I
105TH CONGRESS
1ST SESSION
H. R. 1229
To amend the Public Health Service Act to ensure that affordable, comprehen-
sive, high quality health care coverage is available through the establish-
ment of State-based programs for children and for all uninsured pregnant
women, and to facilitate access to health services, strengthen public
health functions, enhance health-related research, and support other ac-
tivities that improve the health of mothers and children, and for other
purposes.
IN THE HOUSE OF REPRESENTATIVES
APRIL 8, 1997
Mr. ACKERMAN introduced the following bill; which was referred to the Com-
mittee on Commerce, and in addition to the Committees on Ways and
Means, the Judiciary, and Education and the Workforce, for a period to
be subsequently determined by the Speaker, in each case for consider-
ation of such provisions as fall within the jurisdiction of the committee
concerned
A BILL
To amend the Public Health Service Act to ensure that
affordable, comprehensive, high quality health care cov-
erage is available through the establishment of State-
based programs for children and for all uninsured preg-
nant women, and to facilitate access to health services,
strengthen public health functions, enhance health-relat-
ed research, and support other activities that improve
the health of mothers and children, and for other pur-
poses.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE, TABLE OF CONTENTS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Healthy Mothers, Healthy Children Act of 1997’’.
(b) TABLE OF CONTENTS.—The table of contents for
this Act is as follows:
Sec. 1. Short title, table of contents.
TITLE I—NATIONAL HEALTH TRUST FUND FOR MOTHERS AND
CHILDREN
Sec. 101. Establishment.
TITLE II—HEALTHY MOTHERS, HEALTHY CHILDREN PROGRAM
Sec. 201. Establishment and allocation of funds.
‘‘TITLE XXVIII—HEALTHY MOTHERS, HEALTH CHILDREN
PROGRAM
‘‘Sec. 2800. Establishment of program.
‘‘PART A—ALLOCATION OF FUNDS
‘‘Sec. 2801. Allocation of funds to participating States.
‘‘Sec. 2802. State trust funds and matching contribution.
‘‘Sec. 2803. Excess and insufficient funds in trust funds.
‘‘PART B—ELIGIBILITY AND ENROLLMENT
‘‘SUBPART 1—ELIGIBILITY
‘‘Sec. 2810. Eligibility of individuals.
‘‘Sec. 2811. Election of eligibility.
‘‘Sec. 2812. Eligible health plans and providers.
‘‘SUBPART 2—ENROLLMENT
‘‘Sec. 2815. Enrollment of eligible persons.
‘‘Sec. 2816. Transition from eligibility.
Sec. 202. Comprehensive health benefits and cost sharing requirements.
‘‘PART C—COMPREHENSIVE HEALTH BENEFITS AND COST SHARING
REQUIREMENTS
‘‘SUBPART 1—COMPREHENSIVE HEALTH BENEFITS
‘‘Sec. 2821. Comprehensive health benefits package.
‘‘Sec. 2822. General categories of health benefits.
‘‘SUBPART 2—COST SHARING REQUIREMENTS
‘‘Sec. 2825. Principles of cost sharing.
‘‘Sec. 2826. Premiums and premium subsidy.
‘‘Sec. 2827. Utilization copayments.
‘‘Sec. 2828. Maximum annual family contribution.
Sec. 203. State program development and administration.
‘‘PART D—STATE PROGRAM DEVELOPMENT AND ADMINISTRATION
‘‘Sec. 2831. Application and date of implementation.
‘‘Sec. 2832. Special status States.
‘‘Sec. 2833. States with medicaid waivers.
‘‘Sec. 2834. Development grants for State programs.
‘‘Sec. 2835. Expansion of eligibility.
‘‘Sec. 2836. Failure of State to administer a program in compliance with
title.
‘‘Sec. 2837. Limits on State and Federal administrative costs.
‘‘PART E—ENSURING QUALITY, ESTABLISHING INFORMATION SYSTEMS, AND
PREVENTING ABUSE
‘‘Sec. 2841. Annual quality assessment and improvement plans.
‘‘Sec. 2842. National advisory council for mothers’ and children’s health.
‘‘Sec. 2843. National quality assessment and improvement program guide-
lines and utilization review program guidelines.
‘‘Sec. 2844. National health information systems for mothers and children.
‘‘Sec. 2845. National childhood immunization database.
‘‘Sec. 2846. Prevention, monitoring, and control of fraud and abuse.
