H. R. 2015—304
‘‘(B) that children found through the screening to be
eligible for medical assistance under the State medicaid
plan under title XIX are enrolled for such assistance under
such plan;
‘‘(C) that the insurance provided under the State child
health plan does not substitute for coverage under group
health plans;
‘‘(D) the provision of child health assistance to targeted
low-income children in the State who are Indians (as
defined in section 4(c) of the Indian Health Care Improve-
ment Act, 25 U.S.C. 1603(c)); and
‘‘(E) coordination with other public and private pro-
grams providing creditable coverage for low-income chil-
dren.
‘‘(4) NONENTITLEMENT.—Nothing in this title shall be con-
strued as providing an individual with an entitlement to child
health assistance under a State child health plan.
‘‘(c) OUTREACH AND COORDINATION.—A State child health plan
shall include a description of the procedures to be used by the
State to accomplish the following:
‘‘(1) OUTREACH.—Outreach to families of children likely
to be eligible for child health assistance under the plan or
under other public or private health coverage programs to
inform these families of the availability of, and to assist them
in enrolling their children in, such a program.
‘‘(2) COORDINATION WITH OTHER HEALTH INSURANCE PRO-
GRAMS.—Coordination of the administration of the State pro-
gram under this title with other public and private health
insurance programs.
‘‘SEC. 2103. COVERAGE REQUIREMENTS FOR CHILDREN’S HEALTH
INSURANCE.
‘‘(a) REQUIRED SCOPE OF HEALTH INSURANCE COVERAGE.—The
child health assistance provided to a targeted low-income child
under the plan in the form described in paragraph (1) of section
2101(a) shall consist, consistent with subsection (c)(5), of any of
the following:
‘‘(1) BENCHMARK COVERAGE.—Health benefits coverage that
is equivalent to the benefits coverage in a benchmark benefit
package described in subsection (b).
‘‘(2) BENCHMARK-EQUIVALENT COVERAGE.—Health benefits
coverage that meets the following requirements:
‘‘(A) INCLUSION
OF
BASIC
SERVICES.—The coverage
includes benefits for items and services within each of
the categories of basic services described in subsection
(c)(1).
‘‘(B) AGGREGATE
ACTUARIAL
VALUE
EQUIVALENT
TO
BENCHMARK
PACKAGE.—The coverage has an aggregate
actuarial value that is at least actuarially equivalent to
one of the benchmark benefit packages.
‘‘(C) SUBSTANTIAL ACTUARIAL VALUE FOR ADDITIONAL
SERVICES INCLUDED IN BENCHMARK PACKAGE.—With respect
to each of the categories of additional services described
in subsection (c)(2) for which coverage is provided under
the benchmark benefit package used under subparagraph
(B), the coverage has an actuarial value that is equal
H. R. 2015—305
to at least 75 percent of the actuarial value of the coverage
of that category of services in such package.
‘‘(3) EXISTING COMPREHENSIVE STATE-BASED COVERAGE.—
Health benefits coverage under an existing comprehensive
State-based program, described in subsection (d)(1).
‘‘(4) SECRETARY-APPROVED
COVERAGE.—Any other health
benefits coverage that the Secretary determines, upon applica-
tion by a State, provides appropriate coverage for the population
of targeted low-income children proposed to be provided such
coverage.
‘‘(b) BENCHMARK BENEFIT PACKAGES.—The benchmark benefit
packages are as follows:
‘‘(1) FEHBP-EQUIVALENT
CHILDREN’S
HEALTH
INSURANCE
COVERAGE.—The standard Blue Cross/Blue Shield preferred
provider option service benefit plan, described in and offered
under section 8903(1) of title 5, United States Code.
‘‘(2) STATE EMPLOYEE COVERAGE.—A health benefits cov-
erage plan that is offered and generally available to State
employees in the State involved.
‘‘(3) COVERAGE OFFERED THROUGH HMO.—The health insur-
ance coverage plan that—
‘‘(A) is offered by a health maintenance organization
(as defined in section 2791(b)(3) of the Public Health Serv-
ice Act), and
‘‘(B) has the largest insured commercial, non-medicaid
enrollment of covered lives of such coverage plans offered
by such a health maintenance organization in the State
involved.
