II 

Calendar No. 18 

111TH CONGRESS 

1ST SESSION H. R. 2 

IN THE SENATE OF THE UNITED STATES 

JANUARY 14, 2009 

Received 

JANUARY 16, 2009 

Read twice and placed on the calendar 

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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 


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1 SECTION 1. SHORT TITLE; 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.—Ex8 cept as otherwise specifically provided, whenever in this 

9 Act an amendment is expressed in terms of an amendment 

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

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

12 provision of the Social Security Act. 

13 (c) REFERENCES TO CHIP; MEDICAID; SEC14 RETARY.—In this Act: 

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

16 State Children’s Health Insurance Program estab17 lished under title XXI of the Social Security Act (42 

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

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

20 the program for medical assistance established under 

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

22 et seq.). 

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

24 the Secretary of Health and Human Services. 

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

26 this Act is as follows: 


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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. 

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. 


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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. 

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. 

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. 

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. 

Subtitle C—Other Provisions 

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


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

health insurance coverage. 

Sec. 623. Limitation on Medicare exception to the prohibition on certain physician referrals for hospitals. 

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 

3 and stable funding for children’s health insurance under 

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

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

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

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

8 LEGISLATION; CONTINGENT EFFECTIVE 

9 DATE; RELIANCE ON LAW. 

10 (a) GENERAL EFFECTIVE DATE.—Unless otherwise 

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

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

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

14 health assistance and medical assistance provided on or 

15 after that date. 

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

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

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

20 State legislation in order for the respective plan to meet 


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1 one or more additional requirements imposed by amend2 ments made by this Act, the respective plan shall not be 

3 regarded as failing to comply with the requirements of 

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

5 an additional requirement before the first day of the first 

6 calendar quarter beginning after the close of the first reg7 ular session of the State legislature that begins after the 

8 date of enactment of this Act. For purposes of the pre9 vious sentence, in the case of a State that has a 2-year 

10 legislative session, each year of the session shall be consid11 ered to be a separate regular session of the State legisla12 ture. 

13 (c) COORDINATION OF CHIP FUNDING FOR FISCAL

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

15 insofar as funds have been appropriated under section 

16 2104(a)(11), 2104(k), or 2104(l) of the Social Security 

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

18 to provide allotments to States under CHIP for fiscal year 

19 2009— 

20 (1) any amounts that are so appropriated that 

21 are not so allotted and obligated before April 1, 

22 2009, are rescinded; and 

23 (2) any amount provided for CHIP allotments 

24 to a State under this Act (and the amendments 

25 made by this Act) for such fiscal year shall be reVerDate Nov 24 2008 21:36 Jan 16, 2009 Jkt 079200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H2.PCS H2

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1 duced by the amount of such appropriations so allot2 ted and obligated before such date. 

3 (d) RELIANCE ON LAW.—With respect to amend4 ments made by this Act (other than title VII) that become 

5 effective as of a date— 

6 (1) such amendments are effective as of such 

7 date whether or not regulations implementing such 

8 amendments have been issued; and 

9 (2) Federal financial participation for medical 

10 assistance or child health assistance furnished under 

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

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

13 reliance on such amendments before the date of pro14 mulgation of final regulations, if any, to carry out 

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

16 any, regarding the implementation of such amend17 ments) shall not be denied on the basis of the 

18 State’s failure to comply with such regulations or 

19 guidance. 

20 TITLE I—FINANCING 

21 Subtitle A—Funding 

22 SEC. 101. EXTENSION OF CHIP. 

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

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

25 end; 


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

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

3 ‘‘fiscal year 2008’’; and 

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

5 paragraphs: 

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

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

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

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

10 and 

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

13 ‘‘(A) $3,000,000,000 for the period begin14 ning on October 1, 2012, and ending on March 

15 31, 2013, and 

16 ‘‘(B) $3,000,000,000 for the period begin17 ning on April 1, 2013, and ending on Sep18 tember 30, 2013.’’. 

19 SEC. 102. ALLOTMENTS FOR STATES AND TERRITORIES 

20 FOR FISCAL YEARS 2009 THROUGH 2013. 

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

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

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


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

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

3 and 

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

6 ‘‘(m) ALLOTMENTS FOR FISCAL YEARS 2009 

7 THROUGH 2013.— 

8 ‘‘(1) FOR FISCAL YEAR 2009.— 

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

13 year 2009 from the amount made available 

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

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

17 such State or District: 

18 ‘‘(i) The total Federal payments to 

19 the State under this title for fiscal year 

20 2008, multiplied by the allotment increase 

21 factor determined under paragraph (5) for 

22 fiscal year 2009. 

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

24 for fiscal year 2008 under subsection (b), 

25 multiplied by the allotment increase factor 


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1 determined under paragraph (5) for fiscal 

2 year 2009. 

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

6 of the February 2009 projections certified 

7 by the State to the Secretary by not later 

8 than March 31, 2009. 

9 ‘‘(B) FOR THE COMMONWEALTHS AND

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

12 Secretary shall allot for fiscal year 2009 from 

13 the amount made available under subsection 

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

16 amount equal to the highest amount of Federal 

17 payments to the commonwealth or territory 

18 under this title for any fiscal year occurring 

19 during the period of fiscal years 1999 through 

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

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

24 States’ for ‘the State’. 


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1 ‘‘(C) ADJUSTMENT FOR QUALIFYING

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

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

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

7 such projections attributable to the application 

8 of paragraph (4) of such section. 

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

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

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

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

14 through 2012, respectively, the Secretary shall 

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

18 year as follows: 

19 ‘‘(i) GROWTH FACTOR UPDATE FOR

20 FISCAL YEAR 2010.—For fiscal year 2010, 

21 the allotment of the State is equal to the 

22 sum of— 

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

25 year 2009; and 


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

4 2009, 

5 multiplied by the allotment increase factor 

6 under paragraph (5) for fiscal year 2010. 

7 ‘‘(ii) REBASING IN FISCAL YEAR

8 2011.—For fiscal year 2011, the allotment 

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

11 (and countable towards) the total amount 

12 of allotments available under this section 

13 to the State in fiscal year 2010 (including 

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

16 amounts redistributed to the State in fiscal 

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

20 ‘‘(iii) GROWTH FACTOR UPDATE FOR

21 FISCAL YEAR 2012.—For fiscal year 2012, 

22 the allotment of the State is equal to the 

23 sum of— 


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

3 year 2011; and 

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

7 multiplied by the allotment increase factor 

8 under paragraph (5) for fiscal year 2012. 

9 ‘‘(3) FOR FISCAL YEAR 2013.— 

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

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

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

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

15 amount of the appropriation for such period 

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

18 the Secretary shall compute a State allotment 

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

21 such semi-annual period in an amount equal to 

22 the first half ratio (described in subparagraph 

23 (D)) of the amount described in subparagraph 

24 (C). 


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

3 available under subparagraph (B) of paragraph 

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

6 shall compute a State allotment for each State 

7 (including the District of Columbia and each 

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

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

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

13 such State under subparagraph (A); to 

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

15 the allotments made available under such 

16 subparagraph. 

17 ‘‘(C) FULL YEAR AMOUNT BASED ON

18 REBASED AMOUNT.—The amount described in 

19 this subparagraph for a State is equal to the 

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

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

24 payments made to the State under subsection 

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1 distributed to the State in fiscal year 2012), 

2 multiplied by the allotment increase factor 

3 under paragraph (5) for fiscal year 2013. 

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

5 ratio described in this subparagraph is the ratio 

6 of— 

7 ‘‘(i) the sum of— 

8 ‘‘(I) the amount made available 

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

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

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

14 2009; to 

15 ‘‘(ii) the sum of the— 

16 ‘‘(I) amount described in clause 

17 (i); and 

18 ‘‘(II) the amount made available 

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

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

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

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

3 any State under such paragraph for such fiscal year 

4 or period on a proportional basis. 

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

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

8 ‘‘(A) PER CAPITA HEALTH CARE GROWTH

9 FACTOR.—1 plus the percentage increase in the 

10 projected per capita amount of National Health 

11 Expenditures from the calendar year in which 

12 the previous fiscal year ends to the calendar 

13 year in which the fiscal year involved ends, as 

14 most recently published by the Secretary before 

15 the beginning of the fiscal year. 

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

18 the population of children in the State from 

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

20 the fiscal year involved, as determined by the 

21 Secretary based on the most recent published 

22 estimates of the Bureau of the Census before 

23 the beginning of the fiscal year involved, plus 1 

24 percentage point. 


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1 ‘‘(6) INCREASE IN ALLOTMENT TO ACCOUNT

2 FOR APPROVED PROGRAM EXPANSIONS.—In the case 

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

4 that— 

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

6 has approved by the Secretary, a State plan 

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

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

11 ending with fiscal year 2013); and 

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

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

16 fiscal year that specifies— 

17 ‘‘(i) the additional expenditures that 

18 are attributable to the eligibility or benefit 

19 expansion provided under the amendment 

20 or waiver described in subparagraph (A), 

21 as certified by the State and submitted to 

22 the Secretary by not later than August 31 

23 preceding the beginning of the fiscal year; 

24 and 


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

3 the allotment of the State or District for 

4 the year, 

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

7 for such fiscal year shall be increased by the excess 

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

9 District may only obtain an increase under this 

10 paragraph for an allotment for fiscal year 2010 or 

11 fiscal year 2012. 

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

15 period in fiscal year 2013 shall remain available for 

16 expenditure under this title for periods after the end 

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

19 year.’’. 

20 SEC. 103. CHILD ENROLLMENT CONTINGENCY FUND. 

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

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

23 new subsection: 

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


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

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

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

6 without further appropriations for payments under 

7 this subsection. 

8 ‘‘(2) DEPOSITS INTO FUND.— 

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

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

12 United States not otherwise appropriated, there 

13 are appropriated to the Fund— 

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

15 equal to 20 percent of the amount made 

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

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

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

21 2013), such sums as are necessary for 

22 making payments to eligible States for 

23 such fiscal year or period, but not in excess 

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


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

2 available for payment from the Fund for each 

3 of fiscal years 2010 through 2012 (and for each 

4 of the semi-annual allotment periods for fiscal 

5 year 2013), taking into account deposits made 

6 under subparagraph (C), shall not exceed 20 

7 percent of the amount made available under 

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

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

11 bearing securities of the United States, such 

12 currently available portions of the Fund as are 

13 not immediately required for payments from the 

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

16 ‘‘(D) AVAILABILITY OF EXCESS FUNDS

17 FOR PERFORMANCE BONUSES.—Any amounts 

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

20 be made available for purposes of carrying out 

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

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

24 made available. 


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1 ‘‘(3) CHILD ENROLLMENT CONTINGENCY FUND

2 PAYMENTS.— 

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

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

6 a semi-annual allotment period for fiscal year 

7 2013, exceed the total amount of allotments 

8 available under this section to the State in the 

9 fiscal year or period (determined without regard 

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

13 carryover from a previous fiscal year) and if the 

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

16 title (including children receiving health care 

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

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

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

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

24 amount equal to the product of— 


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

3 number of enrollees; and 

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

6 determined under subparagraph (C) for 

7 the fiscal year), multiplied by the enhanced 

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

9 the State and fiscal year involved (or in 

10 which the period occurs). 

11 ‘‘(B) TARGET AVERAGE NUMBER OF CHILD

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

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

15 the monthly average unduplicated number 

16 of children enrolled in the State child 

17 health plan under this title (including such 

18 children receiving health care coverage 

19 through funds under this title pursuant to 

20 a waiver under section 1115) during fiscal 

21 year 2008 increased by the population 

22 growth for children in that State for the 

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

25 1 percentage point; or 


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

2 semi-annual period occurring in a fiscal 

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

5 previous fiscal year increased by the child 

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

8 prior fiscal year. 

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

11 the projected per capita expenditures under a 

12 State child health plan— 

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

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

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

18 average monthly caseload for purposes of 

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

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

23 by the Secretary) for 2009; or 

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

25 semi-annual period occurring in a fiscal 


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1 year) is equal to the projected per capita 

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

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

5 annual percentage increase in the projected 

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

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

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

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

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

15 amount to be paid under such subparagraph to 

16 each eligible State shall be reduced proportion17 ally. 

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

20 fiscal year or period shall be made before the 

21 end of the fiscal year or period based upon the 

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

24 section 2105 shall apply to payments under this 


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1 subsection in the same manner as they apply to 

2 payments under such section. 

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

5 State shall submit to the Secretary the State’s 

6 projected Federal expenditures, even if the 

7 amount of such expenditures exceeds the total 

8 amount of allotments available to the State in 

9 such fiscal year or period. 

10 ‘‘(G) APPLICATION TO COMMONWEALTHS

11 AND TERRITORIES.—No payment shall be made 

12 under this paragraph to a commonwealth or 

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

14 such time as the Secretary determines that 

15 there are in effect methods, satisfactory to the 

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

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

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

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


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

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

6 by adding at the end the following new paragraphs: 

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

10 AND RETENTION EFFORTS.— 

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

12 payments made under paragraph (1), for each 

13 fiscal year (beginning with fiscal year 2009 and 

14 ending with fiscal year 2013), the Secretary 

15 shall pay from amounts made available under 

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

17 condition under paragraph (4) for the fiscal 

18 year, an amount equal to the amount described 

19 in subparagraph (B) for the State and fiscal 

20 year. The payment under this paragraph shall 

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

22 payment not later than the last day of the first 

23 calendar quarter of the following fiscal year. 

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

26 subparagraph (E), the amount described in this 


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1 subparagraph for a State for a fiscal year is 

2 equal to the sum of the following amounts: 

3 ‘‘(i) FIRST TIER ABOVE BASELINE

4 MEDICAID ENROLLEES.—An amount equal 

5 to the number of first tier above baseline 

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

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

11 subparagraph (D)) for the State and fiscal 

12 year under title XIX. 

13 ‘‘(ii) SECOND TIER ABOVE BASELINE

14 MEDICAID ENROLLEES.—An amount equal 

15 to the number of second tier above baseline 

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

18 State and fiscal year, multiplied by 62.5 

19 percent of the projected per capita State 

20 Medicaid expenditures (as determined 

21 under subparagraph (D)) for the State and 

22 fiscal year under title XIX. 

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

24 ABOVE BASELINE CHILD ENROLLEES; BASELINE


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1 NUMBER OF CHILD ENROLLEES.—For purposes 

2 of this paragraph: 

3 ‘‘(i) FIRST TIER ABOVE BASELINE

4 CHILD ENROLLEES.—The number of first 

5 tier above baseline child enrollees for a 

6 State for a fiscal year under title XIX is 

7 equal to the number (if any, as determined 

8 by the Secretary) by which— 

9 ‘‘(I) the monthly average 

10 unduplicated number of qualifying 

11 children (as defined in subparagraph 

12 (F)) enrolled during the fiscal year 

13 under the State plan under title XIX, 

14 respectively; exceeds 

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

17 State and fiscal year under title XIX, 

18 respectively; 

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

22 ‘‘(ii) SECOND TIER ABOVE BASELINE

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

25 a State for a fiscal year under title XIX is 


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1 equal to the number (if any, as determined 

2 by the Secretary) by which— 

3 ‘‘(I) the monthly average 

4 unduplicated number of qualifying 

5 children (as defined in subparagraph 

6 (F)) enrolled during the fiscal year 

7 under title XIX as described in clause 

8 (i)(I); exceeds 

9 ‘‘(II) the sum of the baseline 

10 number of child enrollees described in 

11 clause (iii) for the State and fiscal 

12 year under title XIX, as described in 

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

15 enrollees for the State and fiscal year 

16 under title XIX, as determined under 

17 clause (i). 

18 ‘‘(iii) BASELINE NUMBER OF CHILD

19 ENROLLEES.—Subject to subparagraph 

20 (H), the baseline number of child enrollees 

21 for a State under title XIX— 

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

23 to the monthly average unduplicated 

24 number of qualifying children enrolled 

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1 ing fiscal year 2007 increased by the 

2 population growth for children in that 

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

5 plus 4 percentage points, and further 

6 increased by the population growth 

7 for children in that State from 2008 

8 to 2009 (as estimated by the Bureau 

9 of the Census) plus 4 percentage 

10 points; 

11 ‘‘(II) for each of fiscal years 

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

13 baseline number of child enrollees for 

14 the State for the previous fiscal year 

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

17 State from the calendar year in which 

18 the respective fiscal year begins to the 

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

21 plus 3.5 percentage points; 

22 ‘‘(III) for each of fiscal years 

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

24 baseline number of child enrollees for 

25 the State for the previous fiscal year 


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

3 State from the calendar year in which 

4 the respective fiscal year begins to the 

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

7 plus 3 percentage points; and 

8 ‘‘(IV) for a subsequent fiscal year 

9 is equal to the baseline number of 

10 child enrollees for the State for the 

11 previous fiscal year under title XIX, 

12 increased by the population growth 

13 for children in that State from the 

14 calendar year in which the fiscal year 

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

18 points. 

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

22 Medicaid expenditures for a State and fiscal 

23 year under title XIX is equal to the average per 

24 capita expenditures (including both State and 

25 Federal financial participation) for children 


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1 under the State plan under such title, including 

2 under waivers but not including such children 

3 eligible for assistance by virtue of the receipt of 

4 benefits under title XVI, for the most recent 

5 fiscal year for which actual data are available 

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

7 each subsequent fiscal year up to and including 

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

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

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

16 for the fiscal year involved. 

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

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

20 any money in the Treasury not otherwise 

21 appropriated, there are appropriated 

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

23 making payments under this paragraph, to 

24 be available until expended. 


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1 ‘‘(ii) TRANSFERS.—Notwithstanding 

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

4 without fiscal year limitation, for making 

5 payments under this paragraph: 

6 ‘‘(I) UNOBLIGATED NATIONAL

7 ALLOTMENT.— 

8 ‘‘(aa) FISCAL YEARS 2009

9 THROUGH 2012.—As of December 

10 31 of fiscal year 2009, and as of 

11 December 31 of each succeeding 

12 fiscal year through fiscal year 

13 2012, the portion, if any, of the 

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

16 that is unobligated for allotment 

17 to a State under subsection (m) 

18 for such fiscal year or set aside 

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

20 of section 2111 for such fiscal 

21 year. 

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

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


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

4 Insurance Reauthorization Act of 

5 2009 for the period beginning on 

6 October 1, 2012, and ending on 

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

9 under subsection (m) for such 

10 fiscal year or set aside under 

11 subsection (b)(2) of section 2111 

12 for such fiscal year. 

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

15 of fiscal year 2013, the portion, 

16 if any, of the amount appro17 priated under subsection 

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

21 is unobligated for allotment to a 

22 State under subsection (m) for 

23 such fiscal year or set aside 

24 under subsection (b)(2) of section 

25 2111 for such fiscal year. 


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

4 fiscal years 2010 through 2013, the 

5 total amount of allotments made to 

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

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

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

16 October 1 of each of fiscal years 2010 

17 through 2013, any amount in excess 

18 of the aggregate cap applicable to the 

19 Child Enrollment Contingency Fund 

20 for the fiscal year under section 

21 2104(n). 

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

24 NONPREGNANT CHILDLESS ADULTS.— 

25 As of October 1, 2011, any amounts 


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

2 that are not expended by September 

3 30, 2011. 

4 ‘‘(iii) PROPORTIONAL REDUCTION.—If 

5 the sum of the amounts otherwise payable 

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

8 year under this subparagraph, the amount 

9 to be paid under this paragraph to each 

10 State shall be reduced proportionally. 

11 ‘‘(F) QUALIFYING CHILDREN DEFINED.— 

12 For purposes of this subsection, the term 

13 ‘qualifying children’ means children who meet 

14 the eligibility criteria (including income, cat15 egorical eligibility, age, and immigration status 

16 criteria) in effect as of July 1, 2008, for enroll17 ment under title XIX, taking into account cri18 teria applied as of such date under title XIX 

19 pursuant to a waiver under section 1115. Such 

20 term does not include any children for whom 

21 the State has made an election to provide med22 ical assistance under section 1903(v)(4). 

23 ‘‘(G) APPLICATION TO COMMONWEALTHS

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


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1 with respect to payment under this paragraph 

2 in the same manner as such provisions apply to 

3 payment under such section. 

4 ‘‘(H) APPLICATION TO STATES THAT IM5 PLEMENT A MEDICAID EXPANSION FOR CHIL6 DREN AFTER FISCAL YEAR 2008.—In the case of 

7 a State that provides coverage under section 

8 115 of the Children’s Health Insurance Pro9 gram Reauthorization Act of 2009 for any fis10 cal year after fiscal 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 dis14 regarded from the determination for the 

15 State of the monthly average unduplicated 

16 number of qualifying children enrolled in 

17 such plan during the first 3 fiscal years in 

18 which such 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 enroll23 ees for the State under title XIX for the 

24 third of such fiscal years shall be the 

25 monthly average unduplicated number of 


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1 qualifying children enrolled in the State 

2 plan under title XIX for such third fiscal 

3 year. 

4 ‘‘(4) ENROLLMENT AND RETENTION PROVI5 SIONS FOR CHILDREN.—For purposes of paragraph 

6 (3)(A), a State meets the condition of this para7 graph for a fiscal year if it is implementing at least 

8 4 of the following enrollment and retention provi9 sions (treating each subparagraph as a separate en10 rollment and retention provision) throughout the en11 tire fiscal year: 

12 ‘‘(A) CONTINUOUS ELIGIBILITY.—The 

13 State has elected the option of continuous eligi14 bility for a full 12 months for all children de15 scribed in section 1902(e)(12) under title XIX 

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

17 policy under its State child health plan under 

18 this title. 

19 ‘‘(B) LIBERALIZATION OF ASSET REQUIRE20 MENTS.—The State meets the requirement 

21 specified in either of the following clauses: 

22 ‘‘(i) ELIMINATION OF ASSET TEST.— 

23 The State does not apply any asset or re24 source test for eligibility for children under 

25 title XIX or this title. 


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1 ‘‘(ii) ADMINISTRATIVE VERIFICATION

2 OF ASSETS.—The State— 

3 ‘‘(I) permits a parent or care4 taker relative who is applying on be5 half of a child for medical assistance 

6 under title XIX or child health assist7 ance under this title to declare and 

8 certify by signature under penalty of 

9 perjury information relating to family 

10 assets for purposes of determining 

11 and redetermining financial eligibility; 

12 and 

13 ‘‘(II) takes steps to verify assets 

14 through means other than by requir15 ing documentation from parents and 

16 applicants except in individual cases 

17 of discrepancies or where otherwise 

18 justified. 

19 ‘‘(C) ELIMINATION OF IN-PERSON INTER20 VIEW REQUIREMENT.—The State does not re21 quire an application of a child for medical as22 sistance under title XIX (or for child health as23 sistance under this title), including an applica24 tion for renewal of such assistance, to be made 

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1 face interview, unless there are discrepancies or 

2 individual circumstances justifying an in-person 

3 application or face-to-face interview. 

4 ‘‘(D) USE OF JOINT APPLICATION FOR

5 MEDICAID AND CHIP.—The application form 

6 and supplemental forms (if any) and informa7 tion verification process is the same for pur8 poses of establishing and renewing eligibility for 

9 children for medical assistance under title XIX 

10 and child health assistance under this title. 

11 ‘‘(E) AUTOMATIC RENEWAL (USE OF AD12 MINISTRATIVE RENEWAL).— 

13 ‘‘(i) IN GENERAL.—The State pro14 vides, in the case of renewal of a child’s 

15 eligibility for medical assistance under title 

16 XIX or child health assistance under this 

17 title, a pre-printed form completed by the 

18 State based on the information available to 

19 the State and notice to the parent or care20 taker relative of the child that eligibility of 

21 the child will be renewed and continued 

22 based on such information unless the State 

23 is provided other information. Nothing in 

24 this clause shall be construed as preventing 

25 a State from verifying, through electronic 


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1 and other means, the information so pro2 vided. 

3 ‘‘(ii) SATISFACTION THROUGH DEM4 ONSTRATED USE OF EX PARTE PROCESS.— 

5 A State shall be treated as satisfying the 

6 requirement of clause (i) if renewal of eli7 gibility of children under title XIX or this 

8 title is determined without any require9 ment for an in-person interview, unless 

10 sufficient information is not in the State’s 

11 possession and cannot be acquired from 

12 other sources (including other State agen13 cies) without the participation of the appli14 cant or the applicant’s parent or caretaker 

15 relative. 

16 ‘‘(F) PRESUMPTIVE ELIGIBILITY FOR

17 CHILDREN.—The State is implementing section 

18 1920A under title XIX as well as, pursuant to 

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

20 ‘‘(G) EXPRESS LANE.—The State is imple21 menting the option described in section 

22 1902(e)(13) under title XIX as well as, pursu23 ant to section 2107(e)(1), under this title.’’. 


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1 SEC. 105. TWO-YEAR INITIAL AVAILABILITY OF CHIP AL2 LOTMENTS. 

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

4 to 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 

21 they 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— 


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1 (A) by striking ‘‘The Secretary’’ and in2 serting the following: 

3 ‘‘(1) IN GENERAL.—The Secretary’’; 

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

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

7 Secretary determines with respect to the fiscal 

8 year for which unused allotments are available 

9 for redistribution under this subsection, are 

10 shortfall States described in paragraph (2) for 

11 such fiscal year, but not to exceed the amount 

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

13 for each such State (as may be adjusted under 

14 paragraph (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 esti23 mates on the basis of the most recent data 

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1 penditures under such plan for the State for the 

2 fiscal year 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 

10 under 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 

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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— 


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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 provi5 sion of law,’’; and 

6 (B) by striking ‘‘2008, or 2009’’ and in7 serting ‘‘or 2008’’; and 

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

9 paragraph: 

10 ‘‘(4) OPTION FOR ALLOTMENTS FOR FISCAL

11 YEARS 2009 THROUGH 2013.— 

12 ‘‘(A) PAYMENT OF ENHANCED PORTION OF

13 MATCHING RATE FOR CERTAIN EXPENDI14 TURES.—In the case of expenditures described 

15 in subparagraph (B), a qualifying State (as de16 fined in paragraph (2)) may elect to be paid 

17 from the State’s allotment made under section 

18 2104 for any of fiscal years 2009 through 2013 

19 (insofar as the allotment is available to the 

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

21 section) an amount each quarter equal to the 

22 additional amount that would have been paid to 

23 the State under title XIX with respect to such 

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1 stituted for the Federal medical assistance per2 centage (as defined in section 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 at14 tained age 19 (or, if a State has so elected 

15 under the State plan under title XIX, age 20 

16 or 21), and whose family income equals or ex17 ceeds 133 percent of the poverty line but does 

18 not exceed the Medicaid applicable income 

19 level.’’. 

20 (b) REPEAL OF LIMITATION ON AVAILABILITY OF

21 FISCAL YEAR 2009 ALLOTMENTS.—Paragraph (2) of sec22 tion 201(b) of the Medicare, Medicaid, and SCHIP Exten23 sion Act of 2007 (Public Law 110-173) is repealed. 


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1 SEC. 108. ONE-TIME APPROPRIATION. 

2 There is appropriated to the Secretary, out of any 

3 money in the Treasury not otherwise appropriated, 

4 $11,406,000,000 to accompany the allotment made for the 

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

6 March 31, 2013, under section 2104(a)(16)(A) of the So7 cial Security Act (42 U.S.C. 1397dd(a)(16)(A)) (as added 

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

9 amount shall be used to provide allotments to States under 

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

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

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

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

14 such section 2104 and subject to the same terms and con15 ditions as apply to the allotments provided from such sub16 section (a)(16)(A). 

17 SEC. 109. IMPROVING FUNDING FOR THE TERRITORIES 

18 UNDER CHIP AND MEDICAID. 

19 (a) REMOVAL OF FEDERAL MATCHING PAYMENTS

20 FOR DATA REPORTING SYSTEMS FROM THE OVERALL

21 LIMIT ON PAYMENTS TO TERRITORIES UNDER TITLE

22 XIX.—Section 1108(g) (42 U.S.C. 1308(g)) is amended 

23 by adding at the end the following new paragraph: 

24 ‘‘(4) EXCLUSION OF CERTAIN EXPENDITURES

25 FROM PAYMENT LIMITS.—With respect to fiscal 

26 years beginning with fiscal year 2009, if Puerto 


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1 Rico, the Virgin Islands, Guam, the Northern Mar2 iana Islands, or American Samoa qualify for a pay3 ment under subparagraph (A)(i), (B), or (F) of sec4 tion 1903(a)(3) for a calendar quarter of such fiscal 

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

6 applying subsection (f) (as increased in accordance 

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

8 to such commonwealth or territory for such fiscal 

9 year.’’. 

10 (b) GAO STUDY AND REPORT.—Not later than Sep11 tember 30, 2010, the Comptroller General of the United 

12 States shall submit a report to the Committee on Finance 

13 of the Senate and the Committee on Energy and Com14 merce of the House of Representatives regarding Federal 

15 funding under Medicaid and CHIP for Puerto Rico, the 

16 United States Virgin Islands, Guam, American Samoa, 

17 and the Northern Mariana Islands. The report shall in18 clude the following: 

19 (1) An analysis of all relevant factors with re20 spect to— 

21 (A) eligible Medicaid and CHIP popu22 lations in such commonwealths and territories; 

23 (B) historical and projected spending needs 

24 of such commonwealths and territories and the 


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1 ability of capped funding streams to respond to 

2 those spending needs; 

3 (C) the extent to which Federal poverty 

4 guidelines are used by such commonwealths and 

5 territories to determine Medicaid and CHIP eli6 gibility; and 

7 (D) the extent to which such common8 wealths and territories participate in data col9 lection and reporting related to Medicaid and 

10 CHIP, including an analysis of territory partici11 pation in the Current Population Survey versus 

12 the American Community Survey. 

13 (2) Recommendations regarding methods for 

14 the collection and reporting of reliable data regard15 ing the enrollment under Medicaid and CHIP of 

16 children in such commonwealths and territories. 

17 (3) Recommendations for improving Federal 

18 funding under Medicaid and CHIP for such com19 monwealths and territories. 


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1 Subtitle B—Focus on Low-Income 

2 Children and Pregnant Women 

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

5 STATE PLAN AMENDMENT. 

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

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

8 at the end the following new section: 

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

11 PLAN AMENDMENT. 

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

15 provide pregnancy-related assistance under such plan for 

16 targeted low-income pregnant women. 

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

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

20 ‘‘(1) MINIMUM INCOME ELIGIBILITY LEVELS

21 FOR PREGNANT WOMEN AND CHILDREN.—The State 

22 has established an income eligibility level— 

23 ‘‘(A) for pregnant women under subsection 

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

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


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1 percent (or such higher percent as the State 

2 has in effect with regard to pregnant women 

3 under this title) of the poverty line applicable to 

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

5 lower than the percent in effect under any such 

6 subsection as of July 1, 2008; and 

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

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

9 200 percent of the poverty line applicable to a 

10 family of the size involved. 

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

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

14 income level for pregnant women under the State 

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

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

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

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

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

24 PREGNANT WOMEN.—The State does not provide 

25 coverage for pregnant women with higher family inVerDate Nov 24 2008 21:36 Jan 16, 2009 Jkt 079200 PO 00000 Frm 00052 Fmt 6652 Sfmt 6201 E:\BILLS\H2.PCS H2

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1 come without covering pregnant women with a lower 

2 family income. 

3 ‘‘(4) APPLICATION OF REQUIREMENTS FOR

4 COVERAGE OF TARGETED LOW-INCOME CHILDREN.— 

5 The State provides pregnancy-related assistance for 

6 targeted low-income pregnant women in the same 

7 manner, and subject to the same requirements, as 

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

10 health plan, and in addition to providing child health 

11 assistance for such women. 

12 ‘‘(5) NO PREEXISTING CONDITION EXCLUSION

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

14 exclusion of benefits for pregnancy-related assistance 

15 based on any preexisting condition or any waiting 

16 period (including any waiting period imposed to 

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

18 assistance. 

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

22 with the cost-sharing protections under section 

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

24 aggregate cost sharing imposed under paragraph 


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

2 woman. 

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

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

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

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

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

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

15 may elect to apply section 1920 (relating to presumptive 

16 eligibility for pregnant women) to the State child health 

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

18 State plan under title XIX. 

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

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

21 term ‘pregnancy-related assistance’ has the meaning 

22 given the term ‘child health assistance’ in section 

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


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1 ‘‘(2) TARGETED LOW-INCOME PREGNANT

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

3 woman’ means an individual— 

4 ‘‘(A) during pregnancy and through the 

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

6 (beginning on the last day of her pregnancy) 

7 ends; 

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

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

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

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

15 ‘‘(C) who satisfies the requirements of 

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

19 satisfy such requirements. 

20 ‘‘(e) AUTOMATIC ENROLLMENT FOR CHILDREN

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

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

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


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1 assistance under the State child health plan and to have 

2 been found eligible for such assistance under such plan 

3 or to have applied for medical assistance under title XIX 

4 and to have been found eligible for such assistance under 

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

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

8 is deemed under the preceding sentence to be eligible for 

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

11 mother shall also serve as the identification number of the 

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

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

15 ‘‘(f) STATES PROVIDING ASSISTANCE THROUGH

16 OTHER OPTIONS.— 

17 ‘‘(1) CONTINUATION OF OTHER OPTIONS FOR

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

22 ‘‘(A) child health assistance through the 

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

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

25 Code of Federal Regulations (as in effect after 


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1 the final rule adopted by the Secretary and set 

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

3 2002)), or 

4 ‘‘(B) pregnancy-related services through 

5 the application of any waiver authority (as in 

6 effect on June 1, 2008). 

