I
105TH CONGRESS
2D SESSION
H. R. 4767
To amend titles XIX and XXI of the Social Security Act to improve the
coverage of needy children under the State Children’s Health Insurance
Program (SCHIP) and the Medicaid Program.
IN THE HOUSE OF REPRESENTATIVES
OCTOBER 9, 1998
Ms. DEGETTE introduced the following bill; which was referred to the
Committee on Commerce
A BILL
To amend titles XIX and XXI of the Social Security Act
to improve the coverage of needy children under the
State Children’s Health Insurance Program (SCHIP)
and the Medicaid Program.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; REFERENCES IN ACT; TABLE OF
CONTENTS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Improved Children’s Health Coverage Act of 1998’’.
(b) REFERENCES TO SOCIAL SECURITY ACT.—Ex-
cept as otherwise expressly provided, whenever in this Act
an amendment or repeal is expressed in terms of an
amendment to, or repeal of, a section or other provision,
the reference shall be considered to be made to a section
or other provision of the Social Security Act.
(c) TABLE OF CONTENTS.—The table of contents of
this Act is as follows:
Sec. 1. Short title; references in Act; table of contents.
Sec. 2. Simplified outreach and enrollment.
Sec. 3. Family friendly coverage and enrollment.
Sec. 4. Expanded coverage options.
SEC. 2. SIMPLIFIED OUTREACH AND ENROLLMENT.
(a) USE OF UNIFORM APPLICATION AND COORDI-
NATED ENROLLMENT PROCESS.—
(1) SCHIP 
PROGRAM.—Section 2102 (42
U.S.C. 1397bb) is amended by adding at the end the
following new subsection:
‘‘(d) DEVELOPMENT AND USE OF UNIFORM APPLI-
CATION FORMS AND COORDINATED ENROLLMENT PROC-
ESS.—
‘‘(1) IN GENERAL.—A State child health plan
shall provide, by not later than October 1, 1999,
for—
‘‘(A) the development and use of a uni-
form, simplified application form which is used
both for purposes of establishing eligibility for
benefits under this title and also under title
XIX;
‘‘(B) an enrollment process that is coordi-
nated with that under title XIX so that a fam-
ily need only interact with a single agency in
order to determine whether a child is eligible
for benefits under this title or title XIX; and
‘‘(C) acceptance and timely response to
telephone inquiries and other electronic commu-
nications received through the national toll-free
system established under section 3 of the Im-
proved Children’s Health Coverage Act of
1998.’’.
(2) MEDICAID CONFORMING AMENDMENT.—
(A) IN
GENERAL.—Section 1902(a) (42
U.S.C. 1396a(a)) is amended—
(i) by striking the period at the end of
paragraph (65) and inserting ‘‘; and’’, and
(ii) by inserting after paragraph (65)
the following new paragraph:
‘‘(66) provide, by not later than October 1,
1999, in the case of a State with a State child
health plan under title XXI for—
‘‘(A) the development and use of a uni-
form, simplified application form which is used
both for purposes of establishing eligibility for
benefits under this title and also under title
XXI;
‘‘(B) establishment and operation of an en-
rollment process that is coordinated with that
under title XXI so that a family need only
interact with a single agency in order to deter-
mine whether a child is eligible for benefits
under this title or title XXI; and
‘‘(C) acceptance and timely response to
telephone inquiries and other electronic commu-
nications received through the national toll-free
system established under section 3 of the Im-
proved Children’s Health Coverage Act of
1998.’’.
(B) EFFECTIVE DATE.—The amendments
made by subparagraph (A) apply to calendar
quarters beginning on or after October 1, 1999.
(b) NATIONAL TOLL-FREE INFORMATION LINE.—
The Secretary of Health and Human Services shall estab-
lish, in coordination with State agencies responsible for
administration of State Medicaid and child health insur-
ance programs and by not later than October 1, 1999,
for a national toll-free telephone number that individuals
may access to obtain information on coverage of children
under such programs.
(c) FINANCIAL INCENTIVES TO PROMOTE APPRO-
PRIATE ENROLLMENT.—
(1) ELIMINATING LIMITATION ON ADMINISTRA-
TIVE EXPENDITURES FOR ENROLLMENT AND OUT-
REACH
ACTIVITIES.—Section 2105 (42 U.S.C.
1397ee) is amended—
(A) in subsection (a)(2)(D), by striking the
period and inserting the following: ‘‘, including
costs to administer section 2102(d) regardless
of whether such expenditures might also be re-
lated to the administration of title XIX.
