3)(F) necessary to comply with 

13 subparagraph (A) shall in no event be less than 

14 90 percent and 75 percent, respectively.’’. 

15 (2) NONAPPLICATION OF ADMINISTRATIVE EX16 PENDITURES CAP.—Section 2105(c)(2)(C) (42 U.S.C. 

17 1397ee(c)(2)(C)), as amended by section 202(b), is 

18 amended by adding at the end the following: 

19 ‘‘(ii) EXPENDITURES TO COMPLY WITH

20 CITIZENSHIP OR NATIONALITY VERIFICATION

21 REQUIREMENTS.—Expenditures necessary 

22 for the State to comply with paragraph 

23 (9)(A).’’. 

24 (d) EFFECTIVE DATE.— 

25 (1) IN GENERAL.— 
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1 (A) IN GENERAL.—Except as provided in 

2 subparagraph (B), the amendments made by this 

3 section shall take effect on January 1, 2010. 

4 (B) TECHNICAL AMENDMENTS.—The 

5 amendments made by— 

6 (i) paragraphs (1), (2), and (3) of sub7 section (b) shall take effect as if included in 

8 the enactment of section 6036 of the Deficit 

9 Reduction Act of 2005 (Public Law 109– 

10 171; 120 Stat. 80); and 

11 (ii) paragraph (4) of subsection (b) 

12 shall take effect as if included in the enact13 ment of section 405 of division B of the Tax 

14 Relief and Health Care Act of 2006 (Public 

15 Law 109–432; 120 Stat. 2996). 

16 (2) RESTORATION OF ELIGIBILITY.—In the case 

17 of an individual who, during the period that began 

18 on July 1, 2006, and ends on October 1, 2009, was 

19 determined to be ineligible for medical assistance 

20 under a State Medicaid plan, including any waiver 

21 of such plan, solely as a result of the application of 

22 subsections (i)(22) and (x) of section 1903 of the So23 cial Security Act (as in effect during such period), 

24 but who would have been determined eligible for such 

25 assistance if such subsections, as amended by sub-
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1 section (b), had applied to the individual, a State 

2 may deem the individual to be eligible for such assist3 ance as of the date that the individual was deter4 mined to be ineligible for such medical assistance on 

5 such basis. 

6 (3) SPECIAL TRANSITION RULE FOR INDIANS.— 

7 During the period that begins on July 1, 2006, and 

8 ends on the effective date of final regulations issued 

9 under subclause (II) of section 1903(x)(3)(B)(v) of the 

10 Social Security Act (42 U.S.C. 1396b(x)(3)(B)(v)) (as 

11 added by subsection (b)(1)(B)), an individual who is 

12 a member of a federally-recognized Indian tribe de13 scribed in subclause (II) of that section who presents 

14 a document described in subclause (I) of such section 

15 that is issued by such Indian tribe, shall be deemed 

16 to have presented satisfactory evidence of citizenship 

17 or nationality for purposes of satisfying the require18 ment of subsection (x) of section 1903 of such Act. 

19 SEC. 212. REDUCING ADMINISTRATIVE BARRIERS TO EN20 ROLLMENT. 

21 Section 2102(b) (42 U.S.C. 1397bb(b)) is amended— 

22 (1) by redesignating paragraph (4) as para23 graph (5); and 

24 (2) by inserting after paragraph (3) the fol25 lowing new paragraph: 
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1 ‘‘(4) REDUCTION OF ADMINISTRATIVE BARRIERS

2 TO ENROLLMENT.— 

3 ‘‘(A) IN GENERAL.—Subject to subpara4 graph (B), the plan shall include a description 

5 of the procedures used to reduce administrative 

6 barriers to the enrollment of children and preg7 nant women who are eligible for medical assist8 ance under title XIX or for child health assist9 ance or health benefits coverage under this title. 

10 Such procedures shall be established and revised 

11 as often as the State determines appropriate to 

12 take into account the most recent information 

13 available to the State identifying such barriers. 

14 ‘‘(B) DEEMED COMPLIANCE IF JOINT APPLI15 CATION AND RENEWAL PROCESS THAT PERMITS

16 APPLICATION OTHER THAN IN PERSON.—A State 

17 shall be deemed to comply with subparagraph 

18 (A) if the State’s application and renewal forms 

19 and supplemental forms (if any) and informa20 tion verification process is the same for purposes 

21 of establishing and renewing eligibility for chil22 dren and pregnant women for medical assistance 

23 under title XIX and child health assistance 

24 under this title, and such process does not re-
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1 quire an application to be made in person or a 

2 face-to-face interview.’’. 

3 SEC. 213. MODEL OF INTERSTATE COORDINATED ENROLL4 MENT AND COVERAGE PROCESS. 

5 (a) IN GENERAL.—In order to assure continuity of 

6 coverage of low-income children under the Medicaid pro7 gram and the State Children’s Health Insurance Program 

8 (CHIP), not later than 18 months after the date of the en9 actment of this Act, the Secretary of Health and Human 

10 Services, in consultation with State Medicaid and CHIP 

11 directors and organizations representing program bene12 ficiaries, shall develop a model process for the coordination 

13 of the enrollment, retention, and coverage under such pro14 grams of children who, because of migration of families, 

15 emergency evacuations, natural or other disasters, public 

16 health emergencies, educational needs, or otherwise, fre17 quently change their State of residency or otherwise are 

18 temporarily located outside of the State of their residency. 

19 (b) REPORT TO CONGRESS.—After development of such 

20 model process, the Secretary of Health and Human Services 

21 shall submit to Congress a report describing additional 

22 steps or authority needed to make further improvements to 

23 coordinate the enrollment, retention, and coverage under 

24 CHIP and Medicaid of children described in subsection (a). 
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1 SEC. 214. PERMITTING STATES TO ENSURE COVERAGE 

2 WITHOUT A 5-YEAR DELAY OF CERTAIN CHIL3 DREN AND PREGNANT WOMEN UNDER THE 

4 MEDICAID PROGRAM AND CHIP. 

5 (a) MEDICAID PROGRAM.—Section 1903(v) (42 U.S.C. 

6 1396b(v)) is amended— 

7 (1) in paragraph (1), by striking ‘‘paragraph 

8 (2)’’ and inserting ‘‘paragraphs (2) and (4)’’; and 

9 (2) by adding at the end the following new para10 graph: 

11 ‘‘(4)(A) A State may elect (in a plan amendment 

12 under this title) to provide medical assistance under this 

13 title, notwithstanding sections 401(a), 402(b), 403, and 421 

14 of the Personal Responsibility and Work Opportunity Rec15 onciliation Act of 1996, to children and pregnant women 

16 who are lawfully residing in the United States (including 

17 battered individuals described in section 431(c) of such Act) 

18 and who are otherwise eligible for such assistance, within 

19 either or both of the following eligibility categories: 

20 ‘‘(i) PREGNANT WOMEN.—Women during preg21 nancy (and during the 60-day period beginning on 

22 the last day of the pregnancy). 

23 ‘‘(ii) CHILDREN.—Individuals under 21 years of 

24 age, including optional targeted low-income children 

25 described in section 1905(u)(2)(B). 
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1 ‘‘(B) In the case of a State that has elected to provide 

2 medical assistance to a category of aliens under subpara3 graph (A), no debt shall accrue under an affidavit of sup4 port against any sponsor of such an alien on the basis of 

5 provision of assistance to such category and the cost of such 

6 assistance shall not be considered as an unreimbursed cost. 

7 ‘‘(C) As part of the State’s ongoing eligibility redeter8 mination requirements and procedures for an individual 

9 provided medical assistance as a result of an election by 

10 the State under subparagraph (A), a State shall verify that 

11 the individual continues to lawfully reside in the United 

12 States using the documentation presented to the State by 

13 the individual on initial enrollment. If the State cannot 

14 successfully verify that the individual is lawfully residing 

15 in the United States in this manner, it shall require that 

16 the individual provide the State with further documenta17 tion or other evidence to verify that the individual is law18 fully residing in the United States.’’. 

19 (b) CHIP.—Section 2107(e)(1) (42 U.S.C. 

20 1397gg(e)(1)), as amended by sections 203(a)(2) and 

21 203(d)(2), is amended by redesignating subparagraphs (E) 

22 and (F) as subparagraphs (F) and (G), respectively and 

23 by inserting after subparagraph (D) the following new sub24 paragraph: 
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1 ‘‘(E) Paragraph (4) of section 1903(v) (re2 lating to optional coverage of categories of law3 fully residing immigrant children or pregnant 

4 women), but only if the State has elected to 

5 apply such paragraph with respect to such cat6 egory of children or pregnant women under title 

7 XIX.’’. 

8 TITLE III—REDUCING BARRIERS 

9 TO PROVIDING PREMIUM AS10 SISTANCE 

11 Subtitle A—Additional State Option 

12 for Providing Premium Assistance 

13 SEC. 301. ADDITIONAL STATE OPTION FOR PROVIDING PRE14 MIUM ASSISTANCE. 

15 (a) CHIP.— 

16 (1) IN GENERAL.—Section 2105(c) (42 U.S.C. 

17 1397ee(c)), as amended by sections 114(a) and 211(c), 

18 is amended by adding at the end the following: 

19 ‘‘(10) STATE OPTION TO OFFER PREMIUM AS20 SISTANCE.— 

21 ‘‘(A) IN GENERAL.—A State may elect to 

22 offer a premium assistance subsidy (as defined 

23 in subparagraph (C)) for qualified employer24 sponsored coverage (as defined in subparagraph 

25 (B)) to all targeted low-income children who are 
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1 eligible for child health assistance under the plan 

2 and have access to such coverage in accordance 

3 with the requirements of this paragraph. No sub4 sidy shall be provided to a targeted low-income 

5 child under this paragraph unless the child (or 

6 the child’s parent) voluntarily elects to receive 

7 such a subsidy. A State may not require such an 

8 election as a condition of receipt of child health 

9 assistance. 

10 ‘‘(B) QUALIFIED EMPLOYER-SPONSORED

11 COVERAGE.— 

12 ‘‘(i) IN GENERAL.—Subject to clause 

13 (ii), in this paragraph, the term ‘qualified 

14 employer-sponsored coverage’ means a 

15 group health plan or health insurance cov16 erage offered through an employer— 

17 ‘‘(I) that qualifies as creditable 

18 coverage as a group health plan under 

19 section 2701(c)(1) of the Public Health 

20 Service Act; 

21 ‘‘(II) for which the employer con22 tribution toward any premium for 

23 such coverage is at least 40 percent; 

24 and 
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1 ‘‘(III) that is offered to all indi2 viduals in a manner that would be 

3 considered a nondiscriminatory eligi4 bility classification for purposes of 

5 paragraph (3)(A)(ii) of section 105(h) 

6 of the Internal Revenue Code of 1986 

7 (but determined without regard to 

8 clause (i) of subparagraph (B) of such 

9 paragraph). 

10 ‘‘(ii) EXCEPTION.—Such term does not 

11 include coverage consisting of— 

12 ‘‘(I) benefits provided under a 

13 health flexible spending arrangement 

14 (as defined in section 106(c)(2) of the 

15 Internal Revenue Code of 1986); or 

16 ‘‘(II) a high deductible health 

17 plan (as defined in section 223(c)(2) of 

18 such Code), without regard to whether 

19 the plan is purchased in conjunction 

20 with a health savings account (as de21 fined under section 223(d) of such 

22 Code). 

23 ‘‘(C) PREMIUM ASSISTANCE SUBSIDY.— 

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

25 the term ‘premium assistance subsidy’ 
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1 means, with respect to a targeted low-in2 come child, the amount equal to the dif3 ference between the employee contribution 

4 required for enrollment only of the employee 

5 under qualified employer-sponsored coverage 

6 and the employee contribution required for 

7 enrollment of the employee and the child in 

8 such coverage, less any applicable premium 

9 cost-sharing applied under the State child 

10 health plan (subject to the limitations im11 posed under section 2103(e), including the 

12 requirement to count the total amount of the 

13 employee contribution required for enroll14 ment of the employee and the child in such 

15 coverage toward the annual aggregate cost16 sharing limit applied under paragraph 

17 (3)(B) of such section). 

18 ‘‘(ii) STATE PAYMENT OPTION.—A 

19 State may provide a premium assistance 

20 subsidy either as reimbursement to an em21 ployee for out-of-pocket expenditures or, sub22 ject to clause (iii), directly to the employee’s 

23 employer. 

24 ‘‘(iii) EMPLOYER OPT-OUT.—An em25 ployer may notify a State that it elects to 
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1 opt-out of being directly paid a premium 

2 assistance subsidy on behalf of an employee. 

3 In the event of such a notification, an em4 ployer shall withhold the total amount of 

5 the employee contribution required for en6 rollment of the employee and the child in 

7 the qualified employer-sponsored coverage 

8 and the State shall pay the premium assist9 ance subsidy directly to the employee. 

10 ‘‘(iv) TREATMENT AS CHILD HEALTH

11 ASSISTANCE.—Expenditures for the provi12 sion of premium assistance subsidies shall 

13 be considered child health assistance de14 scribed in paragraph (1)(C) of subsection 

15 (a) for purposes of making payments under 

16 that subsection. 

17 ‘‘(D) APPLICATION OF SECONDARY PAYOR

18 RULES.—The State shall be a secondary payor 

19 for any items or services provided under the 

20 qualified employer-sponsored coverage for which 

21 the State provides child health assistance under 

22 the State child health plan. 

23 ‘‘(E) REQUIREMENT TO PROVIDE SUPPLE24 MENTAL COVERAGE FOR BENEFITS AND COST- 
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1 SHARING PROTECTION PROVIDED UNDER THE

2 STATE CHILD HEALTH PLAN.— 

3 ‘‘(i) IN GENERAL.—Notwithstanding 

4 section 2110(b)(1)(C), the State shall pro5 vide for each targeted low-income child en6 rolled in qualified employer-sponsored cov7 erage, supplemental coverage consisting of— 

8 ‘‘(I) items or services that are not 

9 covered, or are only partially covered, 

10 under the qualified employer-sponsored 

11 coverage; and 

12 ‘‘(II) cost-sharing protection con13 sistent with section 2103(e). 

14 ‘‘(ii) RECORD KEEPING REQUIRE15 MENTS.—For purposes of carrying out 

16 clause (i), a State may elect to directly pay 

17 out-of-pocket expenditures for cost-sharing 

18 imposed under the qualified employer-spon19 sored coverage and collect or not collect all 

20 or any portion of such expenditures from 

21 the parent of the child. 

22 ‘‘(F) APPLICATION OF WAITING PERIOD IM23 POSED UNDER THE STATE.—Any waiting period 

24 imposed under the State child health plan prior 

25 to the provision of child health assistance to a 
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1 targeted low-income child under the State plan 

2 shall apply to the same extent to the provision 

3 of a premium assistance subsidy for the child 

4 under this paragraph. 

5 ‘‘(G) OPT-OUT PERMITTED FOR ANY

6 MONTH.—A State shall establish a process for 

7 permitting the parent of a targeted low-income 

8 child receiving a premium assistance subsidy to 

9 disenroll the child from the qualified employer10 sponsored coverage and enroll the child in, and 

11 receive child health assistance under, the State 

12 child health plan, effective on the first day of 

13 any month for which the child is eligible for such 

14 assistance and in a manner that ensures con15 tinuity of coverage for the child. 

16 ‘‘(H) APPLICATION TO PARENTS.—If a 

17 State provides child health assistance or health 

18 benefits coverage to parents of a targeted low-in19 come child in accordance with section 2111(b), 

20 the State may elect to offer a premium assistance 

21 subsidy to a parent of a targeted low-income 

22 child who is eligible for such a subsidy under 

23 this paragraph in the same manner as the State 

24 offers such a subsidy for the enrollment of the 
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1 child in qualified employer-sponsored coverage, 

2 except that— 

3 ‘‘(i) the amount of the premium assist4 ance subsidy shall be increased to take into 

5 account the cost of the enrollment of the 

6 parent in the qualified employer-sponsored 

7 coverage or, at the option of the State if the 

8 State determines it cost-effective, the cost of 

9 the enrollment of the child’s family in such 

10 coverage; and 

11 ‘‘(ii) any reference in this paragraph 

12 to a child is deemed to include a reference 

13 to the parent or, if applicable under clause 

14 (i), the family of the child. 

15 ‘‘(I) ADDITIONAL STATE OPTION FOR PRO16 VIDING PREMIUM ASSISTANCE.— 

17 ‘‘(i) IN GENERAL.—A State may estab18 lish an employer-family premium assistance 

19 purchasing pool for employers with less 

20 than 250 employees who have at least 1 em21 ployee who is a pregnant woman eligible for 

22 assistance under the State child health plan 

23 (including through the application of an 

24 option described in section 2112(f)) or a 

25 member of a family with at least 1 targeted 
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1 low-income child and to provide a premium 

2 assistance subsidy under this paragraph for 

3 enrollment in coverage made available 

4 through such pool. 

5 ‘‘(ii) ACCESS TO CHOICE OF COV6 ERAGE.—A State that elects the option 

7 under clause (i) shall identify and offer ac8 cess to not less than 2 private health plans 

9 that are health benefits coverage that is 

10 equivalent to the benefits coverage in a 

11 benchmark benefit package described in sec12 tion 2103(b) or benchmark-equivalent cov13 erage that meets the requirements of section 

14 2103(a)(2) for employees described in clause 

15 (i). 

16 ‘‘(iii) CLARIFICATION OF PAYMENT FOR

17 ADMINISTRATIVE EXPENDITURES.—Nothing 

18 in this subparagraph shall be construed as 

19 permitting payment under this section for 

20 administrative expenditures attributable to 

21 the establishment or operation of such pool, 

22 except to the extent that such payment 

23 would otherwise be permitted under this 

24 title. 
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1 ‘‘(J) NO EFFECT ON PREMIUM ASSISTANCE

2 WAIVER PROGRAMS.—Nothing in this paragraph 

3 shall be construed as limiting the authority of a 

4 State to offer premium assistance under section 

5 1906 or 1906A, a waiver described in paragraph 

6 (2)(B) or (3), a waiver approved under section 

7 1115, or other authority in effect prior to the 

8 date of enactment of the Children’s Health Insur9 ance Program Reauthorization Act of 2009. 

10 ‘‘(K) NOTICE OF AVAILABILITY.—If a State 

11 elects to provide premium assistance subsidies in 

12 accordance with this paragraph, the State 

13 shall— 

14 ‘‘(i) include on any application or en15 rollment form for child health assistance a 

16 notice of the availability of premium assist17 ance subsidies for the enrollment of targeted 

18 low-income children in qualified employer19 sponsored coverage; 

20 ‘‘(ii) provide, as part of the applica21 tion and enrollment process under the State 

22 child health plan, information describing 

23 the availability of such subsidies and how to 

24 elect to obtain such a subsidy; and 
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1 ‘‘(iii) establish such other procedures as 

2 the State determines necessary to ensure 

3 that parents are fully informed of the 

4 choices for receiving child health assistance 

5 under the State child health plan or through 

6 the receipt of premium assistance subsidies. 

7 ‘‘(L) APPLICATION TO QUALIFIED EM8 PLOYER-SPONSORED BENCHMARK COVERAGE.—If 

9 a group health plan or health insurance coverage 

10 offered through an employer is certified by an 

11 actuary as health benefits coverage that is equiv12 alent to the benefits coverage in a benchmark 

13 benefit package described in section 2103(b) or 

14 benchmark-equivalent coverage that meets the re15 quirements of section 2103(a)(2), the State may 

16 provide premium assistance subsidies for enroll17 ment of targeted low-income children in such 

18 group health plan or health insurance coverage 

19 in the same manner as such subsidies are pro20 vided under this paragraph for enrollment in 

21 qualified employer-sponsored coverage, but with22 out regard to the requirement to provide supple23 mental coverage for benefits and cost-sharing 

24 protection provided under the State child health 

25 plan under subparagraph (E). 
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1 ‘‘(M) SATISFACTION OF COST-EFFECTIVE2 NESS TEST.—Premium assistance subsidies for 

3 qualified employer-sponsored coverage offered 

4 under this paragraph shall be deemed to meet the 

5 requirement of subparagraph (A) of paragraph 

6 (3). 

7 ‘‘(N) COORDINATION WITH MEDICAID.—In 

8 the case of a targeted low-income child who re9 ceives child health assistance through a State 

10 plan under title XIX and who voluntarily elects 

11 to receive a premium assistance subsidy under 

12 this section, the provisions of section 1906A shall 

13 apply and shall supersede any other provisions 

14 of this paragraph that are inconsistent with such 

15 section.’’. 

16 (2) DETERMINATION OF COST-EFFECTIVENESS

17 FOR PREMIUM ASSISTANCE OR PURCHASE OF FAMILY

18 COVERAGE.— 

19 (A) IN GENERAL.—Section 2105(c)(3)(A) 

20 (42 U.S.C. 1397ee(c)(3)(A)) is amended by strik21 ing ‘‘relative to’’ and all that follows through the 

22 comma and inserting ‘‘relative to 

23 ‘‘(i) the amount of expenditures under 

24 the State child health plan, including ad25 ministrative expenditures, that the State 
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1 would have made to provide comparable 

2 coverage of the targeted low-income child in3 volved or the family involved (as applica4 ble); or 

5 ‘‘(ii) the aggregate amount of expendi6 tures that the State would have made under 

7 the State child health plan, including ad8 ministrative expenditures, for providing 

9 coverage under such plan for all such chil10 dren or families.’’. 