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

11 such assistance, as well as postpartum services, 

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

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

14 ends, in the same manner as such assistance and 

15 postpartum services would be provided if provided 

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

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

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

20 period. 

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

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

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


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

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

4 (b) ADDITIONAL CONFORMING AMENDMENTS.— 

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

7 1397cc(e)(2)) is amended— 

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

9 PREGNANCY-RELATED ASSISTANCE’’ after 

10 ‘‘PREVENTIVE SERVICES’’; and 

11 (B) by inserting before the period at the 

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

14 (2) NO WAITING PERIOD.—Section 

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

16 amended— 

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

18 end and inserting a semicolon; 

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

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

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

22 clause: 

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

24 (including a waiting period to carry out 

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


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

3 2112.’’. 

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

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

7 (a) PHASE-OUT RULES.— 

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

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

10 following new section: 

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

12 CHILDLESS ADULTS; CONDITIONS FOR COV13 ERAGE OF PARENTS. 

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

16 ‘‘(1) NO NEW CHIP WAIVERS; AUTOMATIC EX17 TENSIONS AT STATE OPTION THROUGH FISCAL YEAR

18 2010.—Notwithstanding section 1115 or any other 

19 provision of this title, except as provided in this sub20 section— 

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

22 date of the enactment of the Children’s Health 

23 Insurance Program Reauthorization Act of 

24 2009, approve or renew a waiver, experimental, 

25 pilot, or demonstration project that would allow 


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1 funds made available under this title to be used 

2 to provide child health assistance or other 

3 health benefits coverage to a nonpregnant child4 less adult; and 

5 ‘‘(B) notwithstanding the terms and condi6 tions of an applicable existing waiver, the provi7 sions of paragraphs (2) and (3) shall apply for 

8 purposes of any period beginning on or after 

9 October 1, 2010, in determining the period to 

10 which the waiver applies, the individuals eligible 

11 to be covered by the waiver, and the amount of 

12 the Federal payment under this title. 

13 ‘‘(2) TERMINATION OF CHIP COVERAGE UNDER

14 APPLICABLE EXISTING WAIVERS AT THE END OF

15 FISCAL YEAR 2010.— 

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

17 available under this title for child health assist18 ance or other health benefits coverage that is 

19 provided to a nonpregnant childless adult under 

20 an applicable existing waiver after September 

21 30, 2010. 

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

25 expire before October 1, 2010, and the State 


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

3 through September 30, 2011. 

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

5 The enhanced FMAP determined under section 

6 2105(b) shall apply to expenditures under an 

7 applicable existing waiver for the provision of 

8 child health assistance or other health benefits 

9 coverage to a nonpregnant childless adult dur10 ing fiscal year 2010. 

11 ‘‘(3) OPTIONAL 1-YEAR TRANSITIONAL COV12 ERAGE BLOCK GRANT FUNDED FROM STATE ALLOT13 MENT.—Subject to paragraph (4)(B), each State for 

14 which coverage under an applicable existing waiver 

15 is terminated under paragraph (2)(A) may elect to 

16 provide nonpregnant childless adults who were pro17 vided child health assistance or health benefits cov18 erage under the applicable existing waiver at any 

19 time during fiscal year 2010 with such assistance or 

20 coverage during fiscal year 2011, as if the authority 

21 to provide such assistance or coverage under an ap22 plicable existing waiver was extended through that 

23 fiscal year, but subject to the following terms and 

24 conditions: 


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1 ‘‘(A) BLOCK GRANT SET ASIDE FROM

2 STATE ALLOTMENT.—The Secretary shall set 

3 aside for the State an amount equal to the Fed4 eral share of the State’s projected expenditures 

5 under the applicable existing waiver for pro6 viding child health assistance or health benefits 

7 coverage to all nonpregnant childless adults 

8 under such waiver for fiscal year 2010 (as cer9 tified by the State and submitted to the Sec10 retary by not later than August 31, 2010, and 

11 without regard to whether any such individual 

12 lost coverage during fiscal year 2010 and was 

13 later provided child health assistance or other 

14 health benefits coverage under the waiver in 

15 that fiscal year), increased by the annual ad16 justment for fiscal year 2011 determined under 

17 section 2104(m)(5)(A). The Secretary may ad18 just the amount set aside under the preceding 

19 sentence, as necessary, on the basis of the ex20 penditure data for fiscal year 2010 reported by 

21 States on CMS Form 64 or CMS Form 21 not 

22 later than November 30, 2010, but in no case 

23 shall the Secretary adjust such amount after 

24 December 31, 2010. 


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1 ‘‘(B) NO COVERAGE FOR NONPREGNANT

2 CHILDLESS ADULTS WHO WERE NOT COVERED

3 DURING FISCAL YEAR 2010.— 

4 ‘‘(i) FMAP APPLIED TO EXPENDI5 TURES.—The Secretary shall pay the State 

6 for each quarter of fiscal year 2011, from 

7 the amount set aside under subparagraph 

8 (A), an amount equal to the Federal med9 ical assistance percentage (as determined 

10 under section 1905(b) without regard to 

11 clause (4) of such section) of expenditures 

12 in the quarter for providing child health 

13 assistance or other health benefits coverage 

14 to a nonpregnant childless adult but only 

15 if such adult was enrolled in the State pro16 gram under this title during fiscal year 

17 2010 (without regard to whether the indi18 vidual lost coverage during fiscal year 

19 2010 and was reenrolled in that fiscal year 

20 or in fiscal year 2011). 

21 ‘‘(ii) FEDERAL PAYMENTS LIMITED

22 TO AMOUNT OF BLOCK GRANT SET23 ASIDE.—No payments shall be made to a 

24 State for expenditures described in this 

25 subparagraph after the total amount set 


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1 aside under subparagraph (A) for fiscal 

2 year 2011 has been paid to the State. 

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

4 WAIVER TO CONTINUE COVERAGE FOR NONPREG5 NANT CHILDLESS ADULTS.— 

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

7 coverage under an applicable existing waiver is 

8 terminated under paragraph (2)(A) may sub9 mit, not later than June 30, 2011, an applica10 tion to the Secretary for a waiver under section 

11 1115 of the State plan under title XIX to pro12 vide medical assistance to a nonpregnant child13 less adult whose coverage is so terminated (in 

14 this subsection referred to as a ‘Medicaid non15 pregnant childless adults waiver’). 

16 ‘‘(B) DEADLINE FOR APPROVAL.—The 

17 Secretary shall make a decision to approve or 

18 deny an application for a Medicaid nonpregnant 

19 childless adults waiver submitted under sub20 paragraph (A) within 90 days of the date of the 

21 submission of the application. If no decision has 

22 been made by the Secretary as of September 

23 30, 2011, on the application of a State for a 

24 Medicaid nonpregnant childless adults waiver 

25 that was submitted to the Secretary by June 


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1 30, 2011, the application shall be deemed ap2 proved. 

3 ‘‘(C) STANDARD FOR BUDGET NEU4 TRALITY.—The budget neutrality requirement 

5 applicable with respect to expenditures for med6 ical assistance under a Medicaid nonpregnant 

7 childless adults waiver shall— 

8 ‘‘(i) in the case of fiscal year 2012, 

9 allow expenditures for medical assistance 

10 under title XIX for all such adults to not 

11 exceed the total amount of payments made 

12 to the State under paragraph (3)(B) for 

13 fiscal year 2011, increased by the percent14 age increase (if any) in the projected nomi15 nal per capita amount of National Health 

16 Expenditures for calendar year 2012 over 

17 2011, as most recently published by the 

18 Secretary; and 

19 ‘‘(ii) in the case of any succeeding fis20 cal year, allow such expenditures to not ex21 ceed the amount in effect under this sub22 paragraph for the preceding fiscal year, in23 creased by the percentage increase (if any) 

24 in the projected nominal per capita amount 

25 of National Health Expenditures for the 


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1 calendar year that begins during the fiscal 

2 year involved over the preceding calendar 

3 year, as most recently published by the 

4 Secretary. 

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

6 PARENTS OF TARGETED LOW-INCOME CHILDREN.— 

7 ‘‘(1) TWO-YEAR TRANSITION PERIOD; AUTO8 MATIC EXTENSION AT STATE OPTION THROUGH FIS9 CAL YEAR 2011.— 

10 ‘‘(A) NO NEW CHIP WAIVERS.—Notwith11 standing section 1115 or any other provision of 

12 this title, except as provided in this sub13 section— 

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

15 the date of the enactment of the Children’s 

16 Health Insurance Program Reauthoriza17 tion Act of 2009 approve or renew a waiv18 er, experimental, pilot, or demonstration 

19 project that would allow funds made avail20 able under this title to be used to provide 

21 child health assistance or other health ben22 efits coverage to a parent of a targeted 

23 low-income child; and 

24 ‘‘(ii) notwithstanding the terms and 

25 conditions of an applicable existing waiver, 


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

2 shall apply for purposes of any fiscal year 

3 beginning on or after October 1, 2011, in 

4 determining the period to which the waiver 

5 applies, the individuals eligible to be cov6 ered by the waiver, and the amount of the 

7 Federal payment under this title. 

8 ‘‘(B) EXTENSION UPON STATE RE9 QUEST.—If an applicable existing waiver de10 scribed in subparagraph (A) would otherwise 

11 expire before October 1, 2011, and the State 

12 requests an extension of such waiver, the Sec13 retary shall grant such an extension, but only, 

14 subject to paragraph (2)(A), through Sep15 tember 30, 2011. 

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

17 The enhanced FMAP determined under section 

18 2105(b) shall apply to expenditures under an 

19 applicable existing waiver for the provision of 

20 child health assistance or other health benefits 

21 coverage to a parent of a targeted low-income 

22 child during the third and fourth quarters of 

23 fiscal year 2009 and during fiscal years 2010 

24 and 2011. 


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

2 2013.— 

3 ‘‘(A) PAYMENTS FOR COVERAGE LIMITED

4 TO BLOCK GRANT FUNDED FROM STATE ALLOT5 MENT.—Any State that provides child health 

6 assistance or health benefits coverage under an 

7 applicable existing waiver for a parent of a tar8 geted low-income child may elect to continue to 

9 provide such assistance or coverage through fis10 cal year 2012 or 2013, subject to the same 

11 terms and conditions that applied under the ap12 plicable existing waiver, unless otherwise modi13 fied in subparagraph (B). 

14 ‘‘(B) TERMS AND CONDITIONS.— 

15 ‘‘(i) BLOCK GRANT SET ASIDE FROM

16 STATE ALLOTMENT.—If the State makes 

17 an election under subparagraph (A), the 

18 Secretary shall set aside for the State for 

19 each such fiscal year an amount equal to 

20 the Federal share of 110 percent of the 

21 State’s projected expenditures under the 

22 applicable existing waiver for providing 

23 child health assistance or health benefits 

24 coverage to all parents of targeted low-in25 come children enrolled under such waiver 


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1 for the fiscal year (as certified by the State 

2 and submitted to the Secretary by not 

3 later than August 31 of the preceding fis4 cal year). In the case of fiscal year 2013, 

5 the set aside for any State shall be com6 puted separately for each period described 

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

8 2104(a)(16) and any reduction in the allot9 ment for either such period under section 

10 2104(m)(4) shall be allocated on a pro 

11 rata basis to such set aside. 

12 ‘‘(ii) PAYMENTS FROM BLOCK

13 GRANT.—The Secretary shall pay the State 

14 from the amount set aside under clause (i) 

15 for the fiscal year, an amount for each 

16 quarter of such fiscal year equal to the ap17 plicable percentage determined under 

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

19 quarter for providing child health assist20 ance or other health benefits coverage to a 

21 parent of a targeted low-income child. 

22 ‘‘(iii) ENHANCED FMAP ONLY IN FIS23 CAL YEAR 2012 FOR STATES WITH SIGNIFI24 CANT CHILD OUTREACH OR THAT ACHIEVE

25 CHILD COVERAGE BENCHMARKS; FMAP


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1 FOR ANY OTHER STATES.—For purposes 

2 of clause (ii), the applicable percentage for 

3 any quarter of fiscal year 2012 is equal 

4 to— 

5 ‘‘(I) the enhanced FMAP deter6 mined under section 2105(b) in the 

7 case of a State that meets the out8 reach or coverage benchmarks de9 scribed in any of subparagraph (A), 

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

11 year 2011; or 

12 ‘‘(II) the Federal medical assist13 ance percentage (as determined under 

14 section 1905(b) without regard to 

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

16 of any other State. 

17 ‘‘(iv) AMOUNT OF FEDERAL MATCH18 ING PAYMENT IN 2013.—For purposes of 

19 clause (ii), the applicable percentage for 

20 any quarter of fiscal year 2013 is equal 

21 to— 

22 ‘‘(I) the REMAP percentage if— 

23 ‘‘(aa) the applicable percent24 age for the State under clause 


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1 (iii) was the enhanced FMAP for 

2 fiscal year 2012; and 

3 ‘‘(bb) the State met either of 

4 the coverage benchmarks de5 scribed in subparagraph (B) or 

6 (C) of paragraph (3) for 2012; or 

7 ‘‘(II) the Federal medical assist8 ance percentage (as so determined) in 

9 the case of any State to which sub10 clause (I) does not apply. 

11 For purposes of subclause (I), the REMAP 

12 percentage is the percentage which is the 

13 sum of such Federal medical assistance 

14 percentage and a number of percentage 

15 points equal to one-half of the difference 

16 between such Federal medical assistance 

17 percentage and such enhanced FMAP. 

18 ‘‘(v) NO FEDERAL PAYMENTS OTHER

19 THAN FROM BLOCK GRANT SET ASIDE.— 

20 No payments shall be made to a State for 

21 expenditures described in clause (ii) after 

22 the total amount set aside under clause (i) 

23 for a fiscal year has been paid to the 

24 State. 


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1 ‘‘(vi) NO INCREASE IN INCOME ELIGI2 BILITY LEVEL FOR PARENTS.—No pay3 ments shall be made to a State from the 

4 amount set aside under clause (i) for a fis5 cal year for expenditures for providing 

6 child health assistance or health benefits 

7 coverage to a parent of a targeted low-in8 come child whose family income exceeds 

9 the income eligibility level applied under 

10 the applicable existing waiver to parents of 

11 targeted low-income children on the date of 

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

14 2009. 

15 ‘‘(3) OUTREACH OR COVERAGE BENCH16 MARKS.—For purposes of paragraph (2), the out17 reach or coverage benchmarks described in this 

18 paragraph are as follows: 

19 ‘‘(A) SIGNIFICANT CHILD OUTREACH CAM20 PAIGN.—The State— 

21 ‘‘(i) was awarded a grant under sec22 tion 2113 for fiscal year 2011; 

23 ‘‘(ii) implemented 1 or more of the en24 rollment and retention provisions described 


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

2 or 

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

4 outreach for such fiscal year. 

5 ‘‘(B) HIGH-PERFORMING STATE.—The 

6 State, on the basis of the most timely and accu7 rate published estimates of the Bureau of the 

Census, ranks in the lowest 1 8 ⁄3 of States in 

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

10 children without health insurance. 

11 ‘‘(C) STATE INCREASING ENROLLMENT OF

12 LOW-INCOME CHILDREN.—The State qualified 

13 for a performance bonus payment under section 

14 2105(a)(3)(B) for the most recent fiscal year 

15 applicable under such section. 

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

17 this subsection shall be construed as prohibiting a 

18 State from submitting an application to the Sec19 retary for a waiver under section 1115 of the State 

20 plan under title XIX to provide medical assistance to 

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

22 provided child health assistance or health benefits 

23 coverage under an applicable existing waiver. 

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

25 of this section— 


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1 ‘‘(1) IN GENERAL.—The term ‘applicable exist2 ing waiver’ means a waiver, experimental, pilot, or 

3 demonstration project under section 1115, grand4 fathered under section 6102(c)(3) of the Deficit Re5 duction Act of 2005, or otherwise conducted under 

6 authority that— 

7 ‘‘(A) would allow funds made available 

8 under this title to be used to provide child 

9 health assistance or other health benefits cov10 erage to— 

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

12 child; 

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

14 ‘‘(iii) individuals described in both 

15 clauses (i) and (ii); and 

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

17 ‘‘(2) DEFINITIONS.— 

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

19 a caretaker relative (as such term is used in 

20 carrying out section 1931) and a legal guard21 ian. 

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.— 


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

2 is 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 pe10 riod; 

11 (iii) by striking the second sentence; 

12 and 

13 (iv) by adding at the end the following 

14 new paragraph: 

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

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

17 demonstration project with respect to a State after 

18 the date of enactment of the Children’s Health In19 surance Program Reauthorization Act of 2009 that 

20 would waive or modify the requirements of section 

21 2111.’’. 

22 (B) Section 6102(c) of the Deficit Reduc23 tion Act of 2005 (Public Law 109–171; 120 

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

25 and inserting ‘‘Subject to section 2111 of the 


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1 Social Security Act, as added by section 112 of 

2 the Children’s Health Insurance Program Re3 authorization Act of 2009, nothing’’. 

4 (b) GAO STUDY AND REPORT.— 

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

6 the United States shall conduct a study of wheth7 er— 

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

9 relative (as such term is used in carrying out 

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

11 low-income child under a State health plan 

12 under title XXI of the Social Security Act in13 creases the enrollment of, or the quality of care 

14 for, children, and 

15 (B) such parents, relatives, and legal 

16 guardians who enroll in such a plan are more 

17 likely to enroll their children in such a plan or 

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

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

20 date of the enactment of this Act, the Comptroller 

21 General shall report the results of the study to the 

22 Committee on Finance of the Senate and the Com23 mittee on Energy and Commerce of the House of 

24 Representatives, including recommendations (if any) 

25 for changes in legislation. 


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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 de8 scribed in subparagraph (B), the Federal medical 

9 assistance percentage (as defined in the first sen10 tence of section 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 

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

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

19 woman remains (or would remain if pregnant) eligi20 ble for such 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: 


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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 

9 the 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 EXPENDI16 TURES.—Except as provided in subparagraph 

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

18 2009, the Federal medical assistance percent19 age (as determined under section 1905(b) with20 out regard to clause (4) of such section) shall 

21 be substituted for the enhanced FMAP under 

22 subsection (a)(1) with respect to any expendi23 tures for providing child health assistance or 

24 health benefits coverage for a targeted low-in25 come child whose effective family income would 


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1 exceed 300 percent of the poverty line but for 

2 the application of a general exclusion of a block 

3 of income that is not determined by type of ex4 pense or type of income. 

5 ‘‘(B) EXCEPTION.—Subparagraph (A) 

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

7 of enactment of the Children’s Health Insur8 ance Program Reauthorization Act of 2009, has 

9 an approved State plan amendment or waiver to 

10 provide, or has enacted a State law to submit 

11 a State plan amendment to provide, expendi12 tures described in such subparagraph under the 

13 State child health plan.’’. 

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

15 amendments made by this section shall be construed as— 

16 (1) changing any income eligibility level for chil17 dren under title XXI of the Social Security Act; or 

18 (2) changing the flexibility provided States 

19 under such title to establish the income eligibility 

20 level for targeted low-income children under a State 

21 child health plan and the methodologies used by the 

22 State to determine income or assets under such 

23 plan. 


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1 SEC. 115. STATE AUTHORITY UNDER MEDICAID. 

2 Notwithstanding any other provision of law, including 

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

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

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

6 provide the State with the Federal medical assistance per7 centage determined for the State for Medicaid with respect 

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

9 Act or otherwise made to provide medical assistance under 

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

11 under CHIP. 

12 TITLE II—OUTREACH AND 

13 ENROLLMENT 

14 Subtitle A—Outreach and 

15 Enrollment Activities 

16 SEC. 201. GRANTS AND ENHANCED ADMINISTRATIVE FUND17 ING FOR OUTREACH AND ENROLLMENT. 

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

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

20 end the following: 

21 ‘‘SEC. 2113. GRANTS TO IMPROVE OUTREACH AND ENROLL22 MENT. 

23 ‘‘(a) OUTREACH AND ENROLLMENT GRANTS; NA24 TIONAL CAMPAIGN.— 

25 ‘‘(1) IN GENERAL.—From the amounts appro26 priated under subsection (g), subject to paragraph 


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1 (2), the Secretary shall award grants to eligible enti2 ties during the period of fiscal years 2009 through 

3 2013 to conduct outreach and enrollment efforts 

4 that are designed to increase the enrollment and 

5 participation of eligible children under this title and 

6 title XIX. 

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

8 ENROLLMENT CAMPAIGN.—An amount equal to 10 

9 percent of such amounts shall be used by the Sec10 retary for expenditures during such period to carry 

11 out a national enrollment campaign in accordance 

12 with subsection (h). 

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

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

15 subsection (a), the Secretary shall give priority to el16 igible entities that— 

17 ‘‘(A) propose to target geographic areas 

18 with high rates of— 

19 ‘‘(i) eligible but unenrolled children, 

20 including such children who reside in rural 

21 areas; or 

22 ‘‘(ii) racial and ethnic minorities and 

23 health disparity populations, including 

24 those proposals that address cultural and 

25 linguistic barriers to enrollment; and 


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1 ‘‘(B) submit the most demonstrable evi2 dence required under paragraphs (1) and (2) of 

3 subsection (c). 

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

5 TO INDIAN CHILDREN.—An amount equal to 10 per6 cent of the funds appropriated under subsection (g) 

7 shall be used by the Secretary to award grants to 

8 Indian Health Service providers and urban Indian 

9 organizations receiving funds under title V of the In10 dian Health Care Improvement Act (25 U.S.C. 1651 

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

12 who are Indians. 

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

14 receive a grant under subsection (a) shall submit an appli15 cation to the Secretary in such form and manner, and con16 taining such information, as the Secretary may decide. 

17 Such application shall include— 

18 ‘‘(1) evidence demonstrating that the entity in19 cludes members who have access to, and credibility 

20 with, ethnic or low-income populations in the com21 munities in which activities funded under the grant 

22 are to be conducted; 

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

24 the ability to address barriers to enrollment, such as 

25 lack of awareness of eligibility, stigma concerns and 


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1 punitive fears associated with receipt of benefits, 

2 and other cultural barriers to applying for and re3 ceiving child health assistance or medical assistance; 

4 ‘‘(3) specific quality or outcomes performance 

5 measures to evaluate the effectiveness of activities 

6 funded by a grant awarded under this section; and 

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

8 shall— 

9 ‘‘(A) conduct an assessment of the effec10 tiveness of such activities against the perform11 ance measures; 

12 ‘‘(B) cooperate with the collection and re13 porting of enrollment data and other informa14 tion in order for the Secretary to conduct such 

15 assessments; and 

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

17 is not the State, provide the State with enroll18 ment data and other information as necessary 

19 for the State to make necessary projections of 

20 eligible children and pregnant women. 

21 ‘‘(d) DISSEMINATION OF ENROLLMENT DATA AND

22 INFORMATION DETERMINED FROM EFFECTIVENESS AS23 SESSMENTS; ANNUAL REPORT.—The Secretary shall— 


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1 ‘‘(1) make publicly available the enrollment 

2 data and information collected and reported in ac3 cordance with subsection (c)(4)(B); and 

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

5 the outreach and enrollment activities conducted 

6 with funds appropriated under this section. 

7 ‘‘(e) MAINTENANCE OF EFFORT FOR STATES

8 AWARDED GRANTS; NO STATE MATCH REQUIRED.—In 

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

10 section— 

11 ‘‘(1) the State share of funds expended for out12 reach and enrollment activities under the State child 

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

14 such funds expended in the fiscal year preceding the 

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

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

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

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

19 ‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible en20 tity’ means any of the following: 

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

22 plan under this title. 

23 ‘‘(B) A local government. 

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

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1 tion receiving funds under title V of the Indian 

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

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

4 ‘‘(D) A Federal health safety net organiza5 tion. 

6 ‘‘(E) A national, State, local, or commu7 nity-based public or nonprofit private organiza8 tion, including organizations that use commu9 nity health workers or community-based doula 

10 programs. 

11 ‘‘(F) A faith-based organization or con12 sortia, to the extent that a grant awarded to 

13 such an entity is consistent with the require14 ments of section 1955 of the Public Health 

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

16 grant award to nongovernmental entities. 

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

18 ‘‘(2) FEDERAL HEALTH SAFETY NET ORGANI19 ZATION.—The term ‘Federal health safety net orga20 nization’ means— 

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

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

23 ‘‘(B) a hospital defined as a dispropor24 tionate share hospital for purposes of section 

25 1923; 


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

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

3 (42 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 

13 under the Richard B. Russell National School 

14 Lunch Act, and an elementary or secondary 

15 school. 

16 ‘‘(3) INDIANS; INDIAN TRIBE; TRIBAL ORGANI17 ZATION; URBAN INDIAN ORGANIZATION.—The terms 

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

19 ‘urban Indian organization’ have the meanings given 

20 such terms in section 4 of the Indian Health Care 

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

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

23 ‘community health worker’ means an individual who 

24 promotes health or nutrition within the community 

25 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 sec19 tion. Amounts appropriated and paid under the authority 

20 of this section shall be in addition to amounts appro21 priated under section 2104 and paid to States in accord22 ance with section 2105, including with respect to expendi23 tures for outreach activities in accordance with subsections 

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


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

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

3 Secretary shall develop and implement a national enroll4 ment campaign to improve the enrollment of underserved 

5 child populations in the programs established under this 

6 title and 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 

11 programs each Secretary administers that often 

12 serve the same children; 

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

14 programs established under this title and title XIX 

15 in public health awareness campaigns administered 

16 by 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 impor23 tance of health insurance to building strong commu24 nities 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 ‘‘(i) GRANTS FOR OUTREACH AND ENROLLMENT OF

8 NATIVE AMERICAN BENEFICIARIES.— 

9 ‘‘(1) IN GENERAL.—To overcome language and 

10 cultural barriers to program access by Native Ameri11 cans, the Secretary shall establish grant programs to 

12 conduct outreach and enrollment efforts to increase 

13 the enrollment and participation of eligible individ14 uals in programs of the Social Security Act (42 

15 U.S.C. 1397aa et seq.) and other Federal health and 

16 social service programs. 

17 ‘‘(2) USE OF TRIBAL BENEFITS-COUNSELORS

18 MODEL.—The grant program under this subsection 

19 shall incorporate expansion and stabilization of the 

20 tribal benefits-counselors model developed in the 

21 State of Washington to overcome language and cul22 tural barriers to Federal programs. 

23 ‘‘(3) RECIPIENTS.—In order to qualify for a 

24 grant under this subsection, an applicant shall be a 

25 national, nonprofit organization with successful and 


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1 verifiable experience in assisting Native Americans 

2 access Federal programs. 

3 ‘‘(4) REPORT.—At the end of the period of 

4 funding provided under subsection (f), the Secretary 

5 shall submit to Congress a report on the grants 

6 made under this subsection, including the efficacy of 

7 outreach efforts and the cost effectiveness of 

8 projects funded by such grants in improving access 

9 to Federal programs by Native Americans.’’. 

10 (b) ENHANCED ADMINISTRATIVE FUNDING FOR

11 TRANSLATION OR INTERPRETATION SERVICES UNDER

12 CHIP AND MEDICAID.— 

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

14 1397ee(a)(1)), as amended by section 113, is 

15 amended— 

16 (A) in the matter preceding subparagraph 

17 (A), by inserting ‘‘(or, in the case of expendi18 tures described in subparagraph (D)(iv), the 

19 higher of 75 percent or the sum of the en20 hanced FMAP plus 5 percentage points)’’ after 

21 ‘‘enhanced FMAP’’; and 

22 (B) in subparagraph (D)— 

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

24 the end; 


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1 (ii) by redesignating clause (iv) as 

2 clause (v); and 

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

4 following new clause: 

5 ‘‘(iv) for translation or interpretation 

6 services in connection with the enrollment 

7 of, retention of, and use of services under 

8 this title by, individuals for whom English 

9 is not their primary language (as found 

10 necessary by the Secretary for the proper 

11 and efficient administration of the State 

12 plan); and’’. 

13 (2) MEDICAID.— 

14 (A) USE OF MEDICAID FUNDS.—Section 

15 1903(a)(2) (42 U.S.C. 1396b(a)(2)) is amended 

16 by adding at the end the following new sub17 paragraph: 

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

19 of the sums expended during such quarter (as found 

20 necessary by the Secretary for the proper and effi21 cient administration of the State plan) as are attrib22 utable to translation or interpretation services in 

23 connection with the enrollment of, retention of, and 

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1 lies for whom English is not the primary language; 

2 plus’’. 

3 (B) USE OF COMMUNITY HEALTH WORK4 ERS FOR OUTREACH ACTIVITIES.— 

5 (i) IN GENERAL.—Section 2102(c)(1) 

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

7 amended by inserting ‘‘(through commu8 nity health workers and others)’’ after 

9 ‘‘Outreach’’. 

10 (ii) IN FEDERAL EVALUATION.—Sec11 tion 2108(c)(3)(B) of such Act (42 U.S.C. 

12 1397hh(c)(3)(B)) is amended by inserting 

13 ‘‘(such as through community health work14 ers and others)’’ after ‘‘including prac15 tices’’. 

16 SEC. 202. INCREASED OUTREACH AND ENROLLMENT OF IN17 DIANS. 

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

19 9) is amended to read as follows: 

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

21 HEALTH CARE FOR INDIANS UNDER TITLES 

22 XIX AND XXI. 

23 ‘‘(a) AGREEMENTS WITH STATES FOR MEDICAID

24 AND CHIP OUTREACH ON OR NEAR RESERVATIONS TO


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1 INCREASE THE ENROLLMENT OF INDIANS IN THOSE

2 PROGRAMS.— 

3 ‘‘(1) IN GENERAL.—In order to improve the ac4 cess of Indians residing on or near a reservation to 

5 obtain benefits under the Medicaid and State chil6 dren’s health insurance programs established under 

7 titles XIX and XXI, the Secretary shall encourage 

8 the State to take steps to provide for enrollment on 

9 or near the reservation. Such steps may include out10 reach efforts such as the outstationing of eligibility 

11 workers, entering into agreements with the Indian 

12 Health Service, Indian Tribes, Tribal Organizations, 

13 and Urban Indian Organizations to provide out14 reach, education regarding eligibility and benefits, 

15 enrollment, and translation services when such serv16 ices are appropriate. 

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

18 (1) shall be construed as affecting arrangements en19 tered into between States and the Indian Health 

20 Service, Indian Tribes, Tribal Organizations, or 

21 Urban Indian Organizations for such Service, 

22 Tribes, or Organizations to conduct administrative 

23 activities under such titles. 

24 ‘‘(b) REQUIREMENT TO FACILITATE COOPERA25 TION.—The Secretary, acting through the Centers for 


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

2 necessary to facilitate cooperation with, and agreements 

3 between, States and the Indian Health Service, Indian 

4 Tribes, Tribal Organizations, or Urban Indian Organiza5 tions with respect to the provision of health care items 

6 and services to Indians under the programs established 

7 under title XIX or XXI. 

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

9 HEALTH PROGRAM; TRIBAL ORGANIZATION; URBAN IN10 DIAN ORGANIZATION.—In this section, the terms ‘Indian’, 

11 ‘Indian Tribe’, ‘Indian Health Program’, ‘Tribal Organi12 zation’, and ‘Urban Indian Organization’ have the mean13 ings given those terms in section 4 of the Indian Health 

14 Care Improvement Act.’’. 

15 (b) NONAPPLICATION OF 10 PERCENT LIMIT ON

16 OUTREACH AND CERTAIN OTHER EXPENDITURES.—Sec17 tion 2105(c)(2) (42 U.S.C. 1397ee(c)(2)) is amended by 

18 adding at the end the following: 

19 ‘‘(C) NONAPPLICATION TO CERTAIN EX20 PENDITURES.—The limitation under subpara21 graph (A) shall not apply with respect to the 

22 following expenditures: 

23 ‘‘(i) EXPENDITURES TO INCREASE

24 OUTREACH TO, AND THE ENROLLMENT OF, 

25 INDIAN CHILDREN UNDER THIS TITLE AND


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1 TITLE xix.—Expenditures for outreach ac2 tivities to families of Indian children likely 

3 to be eligible for child health assistance 

4 under the plan or medical assistance under 

5 the State plan under title XIX (or under 

6 a waiver of such plan), to inform such 

7 families of the availability of, and to assist 

8 them in enrolling their children in, such 

9 plans, including such activities conducted 

10 under grants, contracts, or agreements en11 tered into under section 1139(a).’’. 

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

13 EXPRESS LANE AGENCY TO CONDUCT SIM14 PLIFIED ELIGIBILITY DETERMINATIONS. 

15 (a) APPLICATION UNDER MEDICAID AND CHIP PRO16 GRAMS.— 

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

18 1396a(e)) is amended by adding at the end the fol19 lowing: 

20 ‘‘(13) EXPRESS LANE OPTION.— 

21 ‘‘(A) IN GENERAL.— 

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

23 EXPRESS LANE AGENCY.—At the option of the 

24 State, the State plan may provide that in deter25 mining eligibility under this title for a child (as 


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

2 rely on a finding made within a reasonable pe3 riod (as determined by the State) from an Ex4 press Lane agency (as defined in subparagraph 

5 (F)) when it determines whether a child satis6 fies one or more components of eligibility for 

7 medical assistance under this title. The State 

8 may rely on a finding from an Express Lane 

9 agency notwithstanding any differences in 

10 budget unit, disregard, deeming or other meth11 odology, if the following requirements are met: 

12 ‘‘(I) PROHIBITION ON DETERMINING

13 CHILDREN INELIGIBLE FOR COVERAGE.— 

14 If a finding from an Express Lane agency 

15 would result in a determination that a 

16 child does not satisfy an eligibility require17 ment for medical assistance under this title 

18 and for child health assistance under title 

19 XXI, the State shall determine eligibility 

20 for assistance using its regular procedures. 

