H. R. 2—37 
Medicaid plan or the State CHIP plan through reliance 
on a finding made by an Express Lane agency for 
the duration of the State’s election under this para-
graph; 
‘‘(II) annually provide the Secretary with a statis-
tically valid sample (that is approved by Secretary) 
of the children enrolled in such plans through reliance 
on such a finding by conducting a full Medicaid eligi-
bility review of the children identified for such sample 
for purposes of determining an eligibility error rate 
(as described in clause (iv)) with respect to the enroll-
ment of such children (and shall not include such chil-
dren in any data or samples used for purposes of 
complying with a Medicaid Eligibility Quality Control 
(MEQC) review or a payment error rate measurement 
(PERM) requirement); 
‘‘(III) submit the error rate determined under sub-
clause (II) to the Secretary; 
‘‘(IV) if such error rate exceeds 3 percent for either 
of the first 2 fiscal years in which the State elects 
to apply this paragraph, demonstrate to the satisfac-
tion of the Secretary the specific corrective actions 
implemented by the State to improve upon such error 
rate; and 
‘‘(V) if such error rate exceeds 3 percent for any 
fiscal year in which the State elects to apply this 
paragraph, a reduction in the amount otherwise pay-
able to the State under section 1903(a) for quarters 
for that fiscal year, equal to the total amount of erro-
neous excess payments determined for the fiscal year 
only with respect to the children included in the sample 
for the fiscal year that are in excess of a 3 percent 
error rate with respect to such children. 
‘‘(ii) NO
PUNITIVE
ACTION
BASED
ON
ERROR
RATE.— 
The Secretary shall not apply the error rate derived from 
the sample under clause (i) to the entire population of 
children enrolled in the State Medicaid plan or the State 
CHIP plan through reliance on a finding made by an 
Express Lane agency, or to the population of children 
enrolled in such plans on the basis of the State’s regular 
procedures for determining eligibility, or penalize the State 
on the basis of such error rate in any manner other than 
the reduction of payments provided for under clause (i)(V). 
‘‘(iii) RULE OF CONSTRUCTION.—Nothing in this para-
graph shall be construed as relieving a State that elects 
to apply this paragraph from being subject to a penalty 
under section 1903(u), for payments made under the State 
Medicaid plan with respect to ineligible individuals and 
families that are determined to exceed the error rate per-
mitted under that section (as determined without regard 
to the error rate determined under clause (i)(II)). 
‘‘(iv) ERROR RATE DEFINED.—In this subparagraph, the 
term ‘error rate’ means the rate of erroneous excess pay-
ments for medical assistance (as defined in section 
1903(u)(1)(D)) for the period involved, except that such 
payments shall be limited to individuals for which eligi-
bility determinations are made under this paragraph and
H. R. 2—38 
except that in applying this paragraph under title XXI, 
there shall be substituted for references to provisions of 
this title corresponding provisions within title XXI. 
‘‘(F) EXPRESS LANE AGENCY.— 
‘‘(i) IN GENERAL.—In this paragraph, the term ‘Express 
Lane agency’ means a public agency that— 
‘‘(I) is determined by the State Medicaid agency 
or the State CHIP agency (as applicable) to be capable 
of making the determinations of one or more eligibility 
requirements described in subparagraph (A)(i); 
‘‘(II) is identified in the State Medicaid plan or 
the State CHIP plan; and 
‘‘(III) notifies the child’s family— 
‘‘(aa) of the information which shall be dis-
closed in accordance with this paragraph; 
‘‘(bb) that the information disclosed will be 
used solely for purposes of determining eligibility 
for medical assistance under the State Medicaid 
plan or for child health assistance under the State 
CHIP plan; and 
‘‘(cc) that the family may elect to not have 
the information disclosed for such purposes; and 
‘‘(IV) enters into, or is subject to, an interagency 
agreement to limit the disclosure and use of the 
information disclosed. 
‘‘(ii) INCLUSION OF SPECIFIC PUBLIC AGENCIES.—Such 
term includes the following: 
‘‘(I) A public agency that determines eligibility for 
assistance under any of the following: 
‘‘(aa) The temporary assistance for needy fami-
lies program funded under part A of title IV. 
‘‘(bb) A State program funded under part D 
of title IV. 
‘‘(cc) The State Medicaid plan. 
‘‘(dd) The State CHIP plan. 
‘‘(ee) The Food and Nutrition Act of 2008 (7 
U.S.C. 2011 et seq.). 
‘‘(ff) The Head Start Act (42 U.S.C. 9801 et 
seq.). 
‘‘(gg) The Richard B. Russell National School 
Lunch Act (42 U.S.C. 1751 et seq.). 
‘‘(hh) The Child Nutrition Act of 1966 (42 
U.S.C. 1771 et seq.). 
‘‘(ii) The Child Care and Development Block 
Grant Act of 1990 (42 U.S.C. 9858 et seq.). 
‘‘(jj) The Stewart B. McKinney Homeless 
Assistance Act (42 U.S.C. 11301 et seq.). 