11 (B) NONAPPLICATION TO PREVIOUSLY AP12 PROVED COVERAGE.—The amendment made by 

13 subparagraph (A) shall not apply to coverage the 

14 purchase of which has been approved by the Sec15 retary under section 2105(c)(3) of the Social Se16 curity Act prior to the date of enactment of this 

17 Act. 

18 (b) MEDICAID.—Title XIX is amended by inserting 

19 after section 1906 the following new section: 

20 ‘‘PREMIUM ASSISTANCE OPTION FOR CHILDREN

21 ‘‘SEC. 1906A. (a) IN GENERAL.—A State may elect to 

22 offer a premium assistance subsidy (as defined in subsection 

23 (c)) for qualified employer-sponsored coverage (as defined 

24 in subsection (b)) to all individuals under age 19 who are 

25 entitled to medical assistance under this title (and to the 
146 

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1 parent of such an individual) who have access to such cov2 erage if the State meets the requirements of this section. 

3 ‘‘(b) QUALIFIED EMPLOYER-SPONSORED COVERAGE.— 

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

5 in this paragraph, the term ‘qualified employer-spon6 sored coverage’ means a group health plan or health 

7 insurance coverage offered through an employer— 

8 ‘‘(A) that qualifies as creditable coverage as 

9 a group health plan under section 2701(c)(1) of 

10 the Public Health Service Act; 

11 ‘‘(B) for which the employer contribution 

12 toward any premium for such coverage is at 

13 least 40 percent; and 

14 ‘‘(C) that is offered to all individuals in a 

15 manner that would be considered a nondiscrim16 inatory eligibility classification for purposes of 

17 paragraph (3)(A)(ii) of section 105(h) of the In18 ternal Revenue Code of 1986 (but determined 

19 without regard to clause (i) of subparagraph (B) 

20 of such paragraph). 

21 ‘‘(2) EXCEPTION.—Such term does not include 

22 coverage consisting of— 

23 ‘‘(A) benefits provided under a health flexi24 ble spending arrangement (as defined in section 
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1 106(c)(2) of the Internal Revenue Code of 1986); 

2 or 

3 ‘‘(B) a high deductible health plan (as de4 fined in section 223(c)(2) of such Code), without 

5 regard to whether the plan is purchased in con6 junction with a health savings account (as de7 fined under section 223(d) of such Code). 

8 ‘‘(3) TREATMENT AS THIRD PARTY LIABILITY.— 

9 The State shall treat the coverage provided under 

10 qualified employer-sponsored coverage as a third 

11 party liability under section 1902(a)(25). 

12 ‘‘(c) PREMIUM ASSISTANCE SUBSIDY.—In this section, 

13 the term ‘premium assistance subsidy’ means the amount 

14 of the employee contribution for enrollment in the qualified 

15 employer-sponsored coverage by the individual under age 

16 19 or by the individual’s family. Premium assistance sub17 sidies under this section shall be considered, for purposes 

18 of section 1903(a), to be a payment for medical assistance. 

19 ‘‘(d) VOLUNTARY PARTICIPATION.— 

20 ‘‘(1) EMPLOYERS.—Participation by an em21 ployer in a premium assistance subsidy offered by a 

22 State under this section shall be voluntary. An em23 ployer may notify a State that it elects to opt-out of 

24 being directly paid a premium assistance subsidy on 

25 behalf of an employee. 
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1 ‘‘(2) BENEFICIARIES.—No subsidy shall be pro2 vided to an individual under age 19 under this sec3 tion unless the individual (or the individual’s parent) 

4 voluntarily elects to receive such a subsidy. A State 

5 may not require such an election as a condition of re6 ceipt of medical assistance. State may not require, as 

7 a condition of an individual under age 19 (or the in8 dividual’s parent) being or remaining eligible for 

9 medical assistance under this title, apply for enroll10 ment in qualified employer-sponsored coverage under 

11 this section. 

12 ‘‘(3) OPT-OUT PERMITTED FOR ANY MONTH.—A 

13 State shall establish a process for permitting the par14 ent of an individual under age 19 receiving a pre15 mium assistance subsidy to disenroll the individual 

16 from the qualified employer-sponsored coverage. 

17 ‘‘(e) REQUIREMENT TO PAY PREMIUMS AND COST18 SHARING AND PROVIDE SUPPLEMENTAL COVERAGE.—In 

19 the case of the participation of an individual under age 

20 19 (or the individual’s parent) in a premium assistance 

21 subsidy under this section for qualified employer-sponsored 

22 coverage, the State shall provide for payment of all enrollee 

23 premiums for enrollment in such coverage and all 

24 deductibles, coinsurance, and other cost-sharing obligations 

25 for items and services otherwise covered under the State 
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1 plan under this title (exceeding the amount otherwise per2 mitted under section 1916 or, if applicable, section 1916A). 

3 The fact that an individual under age 19 (or a parent) 

4 elects to enroll in qualified employer-sponsored coverage 

5 under this section shall not change the individual’s (or par6 ent’s) eligibility for medical assistance under the State 

7 plan, except insofar as section 1902(a)(25) provides that 

8 payments for such assistance shall first be made under such 

9 coverage.’’. 

10 (c) GAO STUDY AND REPORT.—Not later than Janu11 ary 1, 2010, the Comptroller General of the United States 

12 shall study cost and coverage issues relating to any State 

13 premium assistance programs for which Federal matching 

14 payments are made under title XIX or XXI of the Social 

15 Security Act, including under waiver authority, and shall 

16 submit a report to the Committee on Finance of the Senate 

17 and the Committee on Energy and Commerce of the House 

18 of Representatives on the results of such study. 

19 SEC. 302. OUTREACH, EDUCATION, AND ENROLLMENT AS20 SISTANCE. 

21 (a) REQUIREMENT TO INCLUDE DESCRIPTION OF

22 OUTREACH, EDUCATION, AND ENROLLMENT EFFORTS RE23 LATED TO PREMIUM ASSISTANCE SUBSIDIES IN STATE

24 CHILD HEALTH PLAN.—Section 2102(c) (42 U.S.C. 
150 

† HR 2 EAS 

1 1397bb(c)) is amended by adding at the end the following 

2 new paragraph: 

3 ‘‘(3) PREMIUM ASSISTANCE SUBSIDIES.—In the 

4 case of a State that provides for premium assistance 

5 subsidies under the State child health plan in accord6 ance with paragraph (2)(B), (3), or (10) of section 

7 2105(c), or a waiver approved under section 1115, 

8 outreach, education, and enrollment assistance for 

9 families of children likely to be eligible for such sub10 sidies, to inform such families of the availability of, 

11 and to assist them in enrolling their children in, such 

12 subsidies, and for employers likely to provide coverage 

13 that is eligible for such subsidies, including the spe14 cific, significant resources the State intends to apply 

15 to educate employers about the availability of pre16 mium assistance subsidies under the State child 

17 health plan.’’. 

18 (b) NONAPPLICATION OF 10 PERCENT LIMIT ON OUT19 REACH AND CERTAIN OTHER EXPENDITURES.—Section 

20 2105(c)(2)(C) (42 U.S.C. 1397ee(c)(2)(C)), as amended by 

21 section 211(c)(2), is amended by adding at the end the fol22 lowing new clause: 

23 ‘‘(iii) EXPENDITURES FOR OUTREACH

24 TO INCREASE THE ENROLLMENT OF CHIL25 DREN UNDER THIS TITLE AND TITLE xix 
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1 THROUGH PREMIUM ASSISTANCE SUB2 SIDIES.—Expenditures for outreach activi3 ties to families of children likely to be eligi4 ble for premium assistance subsidies in ac5 cordance with paragraph (2)(B), (3), or 

6 (10), or a waiver approved under section 

7 1115, to inform such families of the avail8 ability of, and to assist them in enrolling 

9 their children in, such subsidies, and to em10 ployers likely to provide qualified employer11 sponsored coverage (as defined in subpara12 graph (B) of such paragraph), but not to 

13 exceed an amount equal to 1.25 percent of 

14 the maximum amount permitted to be ex15 pended under subparagraph (A) for items 

16 described in subsection (a)(1)(D).’’. 
152 

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1 Subtitle B—Coordinating Premium 

2 Assistance With Private Coverage 

3 SEC. 311. SPECIAL ENROLLMENT PERIOD UNDER GROUP 

4 HEALTH PLANS IN CASE OF TERMINATION OF 

5 MEDICAID OR CHIP COVERAGE OR ELIGI6 BILITY FOR ASSISTANCE IN PURCHASE OF 

7 EMPLOYMENT-BASED COVERAGE; COORDINA8 TION OF COVERAGE. 

9 (a) AMENDMENTS TO INTERNAL REVENUE CODE OF

10 1986.—Section 9801(f) of the Internal Revenue Code of 

11 1986 (relating to special enrollment periods) is amended 

12 by adding at the end the following new paragraph: 

13 ‘‘(3) SPECIAL RULES RELATING TO MEDICAID

14 AND CHIP.— 

15 ‘‘(A) IN GENERAL.—A group health plan 

16 shall permit an employee who is eligible, but not 

17 enrolled, for coverage under the terms of the plan 

18 (or a dependent of such an employee if the de19 pendent is eligible, but not enrolled, for coverage 

20 under such terms) to enroll for coverage under 

21 the terms of the plan if either of the following 

22 conditions is met: 

23 ‘‘(i) TERMINATION OF MEDICAID OR

24 CHIP COVERAGE.—The employee or depend25 ent is covered under a Medicaid plan under 
153 

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1 title XIX of the Social Security Act or 

2 under a State child health plan under title 

3 XXI of such Act and coverage of the em4 ployee or dependent under such a plan is 

5 terminated as a result of loss of eligibility 

6 for such coverage and the employee requests 

7 coverage under the group health plan not 

8 later than 60 days after the date of termi9 nation of such coverage. 

10 ‘‘(ii) ELIGIBILITY FOR EMPLOYMENT

11 ASSISTANCE UNDER MEDICAID OR CHIP.— 

12 The employee or dependent becomes eligible 

13 for assistance, with respect to coverage 

14 under the group health plan under such 

15 Medicaid plan or State child health plan 

16 (including under any waiver or demonstra17 tion project conducted under or in relation 

18 to such a plan), if the employee requests 

19 coverage under the group health plan not 

20 later than 60 days after the date the em21 ployee or dependent is determined to be eli22 gible for such assistance. 

23 ‘‘(B) EMPLOYEE OUTREACH AND DISCLO24 SURE.— 
154 

† HR 2 EAS 

1 ‘‘(i) OUTREACH TO EMPLOYEES RE2 GARDING AVAILABILITY OF MEDICAID AND

3 CHIP COVERAGE.— 

4 ‘‘(I) IN GENERAL.—Each em5 ployer that maintains a group health 

6 plan in a State that provides medical 

7 assistance under a State Medicaid 

8 plan under title XIX of the Social Se9 curity Act, or child health assistance 

10 under a State child health plan under 

11 title XXI of such Act, in the form of 

12 premium assistance for the purchase of 

13 coverage under a group health plan, 

14 shall provide to each employee a writ15 ten notice informing the employee of 

16 potential opportunities then currently 

17 available in the State in which the em18 ployee resides for premium assistance 

19 under such plans for health coverage of 

20 the employee or the employee’s depend21 ents. For purposes of compliance with 

22 this clause, the employer may use any 

23 State-specific model notice developed in 

24 accordance with section 

25 701(f)(3)(B)(i)(II) of the Employee Re-
155 

† HR 2 EAS 

1 tirement Income Security Act of 1974 

2 (29 U.S.C. 1181(f)(3)(B)(i)(II)). 

3 ‘‘(II) OPTION TO PROVIDE CON4 CURRENT WITH PROVISION OF PLAN

5 MATERIALS TO EMPLOYEE.—An em6 ployer may provide the model notice 

7 applicable to the State in which an 

8 employee resides concurrent with the 

9 furnishing of materials notifying the 

10 employee of health plan eligibility, con11 current with materials provided to the 

12 employee in connection with an open 

13 season or election process conducted 

14 under the plan, or concurrent with the 

15 furnishing of the summary plan de16 scription as provided in section 104(b) 

17 of the Employee Retirement Income 

18 Security Act of 1974 (29 U.S.C. 1024). 

19 ‘‘(ii) DISCLOSURE ABOUT GROUP

20 HEALTH PLAN BENEFITS TO STATES FOR

21 MEDICAID AND CHIP ELIGIBLE INDIVID22 UALS.—In the case of a participant or bene23 ficiary of a group health plan who is cov24 ered under a Medicaid plan of a State 

25 under title XIX of the Social Security Act 
156 

† HR 2 EAS 

1 or under a State child health plan under 

2 title XXI of such Act, the plan adminis3 trator of the group health plan shall disclose 

4 to the State, upon request, information 

5 about the benefits available under the group 

6 health plan in sufficient specificity, as de7 termined under regulations of the Secretary 

8 of Health and Human Services in consulta9 tion with the Secretary that require use of 

10 the model coverage coordination disclosure 

11 form developed under section 311(b)(1)(C) 

12 of the Children’s Health Insurance Program 

13 Reauthorization Act of 2009, so as to per14 mit the State to make a determination 

15 (under paragraph (2)(B), (3), or (10) of 

16 section 2105(c) of the Social Security Act or 

17 otherwise) concerning the cost-effectiveness 

18 of the State providing medical or child 

19 health assistance through premium assist20 ance for the purchase of coverage under such 

21 group health plan and in order for the 

22 State to provide supplemental benefits re23 quired under paragraph (10)(E) of such sec24 tion or other authority.’’. 

25 (b) CONFORMING AMENDMENTS.— 
157 

† HR 2 EAS 

1 (1) AMENDMENTS TO EMPLOYEE RETIREMENT

2 INCOME SECURITY ACT.— 

3 (A) IN GENERAL.—Section 701(f) of the 

4 Employee Retirement Income Security Act of 

5 1974 (29 U.S.C. 1181(f)) is amended by adding 

6 at the end the following new paragraph: 

7 ‘‘(3) SPECIAL RULES FOR APPLICATION IN CASE

8 OF MEDICAID AND CHIP.— 

9 ‘‘(A) IN GENERAL.—A group health plan, 

10 and a health insurance issuer offering group 

11 health insurance coverage in connection with a 

12 group health plan, shall permit an employee who 

13 is eligible, but not enrolled, for coverage under 

14 the terms of the plan (or a dependent of such an 

15 employee if the dependent is eligible, but not en16 rolled, for coverage under such terms) to enroll 

17 for coverage under the terms of the plan if either 

18 of the following conditions is met: 

19 ‘‘(i) TERMINATION OF MEDICAID OR

20 CHIP COVERAGE.—The employee or depend21 ent is covered under a Medicaid plan under 

22 title XIX of the Social Security Act or 

23 under a State child health plan under title 

24 XXI of such Act and coverage of the em25 ployee or dependent under such a plan is 
158 

† HR 2 EAS 

1 terminated as a result of loss of eligibility 

2 for such coverage and the employee requests 

3 coverage under the group health plan (or 

4 health insurance coverage) not later than 60 

5 days after the date of termination of such 

6 coverage. 

7 ‘‘(ii) ELIGIBILITY FOR EMPLOYMENT

8 ASSISTANCE UNDER MEDICAID OR CHIP.— 

9 The employee or dependent becomes eligible 

10 for assistance, with respect to coverage 

11 under the group health plan or health in12 surance coverage, under such Medicaid plan 

13 or State child health plan (including under 

14 any waiver or demonstration project con15 ducted under or in relation to such a plan), 

16 if the employee requests coverage under the 

17 group health plan or health insurance cov18 erage not later than 60 days after the date 

19 the employee or dependent is determined to 

20 be eligible for such assistance. 

21 ‘‘(B) COORDINATION WITH MEDICAID AND

22 CHIP.— 

23 ‘‘(i) OUTREACH TO EMPLOYEES RE24 GARDING AVAILABILITY OF MEDICAID AND

25 CHIP COVERAGE.— 
159 

† HR 2 EAS 

1 ‘‘(I) IN GENERAL.—Each em2 ployer that maintains a group health 

3 plan in a State that provides medical 

4 assistance under a State Medicaid 

5 plan under title XIX of the Social Se6 curity Act, or child health assistance 

7 under a State child health plan under 

8 title XXI of such Act, in the form of 

9 premium assistance for the purchase of 

10 coverage under a group health plan, 

11 shall provide to each employee a writ12 ten notice informing the employee of 

13 potential opportunities then currently 

14 available in the State in which the em15 ployee resides for premium assistance 

16 under such plans for health coverage of 

17 the employee or the employee’s depend18 ents. 

19 ‘‘(II) MODEL NOTICE.—Not later 

20 than 1 year after the date of enactment 

21 of the Children’s Health Insurance 

22 Program Reauthorization Act of 2009, 

23 the Secretary and the Secretary of 

24 Health and Human Services, in con25 sultation with Directors of State Med-
160 

† HR 2 EAS 

1 icaid agencies under title XIX of the 

2 Social Security Act and Directors of 

3 State CHIP agencies under title XXI 

4 of such Act, shall jointly develop na5 tional and State-specific model notices 

6 for purposes of subparagraph (A). The 

7 Secretary shall provide employers with 

8 such model notices so as to enable em9 ployers to timely comply with the re10 quirements of subparagraph (A). Such 

11 model notices shall include information 

12 regarding how an employee may con13 tact the State in which the employee 

14 resides for additional information re15 garding potential opportunities for 

16 such premium assistance, including 

17 how to apply for such assistance. 

18 ‘‘(III) OPTION TO PROVIDE CON19 CURRENT WITH PROVISION OF PLAN

20 MATERIALS TO EMPLOYEE.—An em21 ployer may provide the model notice 

22 applicable to the State in which an 

23 employee resides concurrent with the 

24 furnishing of materials notifying the 

25 employee of health plan eligibility, con-
161 

† HR 2 EAS 

1 current with materials provided to the 

2 employee in connection with an open 

3 season or election process conducted 

4 under the plan, or concurrent with the 

5 furnishing of the summary plan de6 scription as provided in section 104(b). 

7 ‘‘(ii) DISCLOSURE ABOUT GROUP

8 HEALTH PLAN BENEFITS TO STATES FOR

9 MEDICAID AND CHIP ELIGIBLE INDIVID10 UALS.—In the case of a participant or bene11 ficiary of a group health plan who is cov12 ered under a Medicaid plan of a State 

13 under title XIX of the Social Security Act 

14 or under a State child health plan under 

15 title XXI of such Act, the plan adminis16 trator of the group health plan shall disclose 

17 to the State, upon request, information 

18 about the benefits available under the group 

19 health plan in sufficient specificity, as de20 termined under regulations of the Secretary 

21 of Health and Human Services in consulta22 tion with the Secretary that require use of 

23 the model coverage coordination disclosure 

24 form developed under section 311(b)(1)(C) 

25 of the Children’s Health Insurance Program 
162 

† HR 2 EAS 

1 Reauthorization Act of 2009, so as to per2 mit the State to make a determination 

3 (under paragraph (2)(B), (3), or (10) of 

4 section 2105(c) of the Social Security Act or 

5 otherwise) concerning the cost-effectiveness 

6 of the State providing medical or child 

7 health assistance through premium assist8 ance for the purchase of coverage under such 

9 group health plan and in order for the 

10 State to provide supplemental benefits re11 quired under paragraph (10)(E) of such sec12 tion or other authority.’’. 

13 (B) CONFORMING AMENDMENT.—Section 

14 102(b) of the Employee Retirement Income Secu15 rity Act of 1974 (29 U.S.C. 1022(b)) is amend16 ed— 

17 (i) by striking ‘‘and the remedies’’ and 

18 inserting ‘‘, the remedies’’; and 

19 (ii) by inserting before the period the 

20 following: ‘‘, and if the employer so elects 

21 for purposes of complying with section 

22 701(f)(3)(B)(i), the model notice applicable 

23 to the State in which the participants and 

24 beneficiaries reside’’. 
163 

† HR 2 EAS 

1 (C) WORKING GROUP TO DEVELOP MODEL

2 COVERAGE COORDINATION DISCLOSURE FORM.— 

3 (i) MEDICAID, CHIP, AND EMPLOYER4 SPONSORED COVERAGE COORDINATION

5 WORKING GROUP.— 

6 (I) IN GENERAL.—Not later than 

7 60 days after the date of enactment of 

8 this Act, the Secretary of Health and 

9 Human Services and the Secretary of 

10 Labor shall jointly establish a Med11 icaid, CHIP, and Employer-Sponsored 

12 Coverage Coordination Working Group 

13 (in this subparagraph referred to as 

14 the ‘‘Working Group’’). The purpose of 

15 the Working Group shall be to develop 

16 the model coverage coordination disclo17 sure form described in subclause (II) 

18 and to identify the impediments to the 

19 effective coordination of coverage avail20 able to families that include employees 

21 of employers that maintain group 

22 health plans and members who are eli23 gible for medical assistance under title 

24 XIX of the Social Security Act or child 

25 health assistance or other health bene-
164 

† HR 2 EAS 

1 fits coverage under title XXI of such 

2 Act. 

3 (II) MODEL COVERAGE COORDINA4 TION DISCLOSURE FORM DESCRIBED.— 

5 The model form described in this sub6 clause is a form for plan administra7 tors of group health plans to complete 

8 for purposes of permitting a State to 

9 determine the availability and cost-ef10 fectiveness of the coverage available 

11 under such plans to employees who 

12 have family members who are eligible 

13 for premium assistance offered under a 

14 State plan under title XIX or XXI of 

15 such Act and to allow for coordination 

16 of coverage for enrollees of such plans. 

17 Such form shall provide the following 

18 information in addition to such other 

19 information as the Working Group de20 termines appropriate: 

21 (aa) A determination of 

22 whether the employee is eligible 

23 for coverage under the group 

24 health plan. 
165 

† HR 2 EAS 

1 (bb) The name and contract 

2 information of the plan adminis3 trator of the group health plan. 