21 ‘‘(II) NOTICE REQUIREMENT.—For 

22 any child who is found eligible for medical 

23 assistance under the State plan under this 

24 title or child health assistance under title 

25 XXI and who is subject to premiums based 


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1 on an Express Lane agency’s finding of 

2 such child’s income level, the State shall 

3 provide notice that the child may qualify 

4 for lower premium payments if evaluated 

5 by the State using its regular policies and 

6 of the procedures for requesting such an 

7 evaluation. 

8 ‘‘(III) COMPLIANCE WITH SCREEN

9 AND ENROLL REQUIREMENT.—The State 

10 shall satisfy the requirements under sub11 paragraphs (A) and (B) of section 

12 2102(b)(3) (relating to screen and enroll) 

13 before enrolling a child in child health as14 sistance under title XXI. At its option, the 

15 State may fulfill such requirements in ac16 cordance with either option provided under 

17 subparagraph (C) of this paragraph. 

18 ‘‘(IV) VERIFICATION OF CITIZENSHIP, 

19 NATIONALITY STATUS, OR QUALIFIED

20 ALIEN STATUS.—The State shall satisfy 

21 the requirements of sections 1137(d) and 

22 1902(a)(46)(B) for verifications of citizen23 ship, nationality status, or qualified alien 

24 status. 


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1 ‘‘(V) CODING.—The State meets the 

2 requirements of subparagraph (E). 

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

4 REDETERMINATIONS.—The State may apply the 

5 provisions of this paragraph when conducting 

6 initial determinations of eligibility, redetermina7 tions of eligibility, or both, as described in the 

8 State plan. 

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

10 this paragraph shall be construed— 

11 ‘‘(i) to relieve a State of the obligation to 

12 determine components of eligibility that are not 

13 the subject of an Express Lane agency’s find14 ing, as described in subparagraph (A); 

15 ‘‘(ii) to limit or prohibit a State from tak16 ing any actions otherwise permitted under this 

17 title or title XXI in determining eligibility for 

18 or enrolling children into medical assistance 

19 under this title or child health assistance under 

20 title XXI; or 

21 ‘‘(iii) to modify the limitations in section 

22 1902(a)(5) concerning the agencies that may 

23 make a determination of eligibility for medical 

24 assistance under this title. 


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1 ‘‘(C) OPTIONS FOR SATISFYING THE SCREEN

2 AND ENROLL REQUIREMENT.— 

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

4 whose eligibility for medical assistance under 

5 this title or for child health assistance under 

6 title XXI has been evaluated by a State agency 

7 using an income finding from an Express Lane 

8 agency, a State may carry out its duties under 

9 subparagraphs (A) and (B) of section 

10 2102(b)(3) (relating to screen and enroll) in ac11 cordance with either clause (ii) or clause (iii). 

12 ‘‘(ii) ESTABLISHING A SCREENING

13 THRESHOLD.— 

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

15 the State establishes a screening threshold 

16 set as a percentage of the Federal poverty 

17 level that exceeds the highest income 

18 threshold applicable under this title to the 

19 child by a minimum of 30 percentage 

20 points or, at State option, a higher number 

21 of percentage points that reflects the value 

22 (as determined by the State and described 

23 in the State plan) of any differences be24 tween income methodologies used by the 

25 program administered by the Express Lane 


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1 agency and the methodologies used by the 

2 State in determining eligibility for medical 

3 assistance under this title. 

4 ‘‘(II) CHILDREN WITH INCOME NOT

5 ABOVE THRESHOLD.—If the income of a 

6 child does not exceed the screening thresh7 old, the child is deemed to satisfy the in8 come eligibility criteria for medical assist9 ance under this title regardless of whether 

10 such child would otherwise satisfy such cri11 teria. 

12 ‘‘(III) CHILDREN WITH INCOME

13 ABOVE THRESHOLD.—If the income of a 

14 child exceeds the screening threshold, the 

15 child shall be considered to have an income 

16 above the Medicaid applicable income level 

17 described in section 2110(b)(4) and to sat18 isfy the requirement under section 

19 2110(b)(1)(C) (relating to the requirement 

20 that CHIP matching funds be used only 

21 for children not eligible for Medicaid). If 

22 such a child is enrolled in child health as23 sistance under title XXI, the State shall 

24 provide the parent, guardian, or custodial 

25 relative with the following: 


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1 ‘‘(aa) Notice that the child may 

2 be eligible to receive medical assist3 ance under the State plan under this 

4 title if evaluated for such assistance 

5 under the State’s regular procedures 

6 and notice of the process through 

7 which a parent, guardian, or custodial 

8 relative can request that the State 

9 evaluate the child’s eligibility for med10 ical assistance under this title using 

11 such regular procedures. 

12 ‘‘(bb) A description of differences 

13 between the medical assistance pro14 vided under this title and child health 

15 assistance under title XXI, including 

16 differences in cost-sharing require17 ments and covered benefits. 

18 ‘‘(iii) TEMPORARY ENROLLMENT IN CHIP

19 PENDING SCREEN AND ENROLL.— 

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

21 a State enrolls a child in child health as22 sistance under title XXI for a temporary 

23 period if the child appears eligible for such 

24 assistance based on an income finding by 

25 an Express Lane agency. 


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1 ‘‘(II) DETERMINATION OF ELIGI2 BILITY.—During such temporary enroll3 ment period, the State shall determine the 

4 child’s eligibility for child health assistance 

5 under title XXI or for medical assistance 

6 under this title in accordance with this 

7 clause. 

8 ‘‘(III) PROMPT FOLLOW UP.—In mak9 ing such a determination, the State shall 

10 take prompt action to determine whether 

11 the child should be enrolled in medical as12 sistance under this title or child health as13 sistance under title XXI pursuant to sub14 paragraphs (A) and (B) of section 

15 2102(b)(3) (relating to screen and enroll). 

16 ‘‘(IV) REQUIREMENT FOR SIMPLIFIED

17 DETERMINATION.—In making such a de18 termination, the State shall use procedures 

19 that, to the maximum feasible extent, re20 duce the burden imposed on the individual 

21 of such determination. Such procedures 

22 may not require the child’s parent, guard23 ian, or custodial relative to provide or 

24 verify information that already has been 

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1 press Lane agency or another source of in2 formation unless the State agency has rea3 son to believe the information is erroneous. 

4 ‘‘(V) AVAILABILITY OF CHIP MATCH5 ING FUNDS DURING TEMPORARY ENROLL6 MENT PERIOD.—Medical assistance for 

7 items and services that are provided to a 

8 child enrolled in title XXI during a tem9 porary enrollment period under this clause 

10 shall be treated as child health assistance 

11 under such title. 

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

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

14 and determine eligibility for medical assistance 

15 under the State Medicaid plan or for child 

16 health assistance under the State CHIP plan 

17 without a program application from, or on be18 half of, the child based on data obtained from 

19 sources other than the child (or the child’s fam20 ily), but a child can only be automatically en21 rolled in the State Medicaid plan or the State 

22 CHIP plan if the child or the family affirma23 tively consents to being enrolled through affir24 mation and signature on an Express Lane 


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1 agency application, if the requirement of clause 

2 (ii) is met. 

3 ‘‘(ii) INFORMATION REQUIREMENT.—The 

4 requirement of this clause is that the State in5 forms the parent, guardian, or custodial relative 

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

7 appropriate methods for using such services, 

8 premium or other cost sharing charges (if any) 

9 that apply, medical support obligations (under 

10 section 1912(a)) created by enrollment (if appli11 cable), and the actions the parent, guardian, or 

12 relative must take to maintain enrollment and 

13 renew coverage. 

14 ‘‘(E) CODING; APPLICATION TO ENROLLMENT

15 ERROR RATES.— 

16 ‘‘(i) IN GENERAL.—For purposes of sub17 paragraph (A)(iv), the requirement of this sub18 paragraph for a State is that the State agrees 

19 to— 

20 ‘‘(I) assign such codes as the Sec21 retary shall require to the children who are 

22 enrolled in the State Medicaid plan or the 

23 State CHIP plan through reliance on a 

24 finding made by an Express Lane agency 


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1 for the duration of the State’s election 

2 under this paragraph; 

3 ‘‘(II) annually provide the Secretary 

4 with a statistically valid sample (that is ap5 proved by Secretary) of the children en6 rolled in such plans through reliance on 

7 such a finding by conducting a full Med8 icaid eligibility review of the children iden9 tified for such sample for purposes of de10 termining an eligibility error rate (as de11 scribed in clause (iv)) with respect to the 

12 enrollment of such children (and shall not 

13 include such children in any data or sam14 ples used for purposes of complying with a 

15 Medicaid Eligibility Quality Control 

16 (MEQC) review or a payment error rate 

17 measurement (PERM) requirement); 

18 ‘‘(III) submit the error rate deter19 mined under subclause (II) to the Sec20 retary; 

21 ‘‘(IV) if such error rate exceeds 3 per22 cent for either of the first 2 fiscal years in 

23 which the State elects to apply this para24 graph, demonstrate to the satisfaction of 

25 the Secretary the specific corrective actions 


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1 implemented by the State to improve upon 

2 such error rate; and 

3 ‘‘(V) if such error rate exceeds 3 per4 cent for any fiscal year in which the State 

5 elects to apply this paragraph, a reduction 

6 in the amount otherwise payable to the 

7 State under section 1903(a) for quarters 

8 for that fiscal year, equal to the total 

9 amount of erroneous excess payments de10 termined for the fiscal year only with re11 spect to the children included in the sam12 ple for the fiscal year that are in excess of 

13 a 3 percent error rate with respect to such 

14 children. 

15 ‘‘(ii) NO PUNITIVE ACTION BASED ON

16 ERROR RATE.—The Secretary shall not apply 

17 the error rate derived from the sample under 

18 clause (i) to the entire population of children 

19 enrolled in the State Medicaid plan or the State 

20 CHIP plan through reliance on a finding made 

21 by an Express Lane agency, or to the popu22 lation of children enrolled in such plans on the 

23 basis of the State’s regular procedures for de24 termining eligibility, or penalize the State on 

25 the basis of such error rate in any manner 


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1 other than the reduction of payments provided 

2 for under clause (i)(V). 

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

4 in this paragraph shall be construed as relieving 

5 a State that elects to apply this paragraph from 

6 being subject to a penalty under section 

7 1903(u), for payments made under the State 

8 Medicaid plan with respect to ineligible individ9 uals and families that are determined to exceed 

10 the error rate permitted under that section (as 

11 determined without regard to the error rate de12 termined under clause (i)(II)). 

13 ‘‘(iv) ERROR RATE DEFINED.—In this sub14 paragraph, the term ‘error rate’ means the rate 

15 of erroneous excess payments for medical as16 sistance (as defined in section 1903(u)(1)(D)) 

17 for the period involved, except that such pay18 ments shall be limited to individuals for which 

19 eligibility determinations are made under this 

20 paragraph and except that in applying this 

21 paragraph under title XXI, there shall be sub22 stituted for references to provisions of this title 

23 corresponding provisions within title XXI. 

24 ‘‘(F) EXPRESS LANE AGENCY.— 


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

2 term ‘Express Lane agency’ means a public 

3 agency that— 

4 ‘‘(I) is determined by the State Med5 icaid agency or the State CHIP agency (as 

6 applicable) to be capable of making the de7 terminations of one or more eligibility re8 quirements described in subparagraph 

9 (A)(i); 

10 ‘‘(II) is identified in the State Med11 icaid plan or the State CHIP plan; and 

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

13 ‘‘(aa) of the information which 

14 shall be disclosed in accordance with 

15 this paragraph; 

16 ‘‘(bb) that the information dis17 closed will be used solely for purposes 

18 of determining eligibility for medical 

19 assistance under the State Medicaid 

20 plan or for child health assistance 

21 under the State CHIP plan; and 

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

23 not have the information disclosed for 

24 such purposes; and 


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

2 interagency agreement to limit the disclo3 sure and use of the information disclosed. 

4 ‘‘(ii) INCLUSION OF SPECIFIC PUBLIC

5 AGENCIES.—Such term includes the following: 

6 ‘‘(I) A public agency that determines 

7 eligibility for assistance under any of the 

8 following: 

9 ‘‘(aa) The temporary assistance 

10 for needy families program funded 

11 under part A of title IV. 

12 ‘‘(bb) A State program funded 

13 under part D of title IV. 

14 ‘‘(cc) The State Medicaid plan. 

15 ‘‘(dd) The State CHIP plan. 

16 ‘‘(ee) The Food and Nutrition 

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

18 ‘‘(ff) The Head Start Act (42 

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

20 ‘‘(gg) The Richard B. Russell 

21 National School Lunch Act (42 

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

23 ‘‘(hh) The Child Nutrition Act of 

24 1966 (42 U.S.C. 1771 et seq.). 


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1 ‘‘(ii) The Child Care and Devel2 opment Block Grant Act of 1990 (42 

3 U.S.C. 9858 et seq.). 

4 ‘‘(jj) The Stewart B. McKinney 

5 Homeless Assistance Act (42 U.S.C. 

6 11301 et seq.). 

7 ‘‘(kk) The United States Housing 

8 Act of 1937 (42 U.S.C. 1437 et seq.). 

9 ‘‘(ll) The Native American Hous10 ing Assistance and Self-Determination 

11 Act of 1996 (25 U.S.C. 4101 et seq.). 

12 ‘‘(II) A State-specified governmental 

13 agency that has fiscal liability or legal re14 sponsibility for the accuracy of the eligi15 bility determination findings relied on by 

16 the State. 

17 ‘‘(III) A public agency that is subject 

18 to an interagency agreement limiting the 

19 disclosure and use of the information dis20 closed for purposes of determining eligi21 bility under the State Medicaid plan or the 

22 State CHIP plan. 

23 ‘‘(iii) EXCLUSIONS.—Such term does not 

24 include an agency that determines eligibility for 

25 a program established under the Social Services 


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1 Block Grant established under title XX or a 

2 private, for-profit organization. 

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

4 in this paragraph shall be construed as— 

5 ‘‘(I) exempting a State Medicaid 

6 agency from complying with the require7 ments of section 1902(a)(4) relating to 

8 merit-based personnel standards for em9 ployees of the State Medicaid agency and 

10 safeguards against conflicts of interest); or 

11 ‘‘(II) authorizing a State Medicaid 

12 agency that elects to use Express Lane 

13 agencies under this subparagraph to use 

14 the Express Lane option to avoid com15 plying with such requirements for purposes 

16 of making eligibility determinations under 

17 the State Medicaid plan. 

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

19 paragraph: 

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

21 1 of the 50 States or the District of Co22 lumbia. 

23 ‘‘(II) STATE CHIP AGENCY.—The 

24 term ‘State CHIP agency’ means the State 


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1 agency responsible for administering the 

2 State CHIP plan. 

3 ‘‘(III) STATE CHIP PLAN.—The term 

4 ‘State CHIP plan’ means the State child 

5 health plan established under title XXI 

6 and includes any waiver of such plan. 

7 ‘‘(IV) STATE MEDICAID AGENCY.— 

8 The term ‘State Medicaid agency’ means 

9 the State agency responsible for admin10 istering the State Medicaid plan. 

11 ‘‘(V) STATE MEDICAID PLAN.—The 

12 term ‘State Medicaid plan’ means the 

13 State plan established under title XIX and 

14 includes any waiver of such plan. 

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

16 paragraph, the term ‘child’ means an individual 

17 under 19 years of age, or, at the option of a State, 

18 such higher age, not to exceed 21 years of age, as 

19 the State may elect. 

20 ‘‘(H) APPLICATION.—This paragraph shall not 

21 apply to with respect to eligibility determinations 

22 made after September 30, 2013.’’. 

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

24 1397gg(e)(1)) is amended by redesignating subpara25 graphs (B), (C), and (D) as subparagraphs (C), (D), 


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1 and (E), respectively, and by inserting after sub2 paragraph (A) the following new subparagraph: 

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

4 State option to rely on findings from an Ex5 press Lane agency to help evaluate a child’s eli6 gibility for medical assistance).’’. 

7 (b) EVALUATION AND REPORT.— 

8 (1) EVALUATION.—The Secretary shall con9 duct, by grant, contract, or interagency agreement, 

10 a comprehensive, independent evaluation of the op11 tion provided under the amendments made by sub12 section (a). Such evaluation shall include an analysis 

13 of the effectiveness of the option, and shall include— 

14 (A) obtaining a statistically valid sample of 

15 the children who were enrolled in the State 

16 Medicaid plan or the State CHIP plan through 

17 reliance on a finding made by an Express Lane 

18 agency and determining the percentage of chil19 dren who were erroneously enrolled in such 

20 plans; 

21 (B) determining whether enrolling children 

22 in such plans through reliance on a finding 

23 made by an Express Lane agency improves the 

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1 come, uninsured children who are eligible but 

2 not enrolled in such plans; 

3 (C) evaluating the administrative costs or 

4 savings related to identifying and enrolling chil5 dren in such plans through reliance on such 

6 findings, and the extent to which such costs dif7 fer from the costs that the State otherwise 

8 would have incurred to identify and enroll low9 income, uninsured children who are eligible but 

10 not enrolled in such plans; and 

11 (D) any recommendations for legislative or 

12 administrative changes that would improve the 

13 effectiveness of enrolling children in such plans 

14 through reliance on such findings. 

15 (2) REPORT TO CONGRESS.—Not later than 

16 September 30, 2012, the Secretary shall submit a 

17 report to Congress on the results of the evaluation 

18 under paragraph (1). 

19 (3) FUNDING.— 

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

21 Treasury not otherwise appropriated, there is 

22 appropriated to the Secretary to carry out the 

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

24 the period of fiscal years 2009 through 2012. 


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1 (B) BUDGET AUTHORITY.—Subparagraph 

2 (A) constitutes budget authority in advance of 

3 appropriations Act and represents the obliga4 tion of the Federal Government to provide for 

5 the payment of such amount to conduct the 

6 evaluation under this subsection. 

7 (c) ELECTRONIC TRANSMISSION OF INFORMATION.— 

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

9 at the end the following new subsection: 

10 ‘‘(dd) ELECTRONIC TRANSMISSION OF INFORMA11 TION.—If the State agency determining eligibility for med12 ical assistance under this title or child health assistance 

13 under title XXI verifies an element of eligibility based on 

14 information from an Express Lane Agency (as defined in 

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

16 then the applicant’s signature under penalty of perjury 

17 shall not be required as to such element. Any signature 

18 requirement for an application for medical assistance may 

19 be satisfied through an electronic signature, as defined in 

20 section 1710(1) of the Government Paperwork Elimi21 nation Act (44 U.S.C. 3504 note). The requirements of 

22 subparagraphs (A) and (B) of section 1137(d)(2) may be 

23 met through evidence in digital or electronic form.’’. 

24 (d) AUTHORIZATION OF INFORMATION DISCLO25 SURE.— 


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1 (1) IN GENERAL.—Title XIX is amended by 

2 adding at the end the following new section: 

3 ‘‘SEC. 1942. AUTHORIZATION TO RECEIVE RELEVANT IN4 FORMATION. 

5 ‘‘(a) IN GENERAL.—Notwithstanding any other pro6 vision of law, a Federal or State agency or private entity 

7 in possession of the sources of data directly relevant to 

8 eligibility determinations under this title (including eligi9 bility files maintained by Express Lane agencies described 

10 in section 1902(e)(13)(F), information described in para11 graph (2) or (3) of section 1137(a), vital records informa12 tion about births in any State, and information described 

13 in sections 453(i) and 1902(a)(25)(I)) is authorized to 

14 convey such data or information to the State agency ad15 ministering the State plan under this title, to the extent 

16 such conveyance meets the requirements of subsection (b). 

17 ‘‘(b) REQUIREMENTS FOR CONVEYANCE.—Data or 

18 information may be conveyed pursuant to subsection (a) 

19 only if the following requirements are met: 

20 ‘‘(1) The individual whose circumstances are 

21 described in the data or information (or such indi22 vidual’s parent, guardian, caretaker relative, or au23 thorized representative) has either provided advance 

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1 sure after receiving advance notice of disclosure and 

2 a reasonable opportunity to object. 

3 ‘‘(2) Such data or information are used solely 

4 for the purposes of— 

5 ‘‘(A) identifying individuals who are eligi6 ble or potentially eligible for medical assistance 

7 under this title and enrolling or attempting to 

8 enroll such individuals in the State plan; and 

9 ‘‘(B) verifying the eligibility of individuals 

10 for medical assistance under the State plan. 

11 ‘‘(3) An interagency or other agreement, con12 sistent with standards developed by the Secretary— 

13 ‘‘(A) prevents the unauthorized use, disclo14 sure, or modification of such data and other15 wise meets applicable Federal requirements 

16 safeguarding privacy and data security; and 

17 ‘‘(B) requires the State agency admin18 istering the State plan to use the data and in19 formation obtained under this section to seek to 

20 enroll individuals in the plan. 

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

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

23 described in the subsection (a) that publishes, dis24 closes, or makes known in any manner, or to any ex25 tent not authorized by Federal law, any information 


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1 obtained under this section is subject to a civil 

2 money penalty in an amount equal to $10,000 for 

3 each such unauthorized publication or disclosure. 

4 The provisions of section 1128A (other than sub5 sections (a) and (b) and the second sentence of sub6 section (f)) shall apply to a civil money penalty 

7 under this paragraph in the same manner as such 

8 provisions apply to a penalty or proceeding under 

9 section 1128A(a). 

10 ‘‘(2) CRIMINAL PENALTY.—A private entity de11 scribed in the subsection (a) that willfully publishes, 

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

13 extent not authorized by Federal law, any informa14 tion obtained under this section shall be fined not 

15 more than $10,000 or imprisoned not more than 1 

16 year, or both, for each such unauthorized publication 

17 or disclosure. 

18 ‘‘(d) RULE OF CONSTRUCTION.—The limitations and 

19 requirements that apply to disclosure pursuant to this sec20 tion shall not be construed to prohibit the conveyance or 

21 disclosure of data or information otherwise permitted 

22 under Federal law (without regard to this section).’’. 

23 (2) CONFORMING AMENDMENT TO TITLE XXI.— 

24 Section 2107(e)(1) (42 U.S.C. 1397gg(e)(1)), as 


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1 amended by subsection (a)(2), is amended by adding 

2 at the end the following new subparagraph: 

3 ‘‘(F) Section 1942 (relating to authoriza4 tion to receive data directly relevant to eligi5 bility determinations).’’. 

6 (3) CONFORMING AMENDMENT TO PROVIDE AC7 CESS TO DATA ABOUT ENROLLMENT IN INSURANCE

8 FOR PURPOSES OF EVALUATING APPLICATIONS AND

9 FOR CHIP.—Section 1902(a)(25)(I)(i) (42 U.S.C. 

10 1396a(a)(25)(I)(i)) is amended— 

11 (A) by inserting ‘‘(and, at State option, in12 dividuals who apply or whose eligibility for med13 ical assistance is being evaluated in accordance 

14 with section 1902(e)(13)(D))’’ after ‘‘with re15 spect to individuals who are eligible’’; and 

16 (B) by inserting ‘‘under this title (and, at 

17 State option, child health assistance under title 

18 XXI)’’ after ‘‘the State plan’’. 

19 (e) AUTHORIZATION FOR STATES ELECTING EX20 PRESS LANE OPTION TO RECEIVE CERTAIN DATA DI21 RECTLY RELEVANT TO DETERMINING ELIGIBILITY AND

22 CORRECT AMOUNT OF ASSISTANCE.—The Secretary shall 

23 enter into such agreements as are necessary to permit a 

24 State that elects the Express Lane option under section 

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1 rectly relevant to eligibility determinations and deter2 mining the correct amount of benefits under a State child 

3 health plan under CHIP or a State plan under Medicaid 

4 from the following: 

5 (1) The National Directory of New Hires estab6 lished under section 453(i) of the Social Security 

7 Act (42 U.S.C. 653(i)). 

8 (2) Data regarding enrollment in insurance that 

9 may help to facilitate outreach and enrollment under 

10 the State Medicaid plan, the State CHIP plan, and 

11 such other programs as the Secretary may specify. 

12 (f) EFFECTIVE DATE.—The amendments made by 

13 this section are effective on the date of the enactment of 

14 this Act. 

15 Subtitle B—Reducing Barriers to 

16 Enrollment 

17 SEC. 211. VERIFICATION OF DECLARATION OF CITIZENSHIP 

18 OR NATIONALITY FOR PURPOSES OF ELIGI19 BILITY FOR MEDICAID AND CHIP. 

20 (a) ALTERNATIVE STATE PROCESS FOR

21 VERIFICATION OF DECLARATION OF CITIZENSHIP OR NA22 TIONALITY FOR PURPOSES OF ELIGIBILITY FOR MED23 ICAID.— 

24 (1) ALTERNATIVE TO DOCUMENTATION RE25 QUIREMENT.— 


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1 (A) IN GENERAL.—Section 1902 (42 

2 U.S.C. 1396a), as amended by section 203(c), 

3 is amended— 

4 (i) in subsection (a)(46)— 

5 (I) by inserting ‘‘(A)’’ after 

6 ‘‘(46)’’; 

7 (II) by adding ‘‘and’’ after the 

8 semicolon; and 

9 (III) by adding at the end the 

10 following new subparagraph: 

11 ‘‘(B) provide, with respect to an individual de12 claring to be a citizen or national of the United 

13 States for purposes of establishing eligibility under 

14 this title, that the State shall satisfy the require15 ments of— 

16 ‘‘(i) section 1903(x); or 

17 ‘‘(ii) subsection (ee);’’; and 

18 (ii) by adding at the end the following 

19 new subsection: 

20 ‘‘(ee)(1) For purposes of subsection (a)(46)(B)(ii), 

21 the requirements of this subsection with respect to an indi22 vidual declaring to be a citizen or national of the United 

23 States for purposes of establishing eligibility under this 

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1 ality under section 1903(x) (if the individual is not de2 scribed in paragraph (2) of that section), as follows: 

3 ‘‘(A) The State submits the name and social se4 curity number of the individual to the Commissioner 

5 of Social Security as part of the program established 

6 under paragraph (2). 

7 ‘‘(B) If the State receives notice from the Com8 missioner of Social Security that the name or social 

9 security number, or the declaration of citizenship or 

10 nationality, of the individual is inconsistent with in11 formation in the records maintained by the Commis12 sioner— 

13 ‘‘(i) the State makes a reasonable effort to 

14 identify and address the causes of such incon15 sistency, including through typographical or 

16 other clerical errors, by contacting the indi17 vidual to confirm the accuracy of the name or 

18 social security number submitted or declaration 

19 of citizenship or nationality and by taking such 

20 additional actions as the Secretary, through 

21 regulation or other guidance, or the State may 

22 identify, and continues to provide the individual 

23 with medical assistance while making such ef24 fort; and 


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1 ‘‘(ii) in the case such inconsistency is not 

2 resolved under clause (i), the State— 

3 ‘‘(I) notifies the individual of such 

4 fact; 

5 ‘‘(II) provides the individual with a 

6 period of 90 days from the date on which 

7 the notice required under subclause (I) is 

8 received by the individual to either present 

9 satisfactory documentary evidence of citi10 zenship or nationality (as defined in sec11 tion 1903(x)(3)) or resolve the inconsist12 ency with the Commissioner of Social Se13 curity (and continues to provide the indi14 vidual with medical assistance during such 

15 90-day period); and 

16 ‘‘(III) disenrolls the individual from 

17 the State plan under this title within 30 

18 days after the end of such 90-day period if 

19 no such documentary evidence is presented 

20 or if such inconsistency is not resolved. 

21 ‘‘(2)(A) Each State electing to satisfy the require22 ments of this subsection for purposes of section 

23 1902(a)(46)(B) shall establish a program under which the 

24 State submits at least monthly to the Commissioner of So25 cial Security for comparison of the name and social secuVerDate Nov 24 2008 21:36 Jan 16, 2009 Jkt 079200 PO 00000 Frm 00123 Fmt 6652 Sfmt 6201 E:\BILLS\H2.PCS H2

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1 rity number, of each individual newly enrolled in the State 

2 plan under this title that month who is not described in 

3 section 1903(x)(2) and who declares to be a United States 

4 citizen or national, with information in records maintained 

5 by the Commissioner. 

6 ‘‘(B) In establishing the State program under this 

7 paragraph, the State may enter into an agreement with 

8 the Commissioner of Social Security— 

9 ‘‘(i) to provide, through an on-line system or 

10 otherwise, for the electronic submission of, and re11 sponse to, the information submitted under subpara12 graph (A) for an individual enrolled in the State 

13 plan under this title who declares to be citizen or na14 tional on at least a monthly basis; or 

15 ‘‘(ii) to provide for a determination of the con16 sistency of the information submitted with the infor17 mation maintained in the records of the Commis18 sioner through such other method as agreed to by 

19 the State and the Commissioner and approved by 

20 the Secretary, provided that such method is no more 

21 burdensome for individuals to comply with than any 

22 burdens that may apply under a method described in 

23 clause (i). 

24 ‘‘(C) The program established under this paragraph 

25 shall provide that, in the case of any individual who is 


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1 required to submit a social security number to the State 

2 under subparagraph (A) and who is unable to provide the 

3 State with such number, shall be provided with at least 

4 the reasonable opportunity to present satisfactory docu5 mentary evidence of citizenship or nationality (as defined 

6 in section 1903(x)(3)) as is provided under clauses (i) and 

7 (ii) of section 1137(d)(4)(A) to an individual for the sub8 mittal to the State of evidence indicating a satisfactory 

9 immigration status. 

10 ‘‘(3)(A) The State agency implementing the plan ap11 proved under this title shall, at such times and in such 

12 form as the Secretary may specify, provide information on 

13 the percentage each month that the inconsistent submis14 sions bears to the total submissions made for comparison 

15 for such month. For purposes of this subparagraph, a 

16 name, social security number, or declaration of citizenship 

17 or nationality of an individual shall be treated as incon18 sistent and included in the determination of such percent19 age only if— 

20 ‘‘(i) the information submitted by the individual 

21 is not consistent with information in records main22 tained by the Commissioner of Social Security; 

23 ‘‘(ii) the inconsistency is not resolved by the 

24 State; 


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1 ‘‘(iii) the individual was provided with a reason2 able period of time to resolve the inconsistency with 

3 the Commissioner of Social Security or provide satis4 factory documentation of citizenship status and did 

5 not successfully resolve such inconsistency; and 

6 ‘‘(iv) payment has been made for an item or 

7 service furnished to the individual under this title. 

8 ‘‘(B) If, for any fiscal year, the average monthly per9 centage determined under subparagraph (A) is greater 

10 than 3 percent— 

11 ‘‘(i) the State shall develop and adopt a correc12 tive plan to review its procedures for verifying the 

13 identities of individuals seeking to enroll in the State 

14 plan under this title and to identify and implement 

15 changes in such procedures to improve their accu16 racy; and 

17 ‘‘(ii) pay to the Secretary an amount equal to 

18 the amount which bears the same ratio to the total 

19 payments under the State plan for the fiscal year for 

20 providing medical assistance to individuals who pro21 vided inconsistent information as the number of in22 dividuals with inconsistent information in excess of 

23 3 percent of such total submitted bears to the total 

24 number of individuals with inconsistent information. 


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1 ‘‘(C) The Secretary may waive, in certain limited 

2 cases, all or part of the payment under subparagraph 

3 (B)(ii) if the State is unable to reach the allowable error 

4 rate despite a good faith effort by such State. 

5 ‘‘(D) Subparagraphs (A) and (B) shall not apply to 

6 a State for a fiscal year if there is an agreement described 

7 in paragraph (2)(B) in effect as of the close of the fiscal 

8 year that provides for the submission on a real-time basis 

9 of the information described in such paragraph. 

10 ‘‘(4) Nothing in this subsection shall affect the rights 

11 of any individual under this title to appeal any 

12 disenrollment from a State plan.’’. 

13 (B) COSTS OF IMPLEMENTING AND MAIN14 TAINING SYSTEM.—Section 1903(a)(3) (42 

15 U.S.C. 1396b(a)(3)) is amended— 

16 (i) by striking ‘‘plus’’ at the end of 

17 subparagraph (E) and inserting ‘‘and’’, 

18 and 

19 (ii) by adding at the end the following 

20 new subparagraph: 

21 ‘‘(F)(i) 90 percent of the sums expended 

22 during the quarter as are attributable to the de23 sign, development, or installation of such 

24 mechanized verification and information re25 trieval systems as the Secretary determines are 


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1 necessary to implement section 1902(ee) (in2 cluding a system described in paragraph (2)(B) 

3 thereof), and 

4 ‘‘(ii) 75 percent of the sums expended dur5 ing the quarter as are attributable to the oper6 ation of systems to which clause (i) applies, 

7 plus’’. 

8 (2) LIMITATION ON WAIVER AUTHORITY.—Not9 withstanding any provision of section 1115 of the 

10 Social Security Act (42 U.S.C. 1315), or any other 

11 provision of law, the Secretary may not waive the re12 quirements of section 1902(a)(46)(B) of such Act 

13 (42 U.S.C. 1396a(a)(46)(B)) with respect to a 

14 State. 

15 (3) CONFORMING AMENDMENTS.—Section 1903 

16 (42 U.S.C. 1396b) is amended— 

17 (A) in subsection (i)(22), by striking ‘‘sub18 section (x)’’ and inserting ‘‘section 

19 1902(a)(46)(B)’’; and 

20 (B) in subsection (x)(1), by striking ‘‘sub21 section (i)(22)’’ and inserting ‘‘section 

22 1902(a)(46)(B)(i)’’. 