Sec. 204. Responsibilities of families, certified plans, employers, States, and the
Federal government.
‘‘PART F—RESPONSIBILITIES OF FAMILIES, CERTIFIED PLANS, EMPLOYERS,
STATES, AND THE FEDERAL GOVERNMENT
‘‘Sec. 2851. Responsibilities of families.
‘‘Sec. 2852. Responsibilities of certified plans.
‘‘Sec. 2853. Responsibilities of employers.
‘‘Sec. 2854. Responsibilities of the State.
‘‘Sec. 2855. Responsibilities of the Secretary.
‘‘Sec. 2856. Responsibilities of the Attorney General.
‘‘Sec. 2857. Responsibilities of the Secretary of Agriculture.
Sec. 205. Existing programs.
‘‘PART G—IMPACT ON EMPLOYERS AND EXISTING PROGRAMS
‘‘Sec. 2861. Impact on employers.
‘‘Sec. 2862. Impact on medicaid.
‘‘Sec. 2863. Integration of health services and impact on existing Federal
and State government health programs.
Sec. 206. General provisions.
‘‘PART H—GENERAL PROVISIONS
‘‘Sec. 2871. Definitions.
‘‘Sec. 2872. Authorization of appropriations.
Sec. 207. Unlawful use of tobacco products manufactured for export.
TITLE III—FINANCING PROVISIONS
Sec. 301. Increase in taxes on tobacco products.
Sec. 302. Assistance to States adversely affected by the tobacco tax.
Sec. 303. Designation of overpayments and contributions for the National
Health Trust Fund for Mothers and Children.
TITLE 
I—NATIONAL 
HEALTH
TRUST FUND FOR MOTHERS
AND CHILDREN
SEC. 101. ESTABLISHMENT.
(a) IN GENERAL.—Subchapter A of chapter 98 of the
Internal Revenue Code of 1986 (relating to establishment
of trust funds) is amended by adding at the end the follow-
ing new part:
‘‘PART II—HEALTH CARE TRUST FUNDS
‘‘Sec. 9551. National Health Trust Fund for Mothers and Chil-
dren
‘‘SEC. 9551. NATIONAL HEALTH TRUST FUND FOR MOTHERS
AND CHILDREN.
‘‘(a) CREATION OF TRUST FUND.—There is estab-
lished in the Treasury of the United States a trust fund
to be known as the ‘National Health Trust Fund for
Mothers and Children’ to support State-based programs
under title XXVIII of the Public Health Service Act that
ensure affordable, comprehensive, high quality health care
coverage for children, and for all uninsured pregnant
women. The National Health Trust Fund for Mothers and
Children shall consist of such amounts as may be appro-
priated or credited to the Trust Fund as provided for in
this section or section 9602(b) and such cash contribu-
tions as may be made.
‘‘(b) TRANSFERS TO THE TRUST FUND.—
‘‘(1) IN GENERAL.—There are hereby appro-
priated to the National Health Trust Fund for
Mothers and Children amounts received in the
Treasury under—
‘‘(A) section 5701 (relating to taxes on to-
bacco products) to the extent attributable to the
increases of such taxes as the result of the en-
actment of section 301 of the Healthy Mothers,
Healthy Children Act of 1997 minus any
amount appropriated to the Tobacco Alter-
natives Trust Fund under section 9512(b), and
‘‘(B) section 6097 (relating to the designa-
tion of overpayments and contributions to the
Trust Fund).
‘‘(2) SAVINGS AMOUNTS.—There are hereby ap-
propriated to the National Health Trust Fund for
Mothers and Children for each fiscal year amounts
equivalent to the amount of estimated Federal sav-
ings in such fiscal year—
‘‘(A) under the medicaid program under
title XIX of the Social Security Act resulting
from the enactment of the Healthy Mothers,
Healthy Children Act of 1997, and
‘‘(B) attributable to the elimination of
services or functions under any other Federal
health program resulting from the enactment of
the Healthy Mothers, Healthy Children Act of
1997.
‘‘(c) EXPENDITURES.—
‘‘(1) IN GENERAL.—Except as provided in para-
graph (2), amounts in the National Health Trust
Fund for Mothers and Children are appropriated as
provided for in section 2871 of the Public Health
Service Act, and to the extent any such amount is
not expended during any fiscal year, such amount
shall be available for such purpose for subsequent
fiscal years.