‘‘(kk) The United States Housing Act of 1937 
(42 U.S.C. 1437 et seq.). 
‘‘(ll) The Native American Housing Assistance 
and Self-Determination Act of 1996 (25 U.S.C. 
4101 et seq.). 
‘‘(II) A State-specified governmental agency that 
has fiscal liability or legal responsibility for the 
accuracy of the eligibility determination findings relied 
on by the State.
H. R. 2—39 
‘‘(III) A public agency that is subject to an inter-
agency agreement limiting the disclosure and use of 
the information disclosed for purposes of determining 
eligibility under the State Medicaid plan or the State 
CHIP plan. 
‘‘(iii) EXCLUSIONS.—Such term does not include an 
agency that determines eligibility for a program established 
under the Social Services Block Grant established under 
title XX or a private, for-profit organization. 
‘‘(iv) RULES OF CONSTRUCTION.—Nothing in this para-
graph shall be construed as— 
‘‘(I) exempting a State Medicaid agency from com-
plying with the requirements of section 1902(a)(4) 
relating to merit-based personnel standards for 
employees of the State Medicaid agency and safeguards 
against conflicts of interest); or 
‘‘(II) authorizing a State Medicaid agency that 
elects to use Express Lane agencies under this 
subparagraph to use the Express Lane option to avoid 
complying with such requirements for purposes of 
making eligibility determinations under the State Med-
icaid plan. 
‘‘(v) ADDITIONAL DEFINITIONS.—In this paragraph: 
‘‘(I) STATE.—The term ‘State’ means 1 of the 50 
States or the District of Columbia. 
‘‘(II) STATE CHIP AGENCY.—The term ‘State CHIP 
agency’ means the State agency responsible for admin-
istering the State CHIP plan. 
‘‘(III) STATE CHIP PLAN.—The term ‘State CHIP 
plan’ means the State child health plan established 
under title XXI and includes any waiver of such plan. 
‘‘(IV) STATE MEDICAID AGENCY.—The term ‘State 
Medicaid agency’ means the State agency responsible 
for administering the State Medicaid plan. 
‘‘(V) STATE MEDICAID PLAN.—The term ‘State Med-
icaid plan’ means the State plan established under 
title XIX and includes any waiver of such plan. 
‘‘(G) CHILD DEFINED.—For purposes of this paragraph, the 
term ‘child’ means an individual under 19 years of age, or, 
at the option of a State, such higher age, not to exceed 21 
years of age, as the State may elect. 
‘‘(H) STATE OPTION TO RELY ON STATE INCOME TAX DATA 
OR RETURN.—At the option of the State, a finding from an 
Express Lane agency may include gross income or adjusted 
gross income shown by State income tax records or returns. 
‘‘(I) APPLICATION.—This paragraph shall not apply with 
respect to eligibility determinations made after September 30, 
2013.’’. 
(2) CHIP.—Section 2107(e)(1) (42 U.S.C. 1397gg(e)(1)) is 
amended by redesignating subparagraphs (B), (C), and (D) as 
subparagraphs (C), (D), and (E), respectively, and by inserting 
after subparagraph (A) the following new subparagraph: 
‘‘(B) Section 1902(e)(13) (relating to the State option 
to rely on findings from an Express Lane agency to help 
evaluate a child’s eligibility for medical assistance).’’. 
(b) EVALUATION AND REPORT.—
H. R. 2—40 
(1) EVALUATION.—The Secretary shall conduct, by grant, 
contract, or interagency agreement, a comprehensive, inde-
pendent evaluation of the option provided under the amend-
ments made by subsection (a). Such evaluation shall include 
an analysis of the effectiveness of the option, and shall 
include— 
(A) obtaining a statistically valid sample of the children 
who were enrolled in the State Medicaid plan or the State 
CHIP plan through reliance on a finding made by an 
Express Lane agency and determining the percentage of 
children who were erroneously enrolled in such plans; 
(B) determining whether enrolling children in such 
plans through reliance on a finding made by an Express 
Lane agency improves the ability of a State to identify 
and enroll low-income, uninsured children who are eligible 
but not enrolled in such plans; 
(C) evaluating the administrative costs or savings 
related to identifying and enrolling children in such plans 
through reliance on such findings, and the extent to which 
such costs differ from the costs that the State otherwise 
would have incurred to identify and enroll low-income, 
uninsured children who are eligible but not enrolled in 
such plans; and 
(D) any recommendations for legislative or administra-
tive changes that would improve the effectiveness of 
enrolling children in such plans through reliance on such 
findings. 
(2) REPORT TO CONGRESS.—Not later than September 30, 
2012, the Secretary shall submit a report to Congress on the 
results of the evaluation under paragraph (1). 
(3) FUNDING.— 
(A) IN GENERAL.—Out of any funds in the Treasury 
not otherwise appropriated, there is appropriated to the 
Secretary to carry out the evaluation under this subsection 
$5,000,000 for the period of fiscal years 2009 through 2012. 