‘‘(c) CATEGORIES OF SERVICES; DETERMINATION OF ACTUARIAL
VALUE OF COVERAGE.—
‘‘(1) CATEGORIES OF BASIC SERVICES.—For purposes of this
section, the categories of basic services described in this para-
graph are as follows:
‘‘(A) Inpatient and outpatient hospital services.
‘‘(B) Physicians’ surgical and medical services.
‘‘(C) Laboratory and x-ray services.
‘‘(D) Well-baby and well-child care, including age-
appropriate immunizations.
‘‘(2) CATEGORIES OF ADDITIONAL SERVICES.—For purposes
of this section, the categories of additional services described
in this paragraph are as follows:
‘‘(A) Coverage of prescription drugs.
‘‘(B) Mental health services.
‘‘(C) Vision services.
‘‘(D) Hearing services.
‘‘(3) TREATMENT OF OTHER CATEGORIES.—Nothing in this
subsection shall be construed as preventing a State child health
plan from providing coverage of benefits that are not within
a category of services described in paragraph (1) or (2).
‘‘(4) DETERMINATION OF ACTUARIAL VALUE.—The actuarial
value of coverage of benchmark benefit packages, coverage
offered under the State child health plan, and coverage of
any categories of additional services under benchmark benefit
packages and under coverage offered by such a plan, shall
be set forth in an actuarial opinion in an actuarial report
that has been prepared—
H. R. 2015—306
‘‘(A) by an individual who is a member of the American
Academy of Actuaries;
‘‘(B) using generally accepted actuarial principles and
methodologies;
‘‘(C) using a standardized set of utilization and price
factors;
‘‘(D) using a standardized population that is represent-
ative of privately insured children of the age of children
who are expected to be covered under the State child health
plan;
‘‘(E) applying the same principles and factors in
comparing the value of different coverage (or categories
of services);
‘‘(F) without taking into account any differences in
coverage based on the method of delivery or means of
cost control or utilization used; and
‘‘(G) taking into account the ability of a State to reduce
benefits by taking into account the increase in actuarial
value of benefits coverage offered under the State child
health plan that results from the limitations on cost sharing
under such coverage.
The actuary preparing the opinion shall select and specify
in the memorandum the standardized set and population to
be used under subparagraphs (C) and (D).
‘‘(5) CONSTRUCTION ON PROHIBITED COVERAGE.—Nothing in
this section shall be construed as requiring any health benefits
coverage offered under the plan to provide coverage for items
or services for which payment is prohibited under this title,
notwithstanding that any benchmark benefit package includes
coverage for such an item or service.
‘‘(d) DESCRIPTION OF EXISTING COMPREHENSIVE STATE-BASED
COVERAGE.—
‘‘(1) IN GENERAL.—A program described in this paragraph
is a child health coverage program that—
‘‘(A) includes coverage of a range of benefits;
‘‘(B) is administered or overseen by the State and
receives funds from the State;
‘‘(C) is offered in New York, Florida, or Pennsylvania;
and
‘‘(D) was offered as of the date of the enactment of
this title.
‘‘(2) MODIFICATIONS.—A State may modify a program
described in paragraph (1) from time to time so long as it
continues to meet the requirement of subparagraph (A) and
does not reduce the actuarial value of the coverage under
the program below the lower of—
‘‘(A) the actuarial value of the coverage under the
program as of the date of the enactment of this title,
or
‘‘(B) the actuarial value described in subsection
(a)(2)(B),
evaluated as of the time of the modification.
‘‘(e) COST-SHARING.—
‘‘(1) DESCRIPTION; GENERAL CONDITIONS.—
‘‘(A) DESCRIPTION.—A State child health plan shall
include a description, consistent with this subsection, of
the amount (if any) of premiums, deductibles, coinsurance,
H. R. 2015—307
and other cost sharing imposed. Any such charges shall
be imposed pursuant to a public schedule.
‘‘(B) PROTECTION FOR LOWER INCOME CHILDREN.—The
State child health plan may only vary premiums,
deductibles, coinsurance, and other cost sharing based on
the family income of targeted low-income children in a
manner that does not favor children from families with
higher income over children from families with lower
income.