‘‘(2) PREVENTION OF TOBACCO USE.—
‘‘(A) IN GENERAL.—Amounts not to ex-
ceed the amount described in subparagraph (B)
are appropriated in each fiscal year to fund ac-
tivities at the Office on Smoking and Health,
Centers for Disease Control and Prevention to
prevent the initiation of smoking and use of
other tobacco products by children and to co-
ordinate Federal and State tobacco prevention
and control initiatives. To the extent any such
amount is not expended during any fiscal year,
such amount shall be available for such purpose
for subsequent fiscal years.
‘‘(B) AMOUNT DESCRIBED.—The Secretary
of Health and Human Services may determine
an amount under this subparagraph not to ex-
ceed 0.2 percent of the annual amounts de-
scribed under subsection (b)(1)(A) received in
the National Health Trust Fund for Mothers
and Children.’’.
(b) CONFORMING AMENDMENT.—Subchapter A of
chapter 98 is amended by inserting after the subchapter
heading the following new items:
‘‘Part I.
General trust funds.
‘‘Part II. Health care trust fund.
‘‘PART I—GENERAL TRUST FUNDS’’.
TITLE II—HEALTHY MOTHERS,
HEALTHY CHILDREN PROGRAM
SEC. 201. ESTABLISHMENT AND ALLOCATION OF FUNDS.
The Public Health Service Act (42 U.S.C. 201 et
seq.) is amended by adding at the end thereof the follow-
ing new title:
‘‘TITLE XXVIII—HEALTHY MOTH-
ERS, HEALTH CHILDREN PRO-
GRAM
‘‘SEC. 2800. ESTABLISHMENT OF PROGRAM.
‘‘A State that desires to become a participating State
under this title and receive an allocation under section
2801, shall, in accordance with this title, establish a State
program to ensure that eligible children and pregnant
women residing in the State are enrolled in certified plans
that provide for or cover the costs of comprehensive, high
quality health care items or services provided to such eligi-
ble individuals.
‘‘PART A—ALLOCATION OF FUNDS
‘‘SEC. 2801. ALLOCATION OF FUNDS TO PARTICIPATING
STATES.
‘‘(a) INITIAL ALLOCATION.—With respect to a par-
ticipating State, during each of the first two fiscal years
in which the State program is in effect, the Secretary shall
make available to the State, from the Trust Fund, an
amount based on a formula developed by the Secretary
that takes into consideration—
‘‘(1) the estimated number of eligible children
under 7 years of age residing in the State;
‘‘(2) the number of pregnant women residing in
the State that lack health insurance; and
‘‘(3) a geographic adjustment factor for the
State that is dependent on the average cost of health
care in such State.
‘‘(b) SUBSEQUENT FISCAL YEARS.—
‘‘(1) FORMULA.—With respect to a participat-
ing State, during each fiscal year subsequent to the
first two fiscal years in which the State program is
in effect, the Secretary shall make available to the
State, from the Trust Fund, an amount based on a
formula developed by the Secretary that takes into
consideration—
‘‘(A) the factors referred to in subsection
(a);
‘‘(B) to encourage the enrollment of all eli-
gible individuals in the State program of that
State, an additional factor developed by the
Secretary that takes into consideration the
number of eligible individuals enrolled in the
State program in the year immediately preced-
ing the year for which the allocation under this
subsection is being made; and
‘‘(C) an index that reflects the estimated
national average rate of inflation for health care
expenditures for children and a similar index
for pregnant women, to ensure that any in-
crease in allocations under this subsection do
not exceed the increase in such inflation index
from the previous fiscal year.
The additional factor shall be developed under sub-
paragraph (B) so that as the number of eligible indi-
viduals enrolled in the previous year increases, the
amount of the allocation for the State also increases.
‘‘(2) WAIVERS.—
‘‘(A) REQUEST BY STATE.—A participat-
ing State may request that the Secretary, in al-
locating funds under paragraph (1), waive the
consideration of the index under subparagraph
(C) of such paragraph with respect to such
State.
‘‘(B) GRANT OF WAIVER.—The Secretary
may grant a request for a waiver under sub-
paragraph (A) if the Secretary determines that
the participating State has demonstrated that
extenuating circumstances within the State ex-
isted which caused unavoidable increases in the
cost of health services provided to children and
pregnant women, and that the State has consid-
ered all reasonable strategies to control costs,
including working with certified plans to control
costs, reducing administrative costs, restructur-
ing the State program, and minimizing fraud
and abuse.