4 (cc) The benefits offered 

5 under the plan. 

6 (dd) The premiums and cost7 sharing required under the plan. 

8 (ee) Any other information 

9 relevant to coverage under the 

10 plan. 

11 (ii) MEMBERSHIP.—The Working 

12 Group shall consist of not more than 30 

13 members and shall be composed of rep14 resentatives of— 

15 (I) the Department of Labor; 

16 (II) the Department of Health 

17 and Human Services; 

18 (III) State directors of the Med19 icaid program under title XIX of the 

20 Social Security Act; 

21 (IV) State directors of the State 

22 Children’s Health Insurance Program 

23 under title XXI of the Social Security 

24 Act; 
166 

† HR 2 EAS 

1 (V) employers, including owners 

2 of small businesses and their trade or 

3 industry representatives and certified 

4 human resource and payroll profes5 sionals; 

6 (VI) plan administrators and 

7 plan sponsors of group health plans (as 

8 defined in section 607(1) of the Em9 ployee Retirement Income Security Act 

10 of 1974); 

11 (VII) health insurance issuers; 

12 and 

13 (VIII) children and other bene14 ficiaries of medical assistance under 

15 title XIX of the Social Security Act or 

16 child health assistance or other health 

17 benefits coverage under title XXI of 

18 such Act. 

19 (iii) COMPENSATION.—The members of 

20 the Working Group shall serve without com21 pensation. 

22 (iv) ADMINISTRATIVE SUPPORT.—The 

23 Department of Health and Human Services 

24 and the Department of Labor shall jointly 

25 provide appropriate administrative support 
167 

† HR 2 EAS 

1 to the Working Group, including technical 

2 assistance. The Working Group may use the 

3 services and facilities of either such Depart4 ment, with or without reimbursement, as 

5 jointly determined by such Departments. 

6 (v) REPORT.— 

7 (I) REPORT BY WORKING GROUP

8 TO THE SECRETARIES.—Not later than 

9 18 months after the date of the enact10 ment of this Act, the Working Group 

11 shall submit to the Secretary of Labor 

12 and the Secretary of Health and 

13 Human Services the model form de14 scribed in clause (i)(II) along with a 

15 report containing recommendations for 

16 appropriate measures to address the 

17 impediments to the effective coordina18 tion of coverage between group health 

19 plans and the State plans under titles 

20 XIX and XXI of the Social Security 

21 Act. 

22 (II) REPORT BY SECRETARIES TO

23 THE CONGRESS.—Not later than 2 

24 months after receipt of the report pur25 suant to subclause (I), the Secretaries 
168 

† HR 2 EAS 

1 shall jointly submit a report to each 

2 House of the Congress regarding the 

3 recommendations contained in the re4 port under such subclause. 

5 (vi) TERMINATION.—The Working 

6 Group shall terminate 30 days after the 

7 date of the issuance of its report under 

8 clause (v). 

9 (D) EFFECTIVE DATES.—The Secretary of 

10 Labor and the Secretary of Health and Human 

11 Services shall develop the initial model notices 

12 under section 701(f)(3)(B)(i)(II) of the Employee 

13 Retirement Income Security Act of 1974, and the 

14 Secretary of Labor shall provide such notices to 

15 employers, not later than the date that is 1 year 

16 after the date of enactment of this Act, and each 

17 employer shall provide the initial annual notices 

18 to such employer’s employees beginning with the 

19 first plan year that begins after the date on 

20 which such initial model notices are first issued. 

21 The model coverage coordination disclosure form 

22 developed under subparagraph (C) shall apply 

23 with respect to requests made by States begin24 ning with the first plan year that begins after 
169 

† HR 2 EAS 

1 the date on which such model coverage coordina2 tion disclosure form is first issued. 

3 (E) ENFORCEMENT.—Section 502 of the 

4 Employee Retirement Income Security Act of 

5 1974 (29 U.S.C. 1132) is amended— 

6 (i) in subsection (a)(6), by striking ‘‘or 

7 (8)’’ and inserting ‘‘(8), or (9)’’; and 

8 (ii) in subsection (c), by redesignating 

9 paragraph (9) as paragraph (10), and by 

10 inserting after paragraph (8) the following: 

11 ‘‘(9)(A) The Secretary may assess a civil penalty 

12 against any employer of up to $100 a day from the date 

13 of the employer’s failure to meet the notice requirement of 

14 section 701(f)(3)(B)(i)(I). For purposes of this subpara15 graph, each violation with respect to any single employee 

16 shall be treated as a separate violation. 

17 ‘‘(B) The Secretary may assess a civil penalty against 

18 any plan administrator of up to $100 a day from the date 

19 of the plan administrator’s failure to timely provide to any 

20 State the information required to be disclosed under section 

21 701(f)(3)(B)(ii). For purposes of this subparagraph, each 

22 violation with respect to any single participant or bene23 ficiary shall be treated as a separate violation.’’. 

24 (2) AMENDMENTS TO PUBLIC HEALTH SERVICE

25 ACT.—Section 2701(f) of the Public Health Service 
170 

† HR 2 EAS 

1 Act (42 U.S.C. 300gg(f)) is amended by adding at the 

2 end the following new paragraph: 

3 ‘‘(3) SPECIAL RULES FOR APPLICATION IN CASE

4 OF MEDICAID AND CHIP.— 

5 ‘‘(A) IN GENERAL.—A group health plan, 

6 and a health insurance issuer offering group 

7 health insurance coverage in connection with a 

8 group health plan, shall permit an employee who 

9 is eligible, but not enrolled, for coverage under 

10 the terms of the plan (or a dependent of such an 

11 employee if the dependent is eligible, but not en12 rolled, for coverage under such terms) to enroll 

13 for coverage under the terms of the plan if either 

14 of the following conditions is met: 

15 ‘‘(i) TERMINATION OF MEDICAID OR

16 CHIP COVERAGE.—The employee or depend17 ent is covered under a Medicaid plan under 

18 title XIX of the Social Security Act or 

19 under a State child health plan under title 

20 XXI of such Act and coverage of the em21 ployee or dependent under such a plan is 

22 terminated as a result of loss of eligibility 

23 for such coverage and the employee requests 

24 coverage under the group health plan (or 

25 health insurance coverage) not later than 60 
171 

† HR 2 EAS 

1 days after the date of termination of such 

2 coverage. 

3 ‘‘(ii) ELIGIBILITY FOR EMPLOYMENT

4 ASSISTANCE UNDER MEDICAID OR CHIP.— 

5 The employee or dependent becomes eligible 

6 for assistance, with respect to coverage 

7 under the group health plan or health in8 surance coverage, under such Medicaid plan 

9 or State child health plan (including under 

10 any waiver or demonstration project con11 ducted under or in relation to such a plan), 

12 if the employee requests coverage under the 

13 group health plan or health insurance cov14 erage not later than 60 days after the date 

15 the employee or dependent is determined to 

16 be eligible for such assistance. 

17 ‘‘(B) COORDINATION WITH MEDICAID AND

18 CHIP.— 

19 ‘‘(i) OUTREACH TO EMPLOYEES RE20 GARDING AVAILABILITY OF MEDICAID AND

21 CHIP COVERAGE.— 

22 ‘‘(I) IN GENERAL.—Each em23 ployer that maintains a group health 

24 plan in a State that provides medical 

25 assistance under a State Medicaid 
172 

† HR 2 EAS 

1 plan under title XIX of the Social Se2 curity Act, or child health assistance 

3 under a State child health plan under 

4 title XXI of such Act, in the form of 

5 premium assistance for the purchase of 

6 coverage under a group health plan, 

7 shall provide to each employee a writ8 ten notice informing the employee of 

9 potential opportunities then currently 

10 available in the State in which the em11 ployee resides for premium assistance 

12 under such plans for health coverage of 

13 the employee or the employee’s depend14 ents. For purposes of compliance with 

15 this subclause, the employer may use 

16 any State-specific model notice devel17 oped in accordance with section 

18 701(f)(3)(B)(i)(II) of the Employee Re19 tirement Income Security Act of 1974 

20 (29 U.S.C. 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 
173 

† HR 2 EAS 

1 employee resides concurrent with the 

2 furnishing of materials notifying the 

3 employee of health plan eligibility, con4 current with materials provided to the 

5 employee in connection with an open 

6 season or election process conducted 

7 under the plan, or concurrent with the 

8 furnishing of the summary plan de9 scription as provided in section 104(b) 

10 of the Employee Retirement Income 

11 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 of 

18 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, upon 

22 request, information about the benefits 

23 available under the group health plan in 

24 sufficient specificity, as determined under 

25 regulations of the Secretary of Health and 
174 

† HR 2 EAS 

1 Human Services in consultation with the 

2 Secretary that require use of the model cov3 erage coordination disclosure form developed 

4 under section 311(b)(1)(C) of the Children’s 

5 Health Insurance Reauthorization Act of 

6 2009, so as to permit the State to make a 

7 determination (under paragraph (2)(B), 

8 (3), or (10) of section 2105(c) of the Social 

9 Security Act or otherwise) concerning the 

10 cost-effectiveness of the State providing med11 ical or child health assistance through pre12 mium assistance for the purchase of cov13 erage under such group health plan and in 

14 order for the State to provide supplemental 

15 benefits required under paragraph (10)(E) 

16 of such section or other authority.’’. 

17 TITLE IV—STRENGTHENING 

18 QUALITY OF CARE AND 

19 HEALTH OUTCOMES 

20 SEC. 401. CHILD HEALTH QUALITY IMPROVEMENT ACTIVI21 TIES FOR CHILDREN ENROLLED IN MEDICAID 

22 OR CHIP. 

23 (a) DEVELOPMENT OF CHILD HEALTH QUALITY

24 MEASURES FOR CHILDREN ENROLLED IN MEDICAID OR
175 

† HR 2 EAS 

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 gen9 eral comment an initial, recommended core set of 

10 child health quality measures for use by State pro11 grams administered under titles XIX and XXI, health 

12 insurance issuers and managed care entities that 

13 enter into contracts with such programs, and pro14 viders of items and services under such programs. 

15 ‘‘(2) IDENTIFICATION OF INITIAL CORE MEAS16 URES.—In consultation with the individuals and en17 tities described in subsection (b)(3), the Secretary 

18 shall identify existing quality of care measures for 

19 children that are in use under public and privately 

20 sponsored health care coverage arrangements, or that 

21 are part of reporting systems that measure both the 

22 presence and duration of health insurance coverage 

23 over time. 

24 ‘‘(3) RECOMMENDATIONS AND DISSEMINATION.— 

25 Based on such existing and identified measures, the 
176 

† HR 2 EAS 

1 Secretary shall publish an initial core set of child 

2 health quality measures that includes (but is not lim3 ited to) the following: 

4 ‘‘(A) The duration of children’s health in5 surance coverage over a 12-month time period. 

6 ‘‘(B) The availability and effectiveness of a 

7 full range of— 

8 ‘‘(i) preventive services, treatments, 

9 and services for acute conditions, including 

10 services to promote healthy birth, prevent 

11 and treat premature birth, and detect the 

12 presence or risk of physical or mental con13 ditions that could adversely affect growth 

14 and development; and 

15 ‘‘(ii) treatments to correct or amelio16 rate the effects of physical and mental con17 ditions, including chronic conditions, in in18 fants, young children, school-age children, 

19 and adolescents. 

20 ‘‘(C) The availability of care in a range of 

21 ambulatory and inpatient health care settings in 

22 which such care is furnished. 

23 ‘‘(D) The types of measures that, taken to24 gether, can be used to estimate the overall na25 tional quality of health care for children, includ-
177 

† HR 2 EAS 

1 ing children with special needs, and to perform 

2 comparative analyses of pediatric health care 

3 quality and racial, ethnic, and socioeconomic 

4 disparities in child health and health care for 

5 children. 

6 ‘‘(4) ENCOURAGE VOLUNTARY AND STANDARD7 IZED REPORTING.—Not later than 2 years after the 

8 date of enactment of the Children’s Health Insurance 

9 Program Reauthorization Act of 2009, the Secretary, 

10 in consultation with States, shall develop a standard11 ized format for reporting information and procedures 

12 and approaches that encourage States to use the ini13 tial core measurement set to voluntarily report infor14 mation regarding the quality of pediatric health care 

15 under titles XIX and XXI. 

16 ‘‘(5) ADOPTION OF BEST PRACTICES IN IMPLE17 MENTING QUALITY PROGRAMS.—The Secretary shall 

18 disseminate information to States regarding best 

19 practices among States with respect to measuring and 

20 reporting on the quality of health care for children, 

21 and shall facilitate the adoption of such best prac22 tices. In developing best practices approaches, the Sec23 retary shall give particular attention to State meas24 urement techniques that ensure the timeliness and ac25 curacy of provider reporting, encourage provider re-
178 

† HR 2 EAS 

1 porting compliance, encourage successful quality im2 provement strategies, and improve efficiency in data 

3 collection using health information technology. 

4 ‘‘(6) REPORTS TO CONGRESS.—Not later than 

5 January 1, 2011, and every 3 years thereafter, the 

6 Secretary shall report to Congress on— 

7 ‘‘(A) the status of the Secretary’s efforts to 

8 improve— 

9 ‘‘(i) quality related to the duration 

10 and stability of health insurance coverage 

11 for children under titles XIX and XXI; 

12 ‘‘(ii) the quality of children’s health 

13 care under such titles, including preventive 

14 health services, health care for acute condi15 tions, chronic health care, and health serv16 ices to ameliorate the effects of physical and 

17 mental conditions and to aid in growth and 

18 development of infants, young children, 

19 school-age children, and adolescents with 

20 special health care needs; and 

21 ‘‘(iii) the quality of children’s health 

22 care under such titles across the domains of 

23 quality, including clinical quality, health 

24 care safety, family experience with health 

25 care, health care in the most integrated set-
179 

† HR 2 EAS 

1 ting, and elimination of racial, ethnic, and 

2 socioeconomic disparities in health and 

3 health care; 

4 ‘‘(B) the status of voluntary reporting by 

5 States under titles XIX and XXI, utilizing the 

6 initial core quality measurement set; and 

7 ‘‘(C) any recommendations for legislative 

8 changes needed to improve the quality of care 

9 provided to children under titles XIX and XXI, 

10 including recommendations for quality reporting 

11 by States. 

12 ‘‘(7) TECHNICAL ASSISTANCE.—The Secretary 

13 shall provide technical assistance to States to assist 

14 them in adopting and utilizing core child health qual15 ity measures in administering the State plans under 

16 titles XIX and XXI. 

17 ‘‘(8) DEFINITION OF CORE SET.—In this section, 

18 the term ‘core set’ means a group of valid, reliable, 

19 and evidence-based quality measures that, taken to20 gether— 

21 ‘‘(A) provide information regarding the 

22 quality of health coverage and health care for 

23 children; 

24 ‘‘(B) address the needs of children through25 out the developmental age span; and 
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1 ‘‘(C) allow purchasers, families, and health 

2 care providers to understand the quality of care 

3 in relation to the preventive needs of children, 

4 treatments aimed at managing and resolving 

5 acute conditions, and diagnostic and treatment 

6 services whose purpose is to correct or ameliorate 

7 physical, mental, or developmental conditions 

8 that could, if untreated or poorly treated, become 

9 chronic. 

10 ‘‘(b) ADVANCING AND IMPROVING PEDIATRIC QUALITY

11 MEASURES.— 

12 ‘‘(1) ESTABLISHMENT OF PEDIATRIC QUALITY

13 MEASURES PROGRAM.—Not later than January 1, 

14 2011, the Secretary shall establish a pediatric quality 

15 measures program to— 

16 ‘‘(A) improve and strengthen the initial 

17 core child health care quality measures estab18 lished by the Secretary under subsection (a); 

19 ‘‘(B) expand on existing pediatric quality 

20 measures used by public and private health care 

21 purchasers and advance the development of such 

22 new and emerging quality measures; and 

23 ‘‘(C) increase the portfolio of evidence-based, 

24 consensus pediatric quality measures available to 
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1 public and private purchasers of children’s 

2 health care services, providers, and consumers. 

3 ‘‘(2) EVIDENCE-BASED MEASURES.—The meas4 ures developed under the pediatric quality measures 

5 program shall, at a minimum, be— 

6 ‘‘(A) evidence-based and, where appropriate, 

7 risk adjusted; 

8 ‘‘(B) designed to identify and eliminate ra9 cial and ethnic disparities in child health and 

10 the provision of health care; 

11 ‘‘(C) designed to ensure that the data re12 quired for such measures is collected and re13 ported in a standard format that permits com14 parison of quality and data at a State, plan, 

15 and provider level; 

16 ‘‘(D) periodically updated; and 

17 ‘‘(E) responsive to the child health needs, 

18 services, and domains of health care quality de19 scribed in clauses (i), (ii), and (iii) of subsection 

20 (a)(6)(A). 

21 ‘‘(3) PROCESS FOR PEDIATRIC QUALITY MEAS22 URES PROGRAM.—In identifying gaps in existing pe23 diatric quality measures and establishing priorities 

24 for development and advancement of such measures, 

25 the Secretary shall consult with— 
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1 ‘‘(A) States; 

2 ‘‘(B) pediatricians, children’s hospitals, and 

3 other primary and specialized pediatric health 

4 care professionals (including members of the al5 lied health professions) who specialize in the care 

6 and treatment of children, particularly children 

7 with special physical, mental, and developmental 

8 health care needs; 

9 ‘‘(C) dental professionals, including pedi10 atric dental professionals; 

11 ‘‘(D) health care providers that furnish pri12 mary health care to children and families who 

13 live in urban and rural medically underserved 

14 communities or who are members of distinct 

15 population sub-groups at heightened risk for 

16 poor health outcomes; 

17 ‘‘(E) national organizations representing 

18 children, including children with disabilities and 

19 children with chronic conditions; 

20 ‘‘(F) national organizations representing 

21 consumers and purchasers of children’s health 

22 care; 

23 ‘‘(G) national organizations and individ24 uals with expertise in pediatric health quality 

25 measurement; and 
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1 ‘‘(H) voluntary consensus standards setting 

2 organizations and other organizations involved 

3 in the advancement of evidence-based measures of 

4 health care. 

5 ‘‘(4) DEVELOPING, VALIDATING, AND TESTING A

6 PORTFOLIO OF PEDIATRIC QUALITY MEASURES.—As 

7 part of the program to advance pediatric quality 

8 measures, the Secretary shall— 

9 ‘‘(A) award grants and contracts for the de10 velopment, testing, and validation of new, emerg11 ing, and innovative evidence-based measures for 

12 children’s health care services across the domains 

13 of quality described in clauses (i), (ii), and (iii) 

14 of subsection (a)(6)(A); and 

15 ‘‘(B) award grants and contracts for— 

16 ‘‘(i) the development of consensus on 

17 evidence-based measures for children’s 

18 health care services; 

19 ‘‘(ii) the dissemination of such meas20 ures to public and private purchasers of 

21 health care for children; and 

22 ‘‘(iii) the updating of such measures as 

23 necessary. 

24 ‘‘(5) REVISING, STRENGTHENING, AND IMPROV25 ING INITIAL CORE MEASURES.—Beginning no later 
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1 than January 1, 2013, and annually thereafter, the 

2 Secretary shall publish recommended changes to the 

3 core measures described in subsection (a) that shall 

4 reflect the testing, validation, and consensus process 

5 for the development of pediatric quality measures de6 scribed in subsection paragraphs (1) through (4). 

7 ‘‘(6) DEFINITION OF PEDIATRIC QUALITY MEAS8 URE.—In this subsection, the term ‘pediatric quality 

9 measure’ means a measurement of clinical care that 

10 is capable of being examined through the collection 

11 and analysis of relevant information, that is devel12 oped in order to assess 1 or more aspects of pediatric 

13 health care quality in various institutional and am14 bulatory health care settings, including the structure 

15 of the clinical care system, the process of care, the out16 come of care, or patient experiences in care. 

17 ‘‘(7) CONSTRUCTION.—Nothing in this section 

18 shall be construed as supporting the restriction of cov19 erage, under title XIX or XXI or otherwise, to only 

20 those services that are evidence-based. 

21 ‘‘(c) ANNUAL STATE REPORTS REGARDING STATE22 SPECIFIC QUALITY OF CARE MEASURES APPLIED UNDER

23 MEDICAID OR CHIP.— 

24 ‘‘(1) ANNUAL STATE REPORTS.—Each State with 

25 a State plan approved under title XIX or a State 
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1 child health plan approved under title XXI shall an2 nually report to the Secretary on the— 

3 ‘‘(A) State-specific child health quality 

4 measures applied by the States under such plans, 

5 including measures described in subparagraphs 

6 (A) and (B) of subsection (a)(6); and 

7 ‘‘(B) State-specific information on the qual8 ity of health care furnished to children under 

9 such plans, including information collected 

10 through external quality reviews of managed care 

11 organizations under section 1932 of the Social 

12 Security Act (42 U.S.C. 1396u–4) and bench13 mark plans under sections 1937 and 2103 of 

14 such Act (42 U.S.C. 1396u–7, 1397cc). 

15 ‘‘(2) PUBLICATION.—Not later than September 

16 30, 2010, and annually thereafter, the Secretary shall 

17 collect, analyze, and make publicly available the in18 formation reported by States under paragraph (1). 

