I 
108TH CONGRESS 
1ST SESSION H. R. 2268
To amend titles XIX and XXI of the Social Security Act to expand or 
add coverage of pregnant women under the Medicaid and State children’s 
health insurance program, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 22, 2003
Mr. STRICKLAND (for himself, Mr. NEY, Mrs. NAPOLITANO, Mr. TOWNS, Mrs. 
CHRISTENSEN, Mr. MCNULTY, and Mr. FARR) introduced the following 
bill; which was referred to the Committee on Energy and Commerce, and 
in addition to the Committee on Ways and Means, for a period to be sub-
sequently determined by the Speaker, in each case for consideration of 
such provisions as fall within the jurisdiction of the committee concerned 
A BILL 
To amend titles XIX and XXI of the Social Security Act 
to expand or add coverage of pregnant women under 
the Medicaid and State children’s health insurance pro-
gram, and for other purposes.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Start Healthy, Stay 
Healthy Act of 2003’’.
SEC. 2. STATE OPTION TO EXPAND OR ADD COVERAGE OF 
CERTAIN PREGNANT WOMEN UNDER MED-
ICAID AND SCHIP. 
(a) MEDICAID.—
(1) AUTHORITY TO EXPAND COVERAGE.—Sec-
tion 1902(l)(2)(A)(i) of the Social Security Act (42 
U.S.C. 1396a(l)(2)(A)(i)) is amended by inserting 
‘‘(or such higher percent as the State may elect for 
purposes of expenditures for medical assistance for 
pregnant 
women 
described 
in 
section 
1905(u)(4)(A))’’ after ‘‘185 percent’’. 
(2) ENHANCED MATCHING FUNDS AVAILABLE 
IF CERTAIN CONDITIONS MET.—Section 1905 of the 
Social Security Act (42 U.S.C. 1396d) is amended—
(A) in the fourth sentence of subsection 
(b), by striking ‘‘or subsection (u)(3)’’ and in-
serting ‘‘, (u)(3), or (u)(4)’’; and 
(B) in subsection (u)—
(i) by redesignating paragraph (4) as 
paragraph (5); and 
(ii) by inserting after paragraph (3) 
the following: 
‘‘(4) For purposes of the fourth sentence of sub-
section (b) and section 2105(a), the expenditures de-
scribed in this paragraph are the following:
‘‘(A) CERTAIN PREGNANT WOMEN.—If the con-
ditions described in subparagraph (B) are met, ex-
penditures for medical assistance for pregnant 
women described in subsection (n) or under section 
1902(l)(1)(A) in a family the income of which ex-
ceeds the effective income level (expressed as a per-
cent of the poverty line and considering applicable 
income disregards) that has been specified under 
subsection (a)(10)(A)(i)(III) or (l)(2)(A) of section 
1902, as of January 1, 2003, but does not exceed 
the income eligibility level established under title 
XXI for a targeted low-income child. 
‘‘(B) CONDITIONS.—The conditions described 
in this subparagraph are the following: 
‘‘(i) The State plans under this title and 
title XXI do not provide coverage for pregnant 
women described in subparagraph (A) with 
higher family income without covering such 
pregnant women with a lower family income. 
‘‘(ii) The State does not apply an effective 
income level for pregnant women that is lower 
than the effective income level (expressed as a 
percent of the poverty line and considering ap-
plicable income disregards) that has been speci-
fied under the State plan under subsection
(a)(10)(A)(i)(III) or (l)(2)(A) of section 1902, 
as of January 1, 2003, to be eligible for medical 
assistance as a pregnant woman. 
‘‘(C) DEFINITION OF POVERTY LINE.—In this 
subsection, the term ‘poverty line’ has the meaning 
given such term in section 2110(c)(5).’’. 
(3) PAYMENT
FROM
TITLE
XXI
ALLOTMENT 
FOR MEDICAID EXPANSION COSTS; ELIMINATION OF 
COUNTING
MEDICAID
CHILD
PRESUMPTIVE
ELIGI-
BILITY COSTS AGAINST TITLE XXI ALLOTMENT.—
Section 2105(a)(1) of the Social Security Act (42 
U.S.C. 1397ee(a)(1)) is amended—
(A) in the matter preceding subparagraph 
(A), by striking ‘‘(or, in the case of expendi-
tures described in subparagraph (B), the Fed-
eral medical assistance percentage (as defined 
in the first sentence of section 1905(b)))’’; and 
(B) by striking subparagraph (B) and in-
serting the following: 
‘‘(B) for the provision of medical assist-
ance that is attributable to expenditures de-
scribed in section 1905(u)(4)(A);’’. 