‘‘SEC. 2802. STATE TRUST FUNDS AND MATCHING CON-
TRIBUTION.
‘‘(a) STATE TRUST FUND.—
‘‘(1) ESTABLISHMENT.—To be a participating
State under this title, a State shall establish a State
trust fund (or in the case of regional programs, a re-
gional trust fund) in which the State shall deposit—
‘‘(A) all funds allocated to the State under
section 2801;
‘‘(B) all funds provided by the State under
subsection (b); and
‘‘(C) any additional funds determined ap-
propriated by the State.
‘‘(2) TRANSFER OF FUNDS.—From the Trust
Fund, the Secretary shall, on an annual basis, trans-
fer to the trust fund of a participating State the
amount of the State’s allocation under section 2801
for the fiscal year involved. Such annual transfer of
funds shall be contingent on a satisfactory annual
evaluation of the program of the participating State,
and the approval of the annual plan of the State by
the Secretary as required in section 2831(b).
‘‘(3) USE OF FUNDS.—Amounts contained in
the State trust fund shall be used solely for activities
directly related to the provision of health services to
eligible children or pregnant women or for other ac-
tivities specifically authorized under this title.
‘‘(b) MATCHING REQUIREMENT.—
‘‘(1) IN
GENERAL.—The Secretary may not
make an allocation to a participating State under
section 2801 unless that State agrees that, with re-
spect to the costs to be incurred by the State in car-
rying out the program for which the allocation is
provided, the State will make available an amount
determined by the Secretary based on a formula that
takes into account the annual per capita income of
each State. In determining the matching require-
ment applicable to each State under this paragraph,
the Secretary shall ensure that—
‘‘(A) each such matching requirement is
more generous for the State than the matching
requirement applicable under title XIX of the
Social Security Act at the time of the approval
of the State application under this title;
‘‘(B) the average State matching require-
ment for all States is $2 for every $8 of Fed-
eral funds provided under the allocation (aver-
age Federal matching rate for all States of 80
percent); and
‘‘(C) no State shall have a matching re-
quirement that is less than $1 for every $9 of
Federal funds provided under the allocation
(maximum Federal matching rate of 90 per-
cent).
‘‘(2) DONATIONS.—A participating State may
elect to accept a donation of funds, services, or
equipment for a State program under this title from
individuals and entities in the private sector. A State
shall ensure that any such donations from individ-
uals and for-profit entities do not result in a conflict
of interest in terms of the State giving preference to
the individual or entity related to the awarding of
contracts for a program under this title or for any
other State or Federally funded health programs not
covered by this Act.
‘‘(3) NO
REQUIREMENT.—With respect to
amounts deposited in the State trust fund under
subsection (a)(1)(C), such funds shall not be subject
to the matching requirements of paragraph (1) un-
less such funds are deposited for the purposes de-
scribed in sections 2832 and 2835.
‘‘SEC. 2803. EXCESS AND INSUFFICIENT FUNDS IN TRUST
FUNDS.
‘‘(a) AVAILABILITY OF UNALLOCATED FUNDS.—
‘‘(1) NATIONAL TRUST FUND.—With respect to
amounts remaining in the Trust Fund after the Sec-
retary makes the allocations required under section
2801 or otherwise provides grants under this title
for a fiscal year, such amounts shall remain in the
Trust Fund and be available for use in subsequent
years.
‘‘(2) STATE
TRUST
FUNDS.—With respect to
amounts remaining in the trust fund of a participat-
ing State after allocations or expansions in eligibility
are made for a fiscal year under this title, such
amounts shall remain in the State trust fund and
may not be transferred back to the Trust Fund.
‘‘(b) INSUFFICIENT FEDERAL FUNDS.—
‘‘(1) IN GENERAL.—If the Secretary determines
that amounts contained in the Trust Fund for a fis-
cal year are not sufficient to make allocations under
section 2801, or to otherwise carry out this title, the
Secretary shall notify the Advisory Council. Not
later than 60 days after receipt of a notification
under this paragraph, the Advisory Council shall
recommend to the Secretary strategies to correct the
insufficiency of funds.
‘‘(2) RECOMMENDATIONS BY COUNCIL.—Under
paragraph (1), the Advisory Council may rec-
ommend—
‘‘(A) the generation of additional sources
of revenue for the Trust Fund;
‘‘(B) an adjustment of the State matching
requirements under section 2802(b);
‘‘(C) an adjustment in the range or nature
of the health benefits provided under part B;
‘‘(D) an adjustment in the cost sharing re-
quirements for families under part B; or
‘‘(E) other measures as determined appro-
priate by the Council.