(B) BUDGET AUTHORITY.—Subparagraph (A) constitutes 
budget authority in advance of appropriations Act and rep-
resents the obligation of the Federal Government to provide 
for the payment of such amount to conduct the evaluation 
under this subsection. 
(c) ELECTRONIC TRANSMISSION OF INFORMATION.—Section 1902 
(42 U.S.C. 1396a) is amended by adding at the end the following 
new subsection: 
‘‘(dd) ELECTRONIC TRANSMISSION OF INFORMATION.—If the State 
agency determining eligibility for medical assistance under this 
title or child health assistance under title XXI verifies an element 
of eligibility based on information from an Express Lane Agency 
(as defined in subsection (e)(13)(F)), or from another public agency, 
then the applicant’s signature under penalty of perjury shall not 
be required as to such element. Any signature requirement for 
an application for medical assistance may be satisfied through 
an electronic signature, as defined in section 1710(1) of the Govern-
ment Paperwork Elimination Act (44 U.S.C. 3504 note). The require-
ments of subparagraphs (A) and (B) of section 1137(d)(2) may 
be met through evidence in digital or electronic form.’’. 
(d) AUTHORIZATION OF INFORMATION DISCLOSURE.—
H. R. 2—41 
(1) IN GENERAL.—Title XIX is amended by adding at the 
end the following new section: 
‘‘SEC. 1942. AUTHORIZATION TO RECEIVE RELEVANT INFORMATION. 
‘‘(a) IN GENERAL.—Notwithstanding any other provision of law, 
a Federal or State agency or private entity in possession of the 
sources of data directly relevant to eligibility determinations under 
this title (including eligibility files maintained by Express Lane 
agencies described in section 1902(e)(13)(F), information described 
in paragraph (2) or (3) of section 1137(a), vital records information 
about births in any State, and information described in sections 
453(i) and 1902(a)(25)(I)) is authorized to convey such data or 
information to the State agency administering the State plan under 
this title, to the extent such conveyance meets the requirements 
of subsection (b). 
‘‘(b) REQUIREMENTS
FOR CONVEYANCE.—Data or information 
may be conveyed pursuant to subsection (a) only if the following 
requirements are met: 
‘‘(1) The individual whose circumstances are described in 
the data or information (or such individual’s parent, guardian, 
caretaker relative, or authorized representative) has either pro-
vided advance consent to disclosure or has not objected to 
disclosure after receiving advance notice of disclosure and a 
reasonable opportunity to object. 
‘‘(2) Such data or information are used solely for the pur-
poses of— 
‘‘(A) identifying individuals who are eligible or poten-
tially eligible for medical assistance under this title and 
enrolling or attempting to enroll such individuals in the 
State plan; and 
‘‘(B) verifying the eligibility of individuals for medical 
assistance under the State plan. 
‘‘(3) An interagency or other agreement, consistent with 
standards developed by the Secretary— 
‘‘(A) prevents the unauthorized use, disclosure, or modi-
fication of such data and otherwise meets applicable Fed-
eral requirements safeguarding privacy and data security; 
and 
‘‘(B) requires the State agency administering the State 
plan to use the data and information obtained under this 
section to seek to enroll individuals in the plan. 
‘‘(c) PENALTIES FOR IMPROPER DISCLOSURE.— 
‘‘(1) CIVIL MONEY PENALTY.—A private entity described in 
the subsection (a) that publishes, discloses, or makes known 
in any manner, or to any extent not authorized by Federal 
law, any information obtained under this section is subject 
to a civil money penalty in an amount equal to $10,000 for 
each such unauthorized publication or disclosure. The provi-
sions of section 1128A (other than subsections (a) and (b) and 
the second sentence of subsection (f)) shall apply to a civil 
money penalty under this paragraph in the same manner as 
such provisions apply to a penalty or proceeding under section 
1128A(a). 
‘‘(2) CRIMINAL PENALTY.—A private entity described in the 
subsection (a) that willfully publishes, discloses, or makes 
known in any manner, or to any extent not authorized by 
Federal law, any information obtained under this section shall
H. R. 2—42 
be fined not more than $10,000 or imprisoned not more than 
1 year, or both, for each such unauthorized publication or 
disclosure. 
‘‘(d) RULE
OF CONSTRUCTION.—The limitations and require-
ments that apply to disclosure pursuant to this section shall not 
be construed to prohibit the conveyance or disclosure of data or 
information otherwise permitted under Federal law (without regard 
to this section).’’. 
(2) CONFORMING
AMENDMENT
TO
TITLE
XXI.—Section 
2107(e)(1) (42 U.S.C. 1397gg(e)(1)), as amended by subsection 
(a)(2), is amended by adding at the end the following new 
subparagraph: 
‘‘(F) Section 1942 (relating to authorization to receive 
data directly relevant to eligibility determinations).’’. 