19 ‘‘(d) DEMONSTRATION PROJECTS FOR IMPROVING THE

20 QUALITY OF CHILDREN’S HEALTH CARE AND THE USE OF

21 HEALTH INFORMATION TECHNOLOGY.— 

22 ‘‘(1) IN GENERAL.—During the period of fiscal 

23 years 2009 through 2013, the Secretary shall award 

24 not more than 10 grants to States and child health 

25 providers to conduct demonstration projects to evalu-
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1 ate promising ideas for improving the quality of chil2 dren’s health care provided under title XIX or XXI, 

3 including projects to— 

4 ‘‘(A) experiment with, and evaluate the use 

5 of, new measures of the quality of children’s 

6 health care under such titles (including testing 

7 the validity and suitability for reporting of such 

8 measures); 

9 ‘‘(B) promote the use of health information 

10 technology in care delivery for children under 

11 such titles; 

12 ‘‘(C) evaluate provider-based models which 

13 improve the delivery of children’s health care 

14 services under such titles, including care man15 agement for children with chronic conditions and 

16 the use of evidence-based approaches to improve 

17 the effectiveness, safety, and efficiency of health 

18 care services for children; or 

19 ‘‘(D) demonstrate the impact of the model 

20 electronic health record format for children devel21 oped and disseminated under subsection (f) on 

22 improving pediatric health, including the effects 

23 of chronic childhood health conditions, and pedi24 atric health care quality as well as reducing 

25 health care costs. 
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1 ‘‘(2) REQUIREMENTS.—In awarding grants 

2 under this subsection, the Secretary shall ensure 

3 that— 

4 ‘‘(A) only 1 demonstration project funded 

5 under a grant awarded under this subsection 

6 shall be conducted in a State; and 

7 ‘‘(B) demonstration projects funded under 

8 grants awarded under this subsection shall be 

9 conducted evenly between States with large 

10 urban areas and States with large rural areas. 

11 ‘‘(3) AUTHORITY FOR MULTISTATE PROJECTS.— 

12 A demonstration project conducted with a grant 

13 awarded under this subsection may be conducted on 

14 a multistate basis, as needed. 

15 ‘‘(4) FUNDING.—$20,000,000 of the amount ap16 propriated under subsection (i) for a fiscal year shall 

17 be used to carry out this subsection. 

18 ‘‘(e) CHILDHOOD OBESITY DEMONSTRATION

19 PROJECT.— 

20 ‘‘(1) AUTHORITY TO CONDUCT DEMONSTRA21 TION.—The Secretary, in consultation with the Ad22 ministrator of the Centers for Medicare & Medicaid 

23 Services, shall conduct a demonstration project to de24 velop a comprehensive and systematic model for re25 ducing childhood obesity by awarding grants to eligi-
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1 ble entities to carry out such project. Such model 

2 shall— 

3 ‘‘(A) identify, through self-assessment, be4 havioral risk factors for obesity among children; 

5 ‘‘(B) identify, through self-assessment, need6 ed clinical preventive and screening benefits 

7 among those children identified as target indi8 viduals on the basis of such risk factors; 

9 ‘‘(C) provide ongoing support to such target 

10 individuals and their families to reduce risk fac11 tors and promote the appropriate use of preven12 tive and screening benefits; and 

13 ‘‘(D) be designed to improve health out14 comes, satisfaction, quality of life, and appro15 priate use of items and services for which med16 ical assistance is available under title XIX or 

17 child health assistance is available under title 

18 XXI among such target individuals. 

19 ‘‘(2) ELIGIBILITY ENTITIES.—For purposes of 

20 this subsection, an eligible entity is any of the fol21 lowing: 

22 ‘‘(A) A city, county, or Indian tribe. 

23 ‘‘(B) A local or tribal educational agency. 

24 ‘‘(C) An accredited university, college, or 

25 community college. 
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1 ‘‘(D) A Federally-qualified health center. 

2 ‘‘(E) A local health department. 

3 ‘‘(F) A health care provider. 

4 ‘‘(G) A community-based organization. 

5 ‘‘(H) Any other entity determined appro6 priate by the Secretary, including a consortia or 

7 partnership of entities described in any of sub8 paragraphs (A) through (G). 

9 ‘‘(3) USE OF FUNDS.—An eligible entity award10 ed a grant under this subsection shall use the funds 

11 made available under the grant to— 

12 ‘‘(A) carry out community-based activities 

13 related to reducing childhood obesity, including 

14 by— 

15 ‘‘(i) forming partnerships with entities, 

16 including schools and other facilities pro17 viding recreational services, to establish 

18 programs for after school and weekend com19 munity activities that are designed to re20 duce childhood obesity; 

21 ‘‘(ii) forming partnerships with 

22 daycare facilities to establish programs that 

23 promote healthy eating behaviors and phys24 ical activity; and 
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1 ‘‘(iii) developing and evaluating com2 munity educational activities targeting good 

3 nutrition and promoting healthy eating be4 haviors; 

5 ‘‘(B) carry out age-appropriate school-based 

6 activities that are designed to reduce childhood 

7 obesity, including by— 

8 ‘‘(i) developing and testing educational 

9 curricula and intervention programs de10 signed to promote healthy eating behaviors 

11 and habits in youth, which may include— 

12 ‘‘(I) after hours physical activity 

13 programs; and 

14 ‘‘(II) science-based interventions 

15 with multiple components to prevent 

16 eating disorders including nutritional 

17 content, understanding and responding 

18 to hunger and satiety, positive body 

19 image development, positive self-esteem 

20 development, and learning life skills 

21 (such as stress management, commu22 nication skills, problemsolving and de23 cisionmaking skills), as well as consid24 eration of cultural and developmental 
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1 issues, and the role of family, school, 

2 and community; 

3 ‘‘(ii) providing education and training 

4 to educational professionals regarding how 

5 to promote a healthy lifestyle and a healthy 

6 school environment for children; 

7 ‘‘(iii) planning and implementing a 

8 healthy lifestyle curriculum or program 

9 with an emphasis on healthy eating behav10 iors and physical activity; and 

11 ‘‘(iv) planning and implementing 

12 healthy lifestyle classes or programs for par13 ents or guardians, with an emphasis on 

14 healthy eating behaviors and physical activ15 ity for children; 

16 ‘‘(C) carry out educational, counseling, pro17 motional, and training activities through the 

18 local health care delivery systems including by— 

19 ‘‘(i) promoting healthy eating behav20 iors and physical activity services to treat 

21 or prevent eating disorders, being over22 weight, and obesity; 

23 ‘‘(ii) providing patient education and 

24 counseling to increase physical activity and 

25 promote healthy eating behaviors; 
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1 ‘‘(iii) training health professionals on 

2 how to identify and treat obese and over3 weight individuals which may include nu4 trition and physical activity counseling; 

5 and 

6 ‘‘(iv) providing community education 

7 by a health professional on good nutrition 

8 and physical activity to develop a better un9 derstanding of the relationship between diet, 

10 physical activity, and eating disorders, obe11 sity, or being overweight; and 

12 ‘‘(D) provide, through qualified health pro13 fessionals, training and supervision for commu14 nity health workers to— 

15 ‘‘(i) educate families regarding the re16 lationship between nutrition, eating habits, 

17 physical activity, and obesity; 

18 ‘‘(ii) educate families about effective 

19 strategies to improve nutrition, establish 

20 healthy eating patterns, and establish ap21 propriate levels of physical activity; and 

22 ‘‘(iii) educate and guide parents re23 garding the ability to model and commu24 nicate positive health behaviors. 
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1 ‘‘(4) PRIORITY.—In awarding grants under 

2 paragraph (1), the Secretary shall give priority to 

3 awarding grants to eligible entities— 

4 ‘‘(A) that demonstrate that they have pre5 viously applied successfully for funds to carry 

6 out activities that seek to promote individual 

7 and community health and to prevent the inci8 dence of chronic disease and that can cite pub9 lished and peer-reviewed research demonstrating 

10 that the activities that the entities propose to 

11 carry out with funds made available under the 

12 grant are effective; 

13 ‘‘(B) that will carry out programs or activi14 ties that seek to accomplish a goal or goals set 

15 by the State in the Healthy People 2010 plan of 

16 the State; 

17 ‘‘(C) that provide non-Federal contribu18 tions, either in cash or in-kind, to the costs of 

19 funding activities under the grants; 

20 ‘‘(D) that develop comprehensive plans that 

21 include a strategy for extending program activi22 ties developed under grants in the years fol23 lowing the fiscal years for which they receive 

24 grants under this subsection; 
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1 ‘‘(E) located in communities that are medi2 cally underserved, as determined by the Sec3 retary; 

4 ‘‘(F) located in areas in which the average 

5 poverty rate is at least 150 percent or higher of 

6 the average poverty rate in the State involved, as 

7 determined by the Secretary; and 

8 ‘‘(G) that submit plans that exhibit multi9 sectoral, cooperative conduct that includes the in10 volvement of a broad range of stakeholders, in11 cluding— 

12 ‘‘(i) community-based organizations; 

13 ‘‘(ii) local governments; 

14 ‘‘(iii) local educational agencies; 

15 ‘‘(iv) the private sector; 

16 ‘‘(v) State or local departments of 

17 health; 

18 ‘‘(vi) accredited colleges, universities, 

19 and community colleges; 

20 ‘‘(vii) health care providers; 

21 ‘‘(viii) State and local departments of 

22 transportation and city planning; and 

23 ‘‘(ix) other entities determined appro24 priate by the Secretary. 

25 ‘‘(5) PROGRAM DESIGN.— 
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1 ‘‘(A) INITIAL DESIGN.—Not later than 1 

2 year after the date of enactment of the Children’s 

3 Health Insurance Program Reauthorization Act 

4 of 2009, the Secretary shall design the dem5 onstration project. The demonstration should 

6 draw upon promising, innovative models and in7 centives to reduce behavioral risk factors. The 

8 Administrator of the Centers for Medicare & 

9 Medicaid Services shall consult with the Director 

10 of the Centers for Disease Control and Preven11 tion, the Director of the Office of Minority 

12 Health, the heads of other agencies in the De13 partment of Health and Human Services, and 

14 such professional organizations, as the Secretary 

15 determines to be appropriate, on the design, con16 duct, and evaluation of the demonstration. 

17 ‘‘(B) NUMBER AND PROJECT AREAS.—Not 

18 later than 2 years after the date of enactment of 

19 the Children’s Health Insurance Program Reau20 thorization Act of 2009, the Secretary shall 

21 award 1 grant that is specifically designed to de22 termine whether programs similar to programs 

23 to be conducted by other grantees under this sub24 section should be implemented with respect to the 

25 general population of children who are eligible 
196 

† HR 2 EAS 

1 for child health assistance under State child 

2 health plans under title XXI in order to reduce 

3 the incidence of childhood obesity among such 

4 population. 

5 ‘‘(6) REPORT TO CONGRESS.—Not later than 3 

6 years after the date the Secretary implements the 

7 demonstration project under this subsection, the Sec8 retary shall submit to Congress a report that describes 

9 the project, evaluates the effectiveness and cost effec10 tiveness of the project, evaluates the beneficiary satis11 faction under the project, and includes any such other 

12 information as the Secretary determines to be appro13 priate. 

14 ‘‘(7) DEFINITIONS.—In this subsection: 

15 ‘‘(A) FEDERALLY-QUALIFIED HEALTH CEN16 TER.—The term ‘Federally-qualified health cen17 ter’ has the meaning given that term in section 

18 1905(l)(2)(B). 

19 ‘‘(B) INDIAN TRIBE.—The term ‘Indian 

20 tribe’ has the meaning given that term in section 

21 4 of the Indian Health Care Improvement Act 

22 (25 U.S.C. 1603). 

23 ‘‘(C) SELF-ASSESSMENT.—The term ‘self-as24 sessment’ means a form that— 

25 ‘‘(i) includes questions regarding— 
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1 ‘‘(I) behavioral risk factors; 

2 ‘‘(II) needed preventive and 

3 screening services; and 

4 ‘‘(III) target individuals’ pref5 erences for receiving follow-up informa6 tion; 

7 ‘‘(ii) is assessed using such computer 

8 generated assessment programs; and 

9 ‘‘(iii) allows for the provision of such 

10 ongoing support to the individual as the 

11 Secretary determines appropriate. 

12 ‘‘(D) ONGOING SUPPORT.—The term ‘ongo13 ing support’ means— 

14 ‘‘(i) to provide any target individual 

15 with information, feedback, health coaching, 

16 and recommendations regarding— 

17 ‘‘(I) the results of a self-assessment 

18 given to the individual; 

19 ‘‘(II) behavior modification based 

20 on the self-assessment; and 

21 ‘‘(III) any need for clinical pre22 ventive and screening services or treat23 ment including medical nutrition ther24 apy; 
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1 ‘‘(ii) to provide any target individual 

2 with referrals to community resources and 

3 programs available to assist the target indi4 vidual in reducing health risks; and 

5 ‘‘(iii) to provide the information de6 scribed in clause (i) to a health care pro7 vider, if designated by the target individual 

8 to receive such information. 

9 ‘‘(8) AUTHORIZATION OF APPROPRIATIONS.— 

10 There is authorized to be appropriated to carry out 

11 this subsection, $25,000,000 for the period of fiscal 

12 years 2009 through 2013. 

13 ‘‘(f) DEVELOPMENT OF MODEL ELECTRONIC HEALTH

14 RECORD FORMAT FOR CHILDREN ENROLLED IN MEDICAID

15 OR CHIP.— 

16 ‘‘(1) IN GENERAL.—Not later than January 1, 

17 2010, the Secretary shall establish a program to en18 courage the development and dissemination of a 

19 model electronic health record format for children en20 rolled in the State plan under title XIX or the State 

21 child health plan under title XXI that is— 

22 ‘‘(A) subject to State laws, accessible to par23 ents, caregivers, and other consumers for the sole 

24 purpose of demonstrating compliance with school 
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† HR 2 EAS 

1 or leisure activity requirements, such as appro2 priate immunizations or physicals; 

3 ‘‘(B) designed to allow interoperable ex4 changes that conform with Federal and State 

5 privacy and security requirements; 

6 ‘‘(C) structured in a manner that permits 

7 parents and caregivers to view and understand 

8 the extent to which the care their children receive 

9 is clinically appropriate and of high quality; 

10 and 

11 ‘‘(D) capable of being incorporated into, 

12 and otherwise compatible with, other standards 

13 developed for electronic health records. 

14 ‘‘(2) FUNDING.—$5,000,000 of the amount ap15 propriated under subsection (i) for a fiscal year shall 

16 be used to carry out this subsection. 

17 ‘‘(g) STUDY OF PEDIATRIC HEALTH AND HEALTH

18 CARE QUALITY MEASURES.— 

19 ‘‘(1) IN GENERAL.—Not later than July 1, 2010, 

20 the Institute of Medicine shall study and report to 

21 Congress on the extent and quality of efforts to meas22 ure child health status and the quality of health care 

23 for children across the age span and in relation to 

24 preventive care, treatments for acute conditions, and 

25 treatments aimed at ameliorating or correcting phys-
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1 ical, mental, and developmental conditions in chil2 dren. In conducting such study and preparing such 

3 report, the Institute of Medicine shall— 

4 ‘‘(A) consider all of the major national pop5 ulation-based reporting systems sponsored by the 

6 Federal Government that are currently in place, 

7 including reporting requirements under Federal 

8 grant programs and national population surveys 

9 and estimates conducted directly by the Federal 

10 Government; 

11 ‘‘(B) identify the information regarding 

12 child health and health care quality that each 

13 system is designed to capture and generate, the 

14 study and reporting periods covered by each sys15 tem, and the extent to which the information so 

16 generated is made widely available through pub17 lication; 

18 ‘‘(C) identify gaps in knowledge related to 

19 children’s health status, health disparities among 

20 subgroups of children, the effects of social condi21 tions on children’s health status and use and ef22 fectiveness of health care, and the relationship 

23 between child health status and family income, 

24 family stability and preservation, and children’s 
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1 school readiness and educational achievement 

2 and attainment; and 

3 ‘‘(D) make recommendations regarding im4 proving and strengthening the timeliness, qual5 ity, and public transparency and accessibility of 

6 information about child health and health care 

7 quality. 

8 ‘‘(2) FUNDING.—Up to $1,000,000 of the amount 

9 appropriated under subsection (i) for a fiscal year 

10 shall be used to carry out this subsection. 

11 ‘‘(h) RULE OF CONSTRUCTION.—Notwithstanding any 

12 other provision in this section, no evidence based quality 

13 measure developed, published, or used as a basis of measure14 ment or reporting under this section may be used to estab15 lish an irrebuttable presumption regarding either the med16 ical necessity of care or the maximum permissible coverage 

17 for any individual child who is eligible for and receiving 

18 medical assistance under title XIX or child health assist19 ance under title XXI. 

20 ‘‘(i) APPROPRIATION.—Out of any funds in the Treas21 ury not otherwise appropriated, there is appropriated for 

22 each of fiscal years 2009 through 2013, $45,000,000 for the 

23 purpose of carrying out this section (other than subsection 

24 (e)). Funds appropriated under this subsection shall remain 

25 available until expended.’’. 
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† HR 2 EAS 

1 (b) INCREASED MATCHING RATE FOR COLLECTING

2 AND REPORTING ON CHILD HEALTH MEASURES.—Section 

3 1903(a)(3)(A) (42 U.S.C. 1396b(a)(3)(A)), is amended— 

4 (1) by striking ‘‘and’’ at the end of clause (i); 

5 and 

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

7 clause: 

8 ‘‘(iii) an amount equal to the Federal med9 ical assistance percentage (as defined in section 

10 1905(b)) of so much of the sums expended during 

11 such quarter (as found necessary by the Sec12 retary for the proper and efficient administra13 tion of the State plan) as are attributable to such 

14 developments or modifications of systems of the 

15 type described in clause (i) as are necessary for 

16 the efficient collection and reporting on child 

17 health measures; and’’. 

18 SEC. 402. IMPROVED AVAILABILITY OF PUBLIC INFORMA19 TION REGARDING ENROLLMENT OF CHIL20 DREN IN CHIP AND MEDICAID. 

21 (a) INCLUSION OF PROCESS AND ACCESS MEASURES

22 IN ANNUAL STATE REPORTS.—Section 2108 (42 U.S.C. 

23 1397hh) is amended— 
203 

† HR 2 EAS 

1 (1) in subsection (a), in the matter preceding 

2 paragraph (1), by striking ‘‘The State’’ and inserting 

3 ‘‘Subject to subsection (e), the State’’; and 

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

6 ‘‘(e) INFORMATION REQUIRED FOR INCLUSION IN

7 STATE ANNUAL REPORT.—The State shall include the fol8 lowing information in the annual report required under 

9 subsection (a): 

10 ‘‘(1) Eligibility criteria, enrollment, and reten11 tion data (including data with respect to continuity 

12 of coverage or duration of benefits). 

13 ‘‘(2) Data regarding the extent to which the 

14 State uses process measures with respect to deter15 mining the eligibility of children under the State 

16 child health plan, including measures such as 12- 

17 month continuous eligibility, self-declaration of in18 come for applications or renewals, or presumptive eli19 gibility. 

20 ‘‘(3) Data regarding denials of eligibility and re21 determinations of eligibility. 

22 ‘‘(4) Data regarding access to primary and spe23 cialty services, access to networks of care, and care co24 ordination provided under the State child health 

25 plan, using quality care and consumer satisfaction 
204 

† HR 2 EAS 

1 measures included in the Consumer Assessment of 

2 Healthcare Providers and Systems (CAHPS) survey. 

3 ‘‘(5) If the State provides child health assistance 

4 in the form of premium assistance for the purchase of 

5 coverage under a group health plan, data regarding 

6 the provision of such assistance, including the extent 

7 to which employer-sponsored health insurance cov8 erage is available for children eligible for child health 

9 assistance under the State child health plan, the 

10 range of the monthly amount of such assistance pro11 vided on behalf of a child or family, the number of 

12 children or families provided such assistance on a 

13 monthly basis, the income of the children or families 

14 provided such assistance, the benefits and cost-sharing 

15 protection provided under the State child health plan 

16 to supplement the coverage purchased with such pre17 mium assistance, the effective strategies the State en18 gages in to reduce any administrative barriers to the 

19 provision of such assistance, and, the effects, if any, 

20 of the provision of such assistance on preventing the 

21 coverage provided under the State child health plan 

22 from substituting for coverage provided under em23 ployer-sponsored health insurance offered in the State. 

24 ‘‘(6) To the extent applicable, a description of 

25 any State activities that are designed to reduce the 
205 

† HR 2 EAS 

1 number of uncovered children in the State, including 

2 through a State health insurance connector program 

3 or support for innovative private health coverage ini4 tiatives.’’. 

5 (b) STANDARDIZED REPORTING FORMAT.— 

6 (1) IN GENERAL.—Not later than 1 year after 

7 the date of enactment of this Act, the Secretary shall 

8 specify a standardized format for States to use for re9 porting the information required under section 

10 2108(e) of the Social Security Act, as added by sub11 section (a)(2). 

12 (2) TRANSITION PERIOD FOR STATES.—Each 

13 State that is required to submit a report under sub14 section (a) of section 2108 of the Social Security Act 

15 that includes the information required under sub16 section (e) of such section may use up to 3 reporting 

17 periods to transition to the reporting of such informa18 tion in accordance with the standardized format spec19 ified by the Secretary under paragraph (1). 

20 (c) ADDITIONAL FUNDING FOR THE SECRETARY TO

21 IMPROVE TIMELINESS OF DATA REPORTING AND ANALYSIS

22 FOR PURPOSES OF DETERMINING ENROLLMENT INCREASES

23 UNDER MEDICAID AND CHIP.— 

24 (1) APPROPRIATION.—There is appropriated, out 

25 of any money in the Treasury not otherwise appro-
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1 priated, $5,000,000 to the Secretary for fiscal year 

2 2009 for the purpose of improving the timeliness of 

3 the data reported and analyzed from the Medicaid 

4 Statistical Information System (MSIS) for purposes 

5 of providing more timely data on enrollment and eli6 gibility of children under Medicaid and CHIP and to 

7 provide guidance to States with respect to any new 

8 reporting requirements related to such improvements. 