‘‘(3) IMPLEMENTING LEGISLATION.—Not later
than 60 days after receipt of recommendations
under paragraph (1), the Secretary shall prepare
and submit to Congress, appropriate implementing
legislation that incorporates one or more of such rec-
ommendations, if determined appropriate by the
Secretary.
‘‘(c) INSUFFICIENT STATE FUNDS.—
‘‘(1) IN GENERAL.—If the chief executive offi-
cer of a participating State determines that the
State does not have sufficient funds in the State
trust fund to meet the requirements of this title for
a fiscal year, the chief executive officer may petition
the Secretary for additional funds. Not later than 90
days after receipt of a petition under this subsection
the Secretary shall determine whether to provide the
State with additional funds or a loan from the Trust
Fund.
‘‘(2) PROHIBITION.—The Secretary may not
transfer any additional funds to a State under para-
graph (1) if the Secretary determines that the State
mismanaged funds, failed to prevent foreseeable fis-
cal problems, or failed to control fraud and abuse.
‘‘PART B—ELIGIBILITY AND ENROLLMENT
‘‘SUBPART 1—ELIGIBILITY
‘‘SEC. 2810. ELIGIBILITY OF INDIVIDUALS.
‘‘(a) IN GENERAL.—To be eligible to receive benefits
or services under this title an individual shall—
‘‘(1) be a—
‘‘(A) child who is under the age of 7 years,
regardless of the income or health insurance
status of the child or his or her parents, or an
older child (up to 21 years or age) if the Sec-
retary has expanded the program on a national
basis or the State in which the child resides has
expanded the State program to encompass such
older children; or
‘‘(B) pregnant woman who is not insured
(or who if insured, has no pregnancy-related
benefits) through the employer of the woman or
the family’s employer (in compliance with the
Pregnancy Discrimination Act of 1978), regard-
less of the income status of the woman; and
‘‘(2) be a United States citizen or a citizen of
another country legally residing in the United
States.
‘‘(b) CERTAIN INDIVIDUALS NOT ELIGIBLE.—A child
or pregnant woman shall not be eligible to participate in
the program established under this title if such child or
pregnant woman, during the 6-month period ending on the
date on which such individual desires to participate, was
covered under an employer-based health plan, and such
coverage was dropped by the employer.
‘‘(c) DEFINITION.—As used in subsection (a)(2), the
term ‘citizen of another country legally residing in the
United States’ means any of the following:
‘‘(1) An alien lawfully admitted for permanent
residence (within the meaning of section 101(a)(20)
of the Immigration and Nationality Act).
‘‘(2) An alien granted work authorization by
the Immigration and Naturalization Service.
‘‘(3) An alien permanently residing in the
United States under color of law, including (but not
limited to) any of the following:
‘‘(A) An alien who is admitted as a refugee
under section 207 of the Immigration and Na-
tionality Act.
‘‘(B) An alien who is granted asylum
under section 208 of such Act.
‘‘(C) An alien whose deportation is with-
held under section 243(h) of such Act.
‘‘(D) An alien who is admitted for tem-
porary residence under section 210, 210A, or
245A of such Act.
‘‘(E) An alien who has been paroled into
the United States under section 212(d)(5) of
such Act for an indefinite period or who has
been granted extended voluntary departure,
temporary protected status, or deferred en-
forced departure.
‘‘(F) An alien who is the spouse or unmar-
ried child under 21 years of age of a citizen of
the United States, or the parent of such a citi-
zen if the citizen is over 21 years of age, and
with respect to whom an application for adjust-
ment to lawful permanent residence is pending.
‘‘(G) An alien within such other classifica-
tion of aliens permanently residing under color
of law for purposes of this title as the Secretary
may establish by regulation. Such regulation
shall include categories of such aliens who are
included in regulations as in effect on the date
of the enactment of this Act under title XIX of
the Social Security Act and other categories
within a public health priority.
‘‘(4) An alien not otherwise covered under this
subsection who the State elects to consider eligible.
A State shall ensure that Federal funds provided
under this title are not used to provide coverage for
aliens under this paragraph.
‘‘SEC. 2811. ELECTION OF ELIGIBILITY.