23 (4) APPROPRIATION.—Out of any money in the 

24 Treasury of the United States not otherwise appro25 priated, there are appropriated to the Commissioner 


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1 of Social Security $5,000,000 to remain available 

2 until expended to carry out the Commissioner’s re3 sponsibilities under section 1902(ee) of the Social 

4 Security Act, as added by subsection (a). 

5 (b) CLARIFICATION OF REQUIREMENTS RELATING

6 TO PRESENTATION OF SATISFACTORY DOCUMENTARY

7 EVIDENCE OF CITIZENSHIP OR NATIONALITY.— 

8 (1) ACCEPTANCE OF DOCUMENTARY EVIDENCE

9 ISSUED BY A FEDERALLY RECOGNIZED INDIAN

10 TRIBE.—Section 1903(x)(3)(B) (42 U.S.C. 

11 1396b(x)(3)(B)) is amended— 

12 (A) by redesignating clause (v) as clause 

13 (vi); and 

14 (B) by inserting after clause (iv), the fol15 lowing new clause: 

16 ‘‘(v)(I) Except as provided in subclause (II), a 

17 document issued by a federally recognized Indian 

18 tribe evidencing membership or enrollment in, or af19 filiation with, such tribe (such as a tribal enrollment 

20 card or certificate of degree of Indian blood). 

21 ‘‘(II) With respect to those federally recognized 

22 Indian tribes located within States having an inter23 national border whose membership includes individ24 uals who are not citizens of the United States, the 

25 Secretary shall, after consulting with such tribes, 


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1 issue regulations authorizing the presentation of 

2 such other forms of documentation (including tribal 

3 documentation, if appropriate) that the Secretary 

4 determines to be satisfactory documentary evidence 

5 of citizenship or nationality for purposes of satis6 fying the requirement of this subsection.’’. 

7 (2) REQUIREMENT TO PROVIDE REASONABLE

8 OPPORTUNITY TO PRESENT SATISFACTORY DOCU9 MENTARY EVIDENCE.—Section 1903(x) (42 U.S.C. 

10 1396b(x)) is amended by adding at the end the fol11 lowing new paragraph: 

12 ‘‘(4) In the case of an individual declaring to be a 

13 citizen or national of the United States with respect to 

14 whom a State requires the presentation of satisfactory 

15 documentary evidence of citizenship or nationality under 

16 section 1902(a)(46)(B)(i), the individual shall be provided 

17 at least the reasonable opportunity to present satisfactory 

18 documentary evidence of citizenship or nationality under 

19 this subsection as is provided under clauses (i) and (ii) 

20 of section 1137(d)(4)(A) to an individual for the submittal 

21 to the State of evidence indicating a satisfactory immigra22 tion status.’’. 

23 (3) CHILDREN BORN IN THE UNITED STATES

24 TO MOTHERS ELIGIBLE FOR MEDICAID.— 


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1 (A) CLARIFICATION OF RULES.—Section 

2 1903(x) (42 U.S.C. 1396b(x)), as amended by 

3 paragraph (2), is amended— 

4 (i) in paragraph (2)— 

5 (I) in subparagraph (C), by strik6 ing ‘‘or’’ at the end; 

7 (II) by redesignating subpara8 graph (D) as subparagraph (E); and 

9 (III) by inserting after subpara10 graph (C) the following new subpara11 graph: 

12 ‘‘(D) pursuant to the application of section 

13 1902(e)(4) (and, in the case of an individual who is 

14 eligible for medical assistance on such basis, the in15 dividual shall be deemed to have provided satisfac16 tory documentary evidence of citizenship or nation17 ality and shall not be required to provide further 

18 documentary evidence on any date that occurs dur19 ing or after the period in which the individual is eli20 gible for medical assistance on such basis); or’’; and 

21 (ii) by adding at the end the following 

22 new paragraph: 

23 ‘‘(5) Nothing in subparagraph (A) or (B) of section 

24 1902(a)(46), the preceding paragraphs of this subsection, 

25 or the Deficit Reduction Act of 2005, including section 


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1 6036 of such Act, shall be construed as changing the re2 quirement of section 1902(e)(4) that a child born in the 

3 United States to an alien mother for whom medical assist4 ance for the delivery of such child is available as treatment 

5 of an emergency medical condition pursuant to subsection 

6 (v) shall be deemed eligible for medical assistance during 

7 the first year of such child’s life.’’. 

8 (B) STATE REQUIREMENT TO ISSUE SEPA9 RATE IDENTIFICATION NUMBER.—Section 

10 1902(e)(4) (42 U.S.C. 1396a(e)(4)) is amended 

11 by adding at the end the following new sen12 tence: ‘‘Notwithstanding the preceding sentence, 

13 in the case of a child who is born in the United 

14 States to an alien mother for whom medical as15 sistance for the delivery of the child is made 

16 available pursuant to section 1903(v), the State 

17 immediately shall issue a separate identification 

18 number for the child upon notification by the 

19 facility at which such delivery occurred of the 

20 child’s birth.’’. 

21 (4) TECHNICAL AMENDMENTS.—Section 

22 1903(x)(2) (42 U.S.C. 1396b(x)) is amended— 

23 (A) in subparagraph (B)— 


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1 (i) by realigning the left margin of the 

2 matter preceding clause (i) 2 ems to the 

3 left; and 

4 (ii) by realigning the left margins of 

5 clauses (i) and (ii), respectively, 2 ems to 

6 the left; and 

7 (B) in subparagraph (C)— 

8 (i) by realigning the left margin of the 

9 matter preceding clause (i) 2 ems to the 

10 left; and 

11 (ii) by realigning the left margins of 

12 clauses (i) and (ii), respectively, 2 ems to 

13 the left. 

14 (c) APPLICATION OF DOCUMENTATION SYSTEM TO

15 CHIP.— 

16 (1) IN GENERAL.—Section 2105(c) (42 U.S.C. 

17 1397ee(c)), as amended by section 114(a), is amend18 ed by adding at the end the following new para19 graph: 

20 ‘‘(9) CITIZENSHIP DOCUMENTATION REQUIRE21 MENTS.— 

22 ‘‘(A) IN GENERAL.—No payment may be 

23 made under this section with respect to an indi24 vidual who has, or is, declared to be a citizen 

25 or national of the United States for purposes of 


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1 establishing eligibility under this title unless the 

2 State meets the requirements of section 

3 1902(a)(46)(B) with respect to the individual. 

4 ‘‘(B) ENHANCED PAYMENTS.—Notwith5 standing subsection (b), the enhanced FMAP 

6 with respect to payments under subsection (a) 

7 for expenditures described in clause (i) or (ii) of 

8 section 1903(a)(3)(F) necessary to comply with 

9 subparagraph (A) shall in no event be less than 

10 90 percent and 75 percent, respectively.’’. 

11 (2) NONAPPLICATION OF ADMINISTRATIVE EX12 PENDITURES CAP.—Section 2105(c)(2)(C) (42 

13 U.S.C. 1397ee(c)(2)(C)), as amended by section 

14 202(b), is amended by adding at the end the fol15 lowing: 

16 ‘‘(ii) EXPENDITURES TO COMPLY

17 WITH CITIZENSHIP OR NATIONALITY

18 VERIFICATION REQUIREMENTS.—Expendi19 tures necessary for the State to comply 

20 with paragraph (9)(A).’’. 

21 (d) EFFECTIVE DATE.— 

22 (1) IN GENERAL.— 

23 (A) IN GENERAL.—Except as provided in 

24 subparagraph (B), the amendments made by 


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1 this section shall take effect on October 1, 

2 2009. 

3 (B) TECHNICAL AMENDMENTS.—The 

4 amendments made by— 

5 (i) paragraphs (1), (2), and (3) of 

6 subsection (b) shall take effect as if in7 cluded in the enactment of section 6036 of 

8 the Deficit Reduction Act of 2005 (Public 

9 Law 109–171; 120 Stat. 80); and 

10 (ii) paragraph (4) of subsection (b) 

11 shall take effect as if included in the enact12 ment of section 405 of division B of the 

13 Tax Relief and Health Care Act of 2006 

14 (Public Law 109–432; 120 Stat. 2996). 

15 (2) RESTORATION OF ELIGIBILITY.—In the 

16 case of an individual who, during the period that 

17 began on July 1, 2006, and ends on October 1, 

18 2009, was determined to be ineligible for medical as19 sistance under a State Medicaid plan, including any 

20 waiver of such plan, solely as a result of the applica21 tion of subsections (i)(22) and (x) of section 1903 

22 of the Social Security Act (as in effect during such 

23 period), but who would have been determined eligible 

24 for such assistance if such subsections, as amended 

25 by subsection (b), had applied to the individual, a 


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1 State may deem the individual to be eligible for such 

2 assistance as of the date that the individual was de3 termined to be ineligible for such medical assistance 

4 on such basis. 

5 (3) SPECIAL TRANSITION RULE FOR INDIANS.— 

6 During the period that begins on July 1, 2006, and 

7 ends on the effective date of final regulations issued 

8 under subclause (II) of section 1903(x)(3)(B)(v) of 

9 the Social Security Act (42 U.S.C. 

10 1396b(x)(3)(B)(v)) (as added by subsection 

11 (b)(1)(B)), an individual who is a member of a fed12 erally-recognized Indian tribe described in subclause 

13 (II) of that section who presents a document de14 scribed in subclause (I) of such section that is issued 

15 by such Indian tribe, shall be deemed to have pre16 sented satisfactory evidence of citizenship or nation17 ality for purposes of satisfying the requirement of 

18 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 BAR2 RIERS 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 re11 vised as often as the State determines appro12 priate to take into account the most recent in13 formation available to the State identifying 

14 such barriers. 

15 ‘‘(B) DEEMED COMPLIANCE IF JOINT AP16 PLICATION AND RENEWAL PROCESS THAT PER17 MITS APPLICATION OTHER THAN IN PERSON.— 

18 A State shall be deemed to comply with sub19 paragraph (A) if the State’s application and re20 newal forms and supplemental forms (if any) 

21 and information verification process is the same 

22 for purposes of establishing and renewing eligi23 bility for children and pregnant women for 

24 medical assistance under title XIX and child 

25 health assistance under this title, and such 


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1 process does not require an application to be 

2 made in person or a 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 

9 enactment of this Act, the Secretary of Health and 

10 Human Services, in consultation with State Medicaid and 

11 CHIP directors and organizations representing program 

12 beneficiaries, shall develop a model process for the coordi13 nation of the enrollment, retention, and coverage under 

14 such programs of children who, because of migration of 

15 families, emergency evacuations, natural or other disas16 ters, public health emergencies, educational needs, or oth17 erwise, frequently change their State of residency or other18 wise are temporarily located outside of the State of their 

19 residency. 

20 (b) REPORT TO CONGRESS.—After development of 

21 such model process, the Secretary of Health and Human 

22 Services shall submit to Congress a report describing addi23 tional steps or authority needed to make further improve24 ments to coordinate the enrollment, retention, and covVerDate Nov 24 2008 21:36 Jan 16, 2009 Jkt 079200 PO 00000 Frm 00138 Fmt 6652 Sfmt 6201 E:\BILLS\H2.PCS H2

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1 erage under CHIP and Medicaid of children described in 

2 subsection (a). 

3 SEC. 214. PERMITTING STATES TO ENSURE COVERAGE 

4 WITHOUT A 5-YEAR DELAY OF CERTAIN CHIL5 DREN AND PREGNANT WOMEN UNDER THE 

6 MEDICAID PROGRAM AND CHIP. 

7 (a) PURPOSE.—In order to promote the health of 

8 needy children and pregnant women residing lawfully in 

9 the United States, States should be permitted to waive 

10 certain restrictions which result in a 5-year delay for cov11 erage of necessary health services for such children and 

12 women under the Medicaid program and CHIP. 

13 (b) MEDICAID PROGRAM.—Section 1903(v) of the 

14 Social Security Act (42 U.S.C. 1396b(v)) is amended— 

15 (1) in paragraph (1), by striking ‘‘paragraph 

16 (2)’’ and inserting ‘‘paragraphs (2) and (4)’’; and 

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

18 paragraph: 

19 ‘‘(4)(A) A State may elect (in a plan amendment 

20 under this title) to provide, notwithstanding sections 

21 401(a), 402(b), 403, and 421 of Public Law 104–193, 

22 medical assistance under a State plan under this title to 

23 children and pregnant women who are lawfully residing 

24 in the United States (including battered individuals deVerDate Nov 24 2008 21:36 Jan 16, 2009 Jkt 079200 PO 00000 Frm 00139 Fmt 6652 Sfmt 6201 E:\BILLS\H2.PCS H2

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1 scribed in section 431(c) of such Act) and are otherwise 

2 eligible for such assistance. 

3 ‘‘(B) Such election may be made only with respect 

4 to either or both of the following categories of individuals: 

5 ‘‘(i) Children. 

6 ‘‘(ii) Pregnant women. 

7 ‘‘(C) In this paragraph: 

8 ‘‘(i) The term ‘pregnant women’ means 

9 women during pregnancy (and during the 60- 

10 day period beginning on the last day of the 

11 pregnancy). 

12 ‘‘(ii) The term ‘children’ means individuals 

13 under age 19 (or such higher age as the State 

14 has elected under section 1902(l)(1)(D)), in15 cluding optional targeted low-income children 

16 described in section 1905(u)(2)(B).’’. 

17 (c) CHIP.—Section 2107(e)(1) of such Act (42 

18 U.S.C. 1397gg(e)(1)), as amended by section 203(a)(2) 

19 and 203(d)(2), is amended by redesignating subpara20 graphs (E) and (F) as subparagraphs (F) and (G), respec21 tively and by inserting after subparagraph (D) the fol22 lowing new subparagraph: 

23 ‘‘(E) Paragraph (4) of section 1903(v), in24 sofar as it relates to the category of children or 

25 pregnant women (as such terms are defined in 


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1 such paragraph), but only if the State has elect2 ed to apply such paragraph with respect to such 

3 category of children or pregnant women under 

4 title XIX and only if, in the case of pregnant 

5 women, the State has elected the option under 

6 section 2111 to provide assistance for pregnant 

7 women under this title.’’. 

8 (d) CONFORMING AMENDMENT.—Section 423(d)(1) 

9 of Public Law 104-193 is amended by inserting before the 

10 period the following: ‘‘and medical or child health assist11 ance furnished under section 1903(v)(4) or 2107(e)(1)(E), 

12 respectively, of the Social Security Act’’. 

13 (e) EFFECTIVE DATE.—The amendments made by 

14 this section take effect on the date of the enactment of 

15 this Act. 

16 TITLE III—REDUCING BARRIERS 

17 TO PROVIDING PREMIUM AS18 SISTANCE 

19 Subtitle A—Additional State Op20 tion for Providing Premium As21 sistance 

22 SEC. 301. ADDITIONAL STATE OPTION FOR PROVIDING 

23 PREMIUM ASSISTANCE. 

24 (a) CHIP.— 


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

2 1397ee(c)), as amended by sections 114(a) and 

3 211(c), is amended by adding at the end the fol4 lowing: 

5 ‘‘(10) STATE OPTION TO OFFER PREMIUM AS6 SISTANCE.— 

7 ‘‘(A) IN GENERAL.—A State may elect to 

8 offer a premium assistance subsidy (as defined 

9 in subparagraph (C)) for qualified employer10 sponsored coverage (as defined in subparagraph 

11 (B)) to all targeted low-income children who are 

12 eligible for child health assistance under the 

13 plan and have access to such coverage in ac14 cordance with the requirements of this para15 graph. No subsidy shall be provided to a tar16 geted low-income child under this paragraph 

17 unless the child (or the child’s parent) volun18 tarily elects to receive such a subsidy. A State 

19 may not require such an election as a condition 

20 of receipt of child health assistance. 

21 ‘‘(B) QUALIFIED EMPLOYER-SPONSORED

22 COVERAGE.— 

23 ‘‘(i) IN GENERAL.—Subject to clause 

24 (ii), in this paragraph, the term ‘qualified 

25 employer-sponsored coverage’ means a 


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1 group health plan or health insurance cov2 erage offered through an employer— 

3 ‘‘(I) that qualifies as creditable 

4 coverage as a group health plan under 

5 section 2701(c)(1) of the Public 

6 Health Service Act; 

7 ‘‘(II) for which the employer con8 tribution toward any premium for 

9 such coverage is at least 40 percent; 

10 and 

11 ‘‘(III) that is offered to all indi12 viduals in a manner that would be 

13 considered a nondiscriminatory eligi14 bility classification for purposes of 

15 paragraph (3)(A)(ii) of section 105(h) 

16 of the Internal Revenue Code of 1986 

17 (but determined without regard to 

18 clause (i) of subparagraph (B) of such 

19 paragraph). 

20 ‘‘(ii) EXCEPTION.—Such term does 

21 not include coverage consisting of— 

22 ‘‘(I) benefits provided under a 

23 health flexible spending arrangement 

24 (as defined in section 106(c)(2) of the 

25 Internal Revenue Code of 1986); or 


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1 ‘‘(II) a high deductible health 

2 plan (as defined in section 223(c)(2) 

3 of such Code), without regard to 

4 whether the plan is purchased in con5 junction with a health savings account 

6 (as defined under section 223(d) of 

7 such Code). 

8 ‘‘(C) PREMIUM ASSISTANCE SUBSIDY.— 

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

10 the term ‘premium assistance subsidy’ 

11 means, with respect to a targeted low-in12 come child, the amount equal to the dif13 ference between the employee contribution 

14 required for enrollment only of the em15 ployee under qualified employer-sponsored 

16 coverage and the employee contribution re17 quired for enrollment of the employee and 

18 the child in such coverage, less any appli19 cable premium cost-sharing applied under 

20 the State child health plan (subject to the 

21 limitations imposed under section 2103(e), 

22 including the requirement to count the 

23 total amount of the employee contribution 

24 required for enrollment of the employee 

25 and the child in such coverage toward the 


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1 annual aggregate cost-sharing limit applied 

2 under paragraph (3)(B) of such section). 

3 ‘‘(ii) STATE PAYMENT OPTION.—A 

4 State may provide a premium assistance 

5 subsidy either as reimbursement to an em6 ployee for out-of-pocket expenditures or, 

7 subject to clause (iii), directly to the em8 ployee’s employer. 

9 ‘‘(iii) EMPLOYER OPT-OUT.—An em10 ployer may notify a State that it elects to 

11 opt-out of being directly paid a premium 

12 assistance subsidy on behalf of an em13 ployee. In the event of such a notification, 

14 an employer shall withhold the total 

15 amount of the employee contribution re16 quired for enrollment of the employee and 

17 the child in the qualified employer-spon18 sored coverage and the State shall pay the 

19 premium assistance subsidy directly to the 

20 employee. 

21 ‘‘(iv) TREATMENT AS CHILD HEALTH

22 ASSISTANCE.—Expenditures for the provi23 sion of premium assistance subsidies shall 

24 be considered child health assistance de25 scribed in paragraph (1)(C) of subsection 


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1 (a) for purposes of making payments 

2 under that subsection. 

3 ‘‘(D) APPLICATION OF SECONDARY PAYOR

4 RULES.—The State shall be a secondary payor 

5 for any items or services provided under the 

6 qualified employer-sponsored coverage for which 

7 the State provides child health assistance under 

8 the State child health plan. 

9 ‘‘(E) REQUIREMENT TO PROVIDE SUPPLE10 MENTAL COVERAGE FOR BENEFITS AND COST11 SHARING PROTECTION PROVIDED UNDER THE

12 STATE CHILD HEALTH PLAN.— 

13 ‘‘(i) IN GENERAL.—Notwithstanding 

14 section 2110(b)(1)(C), the State shall pro15 vide for each targeted low-income child en16 rolled in qualified employer-sponsored cov17 erage, supplemental coverage consisting 

18 of— 

19 ‘‘(I) items or services that are 

20 not covered, or are only partially cov21 ered, under the qualified employer22 sponsored coverage; and 

23 ‘‘(II) cost-sharing protection con24 sistent with section 2103(e). 


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1 ‘‘(ii) RECORD KEEPING REQUIRE2 MENTS.—For purposes of carrying out 

3 clause (i), a State may elect to directly pay 

4 out-of-pocket expenditures for cost-sharing 

5 imposed under the qualified employer-spon6 sored coverage and collect or not collect all 

7 or any portion of such expenditures from 

8 the parent of the child. 

9 ‘‘(F) APPLICATION OF WAITING PERIOD

10 IMPOSED UNDER THE STATE.—Any waiting pe11 riod imposed under the State child health plan 

12 prior to the provision of child health assistance 

13 to a targeted low-income child under the State 

14 plan shall apply to the same extent to the provi15 sion of a premium assistance subsidy for the 

16 child under this paragraph. 

17 ‘‘(G) OPT-OUT PERMITTED FOR ANY

18 MONTH.—A State shall establish a process for 

19 permitting the parent of a targeted low-income 

20 child receiving a premium assistance subsidy to 

21 disenroll the child from the qualified employer22 sponsored coverage and enroll the child in, and 

23 receive child health assistance under, the State 

24 child health plan, effective on the first day of 

25 any month for which the child is eligible for 


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1 such assistance and in a manner that ensures 

2 continuity of coverage for the child. 

3 ‘‘(H) APPLICATION TO PARENTS.—If a 

4 State provides child health assistance or health 

5 benefits coverage to parents of a targeted low6 income child in accordance with section 

7 2111(b), the State may elect to offer a pre8 mium assistance subsidy to a parent of a tar9 geted low-income child who is eligible for such 

10 a subsidy under this paragraph in the same 

11 manner as the State offers such a subsidy for 

12 the enrollment of the child in qualified em13 ployer-sponsored coverage, except that— 

14 ‘‘(i) the amount of the premium as15 sistance subsidy shall be increased to take 

16 into account the cost of the enrollment of 

17 the parent in the qualified employer-spon18 sored coverage or, at the option of the 

19 State if the State determines it cost-effec20 tive, the cost of the enrollment of the 

21 child’s family in such coverage; and 

22 ‘‘(ii) any reference in this paragraph 

23 to a child is deemed to include a reference 

24 to the parent or, if applicable under clause 

25 (i), the family of the child. 


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1 ‘‘(I) ADDITIONAL STATE OPTION FOR PRO2 VIDING PREMIUM ASSISTANCE.— 

3 ‘‘(i) IN GENERAL.—A State may es4 tablish an employer-family premium assist5 ance purchasing pool for employers with 

6 less than 250 employees who have at least 

7 1 employee who is a pregnant woman eligi8 ble for assistance under the State child 

9 health plan (including through the applica10 tion of an option described in section 

11 2112(f)) or a member of a family with at 

12 least 1 targeted low-income child and to 

13 provide a premium assistance subsidy 

14 under this paragraph for enrollment in 

15 coverage made available through such pool. 

16 ‘‘(ii) ACCESS TO CHOICE OF COV17 ERAGE.—A State that elects the option 

18 under clause (i) shall identify and offer ac19 cess to not less than 2 private health plans 

20 that are health benefits coverage that is 

21 equivalent to the benefits coverage in a 

22 benchmark benefit package described in 

23 section 2103(b) or benchmark-equivalent 

24 coverage that meets the requirements of 


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1 section 2103(a)(2) for employees described 

2 in clause (i). 

3 ‘‘(iii) CLARIFICATION OF PAYMENT

4 FOR ADMINISTRATIVE EXPENDITURES.— 

5 Nothing in this subparagraph shall be con6 strued as permitting payment under this 

7 section for administrative expenditures at8 tributable to the establishment or oper9 ation of such pool, except to the extent 

10 that such payment would otherwise be per11 mitted under this title. 

12 ‘‘(J) NO EFFECT ON PREMIUM ASSISTANCE

13 WAIVER PROGRAMS.—Nothing in this para14 graph shall be construed as limiting the author15 ity of a State to offer premium assistance under 

16 section 1906 or 1906A, a waiver described in 

17 paragraph (2)(B) or (3), a waiver approved 

18 under section 1115, or other authority in effect 

19 prior to the date of enactment of the Children’s 

20 Health Insurance Program Reauthorization Act 

21 of 2009. 

22 ‘‘(K) NOTICE OF AVAILABILITY.—If a 

23 State elects to provide premium assistance sub24 sidies in accordance with this paragraph, the 

25 State shall— 


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1 ‘‘(i) include on any application or en2 rollment form for child health assistance a 

3 notice of the availability of premium assist4 ance subsidies for the enrollment of tar5 geted low-income children in qualified em6 ployer-sponsored coverage; 

7 ‘‘(ii) provide, as part of the applica8 tion and enrollment process under the 

9 State child health plan, information de10 scribing the availability of such subsidies 

11 and how to elect to obtain such a subsidy; 

12 and 

13 ‘‘(iii) establish such other procedures 

14 as the State determines necessary to en15 sure that parents are fully informed of the 

16 choices for receiving child health assistance 

17 under the State child health plan or 

18 through the receipt of premium assistance 

19 subsidies. 

20 ‘‘(L) APPLICATION TO QUALIFIED EM21 PLOYER-SPONSORED BENCHMARK COVERAGE.— 

22 If a group health plan or health insurance cov23 erage offered through an employer is certified 

24 by an actuary as health benefits coverage that 

25 is equivalent to the benefits coverage in a 


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1 benchmark benefit package described in section 

2 2103(b) or benchmark-equivalent coverage that 

3 meets the requirements of section 2103(a)(2), 

4 the State may provide premium assistance sub5 sidies for enrollment of targeted low-income 

6 children in such group health plan or health in7 surance coverage in the same manner as such 

8 subsidies are provided under this paragraph for 

9 enrollment in qualified employer-sponsored cov10 erage, but without regard to the requirement to 

11 provide supplemental coverage for benefits and 

12 cost-sharing protection provided under the 

13 State child health plan under subparagraph 

14 (E). 

15 ‘‘(M) SATISFACTION OF COST-EFFECTIVE16 NESS TEST.—Premium assistance subsidies for 

17 qualified employer-sponsored coverage offered 

18 under this paragraph shall be deemed to meet 

19 the requirement of subparagraph (A) of para20 graph (3).’’. 

21 (2) DETERMINATION OF COST-EFFECTIVENESS

22 FOR PREMIUM ASSISTANCE OR PURCHASE OF FAM23 ILY COVERAGE.— 

24 (A) IN GENERAL.—Section 2105(c)(3)(A) 

25 (42 U.S.C. 1397ee(c)(3)(A)) is amended by 


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1 striking ‘‘relative to’’ and all that follows 

2 through the comma and inserting ‘‘relative to 

3 ‘‘(i) the amount of expenditures under 

4 the State child health plan, including ad5 ministrative expenditures, that the State 

6 would have made to provide comparable 

7 coverage of the targeted low-income child 

8 involved or the family involved (as applica9 ble); or 

10 ‘‘(ii) the aggregate amount of expendi11 tures that the State would have made 

12 under the State child health plan, includ13 ing administrative expenditures, for pro14 viding coverage under such plan for all 

15 such children or families.’’. 

16 (B) NONAPPLICATION TO PREVIOUSLY AP17 PROVED COVERAGE.—The amendment made by 

18 subparagraph (A) shall not apply to coverage 

19 the purchase of which has been approved by the 

20 Secretary under section 2105(c)(3) of the Social 

21 Security Act prior to the date of enactment of 

22 this Act. 

23 (b) MEDICAID.—Title XIX is amended by inserting 

24 after section 1906 the following new section: 


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1 ‘‘PREMIUM ASSISTANCE OPTION FOR CHILDREN

2 ‘‘SEC. 1906A. (a) IN GENERAL.—A State may elect 

3 to offer a premium assistance subsidy (as defined in sub4 section (c)) for qualified employer-sponsored coverage (as 

5 defined in subsection (b)) to all individuals under age 19 

6 who are entitled to medical assistance under this title (and 

7 to the parent of such an individual) who have access to 

8 such coverage if the State meets the requirements of this 

9 section. 

10 ‘‘(b) QUALIFIED EMPLOYER-SPONSORED COV11 ERAGE.— 

12 ‘‘(1) IN GENERAL.—Subject to paragraph (2)), 

13 in this paragraph, the term ‘qualified employer-spon14 sored coverage’ means a group health plan or health 

15 insurance coverage offered through an employer— 

16 ‘‘(A) that qualifies as creditable coverage 

17 as a group health plan under section 2701(c)(1) 

18 of the Public Health Service Act; 

19 ‘‘(B) for which the employer contribution 

20 toward any premium for such coverage is at 

21 least 40 percent; and 

22 ‘‘(C) that is offered to all individuals in a 

23 manner that would be considered a nondiscrim24 inatory eligibility classification for purposes of 

25 paragraph (3)(A)(ii) of section 105(h) of the 


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1 Internal Revenue Code of 1986 (but determined 

2 without regard to clause (i) of subparagraph 

3 (B) of such paragraph). 

4 ‘‘(2) EXCEPTION.—Such term does not include 

5 coverage consisting of— 

6 ‘‘(A) benefits provided under a health flexi7 ble spending arrangement (as defined in section 

8 106(c)(2) of the Internal Revenue Code of 

9 1986); or 

10 ‘‘(B) a high deductible health plan (as de11 fined in section 223(c)(2) of such Code), with12 out regard to whether the plan is purchased in 

13 conjunction with a health savings account (as 

14 defined under section 223(d) of such Code). 

15 ‘‘(3) TREATMENT AS THIRD PARTY LIABIL16 ITY.—The State shall treat the coverage provided 

17 under qualified employer-sponsored coverage as a 

18 third party liability under section 1902(a)(25). 

19 ‘‘(c) PREMIUM ASSISTANCE SUBSIDY.—In this sec20 tion, the term ‘premium assistance subsidy’ means the 

21 amount of the employee contribution for enrollment in the 

22 qualified employer-sponsored coverage by the individual 

23 under age 19 or by the individual’s family. Premium as24 sistance subsidies under this section shall be considered, 


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1 for purposes of section 1903(a), to be a payment for med2 ical assistance. 

3 ‘‘(d) VOLUNTARY PARTICIPATION.— 

4 ‘‘(1) EMPLOYERS.—Participation by an em5 ployer in a premium assistance subsidy offered by a 

6 State under this section shall be voluntary. An em7 ployer may notify a State that it elects to opt-out of 

8 being directly paid a premium assistance subsidy on 

9 behalf of an employee. 

10 ‘‘(2) BENEFICIARIES.—No subsidy shall be pro11 vided to an individual under age 19 under this sec12 tion unless the individual (or the individual’s parent) 

13 voluntarily elects to receive such a subsidy. A State 

14 may not require such an election as a condition of 

15 receipt of medical assistance. State may not require, 

16 as a condition of an individual under age 19 (or the 

17 individual’s parent) being or remaining eligible for 

18 medical assistance under this title, apply for enroll19 ment in qualified employer-sponsored coverage under 

20 this section. 

21 ‘‘(3) OPT-OUT PERMITTED FOR ANY MONTH.— 

22 A State shall establish a process for permitting the 

23 parent of an individual under age 19 receiving a pre24 mium assistance subsidy to disenroll the individual 

25 from the qualified employer-sponsored coverage. 


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1 ‘‘(e) REQUIREMENT TO PAY PREMIUMS AND COST2 SHARING AND PROVIDE SUPPLEMENTAL COVERAGE.—In 

3 the case of the participation of an individual under age 

4 19 (or the individual’s parent) in a premium assistance 

5 subsidy under this section for qualified employer-spon6 sored coverage, the State shall provide for payment of all 

7 enrollee premiums for enrollment in such coverage and all 

8 deductibles, coinsurance, and other cost-sharing obliga9 tions for items and services otherwise covered under the 

10 State plan under this title (exceeding the amount other11 wise permitted under section 1916 or, if applicable, section 

12 1916A). The fact that an individual under age 19 (or a 

13 parent) elects to enroll in qualified employer-sponsored 

14 coverage under this section shall not change the individ15 ual’s (or parent’s) eligibility for medical assistance under 

16 the State plan, except insofar as section 1902(a)(25) pro17 vides that payments for such assistance shall first be made 

18 under such coverage.’’. 

19 (c) GAO STUDY AND REPORT.—Not later than Janu20 ary 1, 2010, the Comptroller General of the United States 

21 shall study cost and coverage issues relating to any State 

22 premium assistance programs for which Federal matching 

23 payments are made under title XIX or XXI of the Social 

24 Security Act, including under waiver authority, and shall 

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1 ate and the Committee on Energy and Commerce of the 

2 House of Representatives on the results of such study. 

3 SEC. 302. OUTREACH, EDUCATION, AND ENROLLMENT AS4 SISTANCE. 

5 (a) REQUIREMENT TO INCLUDE DESCRIPTION OF

6 OUTREACH, EDUCATION, AND ENROLLMENT EFFORTS

7 RELATED TO PREMIUM ASSISTANCE SUBSIDIES IN STATE

8 CHILD HEALTH PLAN.—Section 2102(c) (42 U.S.C. 

9 1397bb(c)) is amended by adding at the end the following 

10 new paragraph: 

11 ‘‘(3) PREMIUM ASSISTANCE SUBSIDIES.—In the 

12 case of a State that provides for premium assistance 

13 subsidies under the State child health plan in ac14 cordance with paragraph (2)(B), (3), or (10) of sec15 tion 2105(c), or a waiver approved under section 

16 1115, outreach, education, and enrollment assistance 

17 for families of children likely to be eligible for such 

18 subsidies, to inform such families of the availability 

19 of, and to assist them in enrolling their children in, 

20 such subsidies, and for employers likely to provide 

21 coverage that is eligible for such subsidies, including 

22 the specific, significant resources the State intends 

23 to apply to educate employers about the availability 

24 of premium assistance subsidies under the State 

25 child health plan.’’. 