(3) CONFORMING AMENDMENT TO PROVIDE ACCESS TO DATA 
ABOUT ENROLLMENT IN INSURANCE FOR PURPOSES OF EVALU-
ATING
APPLICATIONS
AND
FOR
CHIP.—Section 1902(a)(25)(I)(i) 
(42 U.S.C. 1396a(a)(25)(I)(i)) is amended— 
(A) by inserting ‘‘(and, at State option, individuals 
who apply or whose eligibility for medical assistance is 
being evaluated in accordance with section 1902(e)(13)(D))’’ 
after ‘‘with respect to individuals who are eligible’’; and 
(B) by inserting ‘‘under this title (and, at State option, 
child health assistance under title XXI)’’ after ‘‘the State 
plan’’. 
(e) AUTHORIZATION
FOR
STATES
ELECTING
EXPRESS
LANE 
OPTION TO RECEIVE CERTAIN DATA DIRECTLY RELEVANT TO DETER-
MINING ELIGIBILITY AND CORRECT AMOUNT OF ASSISTANCE.—The 
Secretary shall enter into such agreements as are necessary to 
permit a State that elects the Express Lane option under section 
1902(e)(13) of the Social Security Act to receive data directly rel-
evant to eligibility determinations and determining the correct 
amount of benefits under a State child health plan under CHIP 
or a State plan under Medicaid from the following: 
(1) The National Directory of New Hires established under 
section 453(i) of the Social Security Act (42 U.S.C. 653(i)). 
(2) Data regarding enrollment in insurance that may help 
to facilitate outreach and enrollment under the State Medicaid 
plan, the State CHIP plan, and such other programs as the 
Secretary may specify. 
(f) EFFECTIVE DATE.—The amendments made by this section 
are effective on the date of the enactment of this Act. 
Subtitle B—Reducing Barriers to 
Enrollment 
SEC. 211. VERIFICATION OF DECLARATION OF CITIZENSHIP OR 
NATIONALITY FOR PURPOSES OF ELIGIBILITY FOR MED-
ICAID AND CHIP. 
(a) ALTERNATIVE STATE PROCESS FOR VERIFICATION OF DEC-
LARATION OF CITIZENSHIP OR NATIONALITY FOR PURPOSES OF ELIGI-
BILITY FOR MEDICAID.— 
(1) ALTERNATIVE TO DOCUMENTATION REQUIREMENT.— 
(A) IN GENERAL.—Section 1902 (42 U.S.C. 1396a), as 
amended by section 203(c), is amended— 
(i) in subsection (a)(46)—
H. R. 2—43 
(I) by inserting ‘‘(A)’’ after ‘‘(46)’’; 
(II) by adding ‘‘and’’ after the semicolon; and 
(III) by adding at the end the following new 
subparagraph: 
‘‘(B) provide, with respect to an individual declaring to 
be a citizen or national of the United States for purposes 
of establishing eligibility under this title, that the State shall 
satisfy the requirements of— 
‘‘(i) section 1903(x); or 
‘‘(ii) subsection (ee);’’; and 
(ii) by adding at the end the following new sub-
section: 
‘‘(ee)(1) For purposes of subsection (a)(46)(B)(ii), the require-
ments of this subsection with respect to an individual declaring 
to be a citizen or national of the United States for purposes of 
establishing eligibility under this title, are, in lieu of requiring 
the individual to present satisfactory documentary evidence of citi-
zenship or nationality under section 1903(x) (if the individual is 
not described in paragraph (2) of that section), as follows: 
‘‘(A) The State submits the name and social security 
number of the individual to the Commissioner of Social Security 
as part of the program established under paragraph (2). 
‘‘(B) If the State receives notice from the Commissioner 
of Social Security that the name or social security number, 
or the declaration of citizenship or nationality, of the individual 
is inconsistent with information in the records maintained by 
the Commissioner— 
‘‘(i) the State makes a reasonable effort to identify 
and address the causes of such inconsistency, including 
through typographical or other clerical errors, by contacting 
the individual to confirm the accuracy of the name or 
social security number submitted or declaration of citizen-
ship or nationality and by taking such additional actions 
as the Secretary, through regulation or other guidance, 
or the State may identify, and continues to provide the 
individual with medical assistance while making such 
effort; and 
‘‘(ii) in the case such inconsistency is not resolved 
under clause (i), the State— 
‘‘(I) notifies the individual of such fact; 
‘‘(II) provides the individual with a period of 90 
days from the date on which the notice required under 
subclause (I) is received by the individual to either 
present satisfactory documentary evidence of citizen-
ship or nationality (as defined in section 1903(x)(3)) 
or resolve the inconsistency with the Commissioner 
of Social Security (and continues to provide the indi-
vidual with medical assistance during such 90-day 
period); and 
‘‘(III) disenrolls the individual from the State plan 
under this title within 30 days after the end of such 
90-day period if no such documentary evidence is pre-
sented or if such inconsistency is not resolved. 
‘‘(2)(A) Each State electing to satisfy the requirements of this 
subsection for purposes of section 1902(a)(46)(B) shall establish 
a program under which the State submits at least monthly to 
the Commissioner of Social Security for comparison of the name
H. R. 2—44 
and social security number, of each individual newly enrolled in 
the State plan under this title that month who is not described 
in section 1903(x)(2) and who declares to be a United States citizen 
or national, with information in records maintained by the Commis-
sioner. 