‘‘(a) COVERAGE OF CHILDREN UNDER OTHER FED-
ERAL PROGRAMS.—
‘‘(1) IN GENERAL.—An eligible individual de-
scribed in section 2810(a)(1)(A) who receives bene-
fits or services under—
‘‘(A) the Civilian Health and Medical Pro-
gram of the Uniformed Services (CHAMPUS),
as defined in section 1073(4) of title 10, United
States Code;
‘‘(B) chapter 17 of title 38, United States
Code; or
‘‘(C) a health program of the Indian
Health Service;
may elect to continue to use such services or elect
to enroll in a certified plan under this title.
‘‘(2) MEDICAID.—An eligible individual de-
scribed in section 2810(a)(1)(A) who receives bene-
fits or services under title XIX of the Social Security
Act shall, on the date on which the State program
of the participating State in which such individual
resides provides for open enrollment, be automati-
cally enrolled in a certified plan of such individuals
choice under the State program of the participating
State which such individual resides in.
‘‘(3) STATE PROGRAMS.—In the case of an eli-
gible individual described in section 2810(a)(1)(A)
who resides in a State-supervised care setting or who
does not live with his or her parents, such child shall
be enrolled in a certified plan by the State agency
or guardian that has been awarded the temporary or
permanent custody of the child unless there is an
otherwise more appropriate, specially designed
health care system for such a child.
‘‘(b) COVERAGE
OF PREGNANT WOMEN UNDER
OTHER FEDERAL PROGRAMS.—
‘‘(1) IN GENERAL.—An eligible individual de-
scribed in section 2810(a)(1)(B) who receives bene-
fits or services under—
‘‘(A) the Civilian Health and Medical Pro-
gram of the Uniformed Services (CHAMPUS),
as defined in section 1073(4) of title 10, United
States Code;
‘‘(B) chapter 17 of title 38, United States
Code; or
‘‘(C) a health program of the Indian
Health Service;
shall not be eligible for coverage under a certified
plan under this title.
‘‘(2) MEDICAID.—An eligible individual de-
scribed in section 2810(a)(1)(B) who receives bene-
fits or services under title XIX of the Social Security
Act shall, on the date on which the State program
of the participating State in which such individual
resides provides for open enrollment, be automati-
cally enrolled in a certified plan of such individuals
choice under the State program of the participating
State which such individual resides in.
‘‘(c) ENROLLMENT IN CERTIFIED PLANS.—In the
case of an eligible individual who elects or is automatically
enrolled in a State program under this title, all privileges
(such as choice of certified plans) and responsibilities
(such as payment of premiums or copayments) accorded
to their families or themselves under this title shall apply.
‘‘SEC. 2812. ELIGIBLE HEALTH PLANS AND PROVIDERS.
‘‘A health plan or health care provider that is licensed
and credentialed, or otherwise legally authorized by the
State in which such plan or provider operates, to provide
health services of a type described in this title, under the
respective rules and regulations of the State, shall be eligi-
ble to participate in the State program under this title
if such plan or provider meets all applicable Federal and
State requirements under this title.
‘‘SUBPART 2—ENROLLMENT
‘‘SEC. 2815. ENROLLMENT OF ELIGIBLE PERSONS.
‘‘(a) NATIONAL OPEN ENROLLMENT PERIOD.—Not
later than 30 days after the effective date, the Secretary
shall establish a national annual open enrollment period
to be held during a month that shall be designated as ‘Na-
tional Healthy Mothers, Healthy Children Month’. During
such enrollment period, an eligible child may be enrolled
in a certified plan operating in the State in which such
individual resides in accordance with the enrollment re-
quirements of the State.
‘‘(b) ESTABLISHMENT OF ENROLLMENT SYSTEM.—
‘‘(1) IN
GENERAL.—Not later than 30 days
after the approval of a State program under section
2831, the State shall establish a system for the en-
rollment of all eligible individuals residing within the
State in a certified plan under this title. Such enroll-
ment system shall be designed to minimize, to the
maximum extent practicable, any barriers that may
exist to prevent enrollment. All applicants shall be
presumed to be eligible until the State has deter-
mined otherwise.
‘‘(2) METHOD OF ENROLLMENT.—The enroll-
ment process established under paragraph (1) shall
be reasonably convenient, efficient, and provide for
enrollment through a wide range of methods. At a
minimum, such process shall provide for enrollment
through the mail, telephone (via a toll free number),
and in person.