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1 (b) NONAPPLICATION OF 10 PERCENT LIMIT ON

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

4 amended by section 211(c)(2), is amended by adding at 

5 the end the following new clause: 

6 ‘‘(iii) EXPENDITURES FOR OUTREACH

7 TO INCREASE THE ENROLLMENT OF CHIL8 DREN UNDER THIS TITLE AND TITLE xix 

9 THROUGH PREMIUM ASSISTANCE SUB10 SIDIES.—Expenditures for outreach activi11 ties to families of children likely to be eligi12 ble for premium assistance subsidies in ac13 cordance with paragraph (2)(B), (3), or 

14 (10), or a waiver approved under section 

15 1115, to inform such families of the avail16 ability of, and to assist them in enrolling 

17 their children in, such subsidies, and to 

18 employers likely to provide qualified em19 ployer-sponsored coverage (as defined in 

20 subparagraph (B) of such paragraph), but 

21 not to exceed an amount equal to 1.25 per22 cent of the maximum amount permitted to 

23 be expended under subparagraph (A) for 

24 items described in subsection (a)(1)(D).’’. 


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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 

17 not enrolled, for coverage under the terms of 

18 the plan (or a dependent of such an employee 

19 if the dependent is eligible, but not enrolled, for 

20 coverage under such terms) to enroll for cov21 erage under the terms of the plan if either of 

22 the following conditions is met: 

23 ‘‘(i) TERMINATION OF MEDICAID OR

24 CHIP COVERAGE.—The employee or de25 pendent is covered under a Medicaid plan 


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1 under title XIX of the Social Security Act 

2 or under a State child health plan under 

3 title XXI of such Act and coverage of the 

4 employee or dependent under such a plan 

5 is terminated as a result of loss of eligi6 bility for such coverage and the employee 

7 requests coverage under the group health 

8 plan not later than 60 days after the date 

9 of termination of such coverage. 

10 ‘‘(ii) ELIGIBILITY FOR EMPLOYMENT

11 ASSISTANCE UNDER MEDICAID OR CHIP.— 

12 The employee or dependent becomes eligi13 ble 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 el22 igible for such assistance. 

23 ‘‘(B) EMPLOYEE OUTREACH AND DISCLO24 SURE.— 


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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 

13 of coverage under a group health 

14 plan, shall provide to each employee a 

15 written notice informing the employee 

16 of potential opportunities then cur17 rently available in the State in which 

18 the employee resides for premium as19 sistance under such plans for health 

20 coverage of the employee or the em21 ployee’s dependents. For purposes of 

22 compliance with this clause, the em23 ployer may use any State-specific 

24 model notice developed in accordance 

25 with section 701(f)(3)(B)(i)(II) of the 


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1 Employee Retirement Income Security 

2 Act of 1974 (29 U.S.C. 

3 1181(f)(3)(B)(i)(II)). 

4 ‘‘(II) OPTION TO PROVIDE CON5 CURRENT WITH PROVISION OF PLAN

6 MATERIALS TO EMPLOYEE.—An em7 ployer may provide the model notice 

8 applicable to the State in which an 

9 employee resides concurrent with the 

10 furnishing of materials notifying the 

11 employee of health plan eligibility, 

12 concurrent with materials provided to 

13 the employee in connection with an 

14 open season or election process con15 ducted under the plan, or concurrent 

16 with the furnishing of the summary 

17 plan description as provided in section 

18 104(b) of the Employee Retirement 

19 Income Security Act of 1974 (29 

20 U.S.C. 1024). 

21 ‘‘(ii) DISCLOSURE ABOUT GROUP

22 HEALTH PLAN BENEFITS TO STATES FOR

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1 ered under a Medicaid plan of a State 

2 under title XIX of the Social Security Act 

3 or under a State child health plan under 

4 title XXI of such Act, the plan adminis5 trator of the group health plan shall dis6 close to the State, upon request, informa7 tion about the benefits available under the 

8 group health plan in sufficient specificity, 

9 as determined under regulations of the 

10 Secretary of Health and Human Services 

11 in consultation with the Secretary that re12 quire use of the model coverage coordina13 tion disclosure form developed under sec14 tion 311(b)(1)(C) of the Children’s Health 

15 Insurance Program Reauthorization Act of 

16 2009, so as to permit the State to make a 

17 determination (under paragraph (2)(B), 

18 (3), or (10) of section 2105(c) of the So19 cial Security Act or otherwise) concerning 

20 the cost-effectiveness of the State pro21 viding medical or child health assistance 

22 through premium assistance for the pur23 chase of coverage under such group health 

24 plan and in order for the State to provide 

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1 graph (10)(E) of such section or other au2 thority.’’. 

3 (b) CONFORMING AMENDMENTS.— 

4 (1) AMENDMENTS TO EMPLOYEE RETIREMENT

5 INCOME SECURITY ACT.— 

6 (A) IN GENERAL.—Section 701(f) of the 

7 Employee Retirement Income Security Act of 

8 1974 (29 U.S.C. 1181(f)) is amended by adding 

9 at the end the following new paragraph: 

10 ‘‘(3) SPECIAL RULES FOR APPLICATION IN CASE

11 OF MEDICAID AND CHIP.— 

12 ‘‘(A) IN GENERAL.—A group health plan, 

13 and a health insurance issuer offering group 

14 health insurance coverage in connection with a 

15 group health plan, shall permit an employee 

16 who is eligible, but not enrolled, for coverage 

17 under the terms of the plan (or a dependent of 

18 such an employee if the dependent is eligible, 

19 but not enrolled, for coverage under such 

20 terms) to enroll for coverage under the terms of 

21 the plan if either of the following conditions is 

22 met: 

23 ‘‘(i) TERMINATION OF MEDICAID OR

24 CHIP COVERAGE.—The employee or de25 pendent is covered under a Medicaid plan 


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1 under title XIX of the Social Security Act 

2 or under a State child health plan under 

3 title XXI of such Act and coverage of the 

4 employee or dependent under such a plan 

5 is terminated as a result of loss of eligi6 bility for such coverage and the employee 

7 requests coverage under the group health 

8 plan (or health insurance coverage) not 

9 later than 60 days after the date of termi10 nation of such coverage. 

11 ‘‘(ii) ELIGIBILITY FOR EMPLOYMENT

12 ASSISTANCE UNDER MEDICAID OR CHIP.— 

13 The employee or dependent becomes eligi14 ble for assistance, with respect to coverage 

15 under the group health plan or health in16 surance coverage, under such Medicaid 

17 plan or State child health plan (including 

18 under any waiver or demonstration project 

19 conducted under or in relation to such a 

20 plan), if the employee requests coverage 

21 under the group health plan or health in22 surance coverage not later than 60 days 

23 after the date the employee or dependent is 

24 determined to be eligible for such assist25 ance. 


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1 ‘‘(B) COORDINATION WITH MEDICAID AND

2 CHIP.— 

3 ‘‘(i) OUTREACH TO EMPLOYEES RE4 GARDING AVAILABILITY OF MEDICAID AND

5 CHIP COVERAGE.— 

6 ‘‘(I) IN GENERAL.—Each em7 ployer that maintains a group health 

8 plan in a State that provides medical 

9 assistance under a State Medicaid 

10 plan under title XIX of the Social Se11 curity Act, or child health assistance 

12 under a State child health plan under 

13 title XXI of such Act, in the form of 

14 premium assistance for the purchase 

15 of coverage under a group health 

16 plan, shall provide to each employee a 

17 written notice informing the employee 

18 of potential opportunities then cur19 rently available in the State in which 

20 the employee resides for premium as21 sistance under such plans for health 

22 coverage of the employee or the em23 ployee’s dependents. 

24 ‘‘(II) MODEL NOTICE.—Not later 

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

3 2009, the Secretary and the Secretary 

4 of Health and Human Services, in 

5 consultation with Directors of State 

6 Medicaid agencies under title XIX of 

7 the Social Security Act and Directors 

8 of State CHIP agencies under title 

9 XXI of such Act, shall jointly develop 

10 national and State-specific model no11 tices for purposes of subparagraph 

12 (A). The Secretary shall provide em13 ployers with such model notices so as 

14 to enable employers to timely comply 

15 with the requirements of subpara16 graph (A). Such model notices shall 

17 include information regarding how an 

18 employee may contact the State in 

19 which the employee resides for addi20 tional information regarding potential 

21 opportunities for such premium assist22 ance, including how to apply for such 

23 assistance. 

24 ‘‘(III) OPTION TO PROVIDE CON25 CURRENT WITH PROVISION OF PLAN


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1 MATERIALS TO EMPLOYEE.—An em2 ployer may provide the model notice 

3 applicable to the State in which an 

4 employee resides concurrent with the 

5 furnishing of materials notifying the 

6 employee of health plan eligibility, 

7 concurrent with materials provided to 

8 the employee in connection with an 

9 open season or election process con10 ducted under the plan, or concurrent 

11 with the furnishing of the summary 

12 plan description as provided in section 

13 104(b). 

14 ‘‘(ii) DISCLOSURE ABOUT GROUP

15 HEALTH PLAN BENEFITS TO STATES FOR

16 MEDICAID AND CHIP ELIGIBLE INDIVID17 UALS.—In the case of a participant or ben18 eficiary of a group health plan who is cov19 ered under a Medicaid plan of a State 

20 under title XIX of the Social Security Act 

21 or under a State child health plan under 

22 title XXI of such Act, the plan adminis23 trator of the group health plan shall dis24 close to the State, upon request, informa25 tion about the benefits available under the 


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1 group health plan in sufficient specificity, 

2 as determined under regulations of the 

3 Secretary of Health and Human Services 

4 in consultation with the Secretary that re5 quire use of the model coverage coordina6 tion disclosure form developed under sec7 tion 311(b)(1)(C) of the Children’s Health 

8 Insurance Program Reauthorization Act of 

9 2009, so as to permit the State to make a 

10 determination (under paragraph (2)(B), 

11 (3), or (10) of section 2105(c) of the So12 cial Security Act or otherwise) concerning 

13 the cost-effectiveness of the State pro14 viding medical or child health assistance 

15 through premium assistance for the pur16 chase of coverage under such group health 

17 plan and in order for the State to provide 

18 supplemental benefits required under para19 graph (10)(E) of such section or other au20 thority.’’. 

21 (B) CONFORMING AMENDMENT.—Section 

22 102(b) of the Employee Retirement Income Se23 curity Act of 1974 (29 U.S.C. 1022(b)) is 

24 amended— 


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1 (i) by striking ‘‘and the remedies’’ 

2 and inserting ‘‘, the remedies’’; and 

3 (ii) by inserting before the period the 

4 following: ‘‘, and if the employer so elects 

5 for purposes of complying with section 

6 701(f)(3)(B)(i), the model notice applicable 

7 to the State in which the participants and 

8 beneficiaries reside’’. 

9 (C) WORKING GROUP TO DEVELOP MODEL

10 COVERAGE COORDINATION DISCLOSURE

11 FORM.— 

12 (i) MEDICAID, CHIP, AND EMPLOYER13 SPONSORED COVERAGE COORDINATION

14 WORKING GROUP.— 

15 (I) IN GENERAL.—Not later than 

16 60 days after the date of enactment of 

17 this Act, the Secretary of Health and 

18 Human Services and the Secretary of 

19 Labor shall jointly establish a Med20 icaid, CHIP, and Employer-Sponsored 

21 Coverage Coordination Working 

22 Group (in this subparagraph referred 

23 to as the ‘‘Working Group’’). The 

24 purpose of the Working Group shall 

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1 ordination disclosure form described 

2 in subclause (II) and to identify the 

3 impediments to the effective coordina4 tion of coverage available to families 

5 that include employees of employers 

6 that maintain group health plans and 

7 members who are eligible for medical 

8 assistance under title XIX of the So9 cial Security Act or child health as10 sistance or other health benefits cov11 erage under title XXI of such Act. 

12 (II) MODEL COVERAGE COORDI13 NATION DISCLOSURE FORM DE14 SCRIBED.—The model form described 

15 in this subclause is a form for plan 

16 administrators of group health plans 

17 to complete for purposes of permitting 

18 a State to determine the availability 

19 and cost-effectiveness of the coverage 

20 available under such plans to employ21 ees who have family members who are 

22 eligible for premium assistance offered 

23 under a State plan under title XIX or 

24 XXI of such Act and to allow for co25 ordination of coverage for enrollees of 


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1 such plans. Such form shall provide 

2 the following information in addition 

3 to such other information as the 

4 Working Group determines appro5 priate: 

6 (aa) A determination of 

7 whether the employee is eligible 

8 for coverage under the group 

9 health plan. 

10 (bb) The name and contract 

11 information of the plan adminis12 trator of the group health plan. 

13 (cc) The benefits offered 

14 under the plan. 

15 (dd) The premiums and 

16 cost-sharing required under the 

17 plan. 

18 (ee) Any other information 

19 relevant to coverage under the 

20 plan. 

21 (ii) MEMBERSHIP.—The Working 

22 Group shall consist of not more than 30 

23 members and shall be composed of rep24 resentatives of— 

25 (I) the Department of Labor; 


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1 (II) the Department of Health 

2 and Human Services; 

3 (III) State directors of the Med4 icaid program under title XIX of the 

5 Social Security Act; 

6 (IV) State directors of the State 

7 Children’s Health Insurance Program 

8 under title XXI of the Social Security 

9 Act; 

10 (V) employers, including owners 

11 of small businesses and their trade or 

12 industry representatives and certified 

13 human resource and payroll profes14 sionals; 

15 (VI) plan administrators and 

16 plan sponsors of group health plans 

17 (as defined in section 607(1) of the 

18 Employee Retirement Income Security 

19 Act of 1974); 

20 (VII) health insurance issuers; 

21 and 

22 (VIII) children and other bene23 ficiaries of medical assistance under 

24 title XIX of the Social Security Act or 

25 child health assistance or other health 


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1 benefits coverage under title XXI of 

2 such Act. 

3 (iii) COMPENSATION.—The members 

4 of the Working Group shall serve without 

5 compensation. 

6 (iv) ADMINISTRATIVE SUPPORT.—The 

7 Department of Health and Human Serv8 ices and the Department of Labor shall 

9 jointly provide appropriate administrative 

10 support to the Working Group, including 

11 technical assistance. The Working Group 

12 may use the services and facilities of either 

13 such Department, with or without reim14 bursement, as jointly determined by such 

15 Departments. 

16 (v) REPORT.— 

17 (I) REPORT BY WORKING GROUP

18 TO THE SECRETARIES.—Not later 

19 than 18 months after the date of the 

20 enactment of this Act, the Working 

21 Group shall submit to the Secretary of 

22 Labor and the Secretary of Health 

23 and Human Services the model form 

24 described in clause (i)(II) along with a 

25 report containing recommendations 


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1 for appropriate measures to address 

2 the impediments to the effective co3 ordination of coverage between group 

4 health plans and the State plans 

5 under titles XIX and XXI of the So6 cial Security Act. 

7 (II) REPORT BY SECRETARIES TO

8 THE CONGRESS.—Not later than 2 

9 months after receipt of the report 

10 pursuant to subclause (I), the Secre11 taries shall jointly submit a report to 

12 each House of the Congress regarding 

13 the recommendations contained in the 

14 report under such subclause. 

15 (vi) TERMINATION.—The Working 

16 Group shall terminate 30 days after the 

17 date of the issuance of its report under 

18 clause (v). 

19 (D) EFFECTIVE DATES.—The Secretary of 

20 Labor and the Secretary of Health and Human 

21 Services shall develop the initial model notices 

22 under section 701(f)(3)(B)(i)(II) of the Em23 ployee Retirement Income Security Act of 1974, 

24 and the Secretary of Labor shall provide such 

25 notices to employers, not later than the date 


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1 that is 1 year after the date of enactment of 

2 this Act, and each employer shall provide the 

3 initial annual notices to such employer’s em4 ployees beginning with the first plan year that 

5 begins after the date on which such initial 

6 model notices are first issued. The model cov7 erage coordination disclosure form developed 

8 under subparagraph (C) shall apply with re9 spect to requests made by States beginning 

10 with the first plan year that begins after the 

11 date on which such model coverage coordination 

12 disclosure form is first issued. 

13 (E) ENFORCEMENT.—Section 502 of the 

14 Employee Retirement Income Security Act of 

15 1974 (29 U.S.C. 1132) is amended— 

16 (i) in subsection (a)(6), by striking 

17 ‘‘or (8)’’ and inserting ‘‘(8), or (9)’’; and 

18 (ii) in subsection (c), by redesignating 

19 paragraph (9) as paragraph (10), and by 

20 inserting after paragraph (8) the following: 

21 ‘‘(9)(A) The Secretary may assess a civil penalty 

22 against any employer of up to $100 a day from the date 

23 of the employer’s failure to meet the notice requirement 

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1 paragraph, each violation with respect to any single em2 ployee shall be treated as a separate violation. 

3 ‘‘(B) The Secretary may assess a civil penalty against 

4 any plan administrator of up to $100 a day from the date 

5 of the plan administrator’s failure to timely provide to any 

6 State the information required to be disclosed under sec7 tion 701(f)(3)(B)(ii). For purposes of this subparagraph, 

8 each violation with respect to any single participant or 

9 beneficiary shall be treated as a separate violation.’’. 

10 (2) AMENDMENTS TO PUBLIC HEALTH SERVICE

11 ACT.—Section 2701(f) of the Public Health Service 

12 Act (42 U.S.C. 300gg(f)) is amended by adding at 

13 the end the following new paragraph: 

14 ‘‘(3) SPECIAL RULES FOR APPLICATION IN CASE

15 OF MEDICAID AND CHIP.— 

16 ‘‘(A) IN GENERAL.—A group health plan, 

17 and a health insurance issuer offering group 

18 health insurance coverage in connection with a 

19 group health plan, shall permit an employee 

20 who is eligible, but not enrolled, for coverage 

21 under the terms of the plan (or a dependent of 

22 such an employee if the dependent is eligible, 

23 but not enrolled, for coverage under such 

24 terms) to enroll for coverage under the terms of 


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1 the plan if either of the following conditions is 

2 met: 

3 ‘‘(i) TERMINATION OF MEDICAID OR

4 CHIP COVERAGE.—The employee or de5 pendent is covered under a Medicaid plan 

6 under title XIX of the Social Security Act 

7 or under a State child health plan under 

8 title XXI of such Act and coverage of the 

9 employee or dependent under such a plan 

10 is terminated as a result of loss of eligi11 bility for such coverage and the employee 

12 requests coverage under the group health 

13 plan (or health insurance coverage) not 

14 later than 60 days after the date of termi15 nation of such coverage. 

16 ‘‘(ii) ELIGIBILITY FOR EMPLOYMENT

17 ASSISTANCE UNDER MEDICAID OR CHIP.— 

18 The employee or dependent becomes eligi19 ble for assistance, with respect to coverage 

20 under the group health plan or health in21 surance coverage, under such Medicaid 

22 plan or State child health plan (including 

23 under any waiver or demonstration project 

24 conducted under or in relation to such a 

25 plan), if the employee requests coverage 


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1 under the group health plan or health in2 surance coverage not later than 60 days 

3 after the date the employee or dependent is 

4 determined to be eligible for such assist5 ance. 

6 ‘‘(B) COORDINATION WITH MEDICAID AND

7 CHIP.— 

8 ‘‘(i) OUTREACH TO EMPLOYEES RE9 GARDING AVAILABILITY OF MEDICAID AND

10 CHIP COVERAGE.— 

11 ‘‘(I) IN GENERAL.—Each em12 ployer that maintains a group health 

13 plan in a State that provides medical 

14 assistance under a State Medicaid 

15 plan under title XIX of the Social Se16 curity Act, or child health assistance 

17 under a State child health plan under 

18 title XXI of such Act, in the form of 

19 premium assistance for the purchase 

20 of coverage under a group health 

21 plan, shall provide to each employee a 

22 written notice informing the employee 

23 of potential opportunities then cur24 rently available in the State in which 

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1 sistance under such plans for health 

2 coverage of the employee or the em3 ployee’s dependents. For purposes of 

4 compliance with this subclause, the 

5 employer may use any State-specific 

6 model notice developed in accordance 

7 with section 701(f)(3)(B)(i)(II) of the 

8 Employee Retirement Income Security 

9 Act of 1974 (29 U.S.C. 

10 1181(f)(3)(B)(i)(II)). 

11 ‘‘(II) OPTION TO PROVIDE CON12 CURRENT WITH PROVISION OF PLAN

13 MATERIALS TO EMPLOYEE.—An em14 ployer may provide the model notice 

15 applicable to the State in which an 

16 employee resides concurrent with the 

17 furnishing of materials notifying the 

18 employee of health plan eligibility, 

19 concurrent with materials provided to 

20 the employee in connection with an 

21 open season or election process con22 ducted under the plan, or concurrent 

23 with the furnishing of the summary 

24 plan description as provided in section 


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1 104(b) of the Employee Retirement 

2 Income Security Act of 1974. 

3 ‘‘(ii) DISCLOSURE ABOUT GROUP

4 HEALTH PLAN BENEFITS TO STATES FOR

5 MEDICAID AND CHIP ELIGIBLE INDIVID6 UALS.—In the case of an enrollee in a 

7 group health plan who is covered under a 

8 Medicaid plan of a State under title XIX 

9 of the Social Security Act or under a State 

10 child health plan under title XXI of such 

11 Act, the plan administrator of the group 

12 health plan shall disclose to the State, 

13 upon request, information about the bene14 fits available under the group health plan 

15 in sufficient specificity, as determined 

16 under regulations of the Secretary of 

17 Health and Human Services in consulta18 tion with the Secretary that require use of 

19 the model coverage coordination disclosure 

20 form developed under section 311(b)(1)(C) 

21 of the Children’s Health Insurance Reau22 thorization Act of 2009, so as to permit 

23 the State to make a determination (under 

24 paragraph (2)(B), (3), or (10) of section 

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1 erwise) concerning the cost-effectiveness of 

2 the State providing medical or child health 

3 assistance through premium assistance for 

4 the purchase of coverage under such group 

5 health plan and in order for the State to 

6 provide supplemental benefits required 

7 under paragraph (10)(E) of such section 

8 or other authority.’’. 

9 TITLE IV—STRENGTHENING 

10 QUALITY OF CARE AND 

11 HEALTH OUTCOMES 

12 SEC. 401. CHILD HEALTH QUALITY IMPROVEMENT ACTIVI13 TIES FOR CHILDREN ENROLLED IN MED14 ICAID OR CHIP. 

15 (a) DEVELOPMENT OF CHILD HEALTH QUALITY

16 MEASURES FOR CHILDREN ENROLLED IN MEDICAID OR

17 CHIP.—Title XI (42 U.S.C. 1301 et seq.) is amended by 

18 inserting after section 1139 the following new section: 

19 ‘‘SEC. 1139A. CHILD HEALTH QUALITY MEASURES. 

20 ‘‘(a) DEVELOPMENT OF AN INITIAL CORE SET OF

21 HEALTH CARE QUALITY MEASURES FOR CHILDREN EN22 ROLLED IN MEDICAID OR CHIP.— 

23 ‘‘(1) IN GENERAL.—Not later than January 1, 

24 2010, the Secretary shall identify and publish for 

25 general comment an initial, recommended core set of 


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1 child health quality measures for use by State pro2 grams administered under titles XIX and XXI, 

3 health insurance issuers and managed care entities 

4 that enter into contracts with such programs, and 

5 providers of items and services under such pro6 grams. 

7 ‘‘(2) IDENTIFICATION OF INITIAL CORE MEAS8 URES.—In consultation with the individuals and en9 tities described in subsection (b)(3), the Secretary 

10 shall identify existing quality of care measures for 

11 children that are in use under public and privately 

12 sponsored health care coverage arrangements, or 

13 that are part of reporting systems that measure both 

14 the presence and duration of health insurance cov15 erage over time. 

16 ‘‘(3) RECOMMENDATIONS AND DISSEMINA17 TION.—Based on such existing and identified meas18 ures, the Secretary shall publish an initial core set 

19 of child health quality measures that includes (but 

20 is not limited to) the following: 

21 ‘‘(A) The duration of children’s health in22 surance coverage over a 12-month time period. 

23 ‘‘(B) The availability and effectiveness of a 

24 full range of— 


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1 ‘‘(i) preventive services, treatments, 

2 and services for acute conditions, including 

3 services to promote healthy birth, prevent 

4 and treat premature birth, and detect the 

5 presence or risk of physical or mental con6 ditions that could adversely affect growth 

7 and development; and 

8 ‘‘(ii) treatments to correct or amelio9 rate the effects of physical and mental con10 ditions, including chronic conditions, in in11 fants, young children, school-age children, 

12 and adolescents. 

13 ‘‘(C) The availability of care in a range of 

14 ambulatory and inpatient health care settings 

15 in which such care is furnished. 

16 ‘‘(D) The types of measures that, taken to17 gether, can be used to estimate the overall na18 tional quality of health care for children, includ19 ing children with special needs, and to perform 

20 comparative analyses of pediatric health care 

21 quality and racial, ethnic, and socioeconomic 

22 disparities in child health and health care for 

23 children. 

24 ‘‘(4) ENCOURAGE VOLUNTARY AND STANDARD25 IZED REPORTING.—Not later than 2 years after the 


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1 date of enactment of the Children’s Health Insur2 ance Program Reauthorization Act of 2009, the Sec3 retary, in consultation with States, shall develop a 

4 standardized format for reporting information and 

5 procedures and approaches that encourage States to 

6 use the initial core measurement set to voluntarily 

7 report information regarding the quality of pediatric 

8 health care under titles XIX and XXI. 

9 ‘‘(5) ADOPTION OF BEST PRACTICES IN IMPLE10 MENTING QUALITY PROGRAMS.—The Secretary shall 

11 disseminate information to States regarding best 

12 practices among States with respect to measuring 

13 and reporting on the quality of health care for chil14 dren, and shall facilitate the adoption of such best 

15 practices. In developing best practices approaches, 

16 the Secretary shall give particular attention to State 

17 measurement techniques that ensure the timeliness 

18 and accuracy of provider reporting, encourage pro19 vider reporting compliance, encourage successful 

20 quality improvement strategies, and improve effi21 ciency in data collection using health information 

22 technology. 

23 ‘‘(6) REPORTS TO CONGRESS.—Not later than 

24 January 1, 2011, and every 3 years thereafter, the 

25 Secretary shall report to Congress on— 


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1 ‘‘(A) the status of the Secretary’s efforts 

2 to improve— 

3 ‘‘(i) quality related to the duration 

4 and stability of health insurance coverage 

5 for children under titles XIX and XXI; 

6 ‘‘(ii) the quality of children’s health 

7 care under such titles, including preventive 

8 health services, health care for acute condi9 tions, chronic health care, and health serv10 ices to ameliorate the effects of physical 

11 and mental conditions and to aid in growth 

12 and development of infants, young chil13 dren, school-age children, and adolescents 

14 with special health care needs; and 

15 ‘‘(iii) the quality of children’s health 

16 care under such titles across the domains 

17 of quality, including clinical quality, health 

18 care safety, family experience with health 

19 care, health care in the most integrated 

20 setting, and elimination of racial, ethnic, 

21 and socioeconomic disparities in health and 

22 health care; 

23 ‘‘(B) the status of voluntary reporting by 

24 States under titles XIX and XXI, utilizing the 

25 initial core quality measurement set; and 


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1 ‘‘(C) any recommendations for legislative 

2 changes needed to improve the quality of care 

3 provided to children under titles XIX and XXI, 

4 including recommendations for quality reporting 

5 by States. 

6 ‘‘(7) TECHNICAL ASSISTANCE.—The Secretary 

7 shall provide technical assistance to States to assist 

8 them in adopting and utilizing core child health 

9 quality measures in administering the State plans 

10 under titles XIX and XXI. 

11 ‘‘(8) DEFINITION OF CORE SET.—In this sec12 tion, the term ‘core set’ means a group of valid, reli13 able, and evidence-based quality measures that, 

14 taken together— 

15 ‘‘(A) provide information regarding the 

16 quality of health coverage and health care for 

17 children; 

18 ‘‘(B) address the needs of children 

19 throughout the developmental age span; and 

20 ‘‘(C) allow purchasers, families, and health 

21 care providers to understand the quality of care 

22 in relation to the preventive needs of children, 

23 treatments aimed at managing and resolving 

24 acute conditions, and diagnostic and treatment 

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1 rate physical, mental, or developmental condi2 tions that could, if untreated or poorly treated, 

3 become chronic. 

4 ‘‘(b) ADVANCING AND IMPROVING PEDIATRIC QUAL5 ITY MEASURES.— 

6 ‘‘(1) ESTABLISHMENT OF PEDIATRIC QUALITY

7 MEASURES PROGRAM.—Not later than January 1, 

8 2011, the Secretary shall establish a pediatric qual9 ity measures program to— 

10 ‘‘(A) improve and strengthen the initial 

11 core child health care quality measures estab12 lished by the Secretary under subsection (a); 

13 ‘‘(B) expand on existing pediatric quality 

14 measures used by public and private health care 

15 purchasers and advance the development of 

16 such new and emerging quality measures; and 

17 ‘‘(C) increase the portfolio of evidence18 based, consensus pediatric quality measures 

19 available to public and private purchasers of 

20 children’s health care services, providers, and 

21 consumers. 

22 ‘‘(2) EVIDENCE-BASED MEASURES.—The meas23 ures developed under the pediatric quality measures 

24 program shall, at a minimum, be— 


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1 ‘‘(A) evidence-based and, where appro2 priate, risk adjusted; 

3 ‘‘(B) designed to identify and eliminate ra4 cial and ethnic disparities in child health and 

5 the provision of health care; 

6 ‘‘(C) designed to ensure that the data re7 quired for such measures is collected and re8 ported in a standard format that permits com9 parison of quality and data at a State, plan, 

10 and provider level; 

11 ‘‘(D) periodically updated; and 

12 ‘‘(E) responsive to the child health needs, 

13 services, and domains of health care quality de14 scribed in clauses (i), (ii), and (iii) of subsection 

15 (a)(6)(A). 

16 ‘‘(3) PROCESS FOR PEDIATRIC QUALITY MEAS17 URES PROGRAM.—In identifying gaps in existing pe18 diatric quality measures and establishing priorities 

19 for development and advancement of such measures, 

20 the Secretary shall consult with— 

21 ‘‘(A) States; 

22 ‘‘(B) pediatricians, children’s hospitals, 

23 and other primary and specialized pediatric 

24 health care professionals (including members of 

25 the allied health professions) who specialize in 


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1 the care and treatment of children, particularly 

2 children with special physical, mental, and de3 velopmental health care needs; 

4 ‘‘(C) dental professionals, including pedi5 atric dental professionals; 

6 ‘‘(D) health care providers that furnish 

7 primary health care to children and families 

8 who live in urban and rural medically under9 served communities or who are members of dis10 tinct population sub-groups at heightened risk 

11 for poor health outcomes; 

12 ‘‘(E) national organizations representing 

13 children, including children with disabilities and 

14 children with chronic conditions; 

15 ‘‘(F) national organizations representing 

16 consumers and purchasers of children’s health 

17 care; 

18 ‘‘(G) national organizations and individuals 

19 with expertise in pediatric health quality meas20 urement; and 

21 ‘‘(H) voluntary consensus standards set22 ting organizations and other organizations in23 volved in the advancement of evidence-based 

24 measures of health care. 


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1 ‘‘(4) DEVELOPING, VALIDATING, AND TESTING

2 A PORTFOLIO OF PEDIATRIC QUALITY MEASURES.— 

3 As part of the program to advance pediatric quality 

4 measures, the Secretary shall— 

5 ‘‘(A) award grants and contracts for the 

6 development, testing, and validation of new, 

7 emerging, and innovative evidence-based meas8 ures for children’s health care services across 

9 the domains of quality described in clauses (i), 

10 (ii), and (iii) of subsection (a)(6)(A); and 

11 ‘‘(B) award grants and contracts for— 

12 ‘‘(i) the development of consensus on 

13 evidence-based measures for children’s 

14 health care services; 

15 ‘‘(ii) the dissemination of such meas16 ures to public and private purchasers of 

17 health care for children; and 

18 ‘‘(iii) the updating of such measures 

19 as necessary. 

20 ‘‘(5) REVISING, STRENGTHENING, AND IMPROV21 ING INITIAL CORE MEASURES.—Beginning no later 

22 than January 1, 2013, and annually thereafter, the 

23 Secretary shall publish recommended changes to the 

24 core measures described in subsection (a) that shall 

25 reflect the testing, validation, and consensus process 


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1 for the development of pediatric quality measures 

2 described in subsection paragraphs (1) through (4). 

3 ‘‘(6) DEFINITION OF PEDIATRIC QUALITY

4 MEASURE.—In this subsection, the term ‘pediatric 

5 quality measure’ means a measurement of clinical 

6 care that is capable of being examined through the 

7 collection and analysis of relevant information, that 

8 is developed in order to assess 1 or more aspects of 

9 pediatric health care quality in various institutional 

10 and ambulatory health care settings, including the 

11 structure of the clinical care system, the process of 

12 care, the outcome of care, or patient experiences in 

13 care. 