9 Amounts appropriated under this paragraph shall re10 main available until expended. 

11 (2) REQUIREMENTS.—The improvements made 

12 by the Secretary under paragraph (1) shall be de13 signed and implemented (including with respect to 

14 any necessary guidance for States to report such in15 formation in a complete and expeditious manner) so 

16 that, beginning no later than October 1, 2009, data 

17 regarding the enrollment of low-income children (as 

18 defined in section 2110(c)(4) of the Social Security 

19 Act (42 U.S.C. 1397jj(c)(4)) of a State enrolled in the 

20 State plan under Medicaid or the State child health 

21 plan under CHIP with respect to a fiscal year shall 

22 be collected and analyzed by the Secretary within 6 

23 months of submission. 

24 (d) GAO STUDY AND REPORT ON ACCESS TO PRIMARY

25 AND SPECIALITY SERVICES.— 
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1 (1) IN GENERAL.—The Comptroller General of 

2 the United States shall conduct a study of children’s 

3 access to primary and specialty services under Med4 icaid and CHIP, including— 

5 (A) the extent to which providers are will6 ing to treat children eligible for such programs; 

7 (B) information on such children’s access to 

8 networks of care; 

9 (C) geographic availability of primary and 

10 specialty services under such programs; 

11 (D) the extent to which care coordination is 

12 provided for children’s care under Medicaid and 

13 CHIP; and 

14 (E) as appropriate, information on the de15 gree of availability of services for children under 

16 such programs. 

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

18 date of enactment of this Act, the Comptroller General 

19 shall submit a report to the Committee on Finance of 

20 the Senate and the Committee on Energy and Com21 merce of the House of Representatives on the study 

22 conducted under paragraph (1) that includes rec23 ommendations for such Federal and State legislative 

24 and administrative changes as the Comptroller Gen25 eral determines are necessary to address any barriers 
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1 to access to children’s care under Medicaid and CHIP 

2 that may exist. 

3 SEC. 403. APPLICATION OF CERTAIN MANAGED CARE QUAL4 ITY SAFEGUARDS TO CHIP. 

5 (a) IN GENERAL.—Section 2103(f) of Social Security 

6 Act (42 U.S.C. 1397bb(f)) is amended by adding at the end 

7 the following new paragraph: 

8 ‘‘(3) COMPLIANCE WITH MANAGED CARE RE9 QUIREMENTS.—The State child health plan shall pro10 vide for the application of subsections (a)(4), (a)(5), 

11 (b), (c), (d), and (e) of section 1932 (relating to re12 quirements for managed care) to coverage, State agen13 cies, enrollment brokers, managed care entities, and 

14 managed care organizations under this title in the 

15 same manner as such subsections apply to coverage 

16 and such entities and organizations under title 

17 XIX.’’. 

18 (b) EFFECTIVE DATE.—The amendment made by sub19 section (a) shall apply to contract years for health plans 

20 beginning on or after July 1, 2009. 

21 TITLE V—IMPROVING ACCESS TO 

22 BENEFITS 

23 SEC. 501. DENTAL BENEFITS. 

24 (a) COVERAGE.— 
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1 (1) IN GENERAL.—Section 2103 (42 U.S.C. 

2 1397cc) is amended— 

3 (A) in subsection (a)— 

4 (i) in the matter before paragraph (1), 

5 by striking ‘‘subsection (c)(5)’’ and insert6 ing ‘‘paragraphs (5) and (7) of subsection 

7 (c)’’; and 

8 (ii) in paragraph (1), by inserting ‘‘at 

9 least’’ after ‘‘that is’’; and 

10 (B) in subsection (c)— 

11 (i) by redesignating paragraph (5) as 

12 paragraph (7); and 

13 (ii) by inserting after paragraph (4), 

14 the following: 

15 ‘‘(5) DENTAL BENEFITS.— 

16 ‘‘(A) IN GENERAL.—The child health assist17 ance provided to a targeted low-income child 

18 shall include coverage of dental services necessary 

19 to prevent disease and promote oral health, re20 store oral structures to health and function, and 

21 treat emergency conditions. 

22 ‘‘(B) PERMITTING USE OF DENTAL BENCH23 MARK PLANS BY CERTAIN STATES.—A State may 

24 elect to meet the requirement of subparagraph 

25 (A) through dental coverage that is equivalent to 
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1 a benchmark dental benefit package described in 

2 subparagraph (C). 

3 ‘‘(C) BENCHMARK DENTAL BENEFIT PACK4 AGES.—The benchmark dental benefit packages 

5 are as follows: 

6 ‘‘(i) FEHBP CHILDREN’S DENTAL COV7 ERAGE.—A dental benefits plan under 

8 chapter 89A of title 5, United States Code, 

9 that has been selected most frequently by 

10 employees seeking dependent coverage, 

11 among such plans that provide such depend12 ent coverage, in either of the previous 2 

13 plan years. 

14 ‘‘(ii) STATE EMPLOYEE DEPENDENT

15 DENTAL COVERAGE.—A dental benefits plan 

16 that is offered and generally available to 

17 State employees in the State involved and 

18 that has been selected most frequently by 

19 employees seeking dependent coverage, 

20 among such plans that provide such depend21 ent coverage, in either of the previous 2 

22 plan years. 

23 ‘‘(iii) COVERAGE OFFERED THROUGH

24 COMMERCIAL DENTAL PLAN.—A dental ben25 efits plan that has the largest insured com-
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1 mercial, non-medicaid enrollment of de2 pendent covered lives of such plans that is 

3 offered in the State involved.’’. 

4 (2) ASSURING ACCESS TO CARE.—Section 

5 2102(a)(7)(B) (42 U.S.C. 1397bb(c)(2)) is amended 

6 by inserting ‘‘and services described in section 

7 2103(c)(5)’’ after ‘‘emergency services’’. 

8 (3) EFFECTIVE DATE.—The amendments made 

9 by paragraphs (1) and (2) shall apply to coverage of 

10 items and services furnished on or after October 1, 

11 2009. 

12 (b) STATE OPTION TO PROVIDE DENTAL-ONLY SUP13 PLEMENTAL COVERAGE.— 

14 (1) IN GENERAL.—Section 2110(b) (42 U.S.C. 

15 1397jj(b)) is amended— 

16 (A) in paragraph (1)(C), by inserting ‘‘, 

17 subject to paragraph (5),’’ after ‘‘under title XIX 

18 or’’; and 

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

20 paragraph: 

21 ‘‘(5) OPTION FOR STATES WITH A SEPARATE

22 CHIP PROGRAM TO PROVIDE DENTAL-ONLY SUPPLE23 MENTAL COVERAGE.— 

24 ‘‘(A) IN GENERAL.—Subject to subpara25 graphs (B) and (C), in the case of any child who 
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1 is enrolled in a group health plan or health in2 surance coverage offered through an employer 

3 who would, but for the application of paragraph 

4 (1)(C), satisfy the requirements for being a tar5 geted low-income child under a State child health 

6 plan that is implemented under this title, a 

7 State may waive the application of such para8 graph to the child in order to provide— 

9 ‘‘(i) dental coverage consistent with the 

10 requirements of subsection (c)(5) of section 

11 2103; or 

12 ‘‘(ii) cost-sharing protection for dental 

13 coverage consistent with such requirements 

14 and the requirements of subsection (e)(3)(B) 

15 of such section. 

16 ‘‘(B) LIMITATION.—A State may limit the 

17 application of a waiver of paragraph (1)(C) to 

18 children whose family income does not exceed a 

19 level specified by the State, so long as the level 

20 so specified does not exceed the maximum income 

21 level otherwise established for other children 

22 under the State child health plan. 

23 ‘‘(C) CONDITIONS.—A State may not offer 

24 dental-only supplemental coverage under this 
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1 paragraph unless the State satisfies the following 

2 conditions: 

3 ‘‘(i) INCOME ELIGIBILITY.—The State 

4 child health plan under this title— 

5 ‘‘(I) has the highest income eligi6 bility standard permitted under this 

7 title (or a waiver) as of January 1, 

8 2009; 

9 ‘‘(II) does not limit the acceptance 

10 of applications for children or impose 

11 any numerical limitation, waiting list, 

12 or similar limitation on the eligibility 

13 of such children for child health assist14 ance under such State plan; and 

15 ‘‘(III) provides benefits to all chil16 dren in the State who apply for and 

17 meet eligibility standards. 

18 ‘‘(ii) NO MORE FAVORABLE TREAT19 MENT.—The State child health plan may 

20 not provide more favorable dental coverage 

21 or cost-sharing protection for dental cov22 erage to children provided dental-only sup23 plemental coverage under this paragraph 

24 than the dental coverage and cost-sharing 

25 protection for dental coverage provided to 
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1 targeted low-income children who are eligi2 ble for the full range of child health assist3 ance provided under the State child health 

4 plan.’’. 

5 (2) STATE OPTION TO WAIVE WAITING PERIOD.— 

6 Section 2102(b)(1)(B) (42 U.S.C. 1397bb(b)(1)(B)), 

7 as amended by section 111(b)(2), is amended— 

8 (A) in clause (ii), by striking ‘‘and’’ at the 

9 end; 

10 (B) in clause (iii), by striking the period 

11 and inserting ‘‘; and’’; and 

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

13 clause: 

14 ‘‘(iv) at State option, may not apply a 

15 waiting period in the case of a child pro16 vided dental-only supplemental coverage 

17 under section 2110(b)(5).’’. 

18 (c) DENTAL EDUCATION FOR PARENTS OF

19 NEWBORNS.—The Secretary shall develop and implement, 

20 through entities that fund or provide perinatal care services 

21 to targeted low-income children under a State child health 

22 plan under title XXI of the Social Security Act, a program 

23 to deliver oral health educational materials that inform new 

24 parents about risks for, and prevention of, early childhood 
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1 caries and the need for a dental visit within their newborn’s 

2 first year of life. 

3 (d) PROVISION OF DENTAL SERVICES THROUGH

4 FQHCS.— 

5 (1) MEDICAID.—Section 1902(a) (42 U.S.C. 

6 1396a(a)) is amended— 

7 (A) by striking ‘‘and’’ at the end of para8 graph (70); 

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

10 paragraph (71) and inserting ‘‘; and’’; and 

11 (C) by inserting after paragraph (71) the 

12 following new paragraph: 

13 ‘‘(72) provide that the State will not prevent a 

14 Federally-qualified health center from entering into 

15 contractual relationships with private practice dental 

16 providers in the provision of Federally-qualified 

17 health center services.’’. 

18 (2) CHIP.—Section 2107(e)(1) (42 U.S.C. 

19 1397g(e)(1)), as amended by subsections (a)(2) and 

20 (d)(2) of section 203, is amended by inserting after 

21 subparagraph (B) the following new subparagraph 

22 (and redesignating the succeeding subparagraphs ac23 cordingly): 
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1 ‘‘(C) Section 1902(a)(72) (relating to lim2 iting FQHC contracting for provision of dental 

3 services).’’. 

4 (3) EFFECTIVE DATE.—The amendments made 

5 by this subsection shall take effect on January 1, 

6 2009. 

7 (e) REPORTING INFORMATION ON DENTAL HEALTH.— 

8 (1) MEDICAID.—Section 1902(a)(43)(D)(iii) (42 

9 U.S.C. 1396a(a)(43)(D)(iii)) is amended by inserting 

10 ‘‘and other information relating to the provision of 

11 dental services to such children described in section 

12 2108(e)’’ after ‘‘receiving dental services,’’. 

13 (2) CHIP.—Section 2108 (42 U.S.C. 1397hh) is 

14 amended by adding at the end the following new sub15 section: 

16 ‘‘(e) INFORMATION ON DENTAL CARE FOR CHIL17 DREN.— 

18 ‘‘(1) IN GENERAL.—Each annual report under 

19 subsection (a) shall include the following information 

20 with respect to care and services described in section 

21 1905(r)(3) provided to targeted low-income children 

22 enrolled in the State child health plan under this title 

23 at any time during the year involved: 
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1 ‘‘(A) The number of enrolled children by age 

2 grouping used for reporting purposes under sec3 tion 1902(a)(43). 

4 ‘‘(B) For children within each such age 

5 grouping, information of the type contained in 

6 questions 12(a)–(c) of CMS Form 416 (that con7 sists of the number of enrolled targeted low in8 come children who receive any, preventive, or re9 storative dental care under the State plan). 

10 ‘‘(C) For the age grouping that includes 

11 children 8 years of age, the number of such chil12 dren who have received a protective sealant on at 

13 least one permanent molar tooth. 

14 ‘‘(2) INCLUSION OF INFORMATION ON ENROLLEES

15 IN MANAGED CARE PLANS.—The information under 

16 paragraph (1) shall include information on children 

17 who are enrolled in managed care plans and other 

18 private health plans and contracts with such plans 

19 under this title shall provide for the reporting of such 

20 information by such plans to the State.’’. 

21 (3) EFFECTIVE DATE.—The amendments made 

22 by this subsection shall be effective for annual reports 

23 submitted for years beginning after date of enactment. 
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1 (f) IMPROVED ACCESSIBILITY OF DENTAL PROVIDER

2 INFORMATION TO ENROLLEES UNDER MEDICAID AND

3 CHIP.—The Secretary shall— 

4 (1) work with States, pediatric dentists, and 

5 other dental providers (including providers that are, 

6 or are affiliated with, a school of dentistry) to in7 clude, not later than 6 months after the date of the 

8 enactment of this Act, on the Insure Kids Now website 

9 (http://www.insurekidsnow.gov/) and hotline (1–877– 

10 KIDS–NOW) (or on any successor websites or hot11 lines) a current and accurate list of all such dentists 

12 and providers within each State that provide dental 

13 services to children enrolled in the State plan (or 

14 waiver) under Medicaid or the State child health plan 

15 (or waiver) under CHIP, and shall ensure that such 

16 list is updated at least quarterly; and 

17 (2) work with States to include, not later than 

18 6 months after the date of the enactment of this Act, 

19 a description of the dental services provided under 

20 each State plan (or waiver) under Medicaid and each 

21 State child health plan (or waiver) under CHIP on 

22 such Insure Kids Now website, and shall ensure that 

23 such list is updated at least annually. 

24 (g) INCLUSION OF STATUS OF EFFORTS TO IMPROVE

25 DENTAL CARE IN REPORTS ON THE QUALITY OF CHIL-
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1 DREN’S HEALTH CARE UNDER MEDICAID AND CHIP.— 

2 Section 1139A(a), as added by section 401(a), is amend3 ed— 

4 (1) in paragraph (3)(B)(ii), by inserting ‘‘and, 

5 with respect to dental care, conditions requiring the 

6 restoration of teeth, relief of pain and infection, and 

7 maintenance of dental health’’ after ‘‘chronic condi8 tions’’; and 

9 (2) in paragraph (6)(A)(ii), by inserting ‘‘dental 

10 care,’’ after ‘‘preventive health services,’’. 

11 (h) GAO STUDY AND REPORT.— 

12 (1) STUDY.—The Comptroller General of the 

13 United States shall provide for a study that exam14 ines— 

15 (A) access to dental services by children in 

16 underserved areas; 

17 (B) children’s access to oral health care, in18 cluding preventive and restorative services, under 

19 Medicaid and CHIP, including— 

20 (i) the extent to which dental providers 

21 are willing to treat children eligible for such 

22 programs; 

23 (ii) information on such children’s ac24 cess to networks of care, including such net25 works that serve special needs children; and 
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1 (iii) geographic availability of oral 

2 health care, including preventive and restor3 ative services, under such programs; and 

4 (C) the feasibility and appropriateness of 

5 using qualified mid-level dental health providers, 

6 in coordination with dentists, to improve access 

7 for children to oral health services and public 

8 health overall. 

9 (2) REPORT.—Not later than 18 months year 

10 after the date of the enactment of this Act, the Comp11 troller General shall submit to Congress a report on 

12 the study conducted under paragraph (1). The report 

13 shall include recommendations for such Federal and 

14 State legislative and administrative changes as the 

15 Comptroller General determines are necessary to ad16 dress any barriers to access to oral health care, in17 cluding preventive and restorative services, under 

18 Medicaid and CHIP that may exist. 

19 SEC. 502. MENTAL HEALTH PARITY IN CHIP PLANS. 

20 (a) ASSURANCE OF PARITY.—Section 2103(c) (42 

21 U.S.C. 1397cc(c)), as amended by section 501(a)(1)(B), is 

22 amended by inserting after paragraph (5), the following: 

23 ‘‘(6) MENTAL HEALTH SERVICES PARITY.— 

24 ‘‘(A) IN GENERAL.—In the case of a State 

25 child health plan that provides both medical and 
221 

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1 surgical benefits and mental health or substance 

2 use disorder benefits, such plan shall ensure that 

3 the financial requirements and treatment limita4 tions applicable to such mental health or sub5 stance use disorder benefits comply with the re6 quirements of section 2705(a) of the Public 

7 Health Service Act in the same manner as such 

8 requirements apply to a group health plan. 

9 ‘‘(B) DEEMED COMPLIANCE.—To the extent 

10 that a State child health plan includes coverage 

11 with respect to an individual described in section 

12 1905(a)(4)(B) and covered under the State plan 

13 under section 1902(a)(10)(A) of the services de14 scribed in section 1905(a)(4)(B) (relating to 

15 early and periodic screening, diagnostic, and 

16 treatment services defined in section 1905(r)) 

17 and provided in accordance with section 

18 1902(a)(43), such plan shall be deemed to satisfy 

19 the requirements of subparagraph (A).’’. 

20 (b) CONFORMING AMENDMENTS.—Section 2103 (42 

21 U.S.C. 1397cc) is amended— 

22 (1) in subsection (a), as amended by section 

23 501(a)(1)(A)(i), in the matter preceding paragraph 

24 (1), by inserting ‘‘, (6),’’ after ‘‘(5)’’; and 
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1 (2) in subsection (c)(2), by striking subpara2 graph (B) and redesignating subparagraphs (C) and 

3 (D) as subparagraphs (B) and (C), respectively. 

4 SEC. 503. APPLICATION OF PROSPECTIVE PAYMENT SYSTEM 

5 FOR SERVICES PROVIDED BY FEDERALLY6 QUALIFIED HEALTH CENTERS AND RURAL 

7 HEALTH CLINICS. 

8 (a) APPLICATION OF PROSPECTIVE PAYMENT SYS9 TEM.— 

10 (1) IN GENERAL.—Section 2107(e)(1) (42 U.S.C. 

11 1397gg(e)(1)), as amended by section 501(c)(2) is 

12 amended by inserting after subparagraph (C) the fol13 lowing new subparagraph (and redesignating the suc14 ceeding subparagraphs accordingly): 

15 ‘‘(D) Section 1902(bb) (relating to payment 

16 for services provided by Federally-qualified 

17 health centers and rural health clinics).’’. 

18 (2) EFFECTIVE DATE.—The amendment made by 

19 paragraph (1) shall apply to services provided on or 

20 after October 1, 2009. 

21 (b) TRANSITION GRANTS.— 

22 (1) APPROPRIATION.—Out of any funds in the 

23 Treasury not otherwise appropriated, there is appro24 priated to the Secretary for fiscal year 2009, 

25 $5,000,000, to remain available until expended, for 
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1 the purpose of awarding grants to States with State 

2 child health plans under CHIP that are operated sep3 arately from the State Medicaid plan under title XIX 

4 of the Social Security Act (including any waiver of 

5 such plan), or in combination with the State Med6 icaid plan, for expenditures related to transitioning 

7 to compliance with the requirement of section 

8 2107(e)(1)(D) of the Social Security Act (as added by 

9 subsection (a)) to apply the prospective payment sys10 tem established under section 1902(bb) of the such Act 

11 (42 U.S.C. 1396a(bb)) to services provided by Feder12 ally-qualified health centers and rural health clinics. 

13 (2) MONITORING AND REPORT.—The Secretary 

14 shall monitor the impact of the application of such 

15 prospective payment system on the States described in 

16 paragraph (1) and, not later than October 1, 2011, 

17 shall report to Congress on any effect on access to ben18 efits, provider payment rates, or scope of benefits of19 fered by such States as a result of the application of 

20 such payment system. 

21 SEC. 504. PREMIUM GRACE PERIOD. 

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

23 1397cc(e)(3)) is amended by adding at the end the following 

24 new subparagraph: 
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1 ‘‘(C) PREMIUM GRACE PERIOD.—The State 

2 child health plan— 

3 ‘‘(i) shall afford individuals enrolled 

4 under the plan a grace period of at least 30 

5 days from the beginning of a new coverage 

6 period to make premium payments before 

7 the individual’s coverage under the plan 

8 may be terminated; and 

9 ‘‘(ii) shall provide to such an indi10 vidual, not later than 7 days after the first 

11 day of such grace period, notice— 

12 ‘‘(I) that failure to make a pre13 mium payment within the grace period 

14 will result in termination of coverage 

15 under the State child health plan; and 

16 ‘‘(II) of the individual’s right to 

17 challenge the proposed termination 

18 pursuant to the applicable Federal reg19 ulations. 

20 For purposes of clause (i), the term ‘new cov21 erage period’ means the month immediately fol22 lowing the last month for which the premium 

23 has been paid.’’. 
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1 (b) EFFECTIVE DATE.—The amendment made by sub2 section (a) shall apply to new coverage periods beginning 

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

4 SEC. 505. CLARIFICATION OF COVERAGE OF SERVICES PRO5 VIDED THROUGH SCHOOL-BASED HEALTH 

6 CENTERS. 

7 (a) IN GENERAL.—Section 2103(c) (42 U.S.C. 