‘‘(c) ENROLLMENT MATERIALS.—
‘‘(1) IN
GENERAL.—Under a process estab-
lished under subsection (b), a State shall ensure that
enrollment materials are made available through
health care providers, health provider organizations,
hospitals, health clinics, at facilities that provide
health and nutrition services to children and women,
and from State and local government health offices.
‘‘(2) ESSENTIAL DATA.—The Secretary, in con-
sultation with the States and representatives of cer-
tified plans, shall develop essential data elements for
the establishment and use by participating States of
a standardized enrollment form that shall not exceed
one page in length. The Secretary may utilize or
permit such States to utilize additional data collec-
tion instruments for the purpose of assessing and
improving State programs so long as such instru-
ments are not a requirement for enrollment in a cer-
tified plan.
‘‘(d) PROCESSING OF APPLICATIONS.—
‘‘(1) IN
GENERAL.—Not later than 30 days
after the date on which an application for enrollment
in a certified plan is submitted to a State by or on
behalf of an eligible individual, the State shall proc-
ess and render a final decision with respect to the
application. Approval of such an application shall be
dependent on eligibility and income verification by
the State. Income verification mechanisms and re-
quirements shall be developed by the State in ac-
cordance with guidelines prescribed by the Secretary.
‘‘(2) WAIVER.—A participating State may elect
to waive the income verification requirements for
families who are already subject to similar require-
ments under other appropriate Federal or State pro-
grams or in other situations determined appropriate
by the State.
‘‘(3) NOTIFICATION.—Not later than 30 days
after the date on which an application for enrollment
is approved under paragraph (1), the State shall no-
tify the family and the relevant certified plan of the
approval and the expected annual premium contribu-
tion of the family, the first payment of which must
be received by the plan or the State within 30 days
of such notification.
‘‘(e) TIME OF ENROLLMENT.—
‘‘(1) IN GENERAL.—An eligible child shall be
enrolled, or change enrollment, in a certified plan
during the national annual open enrollment period.
‘‘(2) PREGNANT WOMAN.—An eligible pregnant
woman may enroll in a certified plan at any time
after the diagnosis of pregnancy is confirmed by a
physician or qualified health professional. A woman
may also enroll in a certified plan in order to con-
firm her pregnancy. Except as otherwise provided in
subsection (f)(1), a pregnant woman enrolled in a
Secretary, in consultation with health professional organi-
zations determined appropriate by the Secretary, shall de-
termine the types of services under the benefits package
that shall be subject to utilization copayments under sec-
tion 2827. The Secretary shall ensure that preventive serv-
ices are exempt from any utilization copayment require-
ments.
‘‘(d) REVIEW AND MODIFICATION.—Not later than
2 years after the development of the comprehensive bene-
fits package under subsection (a), and every 2 years there-
after, the Secretary, in consultation with relevant health
professional organizations and the Advisory Council, shall
review and revise the comprehensive benefits package. The
Secretary shall ensure that any revision of the comprehen-
sive benefits package is consistent with changes in the age
group of eligible children, standard medical practice, new
technologies, emerging health problems and health care
needs. If children seven years of age or older are eligible
on a national basis or in a participating State prior to
2 years after the development of the initial benefits pack-
age, the Secretary shall revise the benefits package as nec-
essary by the methods specified in this section.
‘‘(e) REQUIREMENTS OF CERTIFIED PLAN.—To be
eligible to operate as a certified plan under this title, the
plan shall provide coverage for or directly provide the
retary to designate such State as a special status
State.
‘‘(3) APPROVAL OF PETITIONS.—The Secretary
shall approve a petition under this subsection if the
Secretary determines that the petitioning State has
demonstrated that at least 95 percent of all eligible
children and pregnant women residing in the State
are covered either under the State program or under
other sources of health insurance. The Secretary
shall make a determination on the State petition
under this section within 90 days of the date on
which the Secretary receives the petition.
‘‘(b) EFFECT OF DESIGNATION.—
‘‘(1) EXPANSION OF SERVICES.—A State des-
ignated as a special status State under subsection
(a) may submit a proposal to the Secretary for the
expansion of health services provided under this title
to children under seven years of age and pregnant
women, or to expand comparable coverage with re-
spect to health services for older children up to age
21. Such expanded eligibility shall be consistent with
the requirements and guidelines under this title.
‘‘(2) MATCHING REQUIREMENTS.—The match-
ing requirement in section 2802 shall apply to ex-
panded eligibility programs under paragraph (1).