14 ‘‘(7) CONSTRUCTION.—Nothing in this section 

15 shall be construed as supporting the restriction of 

16 coverage, under title XIX or XXI or otherwise, to 

17 only those services that are evidence-based. 

18 ‘‘(c) ANNUAL STATE REPORTS REGARDING STATE19 SPECIFIC QUALITY OF CARE MEASURES APPLIED UNDER

20 MEDICAID OR CHIP.— 

21 ‘‘(1) ANNUAL STATE REPORTS.—Each State 

22 with a State plan approved under title XIX or a 

23 State child health plan approved under title XXI 

24 shall annually report to the Secretary on the— 


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1 ‘‘(A) State-specific child health quality 

2 measures applied by the States under such 

3 plans, including measures described in subpara4 graphs (A) and (B) of subsection (a)(6); and 

5 ‘‘(B) State-specific information on the 

6 quality of health care furnished to children 

7 under such plans, including information col8 lected through external quality reviews of man9 aged care organizations under section 1932 of 

10 the Social Security Act (42 U.S.C. 1396u–4) 

11 and benchmark plans under sections 1937 and 

12 2103 of such Act (42 U.S.C. 1396u–7, 1397cc). 

13 ‘‘(2) PUBLICATION.—Not later than September 

14 30, 2010, and annually thereafter, the Secretary 

15 shall collect, analyze, and make publicly available the 

16 information reported by States under paragraph (1). 

17 ‘‘(d) DEMONSTRATION PROJECTS FOR IMPROVING

18 THE QUALITY OF CHILDREN’S HEALTH CARE AND THE

19 USE OF HEALTH INFORMATION TECHNOLOGY.— 

20 ‘‘(1) IN GENERAL.—During the period of fiscal 

21 years 2009 through 2013, the Secretary shall award 

22 not more than 10 grants to States and child health 

23 providers to conduct demonstration projects to 

24 evaluate promising ideas for improving the quality of 


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1 children’s health care provided under title XIX or 

2 XXI, including projects to— 

3 ‘‘(A) experiment with, and evaluate the use 

4 of, new measures of the quality of children’s 

5 health care under such titles (including testing 

6 the validity and suitability for reporting of such 

7 measures); 

8 ‘‘(B) promote the use of health information 

9 technology in care delivery for children under 

10 such titles; 

11 ‘‘(C) evaluate provider-based models which 

12 improve the delivery of children’s health care 

13 services under such titles, including care man14 agement for children with chronic conditions 

15 and the use of evidence-based approaches to im16 prove the effectiveness, safety, and efficiency of 

17 health care services for children; or 

18 ‘‘(D) demonstrate the impact of the model 

19 electronic health record format for children de20 veloped and disseminated under subsection (f) 

21 on improving pediatric health, including the ef22 fects of chronic childhood health conditions, and 

23 pediatric health care quality as well as reducing 

24 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

12 PROJECTS.—A demonstration project conducted with 

13 a grant awarded under this subsection may be con14 ducted on a multistate basis, as needed. 

15 ‘‘(4) FUNDING.—$20,000,000 of the amount 

16 appropriated under subsection (i) for a fiscal year 

17 shall 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 

24 develop a comprehensive and systematic model for 

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1 gible 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, 

6 needed 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 tar10 get individuals and their families to reduce risk 

11 factors and promote the appropriate use of pre12 ventive 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 enti16 ties, including schools and other facilities 

17 providing recreational services, to establish 

18 programs for after school and weekend 

19 community activities that are designed to 

20 reduce childhood obesity; 

21 ‘‘(ii) forming partnerships with 

22 daycare facilities to establish programs 

23 that promote healthy eating behaviors and 

24 physical activity; and 


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1 ‘‘(iii) developing and evaluating com2 munity educational activities targeting 

3 good nutrition and promoting healthy eat4 ing behaviors; 

5 ‘‘(B) carry out age-appropriate school6 based activities that are designed to reduce 

7 childhood obesity, including by— 

8 ‘‘(i) developing and testing edu9 cational curricula and intervention pro10 grams designed to promote healthy eating 

11 behaviors and habits in youth, which may 

12 include— 

13 ‘‘(I) after hours physical activity 

14 programs; and 

15 ‘‘(II) science-based interventions 

16 with multiple components to prevent 

17 eating disorders including nutritional 

18 content, understanding and respond19 ing to hunger and satiety, positive 

20 body image development, positive self21 esteem development, and learning life 

22 skills (such as stress management, 

23 communication skills, problemsolving 

24 and decisionmaking skills), as well as 

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1 mental issues, and the role of family, 

2 school, and community; 

3 ‘‘(ii) providing education and training 

4 to educational professionals regarding how 

5 to promote a healthy lifestyle and a 

6 healthy 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 

13 parents or guardians, with an emphasis on 

14 healthy eating behaviors and physical ac15 tivity for children; 

16 ‘‘(C) carry out educational, counseling, 

17 promotional, and training activities through the 

18 local health care delivery systems including 

19 by— 

20 ‘‘(i) promoting healthy eating behav21 iors and physical activity services to treat 

22 or prevent eating disorders, being over23 weight, and obesity; 


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1 ‘‘(ii) providing patient education and 

2 counseling to increase physical activity and 

3 promote healthy eating behaviors; 

4 ‘‘(iii) training health professionals on 

5 how to identify and treat obese and over6 weight individuals which may include nu7 trition and physical activity counseling; 

8 and 

9 ‘‘(iv) providing community education 

10 by a health professional on good nutrition 

11 and physical activity to develop a better 

12 understanding of the relationship between 

13 diet, physical activity, and eating disorders, 

14 obesity, or being overweight; and 

15 ‘‘(D) provide, through qualified health pro16 fessionals, training and supervision for commu17 nity health workers to— 

18 ‘‘(i) educate families regarding the re19 lationship between nutrition, eating habits, 

20 physical activity, and obesity; 

21 ‘‘(ii) educate families about effective 

22 strategies to improve nutrition, establish 

23 healthy eating patterns, and establish ap24 propriate levels of physical activity; and 


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1 ‘‘(iii) educate and guide parents re2 garding the ability to model and commu3 nicate positive health behaviors. 

4 ‘‘(4) PRIORITY.—In awarding grants under 

5 paragraph (1), the Secretary shall give priority to 

6 awarding grants to eligible entities— 

7 ‘‘(A) that demonstrate that they have pre8 viously applied successfully for funds to carry 

9 out activities that seek to promote individual 

10 and community health and to prevent the inci11 dence of chronic disease and that can cite pub12 lished and peer-reviewed research dem13 onstrating that the activities that the entities 

14 propose to carry out with funds made available 

15 under the grant are effective; 

16 ‘‘(B) that will carry out programs or ac17 tivities that seek to accomplish a goal or goals 

18 set by the State in the Healthy People 2010 

19 plan of the State; 

20 ‘‘(C) that provide non-Federal contribu21 tions, either in cash or in-kind, to the costs of 

22 funding activities under the grants; 

23 ‘‘(D) that develop comprehensive plans 

24 that include a strategy for extending program 

25 activities developed under grants in the years 


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1 following the fiscal years for which they receive 

2 grants under this subsection; 

3 ‘‘(E) located in communities that are medi4 cally underserved, as determined by the Sec5 retary; 

6 ‘‘(F) located in areas in which the average 

7 poverty rate is at least 150 percent or higher of 

8 the average poverty rate in the State involved, 

9 as determined by the Secretary; and 

10 ‘‘(G) that submit plans that exhibit multi11 sectoral, cooperative conduct that includes the 

12 involvement of a broad range of stakeholders, 

13 including— 

14 ‘‘(i) community-based organizations; 

15 ‘‘(ii) local governments; 

16 ‘‘(iii) local educational agencies; 

17 ‘‘(iv) the private sector; 

18 ‘‘(v) State or local departments of 

19 health; 

20 ‘‘(vi) accredited colleges, universities, 

21 and community colleges; 

22 ‘‘(vii) health care providers; 

23 ‘‘(viii) State and local departments of 

24 transportation and city planning; and 


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1 ‘‘(ix) other entities determined appro2 priate by the Secretary. 

3 ‘‘(5) PROGRAM DESIGN.— 

4 ‘‘(A) INITIAL DESIGN.—Not later than 1 

5 year after the date of enactment of the Chil6 dren’s Health Insurance Program Reauthoriza7 tion Act of 2009, the Secretary shall design the 

8 demonstration project. The demonstration 

9 should draw upon promising, innovative models 

10 and incentives to reduce behavioral risk factors. 

11 The Administrator of the Centers for Medicare 

12 & Medicaid Services shall consult with the Di13 rector of the Centers for Disease Control and 

14 Prevention, the Director of the Office of Minor15 ity Health, the heads of other agencies in the 

16 Department of Health and Human Services, 

17 and such professional organizations, as the Sec18 retary determines to be appropriate, on the de19 sign, conduct, and evaluation of the demonstra20 tion. 

21 ‘‘(B) NUMBER AND PROJECT AREAS.—Not 

22 later than 2 years after the date of enactment 

23 of the Children’s Health Insurance Program 

24 Reauthorization Act of 2009, the Secretary 

25 shall award 1 grant that is specifically designed 


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1 to determine whether programs similar to pro2 grams to be conducted by other grantees under 

3 this subsection should be implemented with re4 spect to the general population of children who 

5 are eligible for child health assistance under 

6 State child health plans under title XXI in 

7 order to reduce the incidence of childhood obe8 sity among such population. 

9 ‘‘(6) REPORT TO CONGRESS.—Not later than 3 

10 years after the date the Secretary implements the 

11 demonstration project under this subsection, the 

12 Secretary shall submit to Congress a report that de13 scribes the project, evaluates the effectiveness and 

14 cost effectiveness of the project, evaluates the bene15 ficiary satisfaction under the project, and includes 

16 any such other information as the Secretary deter17 mines to be appropriate. 

18 ‘‘(7) DEFINITIONS.—In this subsection: 

19 ‘‘(A) FEDERALLY-QUALIFIED HEALTH

20 CENTER.—The term ‘Federally-qualified health 

21 center’ has the meaning given that term in sec22 tion 1905(l)(2)(B). 

23 ‘‘(B) INDIAN TRIBE.—The term ‘Indian 

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1 tion 4 of the Indian Health Care Improvement 

2 Act (25 U.S.C. 1603). 

3 ‘‘(C) SELF-ASSESSMENT.—The term ‘self4 assessment’ means a form that— 

5 ‘‘(i) includes questions regarding— 

6 ‘‘(I) behavioral risk factors; 

7 ‘‘(II) needed preventive and 

8 screening services; and 

9 ‘‘(III) target individuals’ pref10 erences for receiving follow-up infor11 mation; 

12 ‘‘(ii) is assessed using such computer 

13 generated assessment programs; and 

14 ‘‘(iii) allows for the provision of such 

15 ongoing support to the individual as the 

16 Secretary determines appropriate. 

17 ‘‘(D) ONGOING SUPPORT.—The term ‘on18 going support’ means— 

19 ‘‘(i) to provide any target individual 

20 with information, feedback, health coach21 ing, and recommendations regarding— 

22 ‘‘(I) the results of a self-assess23 ment given to the individual; 

24 ‘‘(II) behavior modification based 

25 on the self-assessment; and 


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1 ‘‘(III) any need for clinical pre2 ventive and screening services or 

3 treatment including medical nutrition 

4 therapy; 

5 ‘‘(ii) to provide any target individual 

6 with referrals to community resources and 

7 programs available to assist the target in8 dividual in reducing health risks; and 

9 ‘‘(iii) to provide the information de10 scribed in clause (i) to a health care pro11 vider, if designated by the target individual 

12 to receive such information. 

13 ‘‘(8) AUTHORIZATION OF APPROPRIATIONS.— 

14 There is authorized to be appropriated to carry out 

15 this subsection, $25,000,000 for the period of fiscal 

16 years 2009 through 2013. 

17 ‘‘(f) DEVELOPMENT OF MODEL ELECTRONIC

18 HEALTH RECORD FORMAT FOR CHILDREN ENROLLED IN

19 MEDICAID OR CHIP.— 

20 ‘‘(1) IN GENERAL.—Not later than January 1, 

21 2010, the Secretary shall establish a program to en22 courage the development and dissemination of a 

23 model electronic health record format for children 

24 enrolled in the State plan under title XIX or the 

25 State child health plan under title XXI that is— 


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1 ‘‘(A) subject to State laws, accessible to 

2 parents, caregivers, and other consumers for 

3 the sole purpose of demonstrating compliance 

4 with school or leisure activity requirements, 

5 such as appropriate immunizations or physicals; 

6 ‘‘(B) designed to allow interoperable ex7 changes that conform with Federal and State 

8 privacy and security requirements; 

9 ‘‘(C) structured in a manner that permits 

10 parents and caregivers to view and understand 

11 the extent to which the care their children re12 ceive is clinically appropriate and of high qual13 ity; and 

14 ‘‘(D) capable of being incorporated into, 

15 and otherwise compatible with, other standards 

16 developed for electronic health records. 

17 ‘‘(2) FUNDING.—$5,000,000 of the amount ap18 propriated under subsection (i) for a fiscal year shall 

19 be used to carry out this subsection. 

20 ‘‘(g) STUDY OF PEDIATRIC HEALTH AND HEALTH

21 CARE QUALITY MEASURES.— 

22 ‘‘(1) IN GENERAL.—Not later than July 1, 

23 2010, the Institute of Medicine shall study and re24 port to Congress on the extent and quality of efforts 

25 to measure child health status and the quality of 


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1 health care for children across the age span and in 

2 relation to preventive care, treatments for acute con3 ditions, and treatments aimed at ameliorating or 

4 correcting physical, mental, and developmental con5 ditions in children. In conducting such study and 

6 preparing such report, the Institute of Medicine 

7 shall— 

8 ‘‘(A) consider all of the major national 

9 population-based reporting systems sponsored 

10 by the Federal Government that are currently 

11 in place, including reporting requirements 

12 under Federal grant programs and national 

13 population surveys and estimates conducted di14 rectly by the Federal Government; 

15 ‘‘(B) identify the information regarding 

16 child health and health care quality that each 

17 system is designed to capture and generate, the 

18 study and reporting periods covered by each 

19 system, and the extent to which the information 

20 so generated is made widely available through 

21 publication; 

22 ‘‘(C) identify gaps in knowledge related to 

23 children’s health status, health disparities 

24 among subgroups of children, the effects of so25 cial conditions on children’s health status and 


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1 use and effectiveness of health care, and the re2 lationship between child health status and fam3 ily income, family stability and preservation, 

4 and children’s school readiness and educational 

5 achievement and attainment; and 

6 ‘‘(D) make recommendations regarding im7 proving and strengthening the timeliness, qual8 ity, and public transparency and accessibility of 

9 information about child health and health care 

10 quality. 

11 ‘‘(2) FUNDING.—Up to $1,000,000 of the 

12 amount appropriated under subsection (i) for a fis13 cal year shall be used to carry out this subsection. 

14 ‘‘(h) RULE OF CONSTRUCTION.—Notwithstanding 

15 any other provision in this section, no evidence based qual16 ity measure developed, published, or used as a basis of 

17 measurement or reporting under this section may be used 

18 to establish an irrebuttable presumption regarding either 

19 the medical necessity of care or the maximum permissible 

20 coverage for any individual child who is eligible for and 

21 receiving medical assistance under title XIX or child 

22 health assistance under title XXI. 

23 ‘‘(i) APPROPRIATION.—Out of any funds in the 

24 Treasury not otherwise appropriated, there is appro25 priated for each of fiscal years 2009 through 2013, 


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1 $45,000,000 for the purpose of carrying out this section 

2 (other than subsection (e)). Funds appropriated under 

3 this subsection shall remain available until expended.’’. 

4 (b) INCREASED MATCHING RATE FOR COLLECTING

5 AND REPORTING ON CHILD HEALTH MEASURES.—Sec6 tion 1903(a)(3)(A) (42 U.S.C. 1396b(a)(3)(A)), is amend7 ed— 

8 (1) by striking ‘‘and’’ at the end of clause (i); 

9 and 

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

11 clause: 

12 ‘‘(iii) an amount equal to the Federal med13 ical assistance percentage (as defined in section 

14 1905(b)) of so much of the sums expended dur15 ing such quarter (as found necessary by the 

16 Secretary for the proper and efficient adminis17 tration of the State plan) as are attributable to 

18 such developments or modifications of systems 

19 of the type described in clause (i) as are nec20 essary for the efficient collection and reporting 

21 on child health measures; and’’. 


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1 SEC. 402. IMPROVED AVAILABILITY OF PUBLIC INFORMA2 TION REGARDING ENROLLMENT OF CHIL3 DREN IN CHIP AND MEDICAID. 

4 (a) INCLUSION OF PROCESS AND ACCESS MEASURES

5 IN ANNUAL STATE REPORTS.—Section 2108 (42 U.S.C. 

6 1397hh) is amended— 

7 (1) in subsection (a), in the matter preceding 

8 paragraph (1), by striking ‘‘The State’’ and insert9 ing ‘‘Subject to subsection (e), the State’’; and 

10 (2) by adding at the end the following new sub11 section: 

12 ‘‘(e) INFORMATION REQUIRED FOR INCLUSION IN

13 STATE ANNUAL REPORT.—The State shall include the fol14 lowing information in the annual report required under 

15 subsection (a): 

16 ‘‘(1) Eligibility criteria, enrollment, and reten17 tion data (including data with respect to continuity 

18 of coverage or duration of benefits). 

19 ‘‘(2) Data regarding the extent to which the 

20 State uses process measures with respect to deter21 mining the eligibility of children under the State 

22 child health plan, including measures such as 12- 

23 month continuous eligibility, self-declaration of in24 come for applications or renewals, or presumptive 

25 eligibility. 


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1 ‘‘(3) Data regarding denials of eligibility and 

2 redeterminations of eligibility. 

3 ‘‘(4) Data regarding access to primary and spe4 cialty services, access to networks of care, and care 

5 coordination provided under the State child health 

6 plan, using quality care and consumer satisfaction 

7 measures included in the Consumer Assessment of 

8 Healthcare Providers and Systems (CAHPS) survey. 

9 ‘‘(5) If the State provides child health assist10 ance in the form of premium assistance for the pur11 chase of coverage under a group health plan, data 

12 regarding the provision of such assistance, including 

13 the extent to which employer-sponsored health insur14 ance coverage is available for children eligible for 

15 child health assistance under the State child health 

16 plan, the range of the monthly amount of such as17 sistance provided on behalf of a child or family, the 

18 number of children or families provided such assist19 ance on a monthly basis, the income of the children 

20 or families provided such assistance, the benefits 

21 and cost-sharing protection provided under the State 

22 child health plan to supplement the coverage pur23 chased with such premium assistance, the effective 

24 strategies the State engages in to reduce any admin25 istrative barriers to the provision of such assistance, 


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1 and, the effects, if any, of the provision of such as2 sistance on preventing the coverage provided under 

3 the State child health plan from substituting for cov4 erage provided under employer-sponsored health in5 surance offered in the State. 

6 ‘‘(6) To the extent applicable, a description of 

7 any State activities that are designed to reduce the 

8 number of uncovered children in the State, including 

9 through a State health insurance connector program 

10 or support for innovative private health coverage ini11 tiatives.’’. 

12 (b) STANDARDIZED REPORTING FORMAT.— 

13 (1) IN GENERAL.—Not later than 1 year after 

14 the date of enactment of this Act, the Secretary 

15 shall specify a standardized format for States to use 

16 for reporting the information required under section 

17 2108(e) of the Social Security Act, as added by sub18 section (a)(2). 

19 (2) TRANSITION PERIOD FOR STATES.—Each 

20 State that is required to submit a report under sub21 section (a) of section 2108 of the Social Security Act 

22 that includes the information required under sub23 section (e) of such section may use up to 3 reporting 

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1 mation in accordance with the standardized format 

2 specified by the Secretary under paragraph (1). 

3 (c) ADDITIONAL FUNDING FOR THE SECRETARY TO

4 IMPROVE TIMELINESS OF DATA REPORTING AND ANAL5 YSIS FOR PURPOSES OF DETERMINING ENROLLMENT IN6 CREASES UNDER MEDICAID AND CHIP.— 

7 (1) APPROPRIATION.—There is appropriated, 

8 out of any money in the Treasury not otherwise ap9 propriated, $5,000,000 to the Secretary for fiscal 

10 year 2009 for the purpose of improving the timeli11 ness of the data reported and analyzed from the 

12 Medicaid Statistical Information System (MSIS) for 

13 purposes of providing more timely data on enroll14 ment and eligibility of children under Medicaid and 

15 CHIP and to provide guidance to States with re16 spect to any new reporting requirements related to 

17 such improvements. Amounts appropriated under 

18 this paragraph shall remain available until expended. 

19 (2) REQUIREMENTS.—The improvements made 

20 by the Secretary under paragraph (1) shall be de21 signed and implemented (including with respect to 

22 any necessary guidance for States to report such in23 formation in a complete and expeditious manner) so 

24 that, beginning no later than October 1, 2009, data 

25 regarding the enrollment of low-income children (as 


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1 defined in section 2110(c)(4) of the Social Security 

2 Act (42 U.S.C. 1397jj(c)(4)) of a State enrolled in 

3 the State plan under Medicaid or the State child 

4 health plan under CHIP with respect to a fiscal year 

5 shall be collected and analyzed by the Secretary 

6 within 6 months of submission. 

7 (d) GAO STUDY AND REPORT ON ACCESS TO PRI8 MARY AND SPECIALITY SERVICES.— 

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

10 the United States shall conduct a study of children’s 

11 access to primary and specialty services under Med12 icaid and CHIP, including— 

13 (A) the extent to which providers are will14 ing to treat children eligible for such programs; 

15 (B) information on such children’s access 

16 to networks of care; 

17 (C) geographic availability of primary and 

18 specialty services under such programs; 

19 (D) the extent to which care coordination 

20 is provided for children’s care under Medicaid 

21 and CHIP; and 

22 (E) as appropriate, information on the de23 gree of availability of services for children under 

24 such programs. 


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

2 date of enactment of this Act, the Comptroller Gen3 eral shall submit a report to the Committee on Fi4 nance of the Senate and the Committee on Energy 

5 and Commerce of the House of Representatives on 

6 the study conducted under paragraph (1) that in7 cludes recommendations for such Federal and State 

8 legislative and administrative changes as the Comp9 troller General determines are necessary to address 

10 any barriers to access to children’s care under Med11 icaid and CHIP that may exist. 

12 SEC. 403. APPLICATION OF CERTAIN MANAGED CARE 

13 QUALITY SAFEGUARDS TO CHIP. 

14 (a) IN GENERAL.—Section 2103(f) of Social Security 

15 Act (42 U.S.C. 1397bb(f)) is amended by adding at the 

16 end the following new paragraph: 

17 ‘‘(3) COMPLIANCE WITH MANAGED CARE RE18 QUIREMENTS.—The State child health plan shall 

19 provide for the application of subsections (a)(4), 

20 (a)(5), (b), (c), (d), and (e) of section 1932 (relating 

21 to requirements for managed care) to coverage, 

22 State agencies, enrollment brokers, managed care 

23 entities, and managed care organizations under this 

24 title in the same manner as such subsections apply 


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1 to coverage and such entities and organizations 

2 under title XIX.’’. 

3 (b) EFFECTIVE DATE.—The amendment made by 

4 subsection (a) shall apply to contract years for health 

5 plans beginning on or after July 1, 2009. 

6 TITLE V—IMPROVING ACCESS 

7 TO BENEFITS 

8 SEC. 501. DENTAL BENEFITS. 

9 (a) COVERAGE.— 

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

11 1397cc) is amended— 

12 (A) in subsection (a)— 

13 (i) in the matter before paragraph 

14 (1), by striking ‘‘subsection (c)(5)’’ and in15 serting ‘‘paragraphs (5) and (7) of sub16 section (c)’’; and 

17 (ii) in paragraph (1), by inserting ‘‘at 

18 least’’ after ‘‘that is’’; and 

19 (B) in subsection (c)— 

20 (i) by redesignating paragraph (5) as 

21 paragraph (7); and 

22 (ii) by inserting after paragraph (4), 

23 the following: 

24 ‘‘(5) DENTAL BENEFITS.— 


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1 ‘‘(A) IN GENERAL.—The child health as2 sistance provided to a targeted low-income child 

3 shall include coverage of dental services nec4 essary to prevent disease and promote oral 

5 health, restore oral structures to health and 

6 function, and treat emergency conditions. 

7 ‘‘(B) PERMITTING USE OF DENTAL

8 BENCHMARK PLANS BY CERTAIN STATES.—A 

9 State may elect to meet the requirement of sub10 paragraph (A) through dental coverage that is 

11 equivalent to a benchmark dental benefit pack12 age described in subparagraph (C). 

13 ‘‘(C) BENCHMARK DENTAL BENEFIT PACK14 AGES.—The benchmark dental benefit packages 

15 are as follows: 

16 ‘‘(i) FEHBP CHILDREN’S DENTAL

17 COVERAGE.—A dental benefits plan under 

18 chapter 89A of title 5, United States Code, 

19 that has been selected most frequently by 

20 employees seeking dependent coverage, 

21 among such plans that provide such de22 pendent coverage, in either of the previous 

23 2 plan years. 

24 ‘‘(ii) STATE EMPLOYEE DEPENDENT

25 DENTAL COVERAGE.—A dental benefits 


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1 plan that is offered and generally available 

2 to State employees in the State involved 

3 and that has been selected most frequently 

4 by employees seeking dependent coverage, 

5 among such plans that provide such de6 pendent coverage, in either of the previous 

7 2 plan years. 

8 ‘‘(iii) COVERAGE OFFERED THROUGH

9 COMMERCIAL DENTAL PLAN.—A dental 

10 benefits plan that has the largest insured 

11 commercial, non-medicaid enrollment of 

12 dependent covered lives of such plans that 

13 is offered in the State involved.’’. 

14 (2) ASSURING ACCESS TO CARE.—Section 

15 2102(a)(7)(B) (42 U.S.C. 1397bb(c)(2)) is amended 

16 by inserting ‘‘and services described in section 

17 2103(c)(5)’’ after ‘‘emergency services’’. 

18 (3) EFFECTIVE DATE.—The amendments made 

19 by paragraph (1) shall apply to coverage of items 

20 and services furnished on or after October 1, 2009. 

21 (b) DENTAL EDUCATION FOR PARENTS OF

22 NEWBORNS.—The Secretary shall develop and implement, 

23 through entities that fund or provide perinatal care serv24 ices to targeted low-income children under a State child 

25 health plan under title XXI of the Social Security Act, 


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1 a program to deliver oral health educational materials that 

2 inform new parents about risks for, and prevention of, 

3 early childhood caries and the need for a dental visit with4 in their newborn’s first year of life. 

5 (c) PROVISION OF DENTAL SERVICES THROUGH

6 FQHCS.— 

7 (1) MEDICAID.—Section 1902(a) (42 U.S.C. 

8 1396a(a)) is amended— 

9 (A) by striking ‘‘and’’ at the end of para10 graph (70); 

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

12 paragraph (71) and inserting ‘‘; and’’; and 

13 (C) by inserting after paragraph (71) the 

14 following new paragraph: 

15 ‘‘(72) provide that the State will not prevent a 

16 Federally-qualified health center from entering into 

17 contractual relationships with private practice dental 

18 providers in the provision of Federally-qualified 

19 health center services.’’. 

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

21 1397g(e)(1)), as amended by subsections (a)(2) and 

22 (d)(2) of section 203, is amended by inserting after 

23 subparagraph (B) the following new subparagraph 

24 (and redesignating the succeeding subparagraphs ac25 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 (d) REPORTING INFORMATION ON DENTAL

8 HEALTH.— 

9 (1) MEDICAID.—Section 1902(a)(43)(D)(iii) 

10 (42 U.S.C. 1396a(a)(43)(D)(iii)) is amended by in11 serting ‘‘and other information relating to the provi12 sion of dental services to such children described in 

13 section 2108(e)’’ after ‘‘receiving dental services,’’. 

14 (2) CHIP.—Section 2108 (42 U.S.C. 1397hh) 

15 is amended by adding at the end the following new 

16 subsection: 

17 ‘‘(e) INFORMATION ON DENTAL CARE FOR CHIL18 DREN.— 

19 ‘‘(1) IN GENERAL.—Each annual report under 

20 subsection (a) shall include the following information 

21 with respect to care and services described in section 

22 1905(r)(3) provided to targeted low-income children 

23 enrolled in the State child health plan under this 

24 title at any time during the year involved: 


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1 ‘‘(A) The number of enrolled children by 

2 age grouping used for reporting purposes under 

3 section 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 

7 consists of the number of enrolled targeted low 

8 income children who receive any, preventive, or 

9 restorative dental care under the State plan). 

10 ‘‘(C) For the age grouping that includes 

11 children 8 years of age, the number of such 

12 children who have received a protective sealant 

13 on at least one permanent molar tooth. 

14 ‘‘(2) INCLUSION OF INFORMATION ON ENROLL15 EES IN MANAGED CARE PLANS.—The information 

16 under paragraph (1) shall include information on 

17 children who are enrolled in managed care plans and 

18 other private health plans and contracts with such 

19 plans under this title shall provide for the reporting 

20 of such information by such plans to the State.’’. 

21 (3) EFFECTIVE DATE.—The amendments made 

22 by this subsection shall be effective for annual re23 ports submitted for years beginning after date of en24 actment. 


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1 (e) 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 

9 website (http://www.insurekidsnow.gov/) and hotline 

10 (1–877–KIDS–NOW) (or on any successor websites 

11 or hotlines) a current and accurate list of all such 

12 dentists and providers within each State that provide 

13 dental services to children enrolled in the State plan 

14 (or waiver) under Medicaid or the State child health 

15 plan (or waiver) under CHIP, and shall ensure that 

16 such 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 

19 Act, a description of the dental services provided 

20 under each State plan (or waiver) under Medicaid 

21 and each State child health plan (or waiver) under 

22 CHIP on such Insure Kids Now website, and shall 

23 ensure that such list is updated at least annually. 

24 (f) INCLUSION OF STATUS OF EFFORTS TO IMPROVE

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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 (g) 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, 

18 including preventive and restorative services, 

19 under Medicaid and CHIP, including— 

20 (i) the extent to which dental pro21 viders are willing to treat children eligible 

22 for such programs; 

23 (ii) information on such children’s ac24 cess to networks of care, including such 


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1 networks that serve special needs children; 

2 and 

3 (iii) geographic availability of oral 

4 health care, including preventive and re5 storative services, under such programs; 

6 and 

7 (C) the feasibility and appropriateness of 

8 using qualified mid-level dental health pro9 viders, in coordination with dentists, to improve 

10 access for children to oral health services and 

11 public health overall. 

12 (2) REPORT.—Not later than 18 months year 

13 after the date of the enactment of this Act, the 

14 Comptroller General shall submit to Congress a re15 port on the study conducted under paragraph (1). 

16 The report shall include recommendations for such 

17 Federal and State legislative and administrative 

18 changes as the Comptroller General determines are 

19 necessary to address any barriers to access to oral 

20 health care, including preventive and restorative 

21 services, under Medicaid and CHIP that may exist. 

22 SEC. 502. MENTAL HEALTH PARITY IN CHIP PLANS. 

23 (a) ASSURANCE OF PARITY.—Section 2103(c) (42 

24 U.S.C. 1397cc(c)), as amended by section 501(a)(1)(B), 

25 is amended by inserting after paragraph (5), the following: 


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1 ‘‘(6) MENTAL HEALTH SERVICES PARITY.— 

2 ‘‘(A) IN GENERAL.—In the case of a State 

3 child health plan that provides both medical 

4 and surgical benefits and mental health or sub5 stance use disorder benefits, such plan shall en6 sure that the financial requirements and treat7 ment limitations applicable to such mental 

8 health or substance use disorder benefits com9 ply with the requirements of section 2705(a) of 

10 the Public Health Service Act in the same man11 ner as such requirements apply to a group 

12 health plan. 

13 ‘‘(B) DEEMED COMPLIANCE.—To the ex14 tent that a State child health plan includes cov15 erage with respect to an individual described in 

16 section 1905(a)(4)(B) and covered under the 

17 State plan under section 1902(a)(10)(A) of the 

18 services described in section 1905(a)(4)(B) (re19 lating to early and periodic screening, diag20 nostic, and treatment services defined in section 

21 1905(r)) and provided in accordance with sec22 tion 1902(a)(43), such plan shall be deemed to 

23 satisfy the requirements of subparagraph (A).’’. 

24 (b) CONFORMING AMENDMENTS.—Section 2103 (42 

25 U.S.C. 1397cc) is amended— 


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1 (1) in subsection (a), as amended by section 

2 501(a)(1)(A)(i), in the matter preceding paragraph 

3 (1), by inserting ‘‘, (6),’’ after ‘‘(5)’’; and 

4 (2) in subsection (c)(2), by striking subpara5 graph (B) and redesignating subparagraphs (C) and 

6 (D) as subparagraphs (B) and (C), respectively. 