The Secretary shall permit common administrative ex-
penditures described in paragraph (2)(D) between this
title and title XIX to be paid for under this title.’’;
(B) in subsection (c)(2)(A), by striking
‘‘paragraph (1)’’ and inserting ‘‘paragraphs (1)
and (2)(C)’’; and
(C) by adding at the end of subsection
(c)(2) the following:
‘‘(C) EXCEPTION FOR COORDINATED OUT-
REACH
AND
ENROLLMENT
EXPENDITURES.—
The limitation under subparagraph (A) on ex-
penditures for items described in subsection
(a)(2) shall not apply to reasonable administra-
tive costs incurred in carrying out section
2102(d) or described in the last sentence of
subsection (a).’’.
(2) ADDITIONAL ACTIVITIES TO ASSURE APPRO-
PRIATE
ENROLLMENT.—Section 2105 is further
amended by adding at the end the following new
subsection:
‘‘(e) AUDITS
OF ENROLLMENT PROCESSES; DIS-
ALLOWANCE BASED ON SUCH AUDITS.—
‘‘(1) PERIODIC AUDITS.—Each State shall pro-
vide for periodic independent audits of the enroll-
ment practices to determine the extent to which chil-
dren provided assistance under this title are eligible
for medical assistance under title XIX (and, there-
fore, should be provided assistance under that title
rather than under this title).
‘‘(2) DISALLOWANCE
BASED
ON
EXTRAPO-
LATION OF AUDIT RESULTS.—Insofar as an audit
under paragraph (1) finds that the proportion of
children provided assistance in a State under this
title are eligible for medical assistance under title
XIX exceeds 5 percent, the Secretary shall provide
that the reference to the enhanced FMAP in sub-
section (a) shall be treated as a reference to the
Federal medical assistance percentage (as defined in
the first sentence of section 1905(b)) with respect to
expenditures for child health assistance for such ex-
cess proportion of child health assistance.’’.
(3) EFFECTIVE DATE.—The amendments made
by this subsection take effect on the date of the en-
actment of this Act and apply to expenditures made
on or after the date of the enactment of this Act.
(d) ADDITIONAL ENTITIES QUALIFIED TO DETER-
MINE MEDICAID PRESUMPTIVE ELIGIBILITY FOR LOW-IN-
COME CHILDREN.—
(1) Section 1920A(b)(3)(A)(i) (42 U.S.C.
1396r–1a(b)(3)(A)(i)) is amended—
(A) by striking ‘‘or (II)’’ and inserting ‘‘,
(II)’’; and
(B) by inserting ‘‘eligibility of a child for
medical assistance under the State plan under
this title, or eligibility of a child for child health
assistance under the program funded under
title XXI, or (III) is an elementary school or
secondary school, as such terms are defined in
section 14101 of the Elementary and Secondary
Education Act of 1965 (20 U.S.C. 8801), an el-
ementary or secondary school operated or sup-
ported by the Bureau of Indian Affairs, a State
child support enforcement agency, a child care
resource and referral agency, or a State office
or private contractor that accepts applications
for or administers a program funded under part
A of title IV or that determines eligibility for
any assistance or benefits provided under any
program of public or assisted housing that re-
ceives Federal funds, including the program
under section 8 or any other section of the
United States Housing Act of 1937 (42 U.S.C.
1437 et seq.)’’ before the semicolon.
SEC. 3. FAMILY FRIENDLY COVERAGE AND ENROLLMENT.
(a) ASSURING COORDINATION OF PEDIATRIC PRO-
VIDERS WITHIN A FAMILY.—
(1) IN
GENERAL.—Section 2103 (42 U.S.C.
1397cc) is amended by adding at the end the follow-
ing new subsection:
‘‘(g) STEPS TAKEN TO COORDINATE PROVISION OF
PEDIATRIC CARE WITHIN
A FAMILY.—A State child
health plan—
‘‘(1) shall specify methods being used to ensure
that children within a family who are eligible for as-
sistance under the plan (or under a State plan under
title XIX) are allowed to be seen by the same pedia-
trician or group of pediatricians in a manner that
permits the coordinated receipt of care by children
in the same family; and
‘‘(2) shall include a description of such methods
in each annual report submitted under section
2108(a).’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) applies on the date of the enact-
ment of this Act and to reports submitted for years
beginning with 1999.
(b) REDUCTION
IN BURDEN
OF ADMINISTERING
COST-SHARING PROVISIONS.—
(1) STATE
RESPONSIBLE
FOR
ASSURING
CAP
ON
COST-SHARING
NOT
EXCEEDED.—Section
2103(e)(3) (42 U.S.C. 1397cc(e)(3)) is amended by
adding at the end the following new subparagraph:
‘‘(C) STATE AND CONTRACTORS RESPON-
SIBLE FOR APPLYING LIMITATIONS ON COST-
SHARING.—The State child health plan shall
provide that responsibility for assuring compli-
ance with the limitations on cost-sharing under
this paragraph falls on the State and on its
contractors, and not on beneficiaries and their
families.’’.