(4) ADDITIONAL AMENDMENTS TO MEDICAID.—
(A) ELIGIBILITY OF A NEWBORN.—Section 
1902(e)(4) of the Social Security Act (42
U.S.C. 1396a(e)(4)) is amended in the first 
sentence by striking ‘‘so long as the child is a 
member of the woman’s household and the 
woman remains (or would remain if pregnant) 
eligible for such assistance’’. 
(B) APPLICATION OF QUALIFIED ENTITIES 
TO PRESUMPTIVE ELIGIBILITY FOR PREGNANT 
WOMEN UNDER MEDICAID.—Section 1920(b) of 
the Social Security Act (42 U.S.C. 1396r–1(b)) 
is amended by adding at the end after and 
below paragraph (2) the following flush sen-
tence: 
‘‘The term ‘qualified provider’ includes a qualified entity 
as defined in section 1920A(b)(3).’’. 
(b) SCHIP.—
(1) COVERAGE.—Title XXI of the Social Secu-
rity Act (42 U.S.C. 1397aa et seq.) is amended by 
adding at the end the following: 
‘‘SEC. 2111. OPTIONAL COVERAGE OF TARGETED LOW-IN-
COME PREGNANT WOMEN. 
‘‘(a) OPTIONAL COVERAGE.—Notwithstanding any 
other provision of this title, a State may provide for cov-
erage, through an amendment to its State child health 
plan under section 2102, of pregnancy-related assistance 
for targeted low-income pregnant women in accordance
with this section, but only if the State meets the conditions 
described in section 1905(u)(4)(B). 
‘‘(b) DEFINITIONS.—For purposes of this title:
‘‘(1) PREGNANCY-RELATED ASSISTANCE.—The 
term ‘pregnancy-related assistance’ has the meaning 
given the term child health assistance in section 
2110(a) as if any reference to targeted low-income 
children were a reference to targeted low-income 
pregnant women, except that the assistance shall be 
limited to services related to pregnancy (which in-
clude prenatal, delivery, and postpartum services 
and services described in section 1905(a)(4)(C)) and 
to other conditions that may complicate pregnancy. 
‘‘(2) 
TARGETED
LOW-INCOME
PREGNANT 
WOMAN.—The term ‘targeted low-income pregnant 
woman’ means a woman—
‘‘(A) during pregnancy and through the 
end of the month in which the 60-day period 
(beginning on the last day of her pregnancy) 
ends; 
‘‘(B) whose family income exceeds the ef-
fective income level (expressed as a percent of 
the poverty line and considering applicable in-
come disregards) that has been specified under 
subsection (a)(10)(A)(i)(III) or (l)(2)(A) of sec-
tion 1902, as of January 1, 2003, to be eligible 
for medical assistance as a pregnant woman 
under title XIX but does not exceed the income 
eligibility level established under the State child 
health plan under this title for a targeted low-
income child; and 
‘‘(C) who satisfies the requirements of 
paragraphs (1)(A), (1)(C), (2), and (3) of sec-
tion 2110(b). 
‘‘(c) 
REFERENCES
TO
TERMS
AND
SPECIAL 
RULES.—In the case of, and with respect to, a State pro-
viding for coverage of pregnancy-related assistance to tar-
geted low-income pregnant women under subsection (a), 
the following special rules apply: 
‘‘(1) Any reference in this title (other than in 
subsection (b)) to a targeted low-income child is 
deemed to include a reference to a targeted low-in-
come pregnant woman. 
‘‘(2) Any such reference to child health assist-
ance with respect to such women is deemed a ref-
erence to pregnancy-related assistance. 
‘‘(3) Any such reference to a child is deemed a 
reference to a woman during pregnancy and the pe-
riod described in subsection (b)(2)(A).
‘‘(4) In applying section 2102(b)(3)(B), any 
reference to children found through screening to be 
eligible for medical assistance under the State med-
icaid plan under title XIX is deemed a reference to 
pregnant women. 
‘‘(5) There shall be no exclusion of benefits for 
services described in subsection (b)(1) based on any 
preexisting condition and no waiting period (includ-
ing any waiting period imposed to carry out section 
2102(b)(3)(C)) shall apply. 
‘‘(6) Subsection (a) of section 2103 (relating to 
required scope of health insurance coverage) shall 
not apply insofar as a State limits coverage to serv-
ices described in subsection (b)(1) and the reference 
to such section in section 2105(a)(1)(C) is deemed 
not to require, in such case, compliance with the re-
quirements of section 2103(a). 
‘‘(7) In applying section 2103(e)(3)(B) in the 
case of a pregnant woman provided coverage under 
this section, the limitation on total annual aggregate 
cost-sharing shall be applied to the entire family of 
such pregnant woman. 