7 SEC. 503. APPLICATION OF PROSPECTIVE PAYMENT SYS8 TEM FOR SERVICES PROVIDED BY FEDER9 ALLY-QUALIFIED HEALTH CENTERS AND 

10 RURAL HEALTH CLINICS. 

11 (a) APPLICATION OF PROSPECTIVE PAYMENT SYS12 TEM.— 

13 (1) IN GENERAL.—Section 2107(e)(1) (42 

14 U.S.C. 1397gg(e)(1)), as amended by section 

15 501(c)(2) is amended by inserting after subpara16 graph (C) the following new subparagraph (and re17 designating the succeeding subparagraphs accord18 ingly): 

19 ‘‘(D) Section 1902(bb) (relating to pay20 ment for services provided by Federally-quali21 fied health centers and rural health clinics).’’. 

22 (2) EFFECTIVE DATE.—The amendment made 

23 by paragraph (1) shall apply to services provided on 

24 or after October 1, 2009. 

25 (b) TRANSITION GRANTS.— 


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1 (1) APPROPRIATION.—Out of any funds in the 

2 Treasury not otherwise appropriated, there is appro3 priated to the Secretary for fiscal year 2009, 

4 $5,000,000, to remain available until expended, for 

5 the purpose of awarding grants to States with State 

6 child health plans under CHIP that are operated 

7 separately from the State Medicaid plan under title 

8 XIX of the Social Security Act (including any waiver 

9 of such plan), or in combination with the State Med10 icaid plan, for expenditures related to transitioning 

11 to compliance with the requirement of section 

12 2107(e)(1)(D) of the Social Security Act (as added 

13 by subsection (a)) to apply the prospective payment 

14 system established under section 1902(bb) of the 

15 such Act (42 U.S.C. 1396a(bb)) to services provided 

16 by Federally-qualified health centers and rural 

17 health clinics. 

18 (2) MONITORING AND REPORT.—The Secretary 

19 shall monitor the impact of the application of such 

20 prospective payment system on the States described 

21 in paragraph (1) and, not later than October 1, 

22 2011, shall report to Congress on any effect on ac23 cess to benefits, provider payment rates, or scope of 

24 benefits offered by such States as a result of the ap25 plication of such payment system. 


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1 SEC. 504. PREMIUM GRACE PERIOD. 

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

3 1397cc(e)(3)) is amended by adding at the end the fol4 lowing new subparagraph: 

5 ‘‘(C) PREMIUM GRACE PERIOD.—The State 

6 child health plan— 

7 ‘‘(i) shall afford individuals enrolled 

8 under the plan a grace period of at least 

9 30 days from the beginning of a new cov10 erage period to make premium payments 

11 before the individual’s coverage under the 

12 plan may be terminated; and 

13 ‘‘(ii) shall provide to such an indi14 vidual, not later than 7 days after the first 

15 day of such grace period, notice— 

16 ‘‘(I) that failure to make a pre17 mium payment within the grace pe18 riod will result in termination of cov19 erage under the State child health 

20 plan; and 

21 ‘‘(II) of the individual’s right to 

22 challenge the proposed termination 

23 pursuant to the applicable Federal 

24 regulations. 

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1 lowing the last month for which the premium 

2 has been paid.’’. 

3 (b) EFFECTIVE DATE.—The amendment made by 

4 subsection (a) shall apply to new coverage periods begin5 ning on or after the date of the enactment of this Act. 

6 SEC. 505. CLARIFICATION OF COVERAGE OF SERVICES 

7 PROVIDED THROUGH SCHOOL-BASED 

8 HEALTH CENTERS. 

9 Section 2103(c) (42 U.S.C. 1397cc(c)), as amended 

10 by section 501(a)(1)(B), is amended by adding at the end 

11 the following new paragraph: 

12 ‘‘(8) AVAILABILITY OF COVERAGE FOR ITEMS

13 AND SERVICES FURNISHED THROUGH SCHOOL14 BASED HEALTH CENTERS.—Nothing in this title 

15 shall be construed as limiting a State’s ability to 

16 provide child health assistance for covered items and 

17 services that are furnished through school-based 

18 health centers.’’. 


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1 TITLE VI—PROGRAM INTEGRITY 

2 AND OTHER MISCELLANEOUS 

3 PROVISIONS 

4 Subtitle A—Program Integrity and 

5 Data Collection 

6 SEC. 601. PAYMENT ERROR RATE MEASUREMENT (‘‘PERM’’). 

7 (a) EXPENDITURES RELATED TO COMPLIANCE WITH

8 REQUIREMENTS.— 

9 (1) ENHANCED PAYMENTS.—Section 2105(c) 

10 (42 U.S.C. 1397ee(c)), as amended by section 

11 301(a), is amended by adding at the end the fol12 lowing new paragraph: 

13 ‘‘(11) ENHANCED PAYMENTS.—Notwith14 standing subsection (b), the enhanced FMAP with 

15 respect to payments under subsection (a) for ex16 penditures related to the administration of the pay17 ment error rate measurement (PERM) requirements 

18 applicable to the State child health plan in accord19 ance with the Improper Payments Information Act 

20 of 2002 and parts 431 and 457 of title 42, Code of 

21 Federal Regulations (or any related or successor 

22 guidance or regulations) shall in no event be less 

23 than 90 percent.’’. 

24 (2) EXCLUSION OF FROM CAP ON ADMINISTRA25 TIVE EXPENDITURES.—Section 2105(c)(2)(C) (42 


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1 U.S.C. 1397ee(c)(2)C)), as amended by section 

2 302(b)), is amended by adding at the end the fol3 lowing: 

4 ‘‘(iv) PAYMENT ERROR RATE MEAS5 UREMENT (PERM) EXPENDITURES.—Ex6 penditures related to the administration of 

7 the payment error rate measurement 

8 (PERM) requirements applicable to the 

9 State child health plan in accordance with 

10 the Improper Payments Information Act of 

11 2002 and parts 431 and 457 of title 42, 

12 Code of Federal Regulations (or any re13 lated or successor guidance or regula14 tions).’’. 

15 (b) FINAL RULE REQUIRED TO BE IN EFFECT FOR

16 ALL STATES.—Notwithstanding parts 431 and 457 of 

17 title 42, Code of Federal Regulations (as in effect on the 

18 date of enactment of this Act), the Secretary shall not cal19 culate or publish any national or State-specific error rate 

20 based on the application of the payment error rate meas21 urement (in this section referred to as ‘‘PERM’’) require22 ments to CHIP until after the date that is 6 months after 

23 the date on which a new final rule (in this section referred 

24 to as the ‘‘new final rule’’) promulgated after the date of 

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1 ments in accordance with the requirements of subsection 

2 (c) is in effect for all States. Any calculation of a national 

3 error rate or a State specific error rate after such new 

4 final rule in effect for all States may only be inclusive of 

5 errors, as defined in such new final rule or in guidance 

6 issued within a reasonable time frame after the effective 

7 date for such new final rule that includes detailed guid8 ance for the specific methodology for error determinations. 

9 (c) REQUIREMENTS FOR NEW FINAL RULE.—For 

10 purposes of subsection (b), the requirements of this sub11 section are that the new final rule implementing the 

12 PERM requirements shall— 

13 (1) include— 

14 (A) clearly defined criteria for errors for 

15 both States and providers; 

16 (B) a clearly defined process for appealing 

17 error determinations by— 

18 (i) review contractors; or 

19 (ii) the agency and personnel de20 scribed in section 431.974(a)(2) of title 42, 

21 Code of Federal Regulations, as in effect 

22 on September 1, 2007, responsible for the 

23 development, direction, implementation, 

24 and evaluation of eligibility reviews and as25 sociated activities; and 


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1 (C) clearly defined responsibilities and 

2 deadlines for States in implementing any cor3 rective action plans; and 

4 (2) provide that the payment error rate deter5 mined for a State shall not take into account pay6 ment errors resulting from the State’s verification of 

7 an applicant’s self-declaration or self-certification of 

8 eligibility for, and the correct amount of, medical as9 sistance or child health assistance, if the State proc10 ess for verifying an applicant’s self-declaration or 

11 self-certification satisfies the requirements for such 

12 process applicable under regulations promulgated by 

13 the Secretary or otherwise approved by the Sec14 retary. 

15 (d) OPTION FOR APPLICATION OF DATA FOR STATES

16 IN FIRST APPLICATION CYCLE UNDER THE INTERIM

17 FINAL RULE.—After the new final rule implementing the 

18 PERM requirements in accordance with the requirements 

19 of subsection (c) is in effect for all States, a State for 

20 which the PERM requirements were first in effect under 

21 an interim final rule for fiscal year 2007 or under a final 

22 rule for fiscal year 2008 may elect to accept any payment 

23 error rate determined in whole or in part for the State 

24 on the basis of data for that fiscal year or may elect to 

25 not have any payment error rate determined on the basis 


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1 of such data and, instead, shall be treated as if fiscal year 

2 2010 or fiscal year 2011 were the first fiscal year for 

3 which the PERM requirements apply to the State. 

4 (e) HARMONIZATION OF MEQC AND PERM.— 

5 (1) REDUCTION OF REDUNDANCIES.—The Sec6 retary shall review the Medicaid Eligibility Quality 

7 Control (in this subsection referred to as the 

8 ‘‘MEQC’’) requirements with the PERM require9 ments and coordinate consistent implementation of 

10 both sets of requirements, while reducing 

11 redundancies. 

12 (2) STATE OPTION TO APPLY PERM DATA.—A 

13 State may elect, for purposes of determining the er14 roneous excess payments for medical assistance ratio 

15 applicable to the State for a fiscal year under section 

16 1903(u) of the Social Security Act (42 U.S.C. 

17 1396b(u)) to substitute data resulting from the ap18 plication of the PERM requirements to the State 

19 after the new final rule implementing such require20 ments is in effect for all States for data obtained 

21 from the application of the MEQC requirements to 

22 the State with respect to a fiscal year. 

23 (3) STATE OPTION TO APPLY MEQC DATA.—For 

24 purposes of satisfying the requirements of subpart Q 

25 of part 431 of title 42, Code of Federal Regulations, 


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1 relating to Medicaid eligibility reviews, a State may 

2 elect to substitute data obtained through MEQC re3 views conducted in accordance with section 1903(u) 

4 of the Social Security Act (42 U.S.C. 1396b(u)) for 

5 data required for purposes of PERM requirements, 

6 but only if the State MEQC reviews are based on a 

7 broad, representative sample of Medicaid applicants 

8 or enrollees in the States. 

9 (f) IDENTIFICATION OF IMPROVED STATE-SPECIFIC

10 SAMPLE SIZES.—The Secretary shall establish State-spe11 cific sample sizes for application of the PERM require12 ments with respect to State child health plans for fiscal 

13 years beginning with fiscal year 2009, on the basis of such 

14 information as the Secretary determines appropriate. In 

15 establishing such sample sizes, the Secretary shall, to the 

16 greatest extent practicable— 

17 (1) minimize the administrative cost burden on 

18 States under Medicaid and CHIP; and 

19 (2) maintain State flexibility to manage such 

20 programs. 

21 SEC. 602. IMPROVING DATA COLLECTION. 

22 (a) INCREASED APPROPRIATION.—Section 

23 2109(b)(2) (42 U.S.C. 1397ii(b)(2)) is amended by strik24 ing ‘‘$10,000,000 for fiscal year 2000’’ and inserting 

25 ‘‘$20,000,000 for fiscal year 2009’’. 


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1 (b) USE OF ADDITIONAL FUNDS.—Section 2109(b) 

2 (42 U.S.C. 1397ii(b)), as amended by subsection (a), is 

3 amended— 

4 (1) by redesignating paragraph (2) as para5 graph (4); and 

6 (2) by inserting after paragraph (1), the fol7 lowing new paragraphs: 

8 ‘‘(2) ADDITIONAL REQUIREMENTS.—In addition 

9 to making the adjustments required to produce the 

10 data described in paragraph (1), with respect to 

11 data collection occurring for fiscal years beginning 

12 with fiscal year 2009, in appropriate consultation 

13 with the Secretary of Health and Human Services, 

14 the Secretary of Commerce shall do the following: 

15 ‘‘(A) Make appropriate adjustments to the 

16 Current Population Survey to develop more ac17 curate State-specific estimates of the number of 

18 children enrolled in health coverage under title 

19 XIX or this title. 

20 ‘‘(B) Make appropriate adjustments to the 

21 Current Population Survey to improve the sur22 vey estimates used to determine the child popu23 lation growth factor under section 

24 2104(m)(5)(B) and any other data necessary 

25 for carrying out this title. 


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1 ‘‘(C) Include health insurance survey infor2 mation in the American Community Survey re3 lated to children. 

4 ‘‘(D) Assess whether American Community 

5 Survey estimates, once such survey data are 

6 first available, produce more reliable estimates 

7 than the Current Population Survey with re8 spect to the purposes described in subparagraph 

9 (B). 

10 ‘‘(E) On the basis of the assessment re11 quired under subparagraph (D), recommend to 

12 the Secretary of Health and Human Services 

13 whether American Community Survey estimates 

14 should be used in lieu of, or in some combina15 tion with, Current Population Survey estimates 

16 for the purposes described in subparagraph (B). 

17 ‘‘(F) Continue making the adjustments de18 scribed in the last sentence of paragraph (1) 

19 with respect to expansion of the sample size 

20 used in State sampling units, the number of 

21 sampling units in a State, and using an appro22 priate verification element. 

23 ‘‘(3) AUTHORITY FOR THE SECRETARY OF

24 HEALTH AND HUMAN SERVICES TO TRANSITION TO

25 THE USE OF ALL, OR SOME COMBINATION OF, ACS


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1 ESTIMATES UPON RECOMMENDATION OF THE SEC2 RETARY OF COMMERCE.—If, on the basis of the as3 sessment required under paragraph (2)(D), the Sec4 retary of Commerce recommends to the Secretary of 

5 Health and Human Services that American Commu6 nity Survey estimates should be used in lieu of, or 

7 in some combination with, Current Population Sur8 vey estimates for the purposes described in para9 graph (2)(B), the Secretary of Health and Human 

10 Services, in consultation with the States, may pro11 vide for a period during which the Secretary may 

12 transition from carrying out such purposes through 

13 the use of Current Population Survey estimates to 

14 the use of American Community Survey estimates 

15 (in lieu of, or in combination with the Current Popu16 lation Survey estimates, as recommended), provided 

17 that any such transition is implemented in a manner 

18 that is designed to avoid adverse impacts upon 

19 States with approved State child health plans under 

20 this title.’’. 

21 SEC. 603. UPDATED FEDERAL EVALUATION OF CHIP. 

22 Section 2108(c) (42 U.S.C. 1397hh(c)) is amended 

23 by striking paragraph (5) and inserting the following: 

24 ‘‘(5) SUBSEQUENT EVALUATION USING UP25 DATED INFORMATION.— 


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1 ‘‘(A) IN GENERAL.—The Secretary, di2 rectly or through contracts or interagency 

3 agreements, shall conduct an independent sub4 sequent evaluation of 10 States with approved 

5 child health plans. 

6 ‘‘(B) SELECTION OF STATES AND MAT7 TERS INCLUDED.—Paragraphs (2) and (3) shall 

8 apply to such subsequent evaluation in the 

9 same manner as such provisions apply to the 

10 evaluation conducted under paragraph (1). 

11 ‘‘(C) SUBMISSION TO CONGRESS.—Not 

12 later than December 31, 2011, the Secretary 

13 shall submit to Congress the results of the eval14 uation conducted under this paragraph. 

15 ‘‘(D) FUNDING.—Out of any money in the 

16 Treasury of the United States not otherwise ap17 propriated, there are appropriated $10,000,000 

18 for fiscal year 2010 for the purpose of con19 ducting the evaluation authorized under this 

20 paragraph. Amounts appropriated under this 

21 subparagraph shall remain available for expend22 iture through fiscal year 2012.’’. 


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1 SEC. 604. ACCESS TO RECORDS FOR IG AND GAO AUDITS 

2 AND EVALUATIONS. 

3 Section 2108(d) (42 U.S.C. 1397hh(d)) is amended 

4 to read as follows: 

5 ‘‘(d) ACCESS TO RECORDS FOR IG AND GAO AUDITS

6 AND EVALUATIONS.—For the purpose of evaluating and 

7 auditing the program established under this title, or title 

8 XIX, the Secretary, the Office of Inspector General, and 

9 the Comptroller General shall have access to any books, 

10 accounts, records, correspondence, and other documents 

11 that are related to the expenditure of Federal funds under 

12 this title and that are in the possession, custody, or control 

13 of States receiving Federal funds under this title or polit14 ical subdivisions thereof, or any grantee or contractor of 

15 such States or political subdivisions.’’. 

16 SEC. 605. NO FEDERAL FUNDING FOR ILLEGAL ALIENS. 

17 Nothing in this Act allows Federal payment for indi18 viduals who are not lawfully residing in the United States. 

19 Titles XI, XIX, and XXI of the Social Security Act pro20 vide for the disallowance of Federal financial participation 

21 for erroneous expenditures under Medicaid and under 

22 CHIP, respectively. 


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1 Subtitle B—Miscellaneous Health 

2 Provisions 

3 SEC. 611. DEFICIT REDUCTION ACT TECHNICAL CORREC4 TIONS. 

5 (a) CLARIFICATION OF REQUIREMENT TO PROVIDE

6 EPSDT SERVICES FOR ALL CHILDREN IN BENCHMARK

7 BENEFIT PACKAGES UNDER MEDICAID.—Section 

8 1937(a)(1) (42 U.S.C. 1396u–7(a)(1)), as inserted by sec9 tion 6044(a) of the Deficit Reduction Act of 2005 (Public 

10 Law 109–171, 120 Stat. 88), is amended— 

11 (1) in subparagraph (A)— 

12 (A) in the matter before clause (i)— 

13 (i) by striking ‘‘Notwithstanding any 

14 other provision of this title’’ and inserting 

15 ‘‘Notwithstanding section 1902(a)(1) (re16 lating to statewideness), section 

17 1902(a)(10)(B) (relating to comparability) 

18 and any other provision of this title which 

19 would be directly contrary to the authority 

20 under this section and subject to sub21 section (E)’’; and 

22 (ii) by striking ‘‘enrollment in cov23 erage that provides’’ and inserting ‘‘cov24 erage that’’; 


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1 (B) in clause (i), by inserting ‘‘provides’’ 

2 after ‘‘(i)’’; and 

3 (C) by striking clause (ii) and inserting the 

4 following: 

5 ‘‘(ii) for any individual described in 

6 section 1905(a)(4)(B) who is eligible under 

7 the State plan in accordance with para8 graphs (10) and (17) of section 1902(a), 

9 consists of the items and services described 

10 in section 1905(a)(4)(B) (relating to early 

11 and periodic screening, diagnostic, and 

12 treatment services defined in section 

13 1905(r)) and provided in accordance with 

14 the requirements of section 1902(a)(43).’’; 

15 (2) in subparagraph (C)— 

16 (A) in the heading, by striking ‘‘WRAP17 AROUND’’ and inserting ‘‘ADDITIONAL’’; and 

18 (B) by striking ‘‘wrap-around or’’; and 

19 (3) by adding at the end the following new sub20 paragraph: 

21 ‘‘(E) RULE OF CONSTRUCTION.—Nothing 

22 in this paragraph shall be construed as— 

23 ‘‘(i) requiring a State to offer all or 

24 any of the items and services required by 

25 subparagraph (A)(ii) through an issuer of 


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1 benchmark coverage described in sub2 section (b)(1) or benchmark equivalent 

3 coverage described in subsection (b)(2); 

4 ‘‘(ii) preventing a State from offering 

5 all or any of the items and services re6 quired by subparagraph (A)(ii) through an 

7 issuer of benchmark coverage described in 

8 subsection (b)(1) or benchmark equivalent 

9 coverage described in subsection (b)(2); or 

10 ‘‘(iii) affecting a child’s entitlement to 

11 care and services described in subsections 

12 (a)(4)(B) and (r) of section 1905 and pro13 vided in accordance with section 

14 1902(a)(43) whether provided through 

15 benchmark coverage, benchmark equivalent 

16 coverage, or otherwise.’’. 

17 (b) CORRECTION OF REFERENCE TO CHILDREN IN

18 FOSTER CARE RECEIVING CHILD WELFARE SERVICES.— 

19 Section 1937(a)(2)(B)(viii) (42 U.S.C. 1396u– 

20 7(a)(2)(B)(viii)), as inserted by section 6044(a) of the 

21 Deficit Reduction Act of 2005, is amended by striking 

22 ‘‘aid or assistance is made available under part B of title 

23 IV to children in foster care and individuals’’ and inserting 

24 ‘‘child welfare services are made available under part B 

25 of title IV on the basis of being a child in foster care or’’. 


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1 (c) TRANSPARENCY.—Section 1937 (42 U.S.C. 

2 1396u–7), as inserted by section 6044(a) of the Deficit 

3 Reduction Act of 2005, is amended by adding at the end 

4 the following: 

5 ‘‘(c) PUBLICATION OF PROVISIONS AFFECTED.— 

6 With respect to a State plan amendment to provide bench7 mark benefits in accordance with subsections (a) and (b) 

8 that is approved by the Secretary, the Secretary shall pub9 lish on the Internet website of the Centers for Medicare 

10 & Medicaid Services, a list of the provisions of this title 

11 that the Secretary has determined do not apply in order 

12 to enable the State to carry out the plan amendment and 

13 the reason for each such determination on the date such 

14 approval is made, and shall publish such list in the Fed15 eral Register and not later than 30 days after such date 

16 of approval.’’. 

17 (d) EFFECTIVE DATE.—The amendments made by 

18 subsections (a), (b), and (c) of this section shall take effect 

19 as if included in the amendment made by section 6044(a) 

20 of the Deficit Reduction Act of 2005. 

21 SEC. 612. REFERENCES TO TITLE XXI. 

22 Section 704 of the Medicare, Medicaid, and SCHIP 

23 Balanced Budget Refinement Act of 1999, as enacted into 

24 law by division B of Public Law 106–113 (113 Stat. 

25 1501A–402) is repealed. 


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1 SEC. 613. PROHIBITING INITIATION OF NEW HEALTH OP2 PORTUNITY ACCOUNT DEMONSTRATION PRO3 GRAMS. 

4 After the date of the enactment of this Act, the Sec5 retary of Health and Human Services may not approve 

6 any new demonstration programs under section 1938 of 

7 the Social Security Act (42 U.S.C. 1396u–8). 

8 SEC. 614. ADJUSTMENT IN COMPUTATION OF MEDICAID 

9 FMAP TO DISREGARD AN EXTRAORDINARY 

10 EMPLOYER PENSION CONTRIBUTION. 

11 (a) IN GENERAL.—Only for purposes of computing 

12 the FMAP (as defined in subsection (e)) for a State for 

13 a fiscal year (beginning with fiscal year 2006) and apply14 ing the FMAP under title XIX of the Social Security Act, 

15 any significantly disproportionate employer pension or in16 surance fund contribution described in subsection (b) shall 

17 be disregarded in computing the per capita income of such 

18 State, but shall not be disregarded in computing the per 

19 capita income for the continental United States (and Alas20 ka) and Hawaii. 

21 (b) SIGNIFICANTLY DISPROPORTIONATE EMPLOYER

22 PENSION AND INSURANCE FUND CONTRIBUTION.— 

23 (1) IN GENERAL.—For purposes of this section, 

24 a significantly disproportionate employer pension 

25 and insurance fund contribution described in this 

26 subsection with respect to a State is any identifiable 


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1 employer contribution towards pension or other em2 ployee insurance funds that is estimated to accrue to 

3 residents of such State for a calendar year (begin4 ning with calendar year 2003) if the increase in the 

5 amount so estimated exceeds 25 percent of the total 

6 increase in personal income in that State for the 

7 year involved. 

8 (2) DATA TO BE USED.—For estimating and 

9 adjustment a FMAP already calculated as of the 

10 date of the enactment of this Act for a State with 

11 a significantly disproportionate employer pension 

12 and insurance fund contribution, the Secretary shall 

13 use the personal income data set originally used in 

14 calculating such FMAP. 

15 (3) SPECIAL ADJUSTMENT FOR NEGATIVE

16 GROWTH.—If in any calendar year the total personal 

17 income growth in a State is negative, an employer 

18 pension and insurance fund contribution for the pur19 poses of calculating the State’s FMAP for a cal20 endar year shall not exceed 125 percent of the 

21 amount of such contribution for the previous cal22 endar year for the State. 

23 (c) HOLD HARMLESS.—No State shall have its 

24 FMAP for a fiscal year reduced as a result of the applica25 tion of this section. 


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1 (d) REPORT.—Not later than May 15, 2009, the Sec2 retary shall submit to the Congress a report on the prob3 lems presented by the current treatment of pension and 

4 insurance fund contributions in the use of Bureau of Eco5 nomic Affairs calculations for the FMAP and for Medicaid 

6 and on possible alternative methodologies to mitigate such 

7 problems. 

8 (e) FMAP DEFINED.—For purposes of this section, 

9 the term ‘‘FMAP’’ means the Federal medical assistance 

10 percentage, as defined in section 1905(b) of the Social Se11 curity Act (42 U.S.C. 1396(d)). 

12 SEC. 615. CLARIFICATION TREATMENT OF REGIONAL MED13 ICAL CENTER. 

14 (a) IN GENERAL.—Nothing in section 1903(w) of the 

15 Social Security Act (42 U.S.C. 1396b(w)) shall be con16 strued by the Secretary of Health and Human Services 

17 as prohibiting a State’s use of funds as the non-Federal 

18 share of expenditures under title XIX of such Act where 

19 such funds are transferred from or certified by a publicly20 owned regional medical center located in another State 

21 and described in subsection (b), so long as the Secretary 

22 determines that such use of funds is proper and in the 

23 interest of the program under title XIX. 


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1 (b) CENTER DESCRIBED.—A center described in this 

2 subsection is a publicly-owned regional medical center 

3 that— 

4 (1) provides level 1 trauma and burn care serv5 ices; 

6 (2) provides level 3 neonatal care services; 

7 (3) is obligated to serve all patients, regardless 

8 of ability to pay; 

9 (4) is located within a Standard Metropolitan 

10 Statistical Area (SMSA) that includes at least 3 

11 States; 

12 (5) provides services as a tertiary care provider 

13 for patients residing within a 125-mile radius; and 

14 (6) meets the criteria for a disproportionate 

15 share hospital under section 1923 of such Act (42 

16 U.S.C. 1396r–4) in at least one State other than the 

17 State in which the center is located. 

18 SEC. 616. EXTENSION OF MEDICAID DSH ALLOTMENTS FOR 

19 TENNESSEE AND HAWAII. 

20 Section 1923(f)(6) (42 U.S.C. 1396r–4(f)(6)), as 

21 amended by section 202 of the Medicare Improvements 

22 for Patients and Providers Act of 2008 (Public Law 110– 

23 275) is amended— 

24 (1) in the paragraph heading, by striking ‘‘2009

25 AND THE FIRST CALENDAR QUARTER OF FISCAL


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1 YEAR 2010’’ and inserting ‘‘2011 AND THE FIRST CAL2 ENDAR QUARTER OF FISCAL YEAR 2012’’; 

3 (2) in subparagraph (A)— 

4 (A) in clause (i)— 

5 (i) in the second sentence— 

6 (I) by striking ‘‘and 2009’’ and 

7 inserting ‘‘, 2009, 2010, and 2011’’; 

8 and 

9 (II) by striking ‘‘such portion 

10 of’’; and 

11 (ii) in the third sentence, by striking 

12 ‘‘2010 for the period ending on December 

13 31, 2009’’ and inserting ‘‘2012 for the pe14 riod ending on December 31, 2011’’; 

15 (B) in clause (ii), by striking ‘‘or for a pe16 riod in fiscal year 2010’’ and inserting ‘‘2010, 

17 2011, or for period in fiscal year 2012’’; and 

18 (C) in clause (iv)— 

19 (i) in the clause heading, by striking 

20 ‘‘2009 AND THE FIRST CALENDAR QUARTER

21 OF FISCAL YEAR 2010’’ and inserting ‘‘2011

22 AND THE FIRST CALENDAR QUARTER OF

23 FISCAL YEAR 2012’’; and 

24 (ii) in each of subclauses (I) and (II), 

25 by striking ‘‘ or for a period in fiscal year 


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1 2010’’ and inserting ‘‘2010, 2011, or for a 

2 period in fiscal year 2012’’; and 

3 (3) in subparagraph (B)— 

4 (A) in clause (i)— 

5 (i) in the first sentence, by striking 

6 ‘‘2009’’ and inserting ‘‘2011’’; and 

7 (ii) in the second sentence, by striking 

8 ‘‘2010 for the period ending on December 

9 31, 2009’’ and inserting ‘‘2012 for the pe10 riod ending on December 31, 2011’’. 

11 Subtitle C—Other Provisions 

12 SEC. 621. OUTREACH REGARDING HEALTH INSURANCE OP13 TIONS AVAILABLE TO CHILDREN. 

14 (a) DEFINITIONS.—In this section— 

15 (1) the terms ‘‘Administration’’ and ‘‘Adminis16 trator’’ means the Small Business Administration 

17 and the Administrator thereof, respectively; 

18 (2) the term ‘‘certified development company’’ 

19 means a development company participating in the 

20 program under title V of the Small Business Invest21 ment Act of 1958 (15 U.S.C. 695 et seq.); 

22 (3) the term ‘‘Medicaid program’’ means the 

23 program established under title XIX of the Social 

24 Security Act (42 U.S.C. 1396 et seq.); 


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1 (4) the term ‘‘Service Corps of Retired Execu2 tives’’ means the Service Corps of Retired Execu3 tives authorized by section 8(b)(1) of the Small 

4 Business Act (15 U.S.C. 637(b)(1)); 

5 (5) the term ‘‘small business concern’’ has the 

6 meaning given that term in section 3 of the Small 

7 Business Act (15 U.S.C. 632); 

8 (6) the term ‘‘small business development cen9 ter’’ means a small business development center de10 scribed in section 21 of the Small Business Act (15 

11 U.S.C. 648); 

12 (7) the term ‘‘State’’ has the meaning given 

13 that term for purposes of title XXI of the Social Se14 curity Act (42 U.S.C. 1397aa et seq.); 

15 (8) the term ‘‘State Children’s Health Insur16 ance Program’’ means the State Children’s Health 

17 Insurance Program established under title XXI of 

18 the Social Security Act (42 U.S.C. 1397aa et seq.); 

19 (9) the term ‘‘task force’’ means the task force 

20 established under subsection (b)(1); and 

21 (10) the term ‘‘women’s business center’’ means 

22 a women’s business center described in section 29 of 

23 the Small Business Act (15 U.S.C. 656). 

24 (b) ESTABLISHMENT OF TASK FORCE.— 


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1 (1) ESTABLISHMENT.—There is established a 

2 task force to conduct a nationwide campaign of edu3 cation and outreach for small business concerns re4 garding the availability of coverage for children 

5 through private insurance options, the Medicaid pro6 gram, and the State Children’s Health Insurance 

7 Program. 

8 (2) MEMBERSHIP.—The task force shall consist 

9 of the Administrator, the Secretary of Health and 

10 Human Services, the Secretary of Labor, and the 

11 Secretary of the Treasury. 

12 (3) RESPONSIBILITIES.—The campaign con13 ducted under this subsection shall include— 

14 (A) efforts to educate the owners of small 

15 business concerns about the value of health cov16 erage for children; 

17 (B) information regarding options available 

18 to the owners and employees of small business 

19 concerns to make insurance more affordable, in20 cluding Federal and State tax deductions and 

21 credits for health care-related expenses and 

22 health insurance expenses and Federal tax ex23 clusion for health insurance options available 

24 under employer-sponsored cafeteria plans under 


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1 section 125 of the Internal Revenue Code of 

2 1986; 

3 (C) efforts to educate the owners of small 

4 business concerns about assistance available 

5 through public programs; and 

6 (D) efforts to educate the owners and em7 ployees of small business concerns regarding 

8 the availability of the hotline operated as part 

9 of the Insure Kids Now program of the Depart10 ment of Health and Human Services. 

11 (4) IMPLEMENTATION.—In carrying out this 

12 subsection, the task force may— 

13 (A) use any business partner of the Ad14 ministration, including— 

15 (i) a small business development cen16 ter; 

17 (ii) a certified development company; 

18 (iii) a women’s business center; and 

19 (iv) the Service Corps of Retired Ex20 ecutives; 

21 (B) enter into— 

22 (i) a memorandum of understanding 

23 with a chamber of commerce; and 


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1 (ii) a partnership with any appro2 priate small business concern or health ad3 vocacy group; and 

4 (C) designate outreach programs at re5 gional offices of the Department of Health and 

6 Human Services to work with district offices of 

7 the Administration. 

8 (5) WEBSITE.—The Administrator shall ensure 

9 that links to information on the eligibility and enroll10 ment requirements for the Medicaid program and 

11 State Children’s Health Insurance Program of each 

12 State are prominently displayed on the website of 

13 the Administration. 

14 (6) REPORT.— 

15 (A) IN GENERAL.—Not later than 2 years 

16 after the date of enactment of this Act, and 

17 every 2 years thereafter, the Administrator 

18 shall submit to the Committee on Small Busi19 ness and Entrepreneurship of the Senate and 

20 the Committee on Small Business of the House 

21 of Representatives a report on the status of the 

22 nationwide campaign conducted under para23 graph (1). 

24 (B) CONTENTS.—Each report submitted 

25 under subparagraph (A) shall include a status 


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1 update on all efforts made to educate owners 

2 and employees of small business concerns on 

3 options for providing health insurance for chil4 dren through public and private alternatives. 

5 SEC. 622. SENSE OF THE SENATE REGARDING ACCESS TO 

6 AFFORDABLE AND MEANINGFUL HEALTH IN7 SURANCE COVERAGE. 

8 (a) FINDINGS.—The Senate finds the following: 

9 (1) There are approximately 45 million Ameri10 cans currently without health insurance. 

