H. R. 976—40 
SEC. 202. INCREASED OUTREACH AND ENROLLMENT OF INDIANS. 
(a) IN GENERAL.—Section 1139 (42 U.S.C. 1320b–9) is amended 
to read as follows: 
‘‘SEC. 1139. IMPROVED ACCESS TO, AND DELIVERY OF, HEALTH CARE 
FOR INDIANS UNDER TITLES XIX AND XXI. 
‘‘(a) AGREEMENTS WITH STATES FOR MEDICAID AND CHIP OUT-
REACH ON OR NEAR RESERVATIONS TO INCREASE THE ENROLLMENT 
OF INDIANS IN THOSE PROGRAMS.— 
‘‘(1) IN GENERAL.—In order to improve the access of Indians 
residing on or near a reservation to obtain benefits under 
the Medicaid and State children’s health insurance programs 
established under titles XIX and XXI, the Secretary shall 
encourage the State to take steps to provide for enrollment 
on or near the reservation. Such steps may include outreach 
efforts such as the outstationing of eligibility workers, entering 
into agreements with the Indian Health Service, Indian Tribes, 
Tribal Organizations, and Urban Indian Organizations to pro-
vide outreach, education regarding eligibility and benefits, 
enrollment, and translation services when such services are 
appropriate. 
‘‘(2) CONSTRUCTION.—Nothing in paragraph (1) shall be 
construed as affecting arrangements entered into between 
States and the Indian Health Service, Indian Tribes, Tribal 
Organizations, or Urban Indian Organizations for such Service, 
Tribes, or Organizations to conduct administrative activities 
under such titles. 
‘‘(b) REQUIREMENT TO FACILITATE COOPERATION.—The Sec-
retary, acting through the Centers for Medicare & Medicaid Serv-
ices, shall take such steps as are necessary to facilitate cooperation 
with, and agreements between, States and the Indian Health 
Service, Indian Tribes, Tribal Organizations, or Urban Indian 
Organizations with respect to the provision of health care items 
and services to Indians under the programs established under title 
XIX or XXI. 
‘‘(c) DEFINITION OF INDIAN; INDIAN TRIBE; INDIAN HEALTH PRO-
GRAM; TRIBAL ORGANIZATION; URBAN INDIAN ORGANIZATION.—In 
this section, the terms ‘Indian’, ‘Indian Tribe’, ‘Indian Health Pro-
gram’, ‘Tribal Organization’, and ‘Urban Indian Organization’ have 
the meanings given those terms in section 4 of the Indian Health 
Care Improvement Act.’’. 
(b) NONAPPLICATION OF 10 PERCENT LIMIT ON OUTREACH AND 
CERTAIN
OTHER
EXPENDITURES.—Section 2105(c)(2) (42 U.S.C. 
1397ee(c)(2)) is amended by adding at the end the following: 
‘‘(C) NONAPPLICATION TO CERTAIN EXPENDITURES.—The 
limitation under subparagraph (A) shall not apply with 
respect to the following expenditures: 
‘‘(i) EXPENDITURES TO INCREASE OUTREACH TO, AND 
THE
ENROLLMENT
OF, INDIAN
CHILDREN
UNDER
THIS 
TITLE AND TITLE xix.—Expenditures for outreach activi-
ties to families of Indian children likely to be eligible 
for child health assistance under the plan or medical 
assistance under the State plan under title XIX (or 
under a waiver of such plan), to inform such families 
of the availability of, and to assist them in enrolling 
their children in, such plans, including such activities
H. R. 976—41 
conducted under grants, contracts, or agreements 
entered into under section 1139(a).’’. 
SEC. 203. STATE OPTION TO RELY ON FINDINGS FROM AN EXPRESS 
LANE AGENCY TO CONDUCT SIMPLIFIED ELIGIBILITY 
DETERMINATIONS. 