(2) STATE OPTION OF FLAT LIMIT ON OUT-OF-
POCKET
EXPENDITURES.—Section 
2103(e)(3)(B)
(42 U.S.C. 1397cc(e)(3)(B)) is amended by insert-
ing before the period at the end the following: ‘‘(or,
at the option of a State, a limiting amount which is
not greater than $500)’’.
(3) EFFECTIVE DATE.—The amendment made
by paragraph (1) takes effect on the date that is 30
days after the date of the enactment of this Act.
(c) PROHIBITION OF WAITING PERIODS.—
(1) IN GENERAL.—Section 2102(b)(1)(B) (42
U.S.C. 1397bb(b)(1)(B)) is amended—
(A) by striking ‘‘and’’ at the end of clause
(i);
(B) by striking the period at the end of
clause (ii) and inserting ‘‘; and’’; and
(C) by adding at the end the following new
clause:
‘‘(iii) shall not permit the use of any
mandatory waiting period (including any
such period in order to carry out para-
graph (3)(C)), unless the Secretary finds
that the imposition of such a period would
not be contrary to the provisions of this
title.’’.
(2) EFFECTIVE DATE.—The amendments made
by paragraph (1) apply to assistance furnished on or
after the date of the enactment of this Act.
(d) GRACE PERIOD
AND PRIOR NOTICE BEFORE
DISENROLLMENT FOR NONPAYMENT OF PREMIUMS.—
(1) IN GENERAL.—Section 2103(e) (42 U.S.C.
1397ee(e)) is amended by adding at the end the fol-
lowing new paragraph:
‘‘(5) GRACE
PERIOD.—Before disenrolling a
child under a State child health plan for non-
payment of a premium, the plan shall provide for
notice in writing to the family involved and a grace
period (of not less than 30 days) in which payment
may be made without disenrollment.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) applies to disenrollments occurring
on or after the date that is 30 days after the date
of the enactment of this Act.
SEC. 4. EXPANDED COVERAGE OPTIONS.
(a) AUTOMATIC REASSESSMENT OF ELIGIBILITY FOR
SCHIP BENEFITS
FOR CHILDREN LOSING MEDICAID
ELIGIBILITY.—
(1) IN
GENERAL.—Section 1902(a)(66) (42
U.S.C. 1396a(a)(66)), as inserted by section 2(a)(2),
is amended—
(A) by striking ‘‘and’’ at the end of sub-
paragraph (B),
(B) by striking the period at the end of
subparagraph (C) and inserting ‘‘; and’’; and
(C) by adding at the end the following new
subparagraph:
‘‘(D) the automatic assessment, in the case
of a child who loses eligibility for medical assist-
ance under this title on the basis of changes in
income, assets, or age, of whether the child is
eligible for benefits under title XXI.’’.
(2) EFFECTIVE DATE.—The amendments made
by paragraph (1) apply to children who lose eligi-
bility under the medicaid program under title XIX
of the Social Security Act on or after the date that
is 30 days after the date of the enactment of this
Act.
(b) OPTIONAL COVERAGE OF LOW-INCOME, UNIN-
SURED PREGNANT WOMEN UNDER
A STATE CHILD
HEALTH PLAN.—
(1) IN GENERAL.—Title XXI is amended by
adding at the end the following new section:
‘‘SEC. 2111. OPTIONAL COVERAGE OF LOW-INCOME, UNIN-
SURED PREGNANT WOMEN.
‘‘(a) OPTIONAL COVERAGE.—Notwithstanding any
other provision of this title, a State child health plan may
provide for coverage of pregnancy-related assistance for
targeted low-income pregnant women in accordance with
this section.
‘‘(b) DEFINITIONS.—For purposes of this section:
‘‘(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 to other conditions that may complicate preg-
nancy and shall not include prepregnancy services
and supplies.
‘‘(2) 
TARGETED
LOW-INCOME
PREGNANT
WOMAN.—The term ‘targeted low-income pregnant
woman’ has the meaning given the term targeted
low-income child in section 2110(b) as if any ref-
erence to a child were deemed a reference to a
woman during pregnancy and through the end of the
month in which the 60-day period (beginning on the
last day of her pregnancy) ends.
‘‘(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 sub-
section (b)) to a targeted low income child is deemed
to include a reference to a targeted low-income preg-
nant 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).
‘‘(4) The medicaid applicable income level is
deemed a reference to the income level established
under section 1902(l)(2)(A).