‘‘(2) NO COST SHARING ON BENEFITS FOR PREVENTIVE SERV-
ICES.—The State child health plan may not impose deductibles,
coinsurance, or other cost sharing with respect to benefits for
services within the category of services described in subsection
(c)(1)(D).
‘‘(3) LIMITATIONS ON PREMIUMS AND COST-SHARING.—
‘‘(A) CHILDREN IN FAMILIES WITH INCOME BELOW 150
PERCENT OF POVERTY LINE.—In the case of a targeted low-
income child whose family income is at or below 150 percent
of the poverty line, the State child health plan may not
impose—
‘‘(i) an enrollment fee, premium, or similar charge
that exceeds the maximum monthly charge permitted
consistent with standards established to carry out sec-
tion 1916(b)(1) (with respect to individuals described
in such section); and
‘‘(ii) a deductible, cost sharing, or similar charge
that exceeds an amount that is nominal (as determined
consistent with regulations referred to in section
1916(a)(3), with such appropriate adjustment for infla-
tion or other reasons as the Secretary determines to
be reasonable).
‘‘(B) OTHER CHILDREN.—For children not described in
subparagraph (A), subject to paragraphs (1)(B) and (2),
any premiums, deductibles, cost sharing or similar charges
imposed under the State child health plan may be imposed
on a sliding scale related to income, except that the total
annual aggregate cost-sharing with respect to all targeted
low-income children in a family under this title may not
exceed 5 percent of such family’s income for the year
involved.
‘‘(4) RELATION
TO
MEDICAID
REQUIREMENTS.—Nothing in
this subsection shall be construed as affecting the rules relating
to the use of enrollment fees, premiums, deductions, cost shar-
ing, and similar charges in the case of targeted low-income
children who are provided child health assistance in the form
of coverage under a medicaid program under section 2101(a)(2).
‘‘(f) APPLICATION OF CERTAIN REQUIREMENTS.—
‘‘(1) RESTRICTION ON APPLICATION OF PREEXISTING CONDI-
TION EXCLUSIONS.—
‘‘(A) IN GENERAL.—Subject to subparagraph (B), the
State child health plan shall not permit the imposition
of any preexisting condition exclusion for covered benefits
under the plan.
‘‘(B) GROUP HEALTH PLANS AND GROUP HEALTH INSUR-
ANCE COVERAGE.—If the State child health plan provides
for benefits through payment for, or a contract with, a
group health plan or group health insurance coverage, the
H. R. 2015—308
plan may permit the imposition of a preexisting condition
exclusion but only insofar as it is permitted under the
applicable provisions of part 7 of subtitle B of title I of
the Employee Retirement Income Security Act of 1974 and
title XXVII of the Public Health Service Act.
‘‘(2) COMPLIANCE
WITH
OTHER
REQUIREMENTS.—Coverage
offered under this section shall comply with the requirements
of subpart 2 of part A of title XXVII of the Public Health
Service Act insofar as such requirements apply with respect
to a health insurance issuer that offers group health insurance
coverage.
‘‘SEC. 2104. ALLOTMENTS.
‘‘(a) APPROPRIATION; TOTAL ALLOTMENT.—For the purpose of
providing allotments to States under this section, there is appro-
priated, out of any money in the Treasury not otherwise appro-
priated—
‘‘(1) for fiscal year 1998, $4,275,000,000;
‘‘(2) for fiscal year 1999, $4,275,000,000;
‘‘(3) for fiscal year 2000, $4,275,000,000;
‘‘(4) for fiscal year 2001, $4,275,000,000;
‘‘(5) for fiscal year 2002, $3,150,000,000;
‘‘(6) for fiscal year 2003, $3,150,000,000;
‘‘(7) for fiscal year 2004, $3,150,000,000;
‘‘(8) for fiscal year 2005, $4,050,000,000;
‘‘(9) for fiscal year 2006, $4,050,000,000; and
‘‘(10) for fiscal year 2007, $5,000,000,000.