(a) APPLICATION UNDER MEDICAID AND CHIP PROGRAMS.— 
(1) MEDICAID.—Section 1902(e) (42 U.S.C. 1396a(e)) is 
amended by adding at the end the following: 
‘‘(13) EXPRESS LANE OPTION.— 
‘‘(A) IN GENERAL.— 
‘‘(i) OPTION TO USE A FINDING FROM AN EXPRESS LANE 
AGENCY.—At the option of the State, the State plan may 
provide that in determining eligibility under this title for 
a child (as defined in subparagraph (G)), the State may 
rely on a finding made within a reasonable period (as 
determined by the State) from an Express Lane agency 
(as defined in subparagraph (F)) when it determines 
whether a child satisfies one or more components of eligi-
bility for medical assistance under this title. The State 
may rely on a finding from an Express Lane agency not-
withstanding sections 1902(a)(46)(B) and 1137(d) and any 
differences in budget unit, disregard, deeming or other 
methodology, if the following requirements are met: 
‘‘(I) PROHIBITION ON DETERMINING CHILDREN INELI-
GIBLE FOR COVERAGE.—If a finding from an Express 
Lane agency would result in a determination that a 
child does not satisfy an eligibility requirement for 
medical assistance under this title and for child health 
assistance under title XXI, the State shall determine 
eligibility for assistance using its regular procedures. 
‘‘(II) NOTICE
REQUIREMENT.—For any child who 
is found eligible for medical assistance under the State 
plan under this title or child health assistance under 
title XXI and who is subject to premiums based on 
an Express Lane agency’s finding of such child’s income 
level, the State shall provide notice that the child 
may qualify for lower premium payments if evaluated 
by the State using its regular policies and of the proce-
dures for requesting such an evaluation. 
‘‘(III) COMPLIANCE
WITH
SCREEN
AND
ENROLL 
REQUIREMENT.—The State shall satisfy the require-
ments under subparagraphs (A) and (B) of section 
2102(b)(3) (relating to screen and enroll) before 
enrolling a child in child health assistance under title 
XXI. At its option, the State may fulfill such require-
ments in accordance with either option provided under 
subparagraph (C) of this paragraph. 
‘‘(IV) VERIFICATION OF CITIZENSHIP OR NATIONALITY 
STATUS.—The State shall satisfy the requirements of 
section 1902(a)(46)(B) or 2105(c)(10), as applicable for 
verifications of citizenship or nationality status. 
‘‘(V) CODING.—The State meets the requirements 
of subparagraph (E). 
‘‘(ii) OPTION TO APPLY TO RENEWALS AND REDETERMINA-
TIONS.—The State may apply the provisions of this para-
graph when conducting initial determinations of eligibility,
H. R. 976—42 
redeterminations of eligibility, or both, as described in the 
State plan. 
‘‘(B) RULES OF CONSTRUCTION.—Nothing in this paragraph 
shall be construed— 
‘‘(i) to limit or prohibit a State from taking any actions 
otherwise permitted under this title or title XXI in deter-
mining eligibility for or enrolling children into medical 
assistance under this title or child health assistance under 
title XXI; or 
‘‘(ii) to modify the limitations in section 1902(a)(5) con-
cerning the agencies that may make a determination of 
eligibility for medical assistance under this title. 
‘‘(C) OPTIONS
FOR
SATISFYING
THE
SCREEN
AND
ENROLL 
REQUIREMENT.— 
‘‘(i) IN GENERAL.—With respect to a child whose eligi-
bility for medical assistance under this title or for child 
health assistance under title XXI has been evaluated by 
a State agency using an income finding from an Express 
Lane agency, a State may carry out its duties under sub-
paragraphs (A) and (B) of section 2102(b)(3) (relating to 
screen and enroll) in accordance with either clause (ii) 
or clause (iii). 