‘‘(B) In establishing the State program under this paragraph, 
the State may enter into an agreement with the Commissioner 
of Social Security— 
‘‘(i) to provide, through an on-line system or otherwise, 
for the electronic submission of, and response to, the informa-
tion submitted under subparagraph (A) for an individual 
enrolled in the State plan under this title who declares to 
be citizen or national on at least a monthly basis; or 
‘‘(ii) to provide for a determination of the consistency of 
the information submitted with the information maintained 
in the records of the Commissioner through such other method 
as agreed to by the State and the Commissioner and approved 
by the Secretary, provided that such method is no more burden-
some for individuals to comply with than any burdens that 
may apply under a method described in clause (i). 
‘‘(C) The program established under this paragraph shall pro-
vide that, in the case of any individual who is required to submit 
a social security number to the State under subparagraph (A) 
and who is unable to provide the State with such number, shall 
be provided with at least the reasonable opportunity to present 
satisfactory documentary evidence of citizenship or nationality (as 
defined in section 1903(x)(3)) as is provided under clauses (i) and 
(ii) of section 1137(d)(4)(A) to an individual for the submittal to 
the State of evidence indicating a satisfactory immigration status. 
‘‘(3)(A) The State agency implementing the plan approved under 
this title shall, at such times and in such form as the Secretary 
may specify, provide information on the percentage each month 
that the inconsistent submissions bears to the total submissions 
made for comparison for such month. For purposes of this subpara-
graph, a name, social security number, or declaration of citizenship 
or nationality of an individual shall be treated as inconsistent 
and included in the determination of such percentage only if— 
‘‘(i) the information submitted by the individual is not 
consistent with information in records maintained by the 
Commissioner of Social Security; 
‘‘(ii) the inconsistency is not resolved by the State; 
‘‘(iii) the individual was provided with a reasonable period 
of time to resolve the inconsistency with the Commissioner 
of Social Security or provide satisfactory documentation of citi-
zenship status and did not successfully resolve such inconsist-
ency; and 
‘‘(iv) payment has been made for an item or service fur-
nished to the individual under this title. 
‘‘(B) If, for any fiscal year, the average monthly percentage 
determined under subparagraph (A) is greater than 3 percent— 
‘‘(i) the State shall develop and adopt a corrective plan 
to review its procedures for verifying the identities of individ-
uals seeking to enroll in the State plan under this title and 
to identify and implement changes in such procedures to 
improve their accuracy; and 
‘‘(ii) pay to the Secretary an amount equal to the amount 
which bears the same ratio to the total payments under the
H. R. 2—45 
State plan for the fiscal year for providing medical assistance 
to individuals who provided inconsistent information as the 
number of individuals with inconsistent information in excess 
of 3 percent of such total submitted bears to the total number 
of individuals with inconsistent information. 
‘‘(C) The Secretary may waive, in certain limited cases, all 
or part of the payment under subparagraph (B)(ii) if the State 
is unable to reach the allowable error rate despite a good faith 
effort by such State. 
‘‘(D) Subparagraphs (A) and (B) shall not apply to a State 
for a fiscal year if there is an agreement described in paragraph 
(2)(B) in effect as of the close of the fiscal year that provides 
for the submission on a real-time basis of the information described 
in such paragraph. 
‘‘(4) Nothing in this subsection shall affect the rights of any 
individual under this title to appeal any disenrollment from a 
State plan.’’. 
(B) 
COSTS
OF
IMPLEMENTING
AND
MAINTAINING 
SYSTEM.—Section 1903(a)(3) (42 U.S.C. 1396b(a)(3)) is 
amended— 
(i) by striking ‘‘plus’’ at the end of subparagraph 
(E) and inserting ‘‘and’’, and 
(ii) by adding at the end the following new 
subparagraph: 
‘‘(F)(i) 90 percent of the sums expended during the 
quarter as are attributable to the design, development, 
or installation of such mechanized verification and informa-
tion retrieval systems as the Secretary determines are nec-
essary to implement section 1902(ee) (including a system 
described in paragraph (2)(B) thereof), and 
‘‘(ii) 75 percent of the sums expended during the 
quarter as are attributable to the operation of systems 
to which clause (i) applies, plus’’. 
(2) LIMITATION ON WAIVER AUTHORITY.—Notwithstanding 
any provision of section 1115 of the Social Security Act (42 
U.S.C. 1315), or any other provision of law, the Secretary 
may not waive the requirements of section 1902(a)(46)(B) of 
such Act (42 U.S.C. 1396a(a)(46)(B)) with respect to a State. 
(3) CONFORMING AMENDMENTS.—Section 1903 (42 U.S.C. 
1396b) is amended— 
(A) in subsection (i)(22), by striking ‘‘subsection (x)’’ 
and inserting ‘‘section 1902(a)(46)(B)’’; and 
(B) in subsection (x)(1), by striking ‘‘subsection (i)(22)’’ 
and inserting ‘‘section 1902(a)(46)(B)(i)’’. 