‘‘(d) AUTOMATIC
ENROLLMENT
FOR
CHILDREN 
BORN TO WOMEN RECEIVING PREGNANCY-RELATED AS-
SISTANCE.—If a child is born to a targeted low-income
pregnant woman who was receiving pregnancy-related as-
sistance under this section on the date of the child’s birth, 
the child shall be deemed to have applied for child health 
assistance under the State child health plan and to have 
been found eligible for such assistance under such plan 
or to have applied for medical assistance under title XIX 
and to have been found eligible for such assistance under 
such title, as appropriate, on the date of such birth and 
to remain eligible for such assistance until the child at-
tains 1 year of age. During the period in which a child 
is deemed under the preceding sentence to be eligible for 
child health or medical assistance, the child health or med-
ical assistance eligibility identification number of the 
mother shall also serve as the identification number of the 
child, and all claims shall be submitted and paid under 
such number (unless the State issues a separate identifica-
tion number for the child before such period expires).’’. 
(2) ADDITIONAL ALLOTMENTS FOR PROVIDING 
COVERAGE OF PREGNANT WOMEN.—
(A) IN GENERAL.—Section 2104 of the So-
cial Security Act (42 U.S.C. 1397dd) is amend-
ed by inserting after subsection (c) the fol-
lowing: 
‘‘(d) ADDITIONAL ALLOTMENTS
FOR PROVIDING 
COVERAGE OF PREGNANT WOMEN.—
‘‘(1) APPROPRIATION; TOTAL
ALLOTMENT.—
For the purpose of providing additional allotments 
to States under this title, there is appropriated, out
of any money in the Treasury not otherwise appro-
priated, for each of fiscal years 2004 through 2007, 
$200,000,000. 
‘‘(2) STATE AND TERRITORIAL ALLOTMENTS.—
In addition to the allotments provided under sub-
sections (b) and (c), subject to paragraphs (3) and 
(4), of the amount available for the additional allot-
ments under paragraph (1) for a fiscal year, the 
Secretary shall allot to each State with a State child 
health plan approved under this title—
‘‘(A) in the case of such a State other than 
a commonwealth or territory described in sub-
paragraph (B), the same proportion as the pro-
portion of the State’s allotment under sub-
section (b) (determined without regard to sub-
section (f)) to the total amount of the allot-
ments under subsection (b) for such States eli-
gible for an allotment under this paragraph for 
such fiscal year; and 
‘‘(B) in the case of a commonwealth or ter-
ritory described in subsection (c)(3), the same 
proportion as the proportion of the common-
wealth’s or territory’s allotment under sub-
section (c) (determined without regard to sub-
section (f)) to the total amount of the allot-
ments under subsection (c) for commonwealths 
and territories eligible for an allotment under 
this paragraph for such fiscal year. 
‘‘(3) USE OF ADDITIONAL ALLOTMENT.—Addi-
tional allotments provided under this subsection are 
not available for amounts expended before October 
1, 2003. Such amounts are available for amounts ex-
pended on or after such date for child health assist-
ance for targeted low-income children, as well as for 
pregnancy-related assistance for targeted low-income 
pregnant women. 
‘‘(4) NO PAYMENTS UNLESS ELECTION TO EX-
PAND COVERAGE OF PREGNANT WOMEN.—No pay-
ments may be made to a State under this title from 
an allotment provided under this subsection unless 
the State provides pregnancy-related assistance for 
targeted low-income pregnant women under this 
title, or provides medical assistance for pregnant 
women under title XIX, whose family income ex-
ceeds the effective income level applicable under sub-
section (a)(10)(A)(i)(III) or (l)(2)(A) of section
1902 to a family of the size involved as of January 
1, 2003.’’. 
(B) CONFORMING AMENDMENTS.—Section 
2104 of the Social Security Act (42 U.S.C. 
1397dd) is amended—
(i) in subsection (a), in the matter 
preceding paragraph (1), by inserting 
‘‘subject to subsection (d),’’ after ‘‘under 
this section,’’; 
(ii) in subsection (b)(1), by inserting 
‘‘and subsection (d)’’ after ‘‘Subject to 
paragraph (4)’’; and 
(iii) in subsection (c)(1), by inserting 
‘‘subject to subsection (d),’’ after ‘‘for a 
fiscal year,’’. 
(3) PRESUMPTIVE
ELIGIBILITY
UNDER
TITLE 
XXI.—
(A) 
APPLICATION
TO
PREGNANT 
WOMEN.—Section 2107(e)(1)(D) of the Social 
Security Act (42 U.S.C. 1397gg(e)(1)) is 
amended to read as follows: 
‘‘(D) Sections 1920 and 1920A (relating to 
presumptive eligibility).’’. 
(B) EXCEPTION FROM LIMITATION ON AD-
MINISTRATIVE EXPENSES.—Section 2105(c)(2)
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1397ee(c)(2)) is amended by adding at the end 
the following new subparagraph: 
‘‘(C) EXCEPTION FOR PRESUMPTIVE ELI-
GIBILITY
EXPENDITURES.—The 
limitation 
under subparagraph (A) on expenditures shall 
not apply to expenditures attributable to the 
application of section 1920 or 1920A (pursuant 
to section 2107(e)(1)(D)), regardless of whether 
the child or pregnant woman is determined to 
be ineligible for the program under this title or 
title XIX.’’. 