‘‘(b) ALLOTMENTS TO 50 STATES AND DISTRICT OF COLUMBIA.—
‘‘(1) IN GENERAL.—Subject to paragraph (4) and subsection
(d), of the amount available for allotment under subsection
(a) for a fiscal year, reduced by the amount of allotments
made under subsection (c) for the fiscal year, the Secretary
shall allot to each State (other than a State described in such
subsection) with a State child health plan approved under
this title the same proportion as the ratio of—
‘‘(A) the product of (i) the number of children described
in paragraph (2) for the State for the fiscal year and
(ii) the State cost factor for that State (established under
paragraph (3)); to
‘‘(B) the sum of the products computed under subpara-
graph (A).
‘‘(2) NUMBER OF CHILDREN.—
‘‘(A) IN GENERAL.—The number of children described
in this paragraph for a State for—
‘‘(i) each of fiscal years 1998 through 2000 is equal
to the number of low-income children in the State
with no health insurance coverage for the fiscal year;
‘‘(ii) fiscal year 2001 is equal to—
‘‘(I) 75 percent of the number of low-income
children in the State for the fiscal year with no
health insurance coverage, plus
‘‘(II) 25 percent of the number of low-income
children in the State for the fiscal year; and
‘‘(iii) each succeeding fiscal year is equal to—
‘‘(I) 50 percent of the number of low-income
children in the State for the fiscal year with no
health insurance coverage, plus
H. R. 2015—309
‘‘(II) 50 percent of the number of low-income
children in the State for the fiscal year.
‘‘(B) DETERMINATION OF NUMBER OF CHILDREN.—For
purposes of subparagraph (A), a determination of the num-
ber of low-income children (and of such children who have
no health insurance coverage) for a State for a fiscal year
shall be made on the basis of the arithmetic average of
the number of such children, as reported and defined in
the 3 most recent March supplements to the Current Popu-
lation Survey of the Bureau of the Census before the begin-
ning of the fiscal year.
‘‘(3) ADJUSTMENT FOR GEOGRAPHIC VARIATIONS IN HEALTH
COSTS.—
‘‘(A) IN GENERAL.—For purposes of paragraph (1)(A)(ii),
the ‘State cost factor’ for a State for a fiscal year equal
to the sum of—
‘‘(i) 0.15, and
‘‘(ii) 0.85 multiplied by the ratio of—
‘‘(I) the annual average wages per employee
for the State for such year (as determined under
subparagraph (B)), to
‘‘(II) the annual average wages per employee
for the 50 States and the District of Columbia.
‘‘(B) ANNUAL AVERAGE WAGES PER EMPLOYEE.—For pur-
poses of subparagraph (A), the ‘annual average wages per
employee’ for a State, or for all the States. for a fiscal
year is equal to the average of the annual wages per
employee for the State or for the 50 States and the District
of Columbia for employees in the health services industry
(SIC code 8000), as reported by the Bureau of Labor Statis-
tics of the Department of Labor for each of the most recent
3 years before the beginning of the fiscal year involved.
‘‘(4) FLOOR FOR STATES.—Subject to paragraph (5), in no
case shall the amount of the allotment under this subsection
for one of the 50 States or the District of Columbia for a
year be less than $2,000,000. To the extent that the application
of the previous sentence results in an increase in the allotment
to a State above the amount otherwise provided, the allotments
for the other States and the District of Columbia under this
subsection shall be reduced in a pro rata manner (but not
below $2,000,000) so that the total of such allotments in a
fiscal year does not exceed the amount otherwise provided
for allotment under paragraph (1) for that fiscal year.
‘‘(c) ALLOTMENTS TO TERRITORIES.—
‘‘(1) IN GENERAL.—Of the amount available for allotment
under subsection (a) for a fiscal year, subject to subsection
(d), the Secretary shall allot 0.25 percent among each of the
commonwealths and territories described in paragraph (3) in
the same proportion as the percentage specified in paragraph
(2) for such commonwealth or territory bears to the sum of
such percentages for all such commonwealths or territories
so described.