(4) APPROPRIATION.—Out of any money in the Treasury 
of the United States not otherwise appropriated, there are 
appropriated to the Commissioner of Social Security $5,000,000 
to remain available until expended to carry out the Commis-
sioner’s responsibilities under section 1902(ee) of the Social 
Security Act, as added by subsection (a). 
(b) CLARIFICATION
OF REQUIREMENTS RELATING
TO PRESEN-
TATION OF SATISFACTORY DOCUMENTARY EVIDENCE OF CITIZENSHIP 
OR NATIONALITY.— 
(1) ACCEPTANCE OF DOCUMENTARY EVIDENCE ISSUED BY A 
FEDERALLY
RECOGNIZED
INDIAN
TRIBE.—Section 1903(x)(3)(B) 
(42 U.S.C. 1396b(x)(3)(B)) is amended— 
(A) by redesignating clause (v) as clause (vi); and
H. R. 2—46 
(B) by inserting after clause (iv), the following new 
clause: 
‘‘(v)(I) Except as provided in subclause (II), a document 
issued by a federally recognized Indian tribe evidencing mem-
bership or enrollment in, or affiliation with, such tribe (such 
as a tribal enrollment card or certificate of degree of Indian 
blood). 
‘‘(II) With respect to those federally recognized Indian tribes 
located within States having an international border whose 
membership includes individuals who are not citizens of the 
United States, the Secretary shall, after consulting with such 
tribes, issue regulations authorizing the presentation of such 
other forms of documentation (including tribal documentation, 
if appropriate) that the Secretary determines to be satisfactory 
documentary evidence of citizenship or nationality for purposes 
of satisfying the requirement of this subsection.’’. 
(2) REQUIREMENT TO PROVIDE REASONABLE OPPORTUNITY 
TO PRESENT SATISFACTORY DOCUMENTARY EVIDENCE.—Section 
1903(x) (42 U.S.C. 1396b(x)) is amended by adding at the 
end the following new paragraph: 
‘‘(4) In the case of an individual declaring to be a citizen 
or national of the United States with respect to whom a State 
requires the presentation of satisfactory documentary evidence of 
citizenship or nationality under section 1902(a)(46)(B)(i), the indi-
vidual shall be provided at least the reasonable opportunity to 
present satisfactory documentary evidence of citizenship or nation-
ality under this subsection as is provided under clauses (i) and 
(ii) of section 1137(d)(4)(A) to an individual for the submittal to 
the State of evidence indicating a satisfactory immigration status.’’. 
(3) CHILDREN BORN IN THE UNITED STATES TO MOTHERS 
ELIGIBLE FOR MEDICAID.— 
(A) CLARIFICATION
OF
RULES.—Section 1903(x) (42 
U.S.C. 1396b(x)), as amended by paragraph (2), is 
amended— 
(i) in paragraph (2)— 
(I) in subparagraph (C), by striking ‘‘or’’ at 
the end; 
(II) by redesignating subparagraph (D) as 
subparagraph (E); and 
(III) by inserting after subparagraph (C) the 
following new subparagraph: 
‘‘(D) pursuant to the application of section 1902(e)(4) (and, 
in the case of an individual who is eligible for medical assistance 
on such basis, the individual shall be deemed to have provided 
satisfactory documentary evidence of citizenship or nationality 
and shall not be required to provide further documentary evi-
dence on any date that occurs during or after the period in 
which the individual is eligible for medical assistance on such 
basis); or’’; and 
(ii) by adding at the end the following new para-
graph: 
‘‘(5) Nothing in subparagraph (A) or (B) of section 1902(a)(46), 
the preceding paragraphs of this subsection, or the Deficit Reduction 
Act of 2005, including section 6036 of such Act, shall be construed 
as changing the requirement of section 1902(e)(4) that a child 
born in the United States to an alien mother for whom medical 
assistance for the delivery of such child is available as treatment
H. R. 2—47 
of an emergency medical condition pursuant to subsection (v) shall 
be deemed eligible for medical assistance during the first year 
of such child’s life.’’. 
(B) STATE REQUIREMENT TO ISSUE SEPARATE IDENTI-
FICATION
NUMBER.—Section 
1902(e)(4) 
(42 
U.S.C. 
1396a(e)(4)) is amended by adding at the end the following 
new sentence: ‘‘Notwithstanding the preceding sentence, 
in the case of a child who is born in the United States 
to an alien mother for whom medical assistance for the 
delivery of the child is made available pursuant to section 
1903(v), the State immediately shall issue a separate 
identification number for the child upon notification by 
the facility at which such delivery occurred of the child’s 
birth.’’. 
(4) TECHNICAL AMENDMENTS.—Section 1903(x)(2) (42 U.S.C. 
1396b(x)) is amended— 
(A) in subparagraph (B)— 
(i) by realigning the left margin of the matter 
preceding clause (i) 2 ems to the left; and 
(ii) by realigning the left margins of clauses (i) 
and (ii), respectively, 2 ems to the left; and 
(B) in subparagraph (C)— 
(i) by realigning the left margin of the matter 
preceding clause (i) 2 ems to the left; and 
(ii) by realigning the left margins of clauses (i) 
and (ii), respectively, 2 ems to the left. 