8 1397cc(c)), as amended by section 501(a)(1)(B), is amended 

9 by adding at the end the following new paragraph: 

10 ‘‘(8) AVAILABILITY OF COVERAGE FOR ITEMS

11 AND SERVICES FURNISHED THROUGH SCHOOL-BASED

12 HEALTH CENTERS.—Nothing in this title shall be con13 strued as limiting a State’s ability to provide child 

14 health assistance for covered items and services that 

15 are furnished through school-based health centers (as 

16 defined in section 2110(c)(9)).’’. 

17 (b) DEFINITION.—Section 2110(c) (42 U.S.C. 1397jj) 

18 is amended by adding at the end the following: 

19 ‘‘(9) SCHOOL-BASED HEALTH CENTER.— 

20 ‘‘(A) IN GENERAL.—The term ‘school-based 

21 health center’ means a health clinic that— 

22 ‘‘(i) is located in or near a school facil23 ity of a school district or board or of an In24 dian tribe or tribal organization; 
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1 ‘‘(ii) is organized through school, com2 munity, and health provider relationships; 

3 ‘‘(iii) is administered by a sponsoring 

4 facility; 

5 ‘‘(iv) provides through health profes6 sionals primary health services to children 

7 in accordance with State and local law, in8 cluding laws relating to licensure and cer9 tification; and 

10 ‘‘(v) satisfies such other requirements 

11 as a State may establish for the operation 

12 of such a clinic. 

13 ‘‘(B) SPONSORING FACILITY.—For purposes 

14 of subparagraph (A)(iii), the term ‘sponsoring 

15 facility’ includes any of the following: 

16 ‘‘(i) A hospital. 

17 ‘‘(ii) A public health department. 

18 ‘‘(iii) A community health center. 

19 ‘‘(iv) A nonprofit health care agency. 

20 ‘‘(v) A school or school system. 

21 ‘‘(vi) A program administered by the 

22 Indian Health Service or the Bureau of In23 dian Affairs or operated by an Indian tribe 

24 or a tribal organization.’’. 
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1 SEC. 506. MEDICAID AND CHIP PAYMENT AND ACCESS COM2 MISSION. 

3 (a) IN GENERAL.—Title XIX (42 U.S.C. 1396 et seq.) 

4 is amended by inserting before section 1901 the following 

5 new section: 

6 ‘‘MEDICAID AND CHIP PAYMENT AND ACCESS COMMISSION

7 ‘‘SEC. 1900. (a) ESTABLISHMENT.—There is hereby es8 tablished the Medicaid and CHIP Payment and Access 

9 Commission (in this section referred to as ‘MACPAC’). 

10 ‘‘(b) DUTIES.— 

11 ‘‘(1) REVIEW OF ACCESS POLICIES AND ANNUAL

12 REPORTS.—MACPAC shall— 

13 ‘‘(A) review policies of the Medicaid pro14 gram established under this title (in this section 

15 referred to as ‘Medicaid’) and the State Chil16 dren’s Health Insurance Program established 

17 under title XXI (in this section referred to as 

18 ‘CHIP’) affecting children’s access to covered 

19 items and services, including topics described in 

20 paragraph (2); 

21 ‘‘(B) make recommendations to Congress 

22 concerning such access policies; 

23 ‘‘(C) by not later than March 1 of each year 

24 (beginning with 2010), submit a report to Con25 gress containing the results of such reviews and 
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1 MACPAC’s recommendations concerning such 

2 policies; and 

3 ‘‘(D) by not later than June 1 of each year 

4 (beginning with 2010), submit a report to Con5 gress containing an examination of issues affect6 ing Medicaid and CHIP, including the implica7 tions of changes in health care delivery in the 

8 United States and in the market for health care 

9 services on such programs. 

10 ‘‘(2) SPECIFIC TOPICS TO BE REVIEWED.—Spe11 cifically, MACPAC shall review and assess the fol12 lowing: 

13 ‘‘(A) MEDICAID AND CHIP PAYMENT POLI14 CIES.—Payment policies under Medicaid and 

15 CHIP, including— 

16 ‘‘(i) the factors affecting expenditures 

17 for items and services in different sectors, 

18 including the process for updating hospital, 

19 skilled nursing facility, physician, Feder20 ally-qualified health center, rural health 

21 center, and other fees; 

22 ‘‘(ii) payment methodologies; and 

23 ‘‘(iii) the relationship of such factors 

24 and methodologies to access and quality of 

25 care for Medicaid and CHIP beneficiaries. 
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1 ‘‘(B) INTERACTION OF MEDICAID AND CHIP

2 PAYMENT POLICIES WITH HEALTH CARE DELIV3 ERY GENERALLY.—The effect of Medicaid and 

4 CHIP payment policies on access to items and 

5 services for children and other Medicaid and 

6 CHIP populations other than under this title or 

7 title XXI and the implications of changes in 

8 health care delivery in the United States and in 

9 the general market for health care items and 

10 services on Medicaid and CHIP. 

11 ‘‘(C) OTHER ACCESS POLICIES.—The effect 

12 of other Medicaid and CHIP policies on access 

13 to covered items and services, including policies 

14 relating to transportation and language barriers. 

15 ‘‘(3) CREATION OF EARLY-WARNING SYSTEM.— 

16 MACPAC shall create an early-warning system to 

17 identify provider shortage areas or any other prob18 lems that threaten access to care or the health care 

19 status of Medicaid and CHIP beneficiaries. 

20 ‘‘(4) COMMENTS ON CERTAIN SECRETARIAL RE21 PORTS.—If the Secretary submits to Congress (or a 

22 committee of Congress) a report that is required by 

23 law and that relates to access policies, including with 

24 respect to payment policies, under Medicaid or CHIP, 

25 the Secretary shall transmit a copy of the report to 
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† HR 2 EAS 

1 MACPAC. MACPAC shall review the report and, not 

2 later than 6 months after the date of submittal of the 

3 Secretary’s report to Congress, shall submit to the ap4 propriate committees of Congress written comments 

5 on such report. Such comments may include such rec6 ommendations as MACPAC deems appropriate. 

7 ‘‘(5) AGENDA AND ADDITIONAL REVIEWS.— 

8 MACPAC shall consult periodically with the chair9 men and ranking minority members of the appro10 priate committees of Congress regarding MACPAC’s 

11 agenda and progress towards achieving the agenda. 

12 MACPAC may conduct additional reviews, and sub13 mit additional reports to the appropriate committees 

14 of Congress, from time to time on such topics relating 

15 to the program under this title or title XXI as may 

16 be requested by such chairmen and members and as 

17 MACPAC deems appropriate. 

18 ‘‘(6) AVAILABILITY OF REPORTS.—MACPAC 

19 shall transmit to the Secretary a copy of each report 

20 submitted under this subsection and shall make such 

21 reports available to the public. 

22 ‘‘(7) APPROPRIATE COMMITTEE OF CONGRESS.— 

23 For purposes of this section, the term ‘appropriate 

24 committees of Congress’ means the Committee on En-
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1 ergy and Commerce of the House of Representatives 

2 and the Committee on Finance of the Senate. 

3 ‘‘(8) VOTING AND REPORTING REQUIREMENTS.— 

4 With respect to each recommendation contained in a 

5 report submitted under paragraph (1), each member 

6 of MACPAC shall vote on the recommendation, and 

7 MACPAC shall include, by member, the results of that 

8 vote in the report containing the recommendation. 

9 ‘‘(9) EXAMINATION OF BUDGET CON10 SEQUENCES.—Before making any recommendations, 

11 MACPAC shall examine the budget consequences of 

12 such recommendations, directly or through consulta13 tion with appropriate expert entities. 

14 ‘‘(c) MEMBERSHIP.— 

15 ‘‘(1) NUMBER AND APPOINTMENT.—MACPAC 

16 shall be composed of 17 members appointed by the 

17 Comptroller General of the United States. 

18 ‘‘(2) QUALIFICATIONS.— 

19 ‘‘(A) IN GENERAL.—The membership of 

20 MACPAC shall include individuals who have 

21 had direct experience as enrollees or parents of 

22 enrollees in Medicaid or CHIP and individuals 

23 with national recognition for their expertise in 

24 Federal safety net health programs, health fi25 nance and economics, actuarial science, health 
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1 facility management, health plans and inte2 grated delivery systems, reimbursement of health 

3 facilities, health information technology, pedi4 atric physicians, dentists, and other providers of 

5 health services, and other related fields, who pro6 vide a mix of different professionals, broad geo7 graphic representation, and a balance between 

8 urban and rural representatives. 

9 ‘‘(B) INCLUSION.—The membership of 

10 MACPAC shall include (but not be limited to) 

11 physicians and other health professionals, em12 ployers, third-party payers, and individuals 

13 with expertise in the delivery of health services. 

14 Such membership shall also include consumers 

15 representing children, pregnant women, the el16 derly, and individuals with disabilities, current 

17 or former representatives of State agencies re18 sponsible for administering Medicaid, and cur19 rent or former representatives of State agencies 

20 responsible for administering CHIP. 

21 ‘‘(C) MAJORITY NONPROVIDERS.—Individ22 uals who are directly involved in the provision, 

23 or management of the delivery, of items and 

24 services covered under Medicaid or CHIP shall 
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1 not constitute a majority of the membership of 

2 MACPAC. 

3 ‘‘(D) ETHICAL DISCLOSURE.—The Comp4 troller General of the United States shall estab5 lish a system for public disclosure by members of 

6 MACPAC of financial and other potential con7 flicts of interest relating to such members. Mem8 bers of MACPAC shall be treated as employees of 

9 Congress for purposes of applying title I of the 

10 Ethics in Government Act of 1978 (Public Law 

11 95–521). 

12 ‘‘(3) TERMS.— 

13 ‘‘(A) IN GENERAL.—The terms of members 

14 of MACPAC shall be for 3 years except that the 

15 Comptroller General of the United States shall 

16 designate staggered terms for the members first 

17 appointed. 

18 ‘‘(B) VACANCIES.—Any member appointed 

19 to fill a vacancy occurring before the expiration 

20 of the term for which the member’s predecessor 

21 was appointed shall be appointed only for the re22 mainder of that term. A member may serve after 

23 the expiration of that member’s term until a suc24 cessor has taken office. A vacancy in MACPAC 
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1 shall be filled in the manner in which the origi2 nal appointment was made. 

3 ‘‘(4) COMPENSATION.—While serving on the busi4 ness of MACPAC (including travel time), a member 

5 of MACPAC shall be entitled to compensation at the 

6 per diem equivalent of the rate provided for level IV 

7 of the Executive Schedule under section 5315 of title 

8 5, United States Code; and while so serving away 

9 from home and the member’s regular place of busi10 ness, a member may be allowed travel expenses, as 

11 authorized by the Chairman of MACPAC. Physicians 

12 serving as personnel of MACPAC may be provided a 

13 physician comparability allowance by MACPAC in 

14 the same manner as Government physicians may be 

15 provided such an allowance by an agency under sec16 tion 5948 of title 5, United States Code, and for such 

17 purpose subsection (i) of such section shall apply to 

18 MACPAC in the same manner as it applies to the 

19 Tennessee Valley Authority. For purposes of pay 

20 (other than pay of members of MACPAC) and em21 ployment benefits, rights, and privileges, all personnel 

22 of MACPAC shall be treated as if they were employees 

23 of the United States Senate. 

24 ‘‘(5) CHAIRMAN; VICE CHAIRMAN.—The Comp25 troller General of the United States shall designate a 
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1 member of MACPAC, at the time of appointment of 

2 the member as Chairman and a member as Vice 

3 Chairman for that term of appointment, except that 

4 in the case of vacancy of the Chairmanship or Vice 

5 Chairmanship, the Comptroller General of the United 

6 States may designate another member for the remain7 der of that member’s term. 

8 ‘‘(6) MEETINGS.—MACPAC shall meet at the 

9 call of the Chairman. 

10 ‘‘(d) DIRECTOR AND STAFF; EXPERTS AND CONSULT11 ANTS.—Subject to such review as the Comptroller General 

12 of the United States deems necessary to assure the efficient 

13 administration of MACPAC, MACPAC may— 

14 ‘‘(1) employ and fix the compensation of an Ex15 ecutive Director (subject to the approval of the Comp16 troller General of the United States) and such other 

17 personnel as may be necessary to carry out its duties 

18 (without regard to the provisions of title 5, United 

19 States Code, governing appointments in the competi20 tive service); 

21 ‘‘(2) seek such assistance and support as may be 

22 required in the performance of its duties from appro23 priate Federal departments and agencies; 

24 ‘‘(3) enter into contracts or make other arrange25 ments, as may be necessary for the conduct of the 
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1 work of MACPAC (without regard to section 3709 of 

2 the Revised Statutes (41 U.S.C. 5)); 

3 ‘‘(4) make advance, progress, and other pay4 ments which relate to the work of MACPAC; 

5 ‘‘(5) provide transportation and subsistence for 

6 persons serving without compensation; and 

7 ‘‘(6) prescribe such rules and regulations as it 

8 deems necessary with respect to the internal organiza9 tion and operation of MACPAC. 

10 ‘‘(e) POWERS.— 

11 ‘‘(1) OBTAINING OFFICIAL DATA.—MACPAC 

12 may secure directly from any department or agency 

13 of the United States information necessary to enable 

14 it to carry out this section. Upon request of the 

15 Chairman, the head of that department or agency 

16 shall furnish that information to MACPAC on an 

17 agreed upon schedule. 

18 ‘‘(2) DATA COLLECTION.—In order to carry out 

19 its functions, MACPAC shall— 

20 ‘‘(A) utilize existing information, both pub21 lished and unpublished, where possible, collected 

22 and assessed either by its own staff or under 

23 other arrangements made in accordance with 

24 this section; 
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1 ‘‘(B) carry out, or award grants or con2 tracts for, original research and experimentation, 

3 where existing information is inadequate; and 

4 ‘‘(C) adopt procedures allowing any inter5 ested party to submit information for MACPAC’s 

6 use in making reports and recommendations. 

7 ‘‘(3) ACCESS OF GAO TO INFORMATION.—The 

8 Comptroller General of the United States shall have 

9 unrestricted access to all deliberations, records, and 

10 nonproprietary data of MACPAC, immediately upon 

11 request. 

12 ‘‘(4) PERIODIC AUDIT.—MACPAC shall be sub13 ject to periodic audit by the Comptroller General of 

14 the United States. 

15 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.— 

16 ‘‘(1) REQUEST FOR APPROPRIATIONS.— 

17 MACPAC shall submit requests for appropriations in 

18 the same manner as the Comptroller General of the 

19 United States submits requests for appropriations, 

20 but amounts appropriated for MACPAC shall be sep21 arate from amounts appropriated for the Comptroller 

22 General of the United States. 

23 ‘‘(2) AUTHORIZATION.—There are authorized to 

24 be appropriated such sums as may be necessary to 

25 carry out the provisions of this section.’’. 
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1 (b) DEADLINE FOR INITIAL APPOINTMENTS.—Not 

2 later than January 1, 2010, the Comptroller General of the 

3 United States shall appoint the initial members of the Med4 icaid and CHIP Payment and Access Commission estab5 lished under section 1900 of the Social Security Act (as 

6 added by subsection (a)). 

7 (c) ANNUAL REPORT ON MEDICAID.—Not later than 

8 January 1, 2010, and annually thereafter, the Secretary, 

9 in consultation with the Secretary of the Treasury, the Sec10 retary of Labor, and the States (as defined for purposes of 

11 Medicaid), shall submit an annual report to Congress on 

12 the financial status of, enrollment in, and spending trends 

13 for, Medicaid for the fiscal year ending on September 30 

14 of the preceding year. 

15 TITLE VI—PROGRAM INTEGRITY 

16 AND OTHER MISCELLANEOUS 

17 PROVISIONS 

18 Subtitle A—Program Integrity and 

19 Data Collection 

20 SEC. 601. PAYMENT ERROR RATE MEASUREMENT (‘‘PERM’’). 

21 (a) EXPENDITURES RELATED TO COMPLIANCE WITH

22 REQUIREMENTS.— 

23 (1) ENHANCED PAYMENTS.—Section 2105(c) (42 

24 U.S.C. 1397ee(c)), as amended by section 301(a), is 
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1 amended by adding at the end the following new 

2 paragraph: 

3 ‘‘(11) ENHANCED PAYMENTS.—Notwithstanding 

4 subsection (b), the enhanced FMAP with respect to 

5 payments under subsection (a) for expenditures re6 lated to the administration of the payment error rate 

7 measurement (PERM) requirements applicable to the 

8 State child health plan in accordance with the Im9 proper Payments Information Act of 2002 and parts 

10 431 and 457 of title 42, Code of Federal Regulations 

11 (or any related or successor guidance or regulations) 

12 shall in no event be less than 90 percent.’’. 

13 (2) EXCLUSION OF FROM CAP ON ADMINISTRA14 TIVE EXPENDITURES.—Section 2105(c)(2)(C) (42 

15 U.S.C. 1397ee(c)(2)C)), as amended by section 

16 302(b)), is amended by adding at the end the fol17 lowing: 

18 ‘‘(iv) PAYMENT ERROR RATE MEAS19 UREMENT (PERM) EXPENDITURES.—Ex20 penditures related to the administration of 

21 the payment error rate measurement 

22 (PERM) requirements applicable to the 

23 State child health plan in accordance with 

24 the Improper Payments Information Act of 

25 2002 and parts 431 and 457 of title 42, 
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1 Code of Federal Regulations (or any related 

2 or successor guidance or regulations).’’. 

3 (b) FINAL RULE REQUIRED TO BE IN EFFECT FOR

4 ALL STATES.—Notwithstanding parts 431 and 457 of title 

5 42, Code of Federal Regulations (as in effect on the date 

6 of enactment of this Act), the Secretary shall not calculate 

7 or publish any national or State-specific error rate based 

8 on the application of the payment error rate measurement 

9 (in this section referred to as ‘‘PERM’’) requirements to 

10 CHIP until after the date that is 6 months after the date 

11 on which a new final rule (in this section referred to as 

12 the ‘‘new final rule’’) promulgated after the date of the en13 actment of this Act and implementing such requirements 

14 in accordance with the requirements of subsection (c) is in 

15 effect for all States. Any calculation of a national error rate 

16 or a State specific error rate after such new final rule in 

17 effect for all States may only be inclusive of errors, as de18 fined in such new final rule or in guidance issued within 

19 a reasonable time frame after the effective date for such new 

20 final rule that includes detailed guidance for the specific 

21 methodology for error determinations. 

22 (c) REQUIREMENTS FOR NEW FINAL RULE.—For pur23 poses of subsection (b), the requirements of this subsection 

24 are that the new final rule implementing the PERM re25 quirements shall— 
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1 (1) include— 

2 (A) clearly defined criteria for errors for 

3 both States and providers; 

4 (B) a clearly defined process for appealing 

5 error determinations by— 

6 (i) review contractors; or 

7 (ii) the agency and personnel described 

8 in section 431.974(a)(2) of title 42, Code of 

9 Federal Regulations, as in effect on Sep10 tember 1, 2007, responsible for the develop11 ment, direction, implementation, and eval12 uation of eligibility reviews and associated 

13 activities; and 

14 (C) clearly defined responsibilities and 

15 deadlines for States in implementing any correc16 tive action plans; and 

17 (2) provide that the payment error rate deter18 mined for a State shall not take into account pay19 ment errors resulting from the State’s verification of 

20 an applicant’s self-declaration or self-certification of 

21 eligibility for, and the correct amount of, medical as22 sistance or child health assistance, if the State process 

23 for verifying an applicant’s self-declaration or self24 certification satisfies the requirements for such process 
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1 applicable under regulations promulgated by the Sec2 retary or otherwise approved by the Secretary. 

3 (d) OPTION FOR APPLICATION OF DATA FOR STATES

4 IN FIRST APPLICATION CYCLE UNDER THE INTERIM FINAL

5 RULE.—After the new final rule implementing the PERM 

6 requirements in accordance with the requirements of sub7 section (c) is in effect for all States, a State for which the 

8 PERM requirements were first in effect under an interim 

9 final rule for fiscal year 2007 or under a final rule for fiscal 

10 year 2008 may elect to accept any payment error rate deter11 mined in whole or in part for the State on the basis of 

12 data for that fiscal year or may elect to not have any pay13 ment error rate determined on the basis of such data and, 

14 instead, shall be treated as if fiscal year 2010 or fiscal year 

15 2011 were the first fiscal year for which the PERM require16 ments apply to the State. 

17 (e) HARMONIZATION OF MEQC AND PERM.— 

18 (1) REDUCTION OF REDUNDANCIES.—The Sec19 retary shall review the Medicaid Eligibility Quality 

20 Control (in this subsection referred to as the 

21 ‘‘MEQC’’) requirements with the PERM requirements 

22 and coordinate consistent implementation of both sets 

23 of requirements, while reducing redundancies. 

24 (2) STATE OPTION TO APPLY PERM DATA.—A 

25 State may elect, for purposes of determining the erro-
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1 neous excess payments for medical assistance ratio 

2 applicable to the State for a fiscal year under section 

3 1903(u) of the Social Security Act (42 U.S.C. 

4 1396b(u)) to substitute data resulting from the appli5 cation of the PERM requirements to the State after 

6 the new final rule implementing such requirements is 

7 in effect for all States for data obtained from the ap8 plication of the MEQC requirements to the State with 

9 respect to a fiscal year. 