‘‘(2) PERCENTAGE.—The percentage specified in this para-
graph for—
‘‘(A) Puerto Rico is 91.6 percent,
‘‘(B) Guam is 3.5 percent,
‘‘(C) Virgin Islands is 2.6 percent,
H. R. 2015—310
‘‘(D) American Samoa is 1.2 percent, and
‘‘(E) the Northern Mariana Islands is 1.1 percent.
‘‘(3) COMMONWEALTHS AND TERRITORIES.—A commonwealth
or territory described in this paragraph is any of the following
if it has a State child health plan approved under this title:
‘‘(A) Puerto Rico.
‘‘(B) Guam.
‘‘(C) the Virgin Islands.
‘‘(D) American Samoa.
‘‘(E) the Northern Mariana Islands.
‘‘(d) CERTAIN
MEDICAID
EXPENDITURES
COUNTED
AGAINST
INDIVIDUAL STATE ALLOTMENTS.—The amount of the allotment
otherwise provided to a State under subsection (b) or (c) for a
fiscal year shall be reduced by the sum of—
‘‘(1) the amount (if any) of the payments made to that
State under section 1903(a) for calendar quarters during such
fiscal year that is attributable to the provision of medical assist-
ance to a child during a presumptive eligibility period under
section 1920A, and
‘‘(2) the amount of payments under such section during
such period that is attributable to the provision of medical
assistance to a child for which payment is made under section
1903(a)(1) on the basis of an enhanced FMAP under section
1905(b).
‘‘(e) 3-YEAR AVAILABILITY OF AMOUNTS ALLOTTED.—Amounts
allotted to a State pursuant to this section for a fiscal year shall
remain available for expenditure by the State through the end
of the second succeeding fiscal year; except that amounts reallotted
to a State under subsection (f) shall be available for expenditure
by the State through the end of the fiscal year in which they
are reallotted.
‘‘(f) PROCEDURE
FOR
REDISTRIBUTION
OF
UNUSED
ALLOT-
MENTS.—The Secretary shall determine an appropriate procedure
for redistribution of allotments from States that were provided
allotments under this section for a fiscal year but that do not
expend all of the amount of such allotments during the period
in which such allotments are available for expenditure under sub-
section (e), to States that have fully expended the amount of their
allotments under this section.
‘‘SEC. 2105. PAYMENTS TO STATES.
‘‘(a) IN GENERAL.—Subject to the succeeding provisions of this
section, the Secretary shall pay to each State with a plan approved
under this title, from its allotment under section 2104 (taking
into account any adjustment under section 2104(d)), an amount
for each quarter equal to the enhanced FMAP of expenditures
in the quarter—
‘‘(1) for child health assistance under the plan for targeted
low-income children in the form of providing health benefits
coverage that meets the requirements of section 2103; and
‘‘(2) only to the extent permitted consistent with subsection
(c)—
‘‘(A) for payment for other child health assistance for
targeted low-income children;
H. R. 2015—311
‘‘(B) for expenditures for health services initiatives
under the plan for improving the health of children (includ-
ing targeted low-income children and other low-income chil-
dren);
‘‘(C) for expenditures for outreach activities as provided
in section 2102(c)(1) under the plan; and
‘‘(D) for other reasonable costs incurred by the State
to administer the plan.
‘‘(b) ENHANCED FMAP.—For purposes of subsection (a), the
‘enhanced FMAP’, for a State for a fiscal year, is equal to the
Federal medical assistance percentage (as defined in the first sen-
tence of section 1905(b)) for the State increased by a number of
percentage points equal to 30 percent of the number of percentage
points by which (1) such Federal medical assistance percentage
for the State, is less than (2) 100 percent; but in no case shall
the enhanced FMAP for a State exceed 85 percent.
‘‘(c) LIMITATION ON CERTAIN PAYMENTS FOR CERTAIN EXPENDI-
TURES.—
‘‘(1) GENERAL
LIMITATIONS.—Funds provided to a State
under this title shall only be used to carry out the purposes
of this title (as described in section 2101), and any health
insurance coverage provided with such funds may include cov-
erage of abortion only if necessary to save the life of the
mother or if the pregnancy is the result of an act of rape
or incest.