(c) APPLICATION OF DOCUMENTATION SYSTEM TO CHIP.— 
(1) IN GENERAL.—Section 2105(c) (42 U.S.C. 1397ee(c)), as 
amended by section 114(a), is amended by adding at the end 
the following new paragraph: 
‘‘(9) CITIZENSHIP DOCUMENTATION REQUIREMENTS.— 
‘‘(A) IN GENERAL.—No payment may be made under 
this section with respect to an individual who has, or 
is, declared to be a citizen or national of the United States 
for purposes of establishing eligibility under this title 
unless the State meets the requirements of section 
1902(a)(46)(B) with respect to the individual. 
‘‘(B) ENHANCED
PAYMENTS.—Notwithstanding sub-
section (b), the enhanced FMAP with respect to payments 
under subsection (a) for expenditures described in clause 
(i) or (ii) of section 1903(a)(3)(F) necessary to comply with 
subparagraph (A) shall in no event be less than 90 percent 
and 75 percent, respectively.’’. 
(2) NONAPPLICATION
OF
ADMINISTRATIVE
EXPENDITURES 
CAP.—Section 2105(c)(2)(C) (42 U.S.C. 1397ee(c)(2)(C)), as 
amended by section 202(b), is amended by adding at the end 
the following: 
‘‘(ii) EXPENDITURES TO COMPLY WITH CITIZENSHIP 
OR
NATIONALITY
VERIFICATION
REQUIREMENTS.— 
Expenditures necessary for the State to comply with 
paragraph (9)(A).’’. 
(d) EFFECTIVE DATE.— 
(1) IN GENERAL.— 
(A) IN GENERAL.—Except as provided in subparagraph 
(B), the amendments made by this section shall take effect 
on January 1, 2010.
H. R. 2—48 
(B) TECHNICAL AMENDMENTS.—The amendments made 
by— 
(i) paragraphs (1), (2), and (3) of subsection (b) 
shall take effect as if included in the enactment of 
section 6036 of the Deficit Reduction Act of 2005 
(Public Law 109–171; 120 Stat. 80); and 
(ii) paragraph (4) of subsection (b) shall take effect 
as if included in the enactment of section 405 of divi-
sion B of the Tax Relief and Health Care Act of 2006 
(Public Law 109–432; 120 Stat. 2996). 
(2) RESTORATION OF ELIGIBILITY.—In the case of an indi-
vidual who, during the period that began on July 1, 2006, 
and ends on October 1, 2009, was determined to be ineligible 
for medical assistance under a State Medicaid plan, including 
any waiver of such plan, solely as a result of the application 
of subsections (i)(22) and (x) of section 1903 of the Social 
Security Act (as in effect during such period), but who would 
have been determined eligible for such assistance if such sub-
sections, as amended by subsection (b), had applied to the 
individual, a State may deem the individual to be eligible 
for such assistance as of the date that the individual was 
determined to be ineligible for such medical assistance on such 
basis. 
(3) SPECIAL TRANSITION RULE FOR INDIANS.—During the 
period that begins on July 1, 2006, and ends on the effective 
date of final regulations issued under subclause (II) of section 
1903(x)(3)(B)(v) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1396b(x)(3)(B)(v)) (as added by subsection (b)(1)(B)), an indi-
vidual who is a member of a federally-recognized Indian tribe 
described in subclause (II) of that section who presents a docu-
ment described in subclause (I) of such section that is issued 
by such Indian tribe, shall be deemed to have presented satis-
factory evidence of citizenship or nationality for purposes of 
satisfying the requirement of subsection (x) of section 1903 
of such Act. 
SEC. 212. REDUCING ADMINISTRATIVE BARRIERS TO ENROLLMENT. 
Section 2102(b) (42 U.S.C. 1397bb(b)) is amended— 
(1) by redesignating paragraph (4) as paragraph (5); and 
(2) by inserting after paragraph (3) the following new para-
graph: 
‘‘(4) REDUCTION OF ADMINISTRATIVE BARRIERS TO ENROLL-
MENT.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 
plan shall include a description of the procedures used 
to reduce administrative barriers to the enrollment of chil-
dren and pregnant women who are eligible for medical 
assistance under title XIX or for child health assistance 
or health benefits coverage under this title. Such proce-
dures shall be established and revised as often as the 
State determines appropriate to take into account the most 
recent information available to the State identifying such 
barriers. 
‘‘(B) DEEMED COMPLIANCE IF JOINT APPLICATION AND 
RENEWAL PROCESS THAT PERMITS APPLICATION OTHER THAN 
IN
PERSON.—A State shall be deemed to comply with 
subparagraph (A) if the State’s application and renewal
H. R. 2—49 
forms and supplemental forms (if any) and information 
verification process is the same for purposes of establishing 
and renewing eligibility for children and pregnant women 
for medical assistance under title XIX and child health 
assistance under this title, and such process does not 
require an application to be made in person or a face- 
to-face interview.’’. 