‘‘(5) 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) is deemed not
to require, in such case, compliance with the require-
ments of section 2103(a).
‘‘(6) There shall be no exclusion of benefits for
services described in subsection (b)(1) based on any
pre-existing condition.
‘‘(d) NO IMPACT ON ALLOTMENTS.—Nothing in this
section shall be construed as affecting the amount of any
initial allotment provided to a State under section
2104(b).
‘‘(e) APPLICATION OF FUNDING RESTRICTIONS.—
The coverage under this section (and the funding of such
coverage) is subject to the restrictions of section 2105(c).
‘‘(f) DEEMED ELIGIBILITY FOR 1-YEAR FOR CHIL-
DREN BORN TO PRESUMPTIVELY ELIGIBLE TARGETED
PREGNANT WOMEN.—If a child is born to a targeted low-
income pregnant woman who was receiving pregnancy-re-
lated assistance under this section at the time of the birth,
the child shall be deemed, notwithstanding any other pro-
vision of this title, to be a targeted low-income child until
the child attains 1 year of age.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall take effect on the date of the
enactment of this Act and shall apply to allotments
for all fiscal years
(c) STATE OPTION FOR COVERAGE OF LEGAL IMMI-
GRANTS
UNDER
THE
MEDICAID
AND
CHILDREN’S
HEALTH INSURANCE PROGRAMS.—
(1) MEDICAID.—Section 1902(a)(10)(a)(ii) (42
U.S.C. 1396a(a)(10)(A)(ii)) is amended—
(A) by striking ‘‘or’’ at the end of sub-
clause (XIII);
(B) by adding ‘‘or’’ at the end of subclause
(XIV); and
(C) by adding at the end the following new
subclause:
‘‘(XV) who are described in sec-
tion 1905(a)(i) and who would be eli-
gible for medical assistance (or for a
greater amount of medical assistance)
under the State plan under this title
but for the provisions of section 403
or section 421 of Public Law 104–
193, but the State may not exercise
the option of providing medical assist-
ance under this subclause with respect
to a subcategory of individuals de-
scribed in this subclause;’’.
(2) CHILDREN’S
HEALTH
INSURANCE
PRO-
GRAM.—Section 2110(b) (42 U.S.C. 1397jj(b)) is
amended—
(A) in paragraph (1)(A), by inserting be-
fore the semicolon ‘‘(including, at the option of
the State, a child described in paragraph
(3)(B))’’; and
(B) in paragraph (3)—
(i) by striking ‘‘SPECIAL
RULE.—’’
and inserting ‘‘SPECIAL RULES.—
‘‘(i) 
HEALTH
INSURANCE
COV-
ERAGE.—’’ by indenting the remainder of
the text accordingly; and
(ii) by adding at the end the following
new subparagraph:
‘‘(B) ELIGIBILITY FOR LEGAL IMMIGRANT
CHILDREN.—For purposes of paragraph (1)(A),
a child is described in this subparagraph if—
‘‘(i) the child would be determined eli-
gible for child health assistance under this
title but for the provisions of sections 403
and 421 of Public Law 104–193; and
‘‘(ii) the State exercises the option to
provide medical assistance to the category
of 
individuals 
described 
in 
section
1902(a)(10)(A)(ii)(XV).’’.
(d) CLARIFICATION OF COVERAGE UNDER VACCINE
FOR CHILDREN PROGRAM.—
(1) IN
GENERAL.—Section 1928(b)(2)(A)(ii)
(42 U.S.C. 1396s(b)(2)(A)(ii)) is amended by insert-
ing ‘‘, except that for purposes of this paragraph a
child who is only insured under title XXI shall be
considered as being not insured’’ after ‘‘not in-
sured’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall take effect as if included in
the enactment of the Balanced Budget Act of 1997.
(e) ELIMINATION OF FUNDING OFFSET FOR EXER-
CISE OF PRESUMPTIVE ELIGIBILITY OPTION.—
(1) IN GENERAL.—Section 2104(d) (42 U.S.C.
1397dd(d)) is amended by striking ‘‘shall be reduced
by the sum of’’ and all that follows through ‘‘(2) the
amount of payments under such section’’ and insert-
ing ‘‘shall be reduced by the amount of payments
under section 1903(a)(1)’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) first applies for allotments for fis-
cal year 1999.
(f) PROGRAM COORDINATION WITH THE MATERNAL
AND CHILD HEALTH PROGRAM (TITLE V).—
(1) IN
GENERAL.—Section 2102(b)(3) (42
U.S.C. 1397bb(b)(3)) is amended—
(A) by striking ‘‘and’’ at the end of sub-
paragraph (D);
(B) by striking the period at the end of
subparagraph (E) and inserting ‘‘; and’’; and