10 (3) STATE OPTION TO APPLY MEQC DATA.—For 

11 purposes of satisfying the requirements of subpart Q 

12 of part 431 of title 42, Code of Federal Regulations, 

13 relating to Medicaid eligibility reviews, a State may 

14 elect to substitute data obtained through MEQC re15 views conducted in accordance with section 1903(u) of 

16 the Social Security Act (42 U.S.C. 1396b(u)) for data 

17 required for purposes of PERM requirements, but 

18 only if the State MEQC reviews are based on a broad, 

19 representative sample of Medicaid applicants or en20 rollees in the States. 

21 (f) IDENTIFICATION OF IMPROVED STATE-SPECIFIC

22 SAMPLE SIZES.—The Secretary shall establish State-spe23 cific sample sizes for application of the PERM requirements 

24 with respect to State child health plans for fiscal years be25 ginning with the first fiscal year that begins on or after 
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1 the date on which the new final rule is in effect for all 

2 States, on the basis of such information as the Secretary 

3 determines appropriate. In establishing such sample sizes, 

4 the Secretary shall, to the greatest extent practicable— 

5 (1) minimize the administrative cost burden on 

6 States under Medicaid and CHIP; and 

7 (2) maintain State flexibility to manage such 

8 programs. 

9 (g) TIME FOR PROMULGATION OF FINAL RULE.—The 

10 final rule implementing the PERM requirements under sub11 section (b) shall be promulgated not later than 6 months 

12 after the date of enactment of this Act. 

13 SEC. 602. IMPROVING DATA COLLECTION. 

14 (a) INCREASED APPROPRIATION.—Section 2109(b)(2) 

15 (42 U.S.C. 1397ii(b)(2)) is amended by striking 

16 ‘‘$10,000,000 for fiscal year 2000’’ and inserting 

17 ‘‘$20,000,000 for fiscal year 2009’’. 

18 (b) USE OF ADDITIONAL FUNDS.—Section 2109(b) (42 

19 U.S.C. 1397ii(b)), as amended by subsection (a), is amend20 ed— 

21 (1) by redesignating paragraph (2) as para22 graph (4); and 

23 (2) by inserting after paragraph (1), the fol24 lowing new paragraphs: 
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1 ‘‘(2) ADDITIONAL REQUIREMENTS.—In addition 

2 to making the adjustments required to produce the 

3 data described in paragraph (1), with respect to data 

4 collection occurring for fiscal years beginning with 

5 fiscal year 2009, in appropriate consultation with the 

6 Secretary of Health and Human Services, the Sec7 retary of Commerce shall do the following: 

8 ‘‘(A) Make appropriate adjustments to the 

9 Current Population Survey to develop more ac10 curate State-specific estimates of the number of 

11 children enrolled in health coverage under title 

12 XIX or this title. 

13 ‘‘(B) Make appropriate adjustments to the 

14 Current Population Survey to improve the sur15 vey estimates used to determine the child popu16 lation growth factor under section 2104(m)(5)(B) 

17 and any other data necessary for carrying out 

18 this title. 

19 ‘‘(C) Include health insurance survey infor20 mation in the American Community Survey re21 lated to children. 

22 ‘‘(D) Assess whether American Community 

23 Survey estimates, once such survey data are first 

24 available, produce more reliable estimates than 
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1 the Current Population Survey with respect to 

2 the purposes described in subparagraph (B). 

3 ‘‘(E) On the basis of the assessment required 

4 under subparagraph (D), recommend to the Sec5 retary of Health and Human Services whether 

6 American Community Survey estimates should 

7 be used in lieu of, or in some combination with, 

8 Current Population Survey estimates for the 

9 purposes described in subparagraph (B). 

10 ‘‘(F) Continue making the adjustments de11 scribed in the last sentence of paragraph (1) with 

12 respect to expansion of the sample size used in 

13 State sampling units, the number of sampling 

14 units in a State, and using an appropriate 

15 verification element. 

16 ‘‘(3) AUTHORITY FOR THE SECRETARY OF

17 HEALTH AND HUMAN SERVICES TO TRANSITION TO

18 THE USE OF ALL, OR SOME COMBINATION OF, ACS ES19 TIMATES UPON RECOMMENDATION OF THE SECRETARY

20 OF COMMERCE.—If, on the basis of the assessment re21 quired under paragraph (2)(D), the Secretary of 

22 Commerce recommends to the Secretary of Health and 

23 Human Services that American Community Survey 

24 estimates should be used in lieu of, or in some com25 bination with, Current Population Survey estimates 
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1 for the purposes described in paragraph (2)(B), the 

2 Secretary of Health and Human Services, in con3 sultation with the States, may provide for a period 

4 during which the Secretary may transition from car5 rying out such purposes through the use of Current 

6 Population Survey estimates to the use of American 

7 Community Survey estimates (in lieu of, or in com8 bination with the Current Population Survey esti9 mates, as recommended), provided that any such 

10 transition is implemented in a manner that is de11 signed to avoid adverse impacts upon States with ap12 proved State child health plans under this title.’’. 

13 SEC. 603. UPDATED FEDERAL EVALUATION OF CHIP. 

14 Section 2108(c) (42 U.S.C. 1397hh(c)) is amended by 

15 striking paragraph (5) and inserting the following: 

16 ‘‘(5) SUBSEQUENT EVALUATION USING UPDATED

17 INFORMATION.— 

18 ‘‘(A) IN GENERAL.—The Secretary, directly 

19 or through contracts or interagency agreements, 

20 shall conduct an independent subsequent evalua21 tion of 10 States with approved child health 

22 plans. 

23 ‘‘(B) SELECTION OF STATES AND MATTERS

24 INCLUDED.—Paragraphs (2) and (3) shall apply 

25 to such subsequent evaluation in the same man-
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1 ner as such provisions apply to the evaluation 

2 conducted under paragraph (1). 

3 ‘‘(C) SUBMISSION TO CONGRESS.—Not later 

4 than December 31, 2011, the Secretary shall sub5 mit to Congress the results of the evaluation con6 ducted under this paragraph. 

7 ‘‘(D) FUNDING.—Out of any money in the 

8 Treasury of the United States not otherwise ap9 propriated, there are appropriated $10,000,000 

10 for fiscal year 2010 for the purpose of conducting 

11 the evaluation authorized under this paragraph. 

12 Amounts appropriated under this subparagraph 

13 shall remain available for expenditure through 

14 fiscal year 2012.’’. 

15 SEC. 604. ACCESS TO RECORDS FOR IG AND GAO AUDITS 

16 AND EVALUATIONS. 

17 Section 2108(d) (42 U.S.C. 1397hh(d)) is amended to 

18 read as follows: 

19 ‘‘(d) ACCESS TO RECORDS FOR IG AND GAO AUDITS

20 AND EVALUATIONS.—For the purpose of evaluating and au21 diting the program established under this title, or title XIX, 

22 the Secretary, the Office of Inspector General, and the 

23 Comptroller General shall have access to any books, ac24 counts, records, correspondence, and other documents that 

25 are related to the expenditure of Federal funds under this 
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1 title and that are in the possession, custody, or control of 

2 States receiving Federal funds under this title or political 

3 subdivisions thereof, or any grantee or contractor of such 

4 States or political subdivisions.’’. 

5 SEC. 605. NO FEDERAL FUNDING FOR ILLEGAL ALIENS; DIS6 ALLOWANCE FOR UNAUTHORIZED EXPENDI7 TURES. 

8 Nothing in this Act allows Federal payment for indi9 viduals who are not legal residents. Titles XI, XIX, and 

10 XXI of the Social Security Act provide for the disallowance 

11 of Federal financial participation for erroneous expendi12 tures under Medicaid and under CHIP, respectively. 

13 Subtitle B—Miscellaneous Health 

14 Provisions 

15 SEC. 611. DEFICIT REDUCTION ACT TECHNICAL CORREC16 TIONS. 

17 (a) CLARIFICATION OF REQUIREMENT TO PROVIDE

18 EPSDT SERVICES FOR ALL CHILDREN IN BENCHMARK

19 BENEFIT PACKAGES UNDER MEDICAID.—Section 

20 1937(a)(1) (42 U.S.C. 1396u–7(a)(1)), as inserted by sec21 tion 6044(a) of the Deficit Reduction Act of 2005 (Public 

22 Law 109–171, 120 Stat. 88), is amended— 

23 (1) in subparagraph (A)— 

24 (A) in the matter before clause (i)— 
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1 (i) by striking ‘‘Notwithstanding any 

2 other provision of this title’’ and inserting 

3 ‘‘Notwithstanding section 1902(a)(1) (relat4 ing to statewideness), section 

5 1902(a)(10)(B) (relating to comparability) 

6 and any other provision of this title which 

7 would be directly contrary to the authority 

8 under this section and subject to subsection 

9 (E)’’; and 

10 (ii) by striking ‘‘enrollment in coverage 

11 that provides’’ and inserting ‘‘coverage 

12 that’’; 

13 (B) in clause (i), by inserting ‘‘provides’’ 

14 after ‘‘(i)’’; and 

15 (C) by striking clause (ii) and inserting the 

16 following: 

17 ‘‘(ii) for any individual described in 

18 section 1905(a)(4)(B) who is eligible under 

19 the State plan in accordance with para20 graphs (10) and (17) of section 1902(a), 

21 consists of the items and services described 

22 in section 1905(a)(4)(B) (relating to early 

23 and periodic screening, diagnostic, and 

24 treatment services defined in section 
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1 1905(r)) and provided in accordance with 

2 the requirements of section 1902(a)(43).’’; 

3 (2) in subparagraph (C)— 

4 (A) in the heading, by striking ‘‘WRAP5 AROUND’’ and inserting ‘‘ADDITIONAL’’; and 

6 (B) by striking ‘‘wrap-around or’’; and 

7 (3) by adding at the end the following new sub8 paragraph: 

9 ‘‘(E) RULE OF CONSTRUCTION.—Nothing in 

10 this paragraph shall be construed as— 

11 ‘‘(i) requiring a State to offer all or 

12 any of the items and services required by 

13 subparagraph (A)(ii) through an issuer of 

14 benchmark coverage described in subsection 

15 (b)(1) or benchmark equivalent coverage de16 scribed in subsection (b)(2); 

17 ‘‘(ii) preventing a State from offering 

18 all or any of the items and services required 

19 by subparagraph (A)(ii) through an issuer 

20 of benchmark coverage described in sub21 section (b)(1) or benchmark equivalent cov22 erage described in subsection (b)(2); or 

23 ‘‘(iii) affecting a child’s entitlement to 

24 care and services described in subsections 

25 (a)(4)(B) and (r) of section 1905 and pro-
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1 vided in accordance with section 

2 1902(a)(43) whether provided through 

3 benchmark coverage, benchmark equivalent 

4 coverage, or otherwise.’’. 

5 (b) CORRECTION OF REFERENCE TO CHILDREN IN

6 FOSTER CARE RECEIVING CHILD WELFARE SERVICES.— 

7 Section 1937(a)(2)(B)(viii) (42 U.S.C. 1396u– 

8 7(a)(2)(B)(viii)), as inserted by section 6044(a) of the Def9 icit Reduction Act of 2005, is amended by striking ‘‘aid 

10 or assistance is made available under part B of title IV 

11 to children in foster care and individuals’’ and inserting 

12 ‘‘child welfare services are made available under part B of 

13 title IV on the basis of being a child in foster care or’’. 

14 (c) TRANSPARENCY.—Section 1937 (42 U.S.C. 1396u– 

15 7), as inserted by section 6044(a) of the Deficit Reduction 

16 Act of 2005, is amended by adding at the end the following: 

17 ‘‘(c) PUBLICATION OF PROVISIONS AFFECTED.—With 

18 respect to a State plan amendment to provide benchmark 

19 benefits in accordance with subsections (a) and (b) that is 

20 approved by the Secretary, the Secretary shall publish on 

21 the Internet website of the Centers for Medicare & Medicaid 

22 Services, a list of the provisions of this title that the Sec23 retary has determined do not apply in order to enable the 

24 State to carry out the plan amendment and the reason for 

25 each such determination on the date such approval is made, 
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1 and shall publish such list in the Federal Register and not 

2 later than 30 days after such date of approval.’’. 

3 (d) EFFECTIVE DATE.—The amendments made by 

4 subsections (a), (b), and (c) of this section shall take effect 

5 as if included in the amendment made by section 6044(a) 

6 of the Deficit Reduction Act of 2005. 

7 SEC. 612. REFERENCES TO TITLE XXI. 

8 Section 704 of the Medicare, Medicaid, and SCHIP 

9 Balanced Budget Refinement Act of 1999, as enacted into 

10 law by division B of Public Law 106–113 (113 Stat. 

11 1501A–402) is repealed. 

12 SEC. 613. PROHIBITING INITIATION OF NEW HEALTH OP13 PORTUNITY ACCOUNT DEMONSTRATION PRO14 GRAMS. 

15 After the date of the enactment of this Act, the Sec16 retary of Health and Human Services may not approve any 

17 new demonstration programs under section 1938 of the So18 cial Security Act (42 U.S.C. 1396u–8). 

19 SEC. 614. ADJUSTMENT IN COMPUTATION OF MEDICAID 

20 FMAP TO DISREGARD AN EXTRAORDINARY 

21 EMPLOYER PENSION CONTRIBUTION. 

22 (a) IN GENERAL.—Only for purposes of computing the 

23 FMAP (as defined in subsection (e)) for a State for a fiscal 

24 year (beginning with fiscal year 2006) and applying the 

25 FMAP under title XIX of the Social Security Act, any sig-
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1 nificantly disproportionate employer pension or insurance 

2 fund contribution described in subsection (b) shall be dis3 regarded in computing the per capita income of such State, 

4 but shall not be disregarded in computing the per capita 

5 income for the continental United States (and Alaska) and 

6 Hawaii. 

7 (b) SIGNIFICANTLY DISPROPORTIONATE EMPLOYER

8 PENSION AND INSURANCE FUND CONTRIBUTION.— 

9 (1) IN GENERAL.—For purposes of this section, 

10 a significantly disproportionate employer pension 

11 and insurance fund contribution described in this 

12 subsection with respect to a State is any identifiable 

13 employer contribution towards pension or other em14 ployee insurance funds that is estimated to accrue to 

15 residents of such State for a calendar year (beginning 

16 with calendar year 2003) if the increase in the 

17 amount so estimated exceeds 25 percent of the total 

18 increase in personal income in that State for the year 

19 involved. 

20 (2) DATA TO BE USED.—For estimating and ad21 justment a FMAP already calculated as of the date of 

22 the enactment of this Act for a State with a signifi23 cantly disproportionate employer pension and insur24 ance fund contribution, the Secretary shall use the 
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1 personal income data set originally used in calcu2 lating such FMAP. 

3 (3) SPECIAL ADJUSTMENT FOR NEGATIVE

4 GROWTH.—If in any calendar year the total personal 

5 income growth in a State is negative, an employer 

6 pension and insurance fund contribution for the pur7 poses of calculating the State’s FMAP for a calendar 

8 year shall not exceed 125 percent of the amount of 

9 such contribution for the previous calendar year for 

10 the State. 

11 (c) HOLD HARMLESS.—No State shall have its FMAP 

12 for a fiscal year reduced as a result of the application of 

13 this section. 

14 (d) REPORT.—Not later than May 15, 2009, the Sec15 retary shall submit to the Congress a report on the problems 

16 presented by the current treatment of pension and insur17 ance fund contributions in the use of Bureau of Economic 

18 Affairs calculations for the FMAP and for Medicaid and 

19 on possible alternative methodologies to mitigate such prob20 lems. 

21 (e) FMAP DEFINED.—For purposes of this section, the 

22 term ‘‘FMAP’’ means the Federal medical assistance per23 centage, as defined in section 1905(b) of the Social Security 

24 Act (42 U.S.C. 1396(d)). 
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1 SEC. 615. CLARIFICATION TREATMENT OF REGIONAL MED2 ICAL CENTER. 

3 (a) IN GENERAL.—Nothing in section 1903(w) of the 

4 Social Security Act (42 U.S.C. 1396b(w)) shall be construed 

5 by the Secretary of Health and Human Services as prohib6 iting a State’s use of funds as the non-Federal share of ex7 penditures under title XIX of such Act where such funds 

8 are transferred from or certified by a publicly-owned re9 gional medical center located in another State and de10 scribed in subsection (b), so long as the Secretary deter11 mines that such use of funds is proper and in the interest 

12 of the program under title XIX. 

13 (b) CENTER DESCRIBED.—A center described in this 

14 subsection is a publicly-owned regional medical center 

15 that— 

16 (1) provides level 1 trauma and burn care serv17 ices; 

18 (2) provides level 3 neonatal care services; 

19 (3) is obligated to serve all patients, regardless of 

20 ability to pay; 

21 (4) is located within a Standard Metropolitan 

22 Statistical Area (SMSA) that includes at least 3 

23 States; 

24 (5) provides services as a tertiary care provider 

25 for patients residing within a 125-mile radius; and 
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1 (6) meets the criteria for a disproportionate 

2 share hospital under section 1923 of such Act (42 

3 U.S.C. 1396r–4) in at least one State other than the 

4 State in which the center is located. 

5 SEC. 616. EXTENSION OF MEDICAID DSH ALLOTMENTS FOR 

6 TENNESSEE AND HAWAII. 

7 Section 1923(f)(6) (42 U.S.C. 1396r–4(f)(6)), as 

8 amended by section 202 of the Medicare Improvements for 

9 Patients and Providers Act of 2008 (Public Law 110–275) 

10 is amended— 

11 (1) in the paragraph heading, by striking ‘‘2009

12 AND THE FIRST CALENDAR QUARTER OF FISCAL YEAR

13 2010’’ and inserting ‘‘2011 AND THE FIRST CALENDAR

14 QUARTER OF FISCAL YEAR 2012’’; 

15 (2) in subparagraph (A)— 

16 (A) in clause (i)— 

17 (i) in the second sentence— 

18 (I) by striking ‘‘and 2009’’ and 

19 inserting ‘‘, 2009, 2010, and 2011’’; 

20 and 

21 (II) by striking ‘‘such portion of’’; 

22 and 

23 (ii) in the third sentence, by striking 

24 ‘‘2010 for the period ending on December 
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1 31, 2009’’ and inserting ‘‘2012 for the pe2 riod ending on December 31, 2011’’; 

3 (B) in clause (ii), by striking ‘‘or for a pe4 riod in fiscal year 2010’’ and inserting ‘‘2010, 

5 2011, or for period in fiscal year 2012’’; and 

6 (C) in clause (iv)— 

7 (i) in the clause heading, by striking 

8 ‘‘2009 AND THE FIRST CALENDAR QUARTER

9 OF FISCAL YEAR 2010’’ and inserting ‘‘2011

10 AND THE FIRST CALENDAR QUARTER OF

11 FISCAL YEAR 2012’’; and 

12 (ii) in each of subclauses (I) and (II), 

13 by striking ‘‘ or for a period in fiscal year 

14 2010’’ and inserting ‘‘2010, 2011, or for a 

15 period in fiscal year 2012’’; and 

16 (3) in subparagraph (B)— 

17 (A) in clause (i)— 

18 (i) in the first sentence, by striking 

19 ‘‘2009’’ and inserting ‘‘2011’’; and 

20 (ii) in the second sentence, by striking 

21 ‘‘2010 for the period ending on December 

22 31, 2009’’ and inserting ‘‘2012 for the pe23 riod ending on December 31, 2011’’. 
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1 SEC. 617. GAO REPORT ON MEDICAID MANAGED CARE PAY2 MENT RATES. 

3 Not later than 18 months after the date of the enact4 ment of this Act, the Comptroller General of the United 

5 States shall submit a report to the Committee on Finance 

6 of the Senate and the Committee on Energy and Commerce 

7 of the House of Representatives analyzing the extent to 

8 which State payment rates for medicaid managed care or9 ganizations under Medicaid are actuarially sound. 

10 Subtitle C—Other Provisions 

11 SEC. 621. OUTREACH REGARDING HEALTH INSURANCE OP12 TIONS AVAILABLE TO CHILDREN. 

13 (a) DEFINITIONS.—In this section— 

14 (1) the terms ‘‘Administration’’ and ‘‘Adminis15 trator’’ means the Small Business Administration 

16 and the Administrator thereof, respectively; 

17 (2) the term ‘‘certified development company’’ 

18 means a development company participating in the 

19 program under title V of the Small Business Invest20 ment Act of 1958 (15 U.S.C. 695 et seq.); 

21 (3) the term ‘‘Medicaid program’’ means the pro22 gram established under title XIX of the Social Secu23 rity Act (42 U.S.C. 1396 et seq.); 

24 (4) the term ‘‘Service Corps of Retired Execu25 tives’’ means the Service Corps of Retired Executives 
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1 authorized by section 8(b)(1) of the Small Business 

2 Act (15 U.S.C. 637(b)(1)); 

3 (5) the term ‘‘small business concern’’ has the 

4 meaning given that term in section 3 of the Small 

5 Business Act (15 U.S.C. 632); 

6 (6) the term ‘‘small business development center’’ 

7 means a small business development center described 

8 in section 21 of the Small Business Act (15 U.S.C. 

9 648); 

10 (7) the term ‘‘State’’ has the meaning given that 

11 term for purposes of title XXI of the Social Security 

12 Act (42 U.S.C. 1397aa et seq.); 

13 (8) the term ‘‘State Children’s Health Insurance 

14 Program’’ means the State Children’s Health Insur15 ance Program established under title XXI of the So16 cial Security Act (42 U.S.C. 1397aa et seq.); 

17 (9) the term ‘‘task force’’ means the task force es18 tablished under subsection (b)(1); and 

19 (10) the term ‘‘women’s business center’’ means 

20 a women’s business center described in section 29 of 

21 the Small Business Act (15 U.S.C. 656). 