SEC. 213. MODEL OF INTERSTATE COORDINATED ENROLLMENT AND 
COVERAGE PROCESS. 
(a) IN GENERAL.—In order to assure continuity of coverage 
of low-income children under the Medicaid program and the State 
Children’s Health Insurance Program (CHIP), not later than 18 
months after the date of the enactment of this Act, the Secretary 
of Health and Human Services, in consultation with State Medicaid 
and CHIP directors and organizations representing program bene-
ficiaries, shall develop a model process for the coordination of the 
enrollment, retention, and coverage under such programs of children 
who, because of migration of families, emergency evacuations, nat-
ural or other disasters, public health emergencies, educational 
needs, or otherwise, frequently change their State of residency 
or otherwise are temporarily located outside of the State of their 
residency. 
(b) REPORT TO CONGRESS.—After development of such model 
process, the Secretary of Health and Human Services shall submit 
to Congress a report describing additional steps or authority needed 
to make further improvements to coordinate the enrollment, reten-
tion, and coverage under CHIP and Medicaid of children described 
in subsection (a). 
SEC. 214. PERMITTING STATES TO ENSURE COVERAGE WITHOUT A 
5-YEAR DELAY OF CERTAIN CHILDREN AND PREGNANT 
WOMEN UNDER THE MEDICAID PROGRAM AND CHIP. 
(a) MEDICAID PROGRAM.—Section 1903(v) (42 U.S.C. 1396b(v)) 
is amended— 
(1) in paragraph (1), by striking ‘‘paragraph (2)’’ and 
inserting ‘‘paragraphs (2) and (4)’’; and 
(2) by adding at the end the following new paragraph: 
‘‘(4)(A) A State may elect (in a plan amendment under this 
title) to provide medical assistance under this title, notwithstanding 
sections 401(a), 402(b), 403, and 421 of the Personal Responsibility 
and Work Opportunity Reconciliation Act of 1996, to children and 
pregnant women who are lawfully residing in the United States 
(including battered individuals described in section 431(c) of such 
Act) and who are otherwise eligible for such assistance, within 
either or both of the following eligibility categories: 
‘‘(i) PREGNANT
WOMEN.—Women during pregnancy (and 
during the 60-day period beginning on the last day of the 
pregnancy). 
‘‘(ii) CHILDREN.—Individuals under 21 years of age, 
including optional targeted low-income children described in 
section 1905(u)(2)(B). 
‘‘(B) In the case of a State that has elected to provide medical 
assistance to a category of aliens under subparagraph (A), no debt 
shall accrue under an affidavit of support against any sponsor 
of such an alien on the basis of provision of assistance to such 
category and the cost of such assistance shall not be considered 
as an unreimbursed cost.
H. R. 2—50 
‘‘(C) As part of the State’s ongoing eligibility redetermination 
requirements and procedures for an individual provided medical 
assistance as a result of an election by the State under subpara-
graph (A), a State shall verify that the individual continues to 
lawfully reside in the United States using the documentation pre-
sented to the State by the individual on initial enrollment. If 
the State cannot successfully verify that the individual is lawfully 
residing in the United States in this manner, it shall require 
that the individual provide the State with further documentation 
or other evidence to verify that the individual is lawfully residing 
in the United States.’’. 
(b) CHIP.—Section 2107(e)(1) (42 U.S.C. 1397gg(e)(1)), as 
amended by sections 203(a)(2) and 203(d)(2), is amended by redesig-
nating subparagraphs (E) and (F) as subparagraphs (F) and (G), 
respectively and by inserting after subparagraph (D) the following 
new subparagraph: 
‘‘(E) Paragraph (4) of section 1903(v) (relating to 
optional coverage of categories of lawfully residing 
immigrant children or pregnant women), but only if the 
State has elected to apply such paragraph with respect 
to such category of children or pregnant women under 
title XIX.’’. 
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. 
(a) CHIP.— 
(1) IN GENERAL.—Section 2105(c) (42 U.S.C. 1397ee(c)), as 
amended by sections 114(a) and 211(c), is amended by adding 
at the end the following: 
‘‘(10) STATE OPTION TO OFFER PREMIUM ASSISTANCE.— 
‘‘(A) IN GENERAL.—A State may elect to offer a pre-
mium assistance subsidy (as defined in subparagraph (C)) 
for qualified employer-sponsored coverage (as defined in 
subparagraph (B)) to all targeted low-income children who 
are eligible for child health assistance under the plan and 
have access to such coverage in accordance with the 
requirements of this paragraph. No subsidy shall be pro-
vided to a targeted low-income child under this paragraph 
unless the child (or the child’s parent) voluntarily elects 
to receive such a subsidy. A State may not require such 
an election as a condition of receipt of child health assist-
ance. 
‘‘(B) QUALIFIED EMPLOYER-SPONSORED COVERAGE.— 
‘‘(i) IN
GENERAL.—Subject to clause (ii), in this 
paragraph, the term ‘qualified employer-sponsored cov-
erage’ means a group health plan or health insurance 
coverage offered through an employer—