(4) 
ADDITIONAL
AMENDMENTS
TO
TITLE 
XXI.—
(A) NO COST-SHARING FOR PREGNANCY-
RELATED SERVICES.—Section 2103(e)(2) of the 
Social Security Act (42 U.S.C. 1397cc(e)(2)) is 
amended—
(i) in the heading, by inserting ‘‘OR 
PREGNANCY-RELATED
SERVICES’’ 
after 
‘‘PREVENTIVE SERVICES’’; and 
(ii) by inserting before the period at 
the end the following: ‘‘or for pregnancy-
related services’’.
(B) 
NO
WAITING
PERIOD.—Section 
2102(b)(1)(B) of the Social Security Act (42 
U.S.C. 1397bb(b)(1)(B)) is amended—
(i) by striking ‘‘, and’’ at the end of 
clause (i) and inserting a semicolon; 
(ii) by striking the period at the end 
of clause (ii) and inserting ‘‘; and’’; and 
(iii) by adding at the end the fol-
lowing: 
‘‘(iii) may not apply a waiting period 
(including a waiting period to carry out 
paragraph (3)(C)) in the case of a targeted 
low-income pregnant woman.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section apply to items and services furnished on or 
after October 1, 2003, without regard to whether regula-
tions implementing such amendments have been promul-
gated. 
SEC. 3. COORDINATION WITH THE MATERNAL AND CHILD 
HEALTH PROGRAM. 
(a) IN GENERAL.—Section 2102(b)(3) of the Social 
Security Act (42 U.S.C. 1397bb(b)(3)) is amended—
(1) in subparagraph (D), by striking ‘‘and’’ at 
the end;
(2) in subparagraph (E), by striking the period 
and inserting ‘‘; and’’; and 
(3) by adding at the end the following new sub-
paragraph: 
‘‘(F) that operations and activities under 
this title are developed and implemented in con-
sultation and coordination with the program op-
erated by the State under title V in areas in-
cluding outreach and enrollment, benefits and 
services, service delivery standards, public 
health and social service agency relationships, 
and quality assurance and data reporting.’’. 
(b) CONFORMING MEDICAID AMENDMENT.—Section 
1902(a)(11) of such Act (42 U.S.C. 1396a(a)(11)) is 
amended—
(1) by striking ‘‘and’’ before ‘‘(C)’’; and 
(2) by inserting before the semicolon at the end 
the following: ‘‘, and (D) provide that operations and 
activities under this title are developed and imple-
mented in consultation and coordination with the 
program operated by the State under title V in areas 
including outreach and enrollment, benefits and 
services, service delivery standards, public health 
and social service agency relationships, and quality 
assurance and data reporting’’.
(c) EFFECTIVE DATE.—The amendments made by 
this section take effect on January 1, 2004. 
SEC. 4. INCREASE IN SCHIP INCOME ELIGIBILITY. 
(a) DEFINITION OF LOW-INCOME CHILD.—Section 
2110(c)(4) of the Social Security Act (42 U.S.C. 42 
U.S.C. 1397jj(c)(4)) is amended by striking ‘‘200’’ and 
inserting ‘‘250’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) applies to child health assistance provided, 
and allotments determined under section 2104 of the So-
cial Security Act (42 U.S.C. 1397dd), for fiscal years be-
ginning with fiscal year 2004. 
SEC. 5. REVIEW OF STATE AGENCY BLINDNESS AND DIS-
ABILITY DETERMINATIONS. 
Section 1633 of the Social Security Act (42 U.S.C. 
1383b) is amended by adding at the end the following: 
‘‘(e)(1) The Commissioner of Social Security shall re-
view determinations, made by State agencies pursuant to 
subsection (a) in connection with applications for benefits 
under this title on the basis of blindness or disability, that 
individuals who have attained 18 years of age are blind 
or disabled as of a specified onset date. The Commissioner 
of Social Security shall review such a determination before 
any action is taken to implement the determination.
‘‘(2)(A) In carrying out paragraph (1), the Commis-
sioner of Social Security shall review—
‘‘(i) at least 25 percent of all determinations re-
ferred to in paragraph (1) that are made in fiscal 
year 2004; and 
‘‘(ii) at least 50 percent of all such determina-
tions that are made in fiscal year 2005 or thereafter. 
‘‘(B) In carrying out subparagraph (A), the Commis-
sioner of Social Security shall, to the extent feasible, select 
for review the determinations which the Commissioner of 
Social Security identifies as being the most likely to be 
incorrect.’’.
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