‘‘(2) LIMITATION ON EXPENDITURES NOT USED FOR MEDICAID
OR HEALTH INSURANCE ASSISTANCE.—
‘‘(A) IN GENERAL.—Except as provided in this para-
graph, payment shall not be made under subsection (a)
for expenditures for items described in subsection (a) (other
than paragraph (1)) for a quarter in a fiscal year to the
extent the total of such expenditures exceeds 10 percent
of the sum of—
‘‘(i) the total Federal payments made under sub-
section (a) for such quarter in the fiscal year, and
‘‘(ii) the total Federal payments made under sec-
tion 1903(a)(1) based on an enhanced FMAP described
in section 1905(u)(2) for such quarter.
‘‘(B) WAIVER AUTHORIZED FOR COST-EFFECTIVE ALTER-
NATIVE.—The limitation under subparagraph (A) on
expenditures for items described in subsection (a)(2) shall
not apply to the extent that a State establishes to the
satisfaction of the Secretary that—
‘‘(i) coverage provided to targeted low-income chil-
dren through such expenditures meets the require-
ments of section 2103;
‘‘(ii) the cost of such coverage is not greater, on
an average per child basis, than the cost of coverage
that would otherwise be provided under section 2103;
and
‘‘(iii) such coverage is provided through the use
of a community-based health delivery system, such
as through contracts with health centers receiving
funds under section 330 of the Public Health Service
Act or with hospitals such as those that receive dis-
proportionate share payment adjustments under sec-
tion 1886(d)(5)(F) or 1923.
H. R. 2015—312
‘‘(3) WAIVER FOR PURCHASE OF FAMILY COVERAGE.—Pay-
ment may be made to a State under subsection (a)(1) for the
purchase of family coverage under a group health plan or
health insurance coverage that includes coverage of targeted
low-income children only if the State establishes to the satisfac-
tion of the Secretary that—
‘‘(A) purchase of such coverage is cost-effective relative
to the amounts that the State would have paid to obtain
comparable coverage only of the targeted low-income chil-
dren involved, and
‘‘(B) such coverage shall not be provided if it would
otherwise substitute for health insurance coverage that
would be provided to such children but for the purchase
of family coverage.
‘‘(4) USE
OF
NON-FEDERAL
FUNDS
FOR
STATE
MATCHING
REQUIREMENT.—Amounts provided by the Federal Government,
or services assisted or subsidized to any significant extent
by the Federal Government, may not be included in determining
the amount of non-Federal contributions required under sub-
section (a).
‘‘(5) OFFSET OF RECEIPTS ATTRIBUTABLE TO PREMIUMS AND
OTHER
COST-SHARING.—For purposes of subsection (a), the
amount of the expenditures under the plan shall be reduced
by the amount of any premiums and other cost-sharing received
by the State.
‘‘(6) PREVENTION OF DUPLICATIVE PAYMENTS.—
‘‘(A) OTHER HEALTH PLANS.—No payment shall be made
to a State under this section for expenditures for child
health assistance provided for a targeted low-income child
under its plan to the extent that a private insurer (as
defined by the Secretary by regulation and including a
group health plan (as defined in section 607(1) of the
Employee Retirement Income Security Act of 1974), a serv-
ice benefit plan, and a health maintenance organization)
would have been obligated to provide such assistance but
for a provision of its insurance contract which has the
effect of limiting or excluding such obligation because the
individual is eligible for or is provided child health assist-
ance under the plan.
‘‘(B) OTHER
FEDERAL
GOVERNMENTAL
PROGRAMS.—
Except as otherwise provided by law, no payment shall
be made to a State under this section for expenditures
for child health assistance provided for a targeted low-
income child under its plan to the extent that payment
has been made or can reasonably be expected to be made
promptly (as determined in accordance with regulations)
under any other federally operated or financed health care
insurance program, other than an insurance program oper-
ated or financed by the Indian Health Service, as identified
by the Secretary. For purposes of this paragraph, rules
similar to the rules for overpayments under section
1903(d)(2) shall apply.
‘‘(7) LIMITATION ON PAYMENT FOR ABORTIONS.—
‘‘(A) IN GENERAL.—Payment shall not be made to a
State under this section for any amount expended under
the State plan to pay for any abortion or to assist in