22 (b) ESTABLISHMENT OF TASK FORCE.— 

23 (1) ESTABLISHMENT.—There is established a 

24 task force to conduct a nationwide campaign of edu25 cation and outreach for small business concerns re-
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1 garding the availability of coverage for children 

2 through private insurance options, the Medicaid pro3 gram, and the State Children’s Health Insurance Pro4 gram. 

5 (2) MEMBERSHIP.—The task force shall consist 

6 of the Administrator, the Secretary of Health and 

7 Human Services, the Secretary of Labor, and the Sec8 retary of the Treasury. 

9 (3) RESPONSIBILITIES.—The campaign con10 ducted under this subsection shall include— 

11 (A) efforts to educate the owners of small 

12 business concerns about the value of health cov13 erage for children; 

14 (B) information regarding options available 

15 to the owners and employees of small business 

16 concerns to make insurance more affordable, in17 cluding Federal and State tax deductions and 

18 credits for health care-related expenses and 

19 health insurance expenses and Federal tax exclu20 sion for health insurance options available under 

21 employer-sponsored cafeteria plans under section 

22 125 of the Internal Revenue Code of 1986; 

23 (C) efforts to educate the owners of small 

24 business concerns about assistance available 

25 through public programs; and 
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1 (D) efforts to educate the owners and em2 ployees of small business concerns regarding the 

3 availability of the hotline operated as part of the 

4 Insure Kids Now program of the Department of 

5 Health and Human Services. 

6 (4) IMPLEMENTATION.—In carrying out this sub7 section, the task force may— 

8 (A) use any business partner of the Admin9 istration, including— 

10 (i) a small business development cen11 ter; 

12 (ii) a certified development company; 

13 (iii) a women’s business center; and 

14 (iv) the Service Corps of Retired Ex15 ecutives; 

16 (B) enter into— 

17 (i) a memorandum of understanding 

18 with a chamber of commerce; and 

19 (ii) a partnership with any appro20 priate small business concern or health ad21 vocacy group; and 

22 (C) designate outreach programs at regional 

23 offices of the Department of Health and Human 

24 Services to work with district offices of the Ad25 ministration. 
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1 (5) WEBSITE.—The Administrator shall ensure 

2 that links to information on the eligibility and enroll3 ment requirements for the Medicaid program and 

4 State Children’s Health Insurance Program of each 

5 State are prominently displayed on the website of the 

6 Administration. 

7 (6) REPORT.— 

8 (A) IN GENERAL.—Not later than 2 years 

9 after the date of enactment of this Act, and every 

10 2 years thereafter, the Administrator shall sub11 mit to the Committee on Small Business and 

12 Entrepreneurship of the Senate and the Com13 mittee on Small Business of the House of Rep14 resentatives a report on the status of the nation15 wide campaign conducted under paragraph (1). 

16 (B) CONTENTS.—Each report submitted 

17 under subparagraph (A) shall include a status 

18 update on all efforts made to educate owners and 

19 employees of small business concerns on options 

20 for providing health insurance for children 

21 through public and private alternatives. 

22 SEC. 622. SENSE OF THE SENATE REGARDING ACCESS TO 

23 AFFORDABLE AND MEANINGFUL HEALTH IN24 SURANCE COVERAGE. 

25 (a) FINDINGS.—The Senate finds the following: 
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1 (1) There are approximately 45 million Ameri2 cans currently without health insurance. 

3 (2) More than half of uninsured workers are em4 ployed by businesses with less than 25 employees or 

5 are self-employed. 

6 (3) Health insurance premiums continue to rise 

7 at more than twice the rate of inflation for all con8 sumer goods. 

9 (4) Individuals in the small group and indi10 vidual health insurance markets usually pay more for 

11 similar coverage than those in the large group market. 

12 (5) The rapid growth in health insurance costs 

13 over the last few years has forced many employers, 

14 particularly small employers, to increase deductibles 

15 and co-pays or to drop coverage completely. 

16 (b) SENSE OF THE SENATE.—The Senate— 

17 (1) recognizes the necessity to improve afford18 ability and access to health insurance for all Ameri19 cans; 

20 (2) acknowledges the value of building upon the 

21 existing private health insurance market; and 

22 (3) affirms its intent to enact legislation this 

23 year that, with appropriate protection for consumers, 

24 improves access to affordable and meaningful health 
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1 insurance coverage for employees of small businesses 

2 and individuals by— 

3 (A) facilitating pooling mechanisms, in4 cluding pooling across State lines, and 

5 (B) providing assistance to small businesses 

6 and individuals, including financial assistance 

7 and tax incentives, for the purchase of private 

8 insurance coverage. 

9 TITLE VII—REVENUE 

10 PROVISIONS 

11 SEC. 701. INCREASE IN EXCISE TAX RATE ON TOBACCO 

12 PRODUCTS. 

13 (a) CIGARS.—Section 5701(a) of the Internal Revenue 

14 Code of 1986 is amended— 

15 (1) by striking ‘‘$1.828 cents per thousand 

16 ($1.594 cents per thousand on cigars removed during 

17 2000 or 2001)’’ in paragraph (1) and inserting 

18 ‘‘$50.33 per thousand’’, 

19 (2) by striking ‘‘20.719 percent (18.063 percent 

20 on cigars removed during 2000 or 2001)’’ in para21 graph (2) and inserting ‘‘52.75 percent’’, and 

22 (3) by striking ‘‘$48.75 per thousand ($42.50 per 

23 thousand on cigars removed during 2000 or 2001)’’ in 

24 paragraph (2) and inserting ‘‘40.26 cents per cigar’’. 
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1 (b) CIGARETTES.—Section 5701(b) of such Code is 

2 amended— 

3 (1) by striking ‘‘$19.50 per thousand ($17 per 

4 thousand on cigarettes removed during 2000 or 

5 2001)’’ in paragraph (1) and inserting ‘‘$50.33 per 

6 thousand’’, and 

7 (2) by striking ‘‘$40.95 per thousand ($35.70 per 

8 thousand on cigarettes removed during 2000 or 

9 2001)’’ in paragraph (2) and inserting ‘‘$105.69 per 

10 thousand’’. 

11 (c) CIGARETTE PAPERS.—Section 5701(c) of such 

12 Code is amended by striking ‘‘1.22 cents (1.06 cents on ciga13 rette papers removed during 2000 or 2001)’’ and inserting 

14 ‘‘3.15 cents’’. 

15 (d) CIGARETTE TUBES.—Section 5701(d) of such Code 

16 is amended by striking ‘‘2.44 cents (2.13 cents on cigarette 

17 tubes removed during 2000 or 2001)’’ and inserting ‘‘6.30 

18 cents’’. 

19 (e) SMOKELESS TOBACCO.—Section 5701(e) of such 

20 Code is amended— 

21 (1) by striking ‘‘58.5 cents (51 cents on snuff re22 moved during 2000 or 2001)’’ in paragraph (1) and 

23 inserting ‘‘$1.51’’, and 
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1 (2) by striking ‘‘19.5 cents (17 cents on chewing 

2 tobacco removed during 2000 or 2001)’’ in paragraph 

3 (2) and inserting ‘‘50.33 cents’’. 

4 (f) PIPE TOBACCO.—Section 5701(f) of such Code is 

5 amended by striking ‘‘$1.0969 cents (95.67 cents on pipe 

6 tobacco removed during 2000 or 2001)’’ and inserting 

7 ‘‘$2.8311 cents’’. 

8 (g) ROLL-YOUR-OWN TOBACCO.—Section 5701(g) of 

9 such Code is amended by striking ‘‘$1.0969 cents (95.67 

10 cents on roll-your-own tobacco removed during 2000 or 

11 2001)’’ and inserting ‘‘$24.78’’. 

12 (h) FLOOR STOCKS TAXES.— 

13 (1) IMPOSITION OF TAX.—On tobacco products 

14 (other than cigars described in section 5701(a)(2) of 

15 the Internal Revenue Code of 1986) and cigarette pa16 pers and tubes manufactured in or imported into the 

17 United States which are removed before April 1, 

18 2009, and held on such date for sale by any person, 

19 there is hereby imposed a tax in an amount equal to 

20 the excess of— 

21 (A) the tax which would be imposed under 

22 section 5701 of such Code on the article if the ar23 ticle had been removed on such date, over 

24 (B) the prior tax (if any) imposed under 

25 section 5701 of such Code on such article. 
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1 (2) CREDIT AGAINST TAX.—Each person shall be 

2 allowed as a credit against the taxes imposed by 

3 paragraph (1) an amount equal to $500. Such credit 

4 shall not exceed the amount of taxes imposed by para5 graph (1) on April 1, 2009, for which such person is 

6 liable. 

7 (3) LIABILITY FOR TAX AND METHOD OF PAY8 MENT.— 

9 (A) LIABILITY FOR TAX.—A person holding 

10 tobacco products, cigarette papers, or cigarette 

11 tubes on April 1, 2009, to which any tax im12 posed by paragraph (1) applies shall be liable for 

13 such tax. 

14 (B) METHOD OF PAYMENT.—The tax im15 posed by paragraph (1) shall be paid in such 

16 manner as the Secretary shall prescribe by regu17 lations. 

18 (C) TIME FOR PAYMENT.—The tax imposed 

19 by paragraph (1) shall be paid on or before Au20 gust 1, 2009. 

21 (4) ARTICLES IN FOREIGN TRADE ZONES.—Not22 withstanding the Act of June 18, 1934 (commonly 

23 known as the Foreign Trade Zone Act, 48 Stat. 998, 

24 19 U.S.C. 81a et seq.) or any other provision of law, 

25 any article which is located in a foreign trade zone 
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1 on April 1, 2009, shall be subject to the tax imposed 

2 by paragraph (1) if— 

3 (A) internal revenue taxes have been deter4 mined, or customs duties liquidated, with respect 

5 to such article before such date pursuant to a re6 quest made under the 1st proviso of section 3(a) 

7 of such Act, or 

8 (B) such article is held on such date under 

9 the supervision of an officer of the United States 

10 Customs and Border Protection of the Depart11 ment of Homeland Security pursuant to the 2d 

12 proviso of such section 3(a). 

13 (5) DEFINITIONS.—For purposes of this sub14 section— 

15 (A) IN GENERAL.—Any term used in this 

16 subsection which is also used in section 5702 of 

17 the Internal Revenue Code of 1986 shall have the 

18 same meaning as such term has in such section. 

19 (B) SECRETARY.—The term ‘‘Secretary’’ 

20 means the Secretary of the Treasury or the Sec21 retary’s delegate. 

22 (6) CONTROLLED GROUPS.—Rules similar to the 

23 rules of section 5061(e)(3) of such Code shall apply 

24 for purposes of this subsection. 
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1 (7) OTHER LAWS APPLICABLE.—All provisions of 

2 law, including penalties, applicable with respect to 

3 the taxes imposed by section 5701 of such Code shall, 

4 insofar as applicable and not inconsistent with the 

5 provisions of this subsection, apply to the floor stocks 

6 taxes imposed by paragraph (1), to the same extent 

7 as if such taxes were imposed by such section 5701. 

8 The Secretary may treat any person who bore the ul9 timate burden of the tax imposed by paragraph (1) 

10 as the person to whom a credit or refund under such 

11 provisions may be allowed or made. 

12 (i) EFFECTIVE DATE.—The amendments made by this 

13 section shall apply to articles removed (as defined in section 

14 5702(j) of the Internal Revenue Code of 1986) after March 

15 31, 2009. 

16 SEC. 702. ADMINISTRATIVE IMPROVEMENTS. 

17 (a) PERMIT, INVENTORIES, REPORTS, AND RECORDS

18 REQUIREMENTS FOR MANUFACTURERS AND IMPORTERS OF

19 PROCESSED TOBACCO.— 

20 (1) PERMIT.— 

21 (A) APPLICATION.—Section 5712 of the In22 ternal Revenue Code of 1986 is amended by in23 serting ‘‘or processed tobacco’’ after ‘‘tobacco 

24 products’’. 
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1 (B) ISSUANCE.—Section 5713(a) of such 

2 Code is amended by inserting ‘‘or processed to3 bacco’’ after ‘‘tobacco products’’. 

4 (2) INVENTORIES, REPORTS, AND PACKAGES.— 

5 (A) INVENTORIES.—Section 5721 of such 

6 Code is amended by inserting ‘‘, processed to7 bacco,’’ after ‘‘tobacco products’’. 

8 (B) REPORTS.—Section 5722 of such Code 

9 is amended by inserting ‘‘, processed tobacco,’’ 

10 after ‘‘tobacco products’’. 

11 (C) PACKAGES, MARKS, LABELS, AND NO12 TICES.—Section 5723 of such Code is amended 

13 by inserting ‘‘, processed tobacco,’’ after ‘‘tobacco 

14 products’’ each place it appears. 

15 (3) RECORDS.—Section 5741 of such Code is 

16 amended by inserting ‘‘, processed tobacco,’’ after ‘‘to17 bacco products’’. 

18 (4) MANUFACTURER OF PROCESSED TOBACCO.— 

19 Section 5702 of such Code is amended by adding at 

20 the end the following new subsection: 

21 ‘‘(p) MANUFACTURER OF PROCESSED TOBACCO.— 

22 ‘‘(1) IN GENERAL.—The term ‘manufacturer of 

23 processed tobacco’ means any person who processes 

24 any tobacco other than tobacco products. 
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1 ‘‘(2) PROCESSED TOBACCO.—The processing of 

2 tobacco shall not include the farming or growing of 

3 tobacco or the handling of tobacco solely for sale, ship4 ment, or delivery to a manufacturer of tobacco prod5 ucts or processed tobacco.’’. 

6 (5) CONFORMING AMENDMENTS.— 

7 (A) Section 5702(h) of such Code is amend8 ed by striking ‘‘tobacco products and cigarette 

9 papers and tubes’’ and inserting ‘‘tobacco prod10 ucts or cigarette papers or tubes or any processed 

11 tobacco’’. 

12 (B) Sections 5702(j) and 5702(k) of such 

13 Code are each amended by inserting ‘‘, or any 

14 processed tobacco,’’ after ‘‘tobacco products or 

15 cigarette papers or tubes’’. 

16 (6) EFFECTIVE DATE.—The amendments made 

17 by this subsection shall take effect on April 1, 2009. 

18 (b) BASIS FOR DENIAL, SUSPENSION, OR REVOCATION

19 OF PERMITS.— 

20 (1) DENIAL.—Paragraph (3) of section 5712 of 

21 such Code is amended to read as follows: 

22 ‘‘(3) such person (including, in the case of a cor23 poration, any officer, director, or principal stock24 holder and, in the case of a partnership, a partner)— 
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1 ‘‘(A) is, by reason of his business experience, 

2 financial standing, or trade connections or by 

3 reason of previous or current legal proceedings 

4 involving a felony violation of any other provi5 sion of Federal criminal law relating to tobacco 

6 products, processed tobacco, cigarette paper, or 

7 cigarette tubes, not likely to maintain operations 

8 in compliance with this chapter, 

9 ‘‘(B) has been convicted of a felony violation 

10 of any provision of Federal or State criminal 

11 law relating to tobacco products, processed to12 bacco, cigarette paper, or cigarette tubes, or 

13 ‘‘(C) has failed to disclose any material in14 formation required or made any material false 

15 statement in the application therefor.’’. 

16 (2) SUSPENSION OR REVOCATION.—Subsection 

17 (b) of section 5713 of such Code is amended to read 

18 as follows: 

19 ‘‘(b) SUSPENSION OR REVOCATION.— 

20 ‘‘(1) SHOW CAUSE HEARING.—If the Secretary 

21 has reason to believe that any person holding a per22 mit— 

23 ‘‘(A) has not in good faith complied with 

24 this chapter, or with any other provision of this 

25 title involving intent to defraud, 
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1 ‘‘(B) has violated the conditions of such per2 mit, 

3 ‘‘(C) has failed to disclose any material in4 formation required or made any material false 

5 statement in the application for such permit, 

6 ‘‘(D) has failed to maintain his premises in 

7 such manner as to protect the revenue, 

8 ‘‘(E) is, by reason of previous or current 

9 legal proceedings involving a felony violation of 

10 any other provision of Federal criminal law re11 lating to tobacco products, processed tobacco, cig12 arette paper, or cigarette tubes, not likely to 

13 maintain operations in compliance with this 

14 chapter, or 

15 ‘‘(F) has been convicted of a felony violation 

16 of any provision of Federal or State criminal 

17 law relating to tobacco products, processed to18 bacco, cigarette paper, or cigarette tubes, 

19 the Secretary shall issue an order, stating the facts 

20 charged, citing such person to show cause why his 

21 permit should not be suspended or revoked. 

22 ‘‘(2) ACTION FOLLOWING HEARING.—If, after 

23 hearing, the Secretary finds that such person has not 

24 shown cause why his permit should not be suspended 

25 or revoked, such permit shall be suspended for such 
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1 period as the Secretary deems proper or shall be re2 voked.’’. 

3 (3) EFFECTIVE DATE.—The amendments made 

4 by this subsection shall take effect on the date of the 

5 enactment of this Act. 

6 (c) APPLICATION OF INTERNAL REVENUE CODE STAT7 UTE OF LIMITATIONS FOR ALCOHOL AND TOBACCO EXCISE

8 TAXES.— 

9 (1) IN GENERAL.—Section 514(a) of the Tariff 

10 Act of 1930 (19 U.S.C. 1514(a)) is amended by strik11 ing ‘‘and section 520 (relating to refunds)’’ and in12 serting ‘‘section 520 (relating to refunds), and section 

13 6501 of the Internal Revenue Code of 1986 (but only 

14 with respect to taxes imposed under chapters 51 and 

15 52 of such Code)’’. 

16 (2) EFFECTIVE DATE.—The amendment made by 

17 this subsection shall apply to articles imported after 

18 the date of the enactment of this Act. 

19 (d) EXPANSION OF DEFINITION OF ROLL-YOUR-OWN

20 TOBACCO.— 

21 (1) IN GENERAL.—Section 5702(o) of the Inter22 nal Revenue Code of 1986 is amended by inserting 

23 ‘‘or cigars, or for use as wrappers thereof’’ before the 

24 period at the end. 
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1 (2) EFFECTIVE DATE.—The amendment made by 

2 this subsection shall apply to articles removed (as de3 fined in section 5702(j) of the Internal Revenue Code 

4 of 1986) after March 31, 2009. 

5 (e) TIME OF TAX FOR UNLAWFULLY MANUFACTURED

6 TOBACCO PRODUCTS.— 

7 (1) IN GENERAL.—Section 5703(b)(2) of such 

8 Code is amended by adding at the end the following 

9 new subparagraph: 

10 ‘‘(F) SPECIAL RULE FOR UNLAWFULLY MAN11 UFACTURED TOBACCO PRODUCTS.—In the case of 

12 any tobacco products, cigarette paper, or ciga13 rette tubes manufactured in the United States at 

14 any place other than the premises of a manufac15 turer of tobacco products, cigarette paper, or cig16 arette tubes that has filed the bond and obtained 

17 the permit required under this chapter, tax shall 

18 be due and payable immediately upon manufac19 ture.’’. 

20 (2) EFFECTIVE DATE.—The amendment made by 

21 this subsection shall take effect on the date of the en22 actment of this Act. 

23 (f) DISCLOSURE.— 

24 (1) IN GENERAL.—Paragraph (1) of section 

25 6103(o) of such Code is amended by designating the 
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1 text as subparagraph (A), moving such text 2 ems to 

2 the right, striking ‘‘Returns’’ and inserting ‘‘(A) IN

3 GENERAL.—Returns’’, and by inserting after subpara4 graph (A) (as so redesignated) the following new sub5 paragraph: 

6 ‘‘(B) USE IN CERTAIN PROCEEDINGS.—Re7 turns and return information disclosed to a Fed8 eral agency under subparagraph (A) may be 

9 used in an action or proceeding (or in prepara10 tion for such action or proceeding) brought under 

11 section 625 of the American Jobs Creation Act of 

12 2004 for the collection of any unpaid assessment 

13 or penalty arising under such Act.’’. 

14 (2) CONFORMING AMENDMENT.—Section 

15 6103(p)(4) of such Code is amended by striking 

16 ‘‘(o)(1)’’ both places it appears and inserting 

17 ‘‘(o)(1)(A)’’. 

18 (3) EFFECTIVE DATE.—The amendments made 

19 by this subsection shall apply on or after the date of 

20 the enactment of this Act. 

21 (g) TRANSITIONAL RULE.—Any person who— 

22 (1) on April 1, 2009 is engaged in business as 

23 a manufacturer of processed tobacco or as an im24 porter of processed tobacco, and 
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1 (2) before the end of the 90-day period beginning 

2 on such date, submits an application under sub3 chapter B of chapter 52 of such Code to engage in 

4 such business, may, notwithstanding such subchapter 

5 B, continue to engage in such business pending final 

6 action on such application. Pending such final ac7 tion, all provisions of such chapter 52 shall apply to 

8 such applicant in the same manner and to the same 

9 extent as if such applicant were a holder of a permit 

10 under such chapter 52 to engage in such business. 

11 SEC. 703. TREASURY STUDY CONCERNING MAGNITUDE OF 

12 TOBACCO SMUGGLING IN THE UNITED 

13 STATES. 

14 Not later than one year after the date of the enactment 

15 of this Act, the Secretary of the Treasury shall conduct a 

16 study concerning the magnitude of tobacco smuggling in the 

17 United States and submit to Congress recommendations for 

18 the most effective steps to reduce tobacco smuggling. Such 

19 study shall also include a review of the loss of Federal tax 

20 receipts due to illicit tobacco trade in the United States and 

21 the role of imported tobacco products in the illicit tobacco 

22 trade in the United States. 
279 

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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. 

Attest: 

Secretary. 
111TH CONGRESS 

1ST SESSION H.R. 2 

AMENDMENT