‘‘(ii) ESTABLISHING A SCREENING THRESHOLD.— 
‘‘(I) IN
GENERAL.—Under this clause, the State 
establishes a screening threshold set as a percentage 
of the Federal poverty level that exceeds the highest 
income threshold applicable under this title to the 
child by a minimum of 30 percentage points or, at 
State option, a higher number of percentage points 
that reflects the value (as determined by the State 
and described in the State plan) of any differences 
between income methodologies used by the program 
administered by the Express Lane agency and the 
methodologies used by the State in determining eligi-
bility for medical assistance under this title. 
‘‘(II) 
CHILDREN
WITH
INCOME
NOT
ABOVE 
THRESHOLD.—If the income of a child does not exceed 
the screening threshold, the child is deemed to satisfy 
the income eligibility criteria for medical assistance 
under this title regardless of whether such child would 
otherwise satisfy such criteria. 
‘‘(III) CHILDREN WITH INCOME ABOVE THRESHOLD.— 
If the income of a child exceeds the screening threshold, 
the child shall be considered to have an income above 
the Medicaid applicable income level described in sec-
tion 2110(b)(4) and to satisfy the requirement under 
section 2110(b)(1)(C) (relating to the requirement that 
CHIP matching funds be used only for children not 
eligible for Medicaid). If such a child is enrolled in 
child health assistance under title XXI, the State shall 
provide the parent, guardian, or custodial relative with 
the following: 
‘‘(aa) Notice that the child may be eligible 
to receive medical assistance under the State plan 
under this title if evaluated for such assistance 
under the State’s regular procedures and notice 
of the process through which a parent, guardian,
H. R. 976—43 
or custodial relative can request that the State 
evaluate the child’s eligibility for medical assist-
ance under this title using such regular proce-
dures. 
‘‘(bb) A description of differences between the 
medical assistance provided under this title and 
child health assistance under title XXI, including 
differences in cost-sharing requirements and cov-
ered benefits. 
‘‘(iii) TEMPORARY ENROLLMENT IN CHIP PENDING SCREEN 
AND ENROLL.— 
‘‘(I) IN
GENERAL.—Under this clause, a State 
enrolls a child in child health assistance under title 
XXI for a temporary period if the child appears eligible 
for such assistance based on an income finding by 
an Express Lane agency. 
‘‘(II) DETERMINATION OF ELIGIBILITY.—During such 
temporary enrollment period, the State shall determine 
the child’s eligibility for child health assistance under 
title XXI or for medical assistance under this title 
in accordance with this clause. 
‘‘(III) PROMPT
FOLLOW
UP.—In making such a 
determination, the State shall take prompt action to 
determine whether the child should be enrolled in med-
ical assistance under this title or child health assist-
ance under title XXI pursuant to subparagraphs (A) 
and (B) of section 2102(b)(3) (relating to screen and 
enroll). 
‘‘(IV) REQUIREMENT
FOR
SIMPLIFIED
DETERMINA-
TION.—In making such a determination, the State shall 
use procedures that, to the maximum feasible extent, 
reduce the burden imposed on the individual of such 
determination. Such procedures may not require the 
child’s parent, guardian, or custodial relative to provide 
or verify information that already has been provided 
to the State agency by an Express Lane agency or 
another source of information unless the State agency 
has reason to believe the information is erroneous. 
‘‘(V) AVAILABILITY
OF
CHIP
MATCHING
FUNDS 
DURING
TEMPORARY
ENROLLMENT
PERIOD.—Medical 
assistance for items and services that are provided 
to a child enrolled in title XXI during a temporary 
enrollment period under this clause shall be treated 
as child health assistance under such title. 
‘‘(D) OPTION FOR AUTOMATIC ENROLLMENT.— 
‘‘(i) IN GENERAL.—The State may initiate and deter-
mine eligibility for medical assistance under the State Med-
icaid plan or for child health assistance under the State 
CHIP plan without a program application from, or on behalf 
of, the child based on data obtained from sources other 
than the child (or the child’s family), but a child can only 
be automatically enrolled in the State Medicaid plan or 
the State CHIP plan if the child or the family affirmatively 
consents to being enrolled through affirmation and signa-
ture on an Express Lane agency application, if the require-
ment of clause (ii) is met.