11 (2) More than half of uninsured workers are 

12 employed by businesses with less than 25 employees 

13 or are self-employed. 

14 (3) Health insurance premiums continue to rise 

15 at more than twice the rate of inflation for all con16 sumer goods. 

17 (4) Individuals in the small group and indi18 vidual health insurance markets usually pay more 

19 for similar coverage than those in the large group 

20 market. 

21 (5) The rapid growth in health insurance costs 

22 over the last few years has forced many employers, 

23 particularly small employers, to increase deductibles 

24 and co-pays or to drop coverage completely. 

25 (b) SENSE OF THE SENATE.—The Senate— 


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1 (1) recognizes the necessity to improve afford2 ability and access to health insurance for all Ameri3 cans; 

4 (2) acknowledges the value of building upon the 

5 existing private health insurance market; and 

6 (3) affirms its intent to enact legislation this 

7 year that, with appropriate protection for con8 sumers, improves access to affordable and meaning9 ful health insurance coverage for employees of small 

10 businesses and individuals by— 

11 (A) facilitating pooling mechanisms, in12 cluding pooling across State lines, and 

13 (B) providing assistance to small busi14 nesses and individuals, including financial as15 sistance and tax incentives, for the purchase of 

16 private insurance coverage. 

17 SEC. 623. LIMITATION ON MEDICARE EXCEPTION TO THE 

18 PROHIBITION ON CERTAIN PHYSICIAN RE19 FERRALS FOR HOSPITALS. 

20 (a) IN GENERAL.—Section 1877 (42 U.S.C. 1395nn) 

21 is amended— 

22 (1) in subsection (d)(2)— 

23 (A) in subparagraph (A), by striking 

24 ‘‘and’’ at the end; 


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1 (B) in subparagraph (B), by striking the 

2 period at the end and inserting ‘‘; and’’; and 

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

4 subparagraph: 

5 ‘‘(C) in the case where the entity is a hos6 pital, the hospital meets the requirements of 

7 paragraph (3)(D).’’; 

8 (2) in subsection (d)(3)— 

9 (A) in subparagraph (B), by striking 

10 ‘‘and’’ at the end; 

11 (B) in subparagraph (C), by striking the 

12 period at the end and inserting ‘‘; and’’; and 

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

14 subparagraph: 

15 ‘‘(D) the hospital meets the requirements 

16 described in subsection (i)(1).’’; and 

17 (3) by adding at the end the following new sub18 section: 

19 ‘‘(i) REQUIREMENTS FOR HOSPITALS TO QUALIFY

20 FOR RURAL PROVIDER AND HOSPITAL EXCEPTION TO

21 OWNERSHIP OR INVESTMENT PROHIBITION.— 

22 ‘‘(1) REQUIREMENTS DESCRIBED.—For pur23 poses of subsection (d)(3)(D), the requirements de24 scribed in this paragraph for a hospital are as fol25 lows: 


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1 ‘‘(A) PROVIDER AGREEMENT.—The hos2 pital had— 

3 ‘‘(i) physician ownership or invest4 ment on January 1, 2009; and 

5 ‘‘(ii) a provider agreement under sec6 tion 1866 in effect on such date. 

7 ‘‘(B) PROHIBITION ON PHYSICIAN OWNER8 SHIP OR INVESTMENT.—The percentage of the 

9 total value of the ownership or investment in10 terests held in the hospital, or in an entity 

11 whose assets include the hospital, by physician 

12 owners or investors in the aggregate does not 

13 exceed such percentage as of the date of enact14 ment of this subsection. 

15 ‘‘(C) PROHIBITION ON EXPANSION OF FA16 CILITY CAPACITY.—Except as provided in para17 graph (3), the number of operating rooms, pro18 cedure rooms, and beds of the hospital at any 

19 time on or after the date of the enactment of 

20 this subsection are no greater than the number 

21 of operating rooms, procedure rooms, and beds 

22 as of such date. 

23 ‘‘(D) PREVENTING CONFLICTS OF INTER24 EST.— 


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1 ‘‘(i) The hospital submits to the Sec2 retary an annual report containing a de3 tailed description of— 

4 ‘‘(I) the identity of each physi5 cian owner and physician investor and 

6 any other owners or investors of the 

7 hospital; and 

8 ‘‘(II) the nature and extent of all 

9 ownership and investment interests in 

10 the hospital. 

11 ‘‘(ii) The hospital has procedures in 

12 place to require that any referring physi13 cian owner or investor discloses to the pa14 tient being referred, by a time that permits 

15 the patient to make a meaningful decision 

16 regarding the receipt of care, as deter17 mined by the Secretary— 

18 ‘‘(I) the ownership or investment 

19 interest, as applicable, of such refer20 ring physician in the hospital; and 

21 ‘‘(II) if applicable, any such own22 ership or investment interest of the 

23 treating physician. 

24 ‘‘(iii) The hospital does not condition 

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1 terests either directly or indirectly on the 

2 physician owner or investor making or in3 fluencing referrals to the hospital or other4 wise generating business for the hospital. 

5 ‘‘(iv) The hospital discloses the fact 

6 that the hospital is partially owned by phy7 sicians— 

8 ‘‘(I) on any public website for the 

9 hospital; and 

10 ‘‘(II) in any public advertising 

11 for the hospital. 

12 ‘‘(E) ENSURING BONA FIDE OWNERSHIP

13 AND INVESTMENT.— 

14 ‘‘(i) Any ownership or investment in15 terests that the hospital offers to a physi16 cian owner or investor are not offered on 

17 more favorable terms than the terms of18 fered to a person who is not a physician 

19 owner or investor. 

20 ‘‘(ii) The hospital (or any investors in 

21 the hospital) does not directly or indirectly 

22 provide loans or financing for any physi23 cian owner or investor in the hospital. 

24 ‘‘(iii) The hospital (or any investors in 

25 the hospital) does not directly or indirectly 


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1 guarantee a loan, make a payment toward 

2 a loan, or otherwise subsidize a loan, for 

3 any individual physician owner or investor 

4 or group of physician owners or investors 

5 that is related to acquiring any ownership 

6 or investment interest in the hospital. 

7 ‘‘(iv) Ownership or investment returns 

8 are distributed to each owner or investor in 

9 the hospital in an amount that is directly 

10 proportional to the ownership or invest11 ment interest of such owner or investor in 

12 the hospital. 

13 ‘‘(v) Physician owners and investors 

14 do not receive, directly or indirectly, any 

15 guaranteed receipt of or right to purchase 

16 other business interests related to the hos17 pital, including the purchase or lease of 

18 any property under the control of other 

19 owners or investors in the hospital or lo20 cated near the premises of the hospital. 

21 ‘‘(vi) The hospital does not offer a 

22 physician owner or investor the oppor23 tunity to purchase or lease any property 

24 under the control of the hospital or any 

25 other owner or investor in the hospital on 


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1 more favorable terms than the terms of2 fered to an individual who is not a physi3 cian owner or investor. 

4 ‘‘(F) PATIENT SAFETY.—The hospital has 

5 the capacity to— 

6 ‘‘(i) provide assessment and initial 

7 treatment for patients; and 

8 ‘‘(ii) refer and transfer patients to 

9 hospitals with the capability to treat the 

10 needs of the patient involved. 

11 ‘‘(G) LIMITATION ON APPLICATION TO

12 CERTAIN CONVERTED FACILITIES.—The hos13 pital was not converted from an ambulatory 

14 surgical center to a hospital on or after the date 

15 of enactment of this subsection. 

16 ‘‘(2) PUBLICATION OF INFORMATION RE17 PORTED.—The Secretary shall publish, and update 

18 on an annual basis, the information submitted by 

19 hospitals under paragraph (1)(D)(i) on the public 

20 Internet website of the Centers for Medicare & Med21 icaid Services. 

22 ‘‘(3) EXCEPTION TO PROHIBITION ON EXPAN23 SION OF FACILITY CAPACITY.— 

24 ‘‘(A) PROCESS.— 


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1 ‘‘(i) ESTABLISHMENT.—The Secretary 

2 shall establish and implement a process 

3 under which an applicable hospital (as de4 fined in subparagraph (E)) may apply for 

5 an exception from the requirement under 

6 paragraph (1)(C). 

7 ‘‘(ii) OPPORTUNITY FOR COMMUNITY

8 INPUT.—The process under clause (i) shall 

9 provide individuals and entities in the com10 munity in which the applicable hospital ap11 plying for an exception is located with the 

12 opportunity to provide input with respect 

13 to the application. 

14 ‘‘(iii) TIMING FOR IMPLEMENTA15 TION.—The Secretary shall implement the 

16 process under clause (i) on July 1, 2010. 

17 ‘‘(iv) REGULATIONS.—Not later than 

18 June 1, 2010, the Secretary shall promul19 gate regulations to carry out the process 

20 under clause (i). 

21 ‘‘(B) FREQUENCY.—The process described 

22 in subparagraph (A) shall permit an applicable 

23 hospital to apply for an exception up to once 

24 every 2 years. 

25 ‘‘(C) PERMITTED INCREASE.— 


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1 ‘‘(i) IN GENERAL.—Subject to clause 

2 (ii) and subparagraph (D), an applicable 

3 hospital granted an exception under the 

4 process described in subparagraph (A) may 

5 increase the number of operating rooms, 

6 procedure rooms, and beds of the applica7 ble hospital above the baseline number of 

8 operating rooms, procedure rooms, and 

9 beds of the applicable hospital (or, if the 

10 applicable hospital has been granted a pre11 vious exception under this paragraph, 

12 above the number of operating rooms, pro13 cedure rooms, and beds of the hospital 

14 after the application of the most recent in15 crease under such an exception). 

16 ‘‘(ii) 100 PERCENT INCREASE LIMITA17 TION.—The Secretary shall not permit an 

18 increase in the number of operating rooms, 

19 procedure rooms, and beds of an applicable 

20 hospital under clause (i) to the extent such 

21 increase would result in the number of op22 erating rooms, procedure rooms, and beds 

23 of the applicable hospital exceeding 200 

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1 ating rooms, procedure rooms, and beds of 

2 the applicable hospital. 

3 ‘‘(iii) BASELINE NUMBER OF OPER4 ATING ROOMS, PROCEDURE ROOMS, AND

5 BEDS.—In this paragraph, the term ‘base6 line number of operating rooms, procedure 

7 rooms, and beds’ means the number of op8 erating rooms, procedure rooms, and beds 

9 of the applicable hospital as of the date of 

10 enactment of this subsection. 

11 ‘‘(D) INCREASE LIMITED TO FACILITIES

12 ON THE MAIN CAMPUS OF THE HOSPITAL.— 

13 Any increase in the number of operating rooms, 

14 procedure rooms, and beds of an applicable hos15 pital pursuant to this paragraph may only occur 

16 in facilities on the main campus of the applica17 ble hospital. 

18 ‘‘(E) APPLICABLE HOSPITAL.—In this 

19 paragraph, the term ‘applicable hospital’ means 

20 a hospital— 

21 ‘‘(i) that is located in a county in 

22 which the percentage increase in the popu23 lation during the most recent 5-year period 

24 (as of the date of the application under 

25 subparagraph (A)) is at least 150 percent 


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1 of the percentage increase in the popu2 lation growth of the State in which the 

3 hospital is located during that period, as 

4 estimated by Bureau of the Census and 

5 available to the Secretary; 

6 ‘‘(ii) whose annual percent of total in7 patient admissions that represent inpatient 

8 admissions under the program under title 

9 XIX is equal to or greater than the aver10 age percent with respect to such admis11 sions for all hospitals located in the county 

12 in which the hospital is located; 

13 ‘‘(iii) that does not discriminate 

14 against beneficiaries of Federal health care 

15 programs and does not permit physicians 

16 practicing at the hospital to discriminate 

17 against such beneficiaries; 

18 ‘‘(iv) that is located in a State in 

19 which the average bed capacity in the 

20 State is less than the national average bed 

21 capacity; and 

22 ‘‘(v) that has an average bed occu23 pancy rate that is greater than the average 

24 bed occupancy rate in the State in which 

25 the hospital is located. 


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1 ‘‘(F) PROCEDURE ROOMS.—In this sub2 section, the term ‘procedure rooms’ includes 

3 rooms in which catheterizations, angiographies, 

4 angiograms, and endoscopies are performed, ex5 cept such term shall not include emergency 

6 rooms or departments (exclusive of rooms in 

7 which catheterizations, angiographies, 

8 angiograms, and endoscopies are performed). 

9 ‘‘(G) PUBLICATION OF FINAL DECI10 SIONS.—Not later than 60 days after receiving 

11 a complete application under this paragraph, 

12 the Secretary shall publish in the Federal Reg13 ister the final decision with respect to such ap14 plication. 

15 ‘‘(H) LIMITATION ON REVIEW.—There 

16 shall be no administrative or judicial review 

17 under section 1869, section 1878, or otherwise 

18 of the process under this paragraph (including 

19 the establishment of such process). 

20 ‘‘(4) COLLECTION OF OWNERSHIP AND INVEST21 MENT INFORMATION.—For purposes of subpara22 graphs (A)(i) and (B) of paragraph (1), the Sec23 retary shall collect physician ownership and invest24 ment information for each hospital. 


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1 ‘‘(5) PHYSICIAN OWNER OR INVESTOR DE2 FINED.—For purposes of this subsection, the term 

3 ‘physician owner or investor’ means a physician (or 

4 an immediate family member of such physician) with 

5 a direct or an indirect ownership or investment in6 terest in the hospital. 

7 ‘‘(6) PATIENT SAFETY REQUIREMENT.—In the 

8 case of a hospital to which the requirements of para9 graph (1) apply, insofar as the hospital described in 

10 this subsection admits a patient and does not have 

11 any physician available on the premises to provide 

12 services during all hours in which the hospital is 

13 providing services to such patient, before admitting 

14 the patient— 

15 ‘‘(A) the hospital shall disclose such fact to 

16 a patient; and 

17 ‘‘(B) following such disclosure, the hospital 

18 shall receive from the patient a signed acknowl19 edgment that the patient understands such fact. 

20 ‘‘(7) CLARIFICATION.—Nothing in this sub21 section shall be construed as preventing the Sec22 retary from revoking a hospital’s provider agreement 

23 if not in compliance with regulations implementing 

24 section 1866.’’. 

25 (b) ENFORCEMENT.— 


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1 (1) ENSURING COMPLIANCE.—The Secretary of 

2 Health and Human Services shall establish policies 

3 and procedures to ensure compliance with the re4 quirements described in subsections (i)(1) and (i)(7) 

5 of section 1877 of the Social Security Act, as added 

6 by subsection (a)(3), beginning on the date such re7 quirements first apply. Such policies and procedures 

8 may include unannounced site reviews of hospitals. 

9 (2) AUDITS.—Beginning not later than July 1, 

10 2011, the Secretary of Health and Human Services 

11 shall conduct audits to determine if hospitals violate 

12 the requirements referred to in paragraph (1). 

13 TITLE VII—REVENUE 

14 PROVISIONS 

15 SEC. 701. INCREASE IN EXCISE TAX RATE ON TOBACCO 

16 PRODUCTS. 

17 (a) CIGARS.— 

18 (1) SMALL CIGARS.—Paragraph (1) of section 

19 5701(a) of the Internal Revenue Code of 1986 is 

20 amended to read as follows: 

21 ‘‘(1) SMALL CIGARS.—On cigars, weighing not 

22 more than 3 pounds per thousand, the amount de23 termined in accordance with the following table: 

‘‘Cigars Removed During Calendar Year— 

Tax Rate 

Per Thousand— 

2009 or 2010 .................................................................................. $12.50


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‘‘Cigars Removed During Calendar Year— 

Tax Rate 

Per Thousand— 

2011 or 2012 .................................................................................. $25.00

2013 or 2014 .................................................................................. $37.50

2015 or thereafter .......................................................................... $50.00.’’. 

1 (2) LARGE CIGARS.—Paragraph (2) of section 

2 5701(a) of such Code is amended— 

3 (A) by striking ‘‘20.719 percent (18.063 

4 percent on cigars removed during 2000 or 

5 2001)’’ and inserting ‘‘52.4 percent’’, and 

6 (B) by striking ‘‘$48.75 per thousand 

7 ($42.50 per thousand on cigars removed during 

8 2000 or 2001)’’ and inserting ‘‘40 cents per 

9 cigar’’. 

10 (b) CIGARETTES.—Section 5701(b) of such Code is 

11 amended— 

12 (1) by striking ‘‘$19.50 per thousand ($17 per 

13 thousand on cigarettes removed during 2000 or 

14 2001)’’ in paragraph (1) and inserting ‘‘$50.00 per 

15 thousand’’, and 

16 (2) by striking ‘‘$40.95 per thousand ($35.70 

17 per thousand on cigarettes removed during 2000 or 

18 2001)’’ in paragraph (2) and inserting ‘‘$105.00 per 

19 thousand’’. 

20 (c) CIGARETTE PAPERS.—Section 5701(c) of such 

21 Code is amended by striking ‘‘1.22 cents (1.06 cents on 


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1 cigarette papers removed during 2000 or 2001)’’ and in2 serting ‘‘3.13 cents’’. 

3 (d) CIGARETTE TUBES.—Section 5701(d) of such 

4 Code is amended by striking ‘‘2.44 cents (2.13 cents on 

5 cigarette tubes removed during 2000 or 2001)’’ and in6 serting ‘‘6.26 cents’’. 

7 (e) SMOKELESS TOBACCO.—Section 5701(e) of such 

8 Code is amended— 

9 (1) by striking ‘‘58.5 cents (51 cents on snuff 

10 removed during 2000 or 2001)’’ in paragraph (1) 

11 and inserting ‘‘$1.50’’, and 

12 (2) by striking ‘‘19.5 cents (17 cents on chew13 ing tobacco removed during 2000 or 2001)’’ in para14 graph (2) and inserting ‘‘50 cents’’. 

15 (f) PIPE TOBACCO.—Section 5701(f) of such Code is 

16 amended by striking ‘‘$1.0969 cents (95.67 cents on pipe 

17 tobacco removed during 2000 or 2001)’’ and inserting 

18 ‘‘$2.8126’’. 

19 (g) ROLL-YOUR-OWN TOBACCO.—Section 5701(g) of 

20 such Code is amended by striking ‘‘$1.0969 cents (95.67 

21 cents on roll-your-own tobacco removed during 2000 or 

22 2001)’’ and inserting ‘‘$24.62’’. 

23 (h) FLOOR STOCKS TAXES.— 

24 (1) IMPOSITION OF TAX.—On tobacco products 

25 (other than cigars described in section 5701(a)(2) of 


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1 the Internal Revenue Code of 1986) and cigarette 

2 papers and tubes manufactured in or imported into 

3 the United States which are removed before any tax 

4 increase date and held on such date for sale by any 

5 person, there is hereby imposed a tax in an amount 

6 equal to the excess of— 

7 (A) the tax which would be imposed under 

8 section 5701 of such Code on the article if the 

9 article had been removed on such date, over 

10 (B) the prior tax (if any) imposed under 

11 section 5701 of such Code on such article. 

12 (2) CREDIT AGAINST TAX.—Each person shall 

13 be allowed as a credit against the taxes imposed by 

14 paragraph (1) an amount equal to $500. Such credit 

15 shall not exceed the amount of taxes imposed by 

16 paragraph (1) on such date, for which such person 

17 is liable. 

18 (3) LIABILITY FOR TAX AND METHOD OF PAY19 MENT.— 

20 (A) LIABILITY FOR TAX.—A person hold21 ing tobacco products, cigarette papers, or ciga22 rette tubes on any tax increase date, to which 

23 any tax imposed by paragraph (1) applies shall 

24 be liable for such tax. 


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1 (B) METHOD OF PAYMENT.—The tax im2 posed by paragraph (1) shall be paid in such 

3 manner as the Secretary shall prescribe by reg4 ulations. 

5 (C) TIME FOR PAYMENT.— 

6 (i) IN GENERAL.—The tax imposed by 

7 paragraph (1) shall be paid on or before 

8 August 1, 2009. 

9 (ii) SPECIAL RULE FOR SMALL CI10 GARS.—In the case of small cigars, the tax 

11 imposed by paragraph (1) on or after Jan12 uary 1, 2011, shall be paid on or before 

13 April 1 following any tax increase date. 

14 (4) ARTICLES IN FOREIGN TRADE ZONES.— 

15 Notwithstanding the Act of June 18, 1934 (com16 monly known as the Foreign Trade Zone Act, 48 

17 Stat. 998, 19 U.S.C. 81a et seq.) or any other provi18 sion of law, any article which is located in a foreign 

19 trade zone on any tax increase date shall be subject 

20 to the tax imposed by paragraph (1) if— 

21 (A) internal revenue taxes have been deter22 mined, or customs duties liquidated, with re23 spect to such article before such date pursuant 

24 to a request made under the 1st proviso of sec25 tion 3(a) of such Act, or 


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1 (B) such article is held on such date under 

2 the supervision of an officer of the United 

3 States Customs and Border Protection of the 

4 Department of Homeland Security pursuant to 

5 the 2d proviso of such section 3(a). 

6 (5) DEFINITIONS.—For purposes of this sub7 section— 

8 (A) IN GENERAL.—Any term used in this 

9 subsection which is also used in section 5702 of 

10 the Internal Revenue Code of 1986 shall have 

11 the same meaning as such term has in such 

12 section. 

13 (B) TAX INCREASE DATE.—The term ‘‘tax 

14 increase date’’ means April 1, 2009, January 1, 

15 2011, January 1, 2013, and January 1, 2015. 

16 (C) SECRETARY.—The term ‘‘Secretary’’ 

17 means the Secretary of the Treasury or the 

18 Secretary’s delegate. 

19 (6) CONTROLLED GROUPS.—Rules similar to 

20 the rules of section 5061(e)(3) of such Code shall 

21 apply for purposes of this subsection. 

22 (7) OTHER LAWS APPLICABLE.—All provisions 

23 of law, including penalties, applicable with respect to 

24 the taxes imposed by section 5701 of such Code 

25 shall, insofar as applicable and not inconsistent with 


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1 the provisions of this subsection, apply to the floor 

2 stocks taxes imposed by paragraph (1), to the same 

3 extent as if such taxes were imposed by such section 

4 5701. The Secretary may treat any person who bore 

5 the ultimate burden of the tax imposed by para6 graph (1) as the person to whom a credit or refund 

7 under such provisions may be allowed or made. 

8 (i) EFFECTIVE DATE.—The amendments made by 

9 this section shall apply to articles removed (as defined in 

10 section 5702(j) of the Internal Revenue Code of 1986) 

11 after March 31, 2009. 

12 SEC. 702. ADMINISTRATIVE IMPROVEMENTS. 

13 (a) PERMIT, INVENTORIES, REPORTS, AND RECORDS

14 REQUIREMENTS FOR MANUFACTURERS AND IMPORTERS

15 OF PROCESSED TOBACCO.— 

16 (1) PERMIT.— 

17 (A) APPLICATION.—Section 5712 of the 

18 Internal Revenue Code of 1986 is amended by 

19 inserting ‘‘or processed tobacco’’ after ‘‘tobacco 

20 products’’. 

21 (B) ISSUANCE.—Section 5713(a) of such 

22 Code is amended by inserting ‘‘or processed to23 bacco’’ after ‘‘tobacco products’’. 

24 (2) INVENTORIES, REPORTS, AND PACKAGES.— 


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1 (A) INVENTORIES.—Section 5721 of such 

2 Code is amended by inserting ‘‘, processed to3 bacco,’’ after ‘‘tobacco products’’. 

4 (B) REPORTS.—Section 5722 of such Code 

5 is amended by inserting ‘‘, processed tobacco,’’ 

6 after ‘‘tobacco products’’. 

7 (C) PACKAGES, MARKS, LABELS, AND NO8 TICES.—Section 5723 of such Code is amended 

9 by inserting ‘‘, processed tobacco,’’ after ‘‘to10 bacco products’’ each place it appears. 

11 (3) RECORDS.—Section 5741 of such Code is 

12 amended by inserting ‘‘, processed tobacco,’’ after 

13 ‘‘tobacco products’’. 

14 (4) MANUFACTURER OF PROCESSED TO15 BACCO.—Section 5702 of such Code is amended by 

16 adding at the end the following new subsection: 

17 ‘‘(p) MANUFACTURER OF PROCESSED TOBACCO.— 

18 ‘‘(1) IN GENERAL.—The term ‘manufacturer of 

19 processed tobacco’ means any person who processes 

20 any tobacco other than tobacco products. 

21 ‘‘(2) PROCESSED TOBACCO.—The processing of 

22 tobacco shall not include the farming or growing of 

23 tobacco or the handling of tobacco solely for sale, 

24 shipment, or delivery to a manufacturer of tobacco 

25 products or processed tobacco.’’. 


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1 (5) CONFORMING AMENDMENT.—Sections 

2 5702(j), 5702(k), and 5704(h) of such Code is 

3 amended by inserting ‘‘, or any processed tobacco,’’ 

4 after ‘‘nontaxpaid tobacco products or cigarette pa5 pers or tubes’’. 

6 (6) EFFECTIVE DATE.—The amendments made 

7 by this subsection shall take effect on April 1, 2009. 

8 (b) BASIS FOR DENIAL, SUSPENSION, OR REVOCA9 TION OF PERMITS.— 

10 (1) DENIAL.—Paragraph (3) of section 5712 of 

11 such Code is amended to read as follows: 

12 ‘‘(3) such person (including, in the case of a 

13 corporation, any officer, director, or principal stock14 holder and, in the case of a partnership, a part15 ner)— 

16 ‘‘(A) is, by reason of his business experi17 ence, financial standing, or trade connections or 

18 by reason of previous or current legal pro19 ceedings involving a felony violation of any 

20 other provision of Federal criminal law relating 

21 to tobacco products, processed tobacco, ciga22 rette paper, or cigarette tubes, not likely to 

23 maintain operations in compliance with this 

24 chapter, 


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1 ‘‘(B) has been convicted of a felony viola2 tion of any provision of Federal or State crimi3 nal law relating to tobacco products, processed 

4 tobacco, cigarette paper, or cigarette tubes, or 

5 ‘‘(C) has failed to disclose any material in6 formation required or made any material false 

7 statement in the application therefor.’’. 

8 (2) SUSPENSION OR REVOCATION.—Subsection 

9 (b) of section 5713 of such Code is amended to read 

10 as follows: 

11 ‘‘(b) SUSPENSION OR REVOCATION.— 

12 ‘‘(1) SHOW CAUSE HEARING.—If the Secretary 

13 has reason to believe that any person holding a per14 mit— 

15 ‘‘(A) has not in good faith complied with 

16 this chapter, or with any other provision of this 

17 title involving intent to defraud, 

18 ‘‘(B) has violated the conditions of such 

19 permit, 

20 ‘‘(C) has failed to disclose any material in21 formation required or made any material false 

22 statement in the application for such permit, 

23 ‘‘(D) has failed to maintain his premises in 

24 such manner as to protect the revenue, 


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1 ‘‘(E) is, by reason of previous or current 

2 legal proceedings involving a felony violation of 

3 any other provision of Federal criminal law re4 lating to tobacco products, processed tobacco, 

5 cigarette paper, or cigarette tubes, not likely to 

6 maintain operations in compliance with this 

7 chapter, or 

8 ‘‘(F) has been convicted of a felony viola9 tion of any provision of Federal or State crimi10 nal law relating to tobacco products, processed 

11 tobacco, cigarette paper, or cigarette tubes, 

12 the Secretary shall issue an order, stating the facts 

13 charged, citing such person to show cause why his 

14 permit should not be suspended or revoked. 

15 ‘‘(2) ACTION FOLLOWING HEARING.—If, after 

16 hearing, the Secretary finds that such person has 

17 not shown cause why his permit should not be sus18 pended or revoked, such permit shall be suspended 

19 for such period as the Secretary deems proper or 

20 shall be revoked.’’. 

21 (3) EFFECTIVE DATE.—The amendments made 

22 by this subsection shall take effect on the date of the 

23 enactment of this Act. 


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1 (c) APPLICATION OF INTERNAL REVENUE CODE

2 STATUTE OF LIMITATIONS FOR ALCOHOL AND TOBACCO

3 EXCISE TAXES.— 

4 (1) IN GENERAL.—Section 514(a) of the Tariff 

5 Act of 1930 (19 U.S.C. 1514(a)) is amended by 

6 striking ‘‘and section 520 (relating to refunds)’’ and 

7 inserting ‘‘section 520 (relating to refunds), and sec8 tion 6501 of the Internal Revenue Code of 1986 

9 (but only with respect to taxes imposed under chap10 ters 51 and 52 of such Code)’’. 

11 (2) EFFECTIVE DATE.—The amendment made 

12 by this subsection shall apply to articles imported 

13 after the date of the enactment of this Act. 

14 (d) EXPANSION OF DEFINITION OF ROLL-YOUR-OWN

15 TOBACCO.— 

16 (1) IN GENERAL.—Section 5702(o) of the In17 ternal Revenue Code of 1986 is amended by insert18 ing ‘‘or cigars, or for use as wrappers thereof’’ be19 fore the period at the end. 

20 (2) EFFECTIVE DATE.—The amendment made 

21 by this subsection shall apply to articles removed (as 

22 defined in section 5702(j) of the Internal Revenue 

23 Code of 1986) after March 31, 2009. 

24 (e) TIME OF TAX FOR UNLAWFULLY MANUFAC25 TURED TOBACCO PRODUCTS.— 


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1 (1) IN GENERAL.—Section 5703(b)(2) of such 

2 Code is amended by adding at the end the following 

3 new subparagraph: 

4 ‘‘(F) SPECIAL RULE FOR UNLAWFULLY

5 MANUFACTURED TOBACCO PRODUCTS.—In the 

6 case of any tobacco products, cigarette paper, 

7 or cigarette tubes manufactured in the United 

8 States at any place other than the premises of 

9 a manufacturer of tobacco products, cigarette 

10 paper, or cigarette tubes that has filed the bond 

11 and obtained the permit required under this 

12 chapter, tax shall be due and payable imme13 diately upon manufacture.’’. 

14 (2) EFFECTIVE DATE.—The amendment made 

15 by this subsection shall take effect on the date of the 

16 enactment of this Act. 

17 (f) DISCLOSURE.— 

18 (1) IN GENERAL.—Paragraph (1) of section 

19 6103(o) of such Code is amended by designating the 

20 text as subparagraph (A), moving such text 2 ems 

21 to the right, striking ‘‘Returns’’ and inserting ‘‘(A)

22 IN GENERAL.—Returns’’, and by inserting after sub23 paragraph (A) (as so redesignated) the following 

24 new subparagraph: 


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1 ‘‘(B) USE IN CERTAIN PROCEEDINGS.—Re2 turns and return information disclosed to a 

3 Federal agency under subparagraph (A) may be 

4 used in an action or proceeding (or in prepara5 tion for such action or proceeding) brought 

6 under section 625 of the American Jobs Cre7 ation Act of 2004 for the collection of any un8 paid assessment or penalty arising under such 

9 Act.’’. 

10 (2) CONFORMING AMENDMENT.—Section 

11 6103(p)(4) of such Code is amended by striking 

12 ‘‘(o)(1)’’ both places it appears and inserting 

13 ‘‘(o)(1)(A)’’. 

14 (3) EFFECTIVE DATE.—The amendments made 

15 by this subsection shall apply on or after the date 

16 of the enactment of this Act. 

17 (g) TRANSITIONAL RULE.—Any person who— 

18 (1) on April 1 is engaged in business as a man19 ufacturer of processed tobacco or as an importer of 

20 processed tobacco, and 

21 (2) before the end of the 90-day period begin22 ning on such date, submits an application under 

23 subchapter B of chapter 52 of such Code to engage 

24 in such business, may, notwithstanding such sub25 chapter B, continue to engage in such business 


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1 pending final action on such application. Pending 

2 such final action, all provisions of such chapter 52 

3 shall apply to such applicant in the same manner 

4 and to the same extent as if such applicant were a 

5 holder of a permit under such chapter 52 to engage 

6 in such business. 

7 SEC. 703. TREASURY STUDY CONCERNING MAGNITUDE OF 

8 TOBACCO SMUGGLING IN THE UNITED 

9 STATES. 

10 Not later than one year after the date of the enact11 ment of this Act, the Secretary of the Treasury shall con12 duct a study concerning the magnitude of tobacco smug13 gling in the United States and submit to Congress rec14 ommendations for the most effective steps to reduce to15 bacco smuggling. Such study shall also include a review 

16 of the loss of Federal tax receipts due to illicit tobacco 

17 trade in the United States and the role of imported to18 bacco products in the illicit tobacco trade in the United 

19 States. 

20 SEC. 704. TIME FOR PAYMENT OF CORPORATE ESTIMATED 

21 TAXES. 

22 The percentage under subparagraph (C) of section 

23 401(1) of the Tax Increase Prevention and Reconciliation 


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1 Act of 2005 in effect on the date of the enactment of this 

2 Act is increased by 1 percentage point. 

Passed the House of Representatives January 14, 

2009. 

Attest: LORRAINE C. MILLER, 

Clerk. 


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Calendar No. 18 

111TH CONGRESS 

1ST SESSION H. R. 2 

AN ACT 

To amend title XXI of the Social Security Act to 

ance Program, and for other purposes. extend and improve the Children’s Health InsurJANUARY 16, 2009 

Read twice and placed on the calendar 


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