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† HR 2 EAS 
(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 de-
sign, development, or installation of such mecha-
nized verification and information retrieval sys-
tems as the Secretary determines are necessary to 
implement section 1902(ee) (including a system 
described in paragraph (2)(B) thereof), and 
‘‘(ii) 75 percent of the sums expended dur-
ing the quarter as are attributable to the oper-
ation of systems to which clause (i) applies, 
plus’’. 
(2) LIMITATION ON WAIVER AUTHORITY.—Not-
withstanding any provision of section 1115 of the So-
cial Security Act (42 U.S.C. 1315), or any other pro-
vision of law, the Secretary may not waive the re-
quirements 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 ‘‘sub-
section 
(x)’’ 
and 
inserting 
‘‘section 
1902(a)(46)(B)’’; and
121 
† HR 2 EAS 
(B) in subsection (x)(1), by striking ‘‘sub-
section 
(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 appro-
priated, there are appropriated to the Commissioner 
of Social Security $5,000,000 to remain available 
until expended to carry out the Commissioner’s re-
sponsibilities under section 1902(ee) of the Social Se-
curity Act, as added by subsection (a). 
(b) CLARIFICATION OF REQUIREMENTS RELATING TO 
PRESENTATION
OF SATISFACTORY DOCUMENTARY EVI-
DENCE 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 
(B) by inserting after clause (iv), the fol-
lowing new clause: 
‘‘(v)(I) Except as provided in subclause (II), a 
document issued by a federally recognized Indian 
tribe evidencing membership or enrollment in, or af-
122 
† HR 2 EAS 
filiation 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 inter-
national border whose membership includes individ-
uals 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 docu-
mentation, if appropriate) that the Secretary deter-
mines to be satisfactory documentary evidence of citi-
zenship or nationality for purposes of satisfying the 
requirement of this subsection.’’. 
(2) REQUIREMENT TO PROVIDE REASONABLE OP-
PORTUNITY
TO
PRESENT
SATISFACTORY
DOCUMEN-
TARY
EVIDENCE.—Section 
1903(x) 
(42 
U.S.C. 
1396b(x)) is amended by adding at the end the fol-
lowing 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 docu-
mentary evidence of citizenship or nationality under section 
1902(a)(46)(B)(i), the individual shall be provided at least 
the reasonable opportunity to present satisfactory documen-
tary evidence of citizenship or nationality under this sub-
123 
† HR 2 EAS 
section 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 sta-
tus.’’. 
(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 strik-
ing ‘‘or’’ at the end; 
(II) by redesignating subpara-
graph (D) as subparagraph (E); and 
(III) by inserting after subpara-
graph (C) the following new subpara-
graph: 
‘‘(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 indi-
vidual shall be deemed to have provided satisfactory 
documentary evidence of citizenship or nationality 
and shall not be required to provide further documen-
tary evidence on any date that occurs during or after
124 
† HR 2 EAS 
the period in which the individual is eligible for med-
ical assistance on such basis); or’’; and 
(ii) by adding at the end the following 
new paragraph: 
‘‘(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 de-
livery of such child is available as treatment of an emer-
gency 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 SEPA-
RATE
IDENTIFICATION
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 imme-
diately shall issue a separate identification num-
ber for the child upon notification by the facility
125 
† HR 2 EAS 
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
REQUIRE-
MENTS.—
126 
† HR 2 EAS 
‘‘(A) IN
GENERAL.—No payment may be 
made under this section with respect to an indi-
vidual who has, or is, declared to be a citizen or 
national of the United States for purposes of es-
tablishing eligibility under this title unless the 
State 
meets 
the 
requirements 
of 
section 
1902(a)(46)(B) with respect to the individual. 
‘‘(B) 
ENHANCED
PAYMENTS.—Notwith-
standing subsection (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
EX-
PENDITURES 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.—
127 
† HR 2 EAS 
(A) IN GENERAL.—Except as provided in 
subparagraph (B), the amendments made by this 
section shall take effect on January 1, 2010. 
(B) 
TECHNICAL
AMENDMENTS.—The 
amendments made by— 
(i) paragraphs (1), (2), and (3) of sub-
section (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 enact-
ment of section 405 of division 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 individual 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 So-
cial Security Act (as in effect during such period), 
but who would have been determined eligible for such 
assistance if such subsections, as amended by sub-
128 
† HR 2 EAS 
section (b), had applied to the individual, a State 
may deem the individual to be eligible for such assist-
ance as of the date that the individual was deter-
mined 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 individual who is 
a member of a federally-recognized Indian tribe de-
scribed in subclause (II) of that section who presents 
a document described in subclause (I) of such section 
that is issued by such Indian tribe, shall be deemed 
to have presented satisfactory evidence of citizenship 
or nationality for purposes of satisfying the require-
ment of subsection (x) of section 1903 of such Act. 
SEC. 212. REDUCING ADMINISTRATIVE BARRIERS TO EN-
ROLLMENT. 
Section 2102(b) (42 U.S.C. 1397bb(b)) is amended— 
(1) by redesignating paragraph (4) as para-
graph (5); and 
(2) by inserting after paragraph (3) the fol-
lowing new paragraph:
129 
† HR 2 EAS 
‘‘(4) REDUCTION OF ADMINISTRATIVE BARRIERS 
TO ENROLLMENT.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the plan shall include a description 
of the procedures used to reduce administrative 
barriers to the enrollment of children and preg-
nant women who are eligible for medical assist-
ance under title XIX or for child health assist-
ance or health benefits coverage under this title. 
Such procedures 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 APPLI-
CATION 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 forms 
and supplemental forms (if any) and informa-
tion verification process is the same for purposes 
of establishing and renewing eligibility for chil-
dren and pregnant women for medical assistance 
under title XIX and child health assistance 
under this title, and such process does not re-
130 
† HR 2 EAS 
quire an application to be made in person or a 
face-to-face interview.’’. 
SEC. 213. MODEL OF INTERSTATE COORDINATED ENROLL-
MENT AND COVERAGE PROCESS. 
(a) IN GENERAL.—In order to assure continuity of 
coverage of low-income children under the Medicaid pro-
gram and the State Children’s Health Insurance Program 
(CHIP), not later than 18 months after the date of the en-
actment 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 pro-
grams of children who, because of migration of families, 
emergency evacuations, natural or other disasters, public 
health emergencies, educational needs, or otherwise, fre-
quently 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, retention, and coverage under 
CHIP and Medicaid of children described in subsection (a).
131 
† HR 2 EAS 
SEC. 214. PERMITTING STATES TO ENSURE COVERAGE 
WITHOUT A 5-YEAR DELAY OF CERTAIN CHIL-
DREN 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 para-
graph: 
‘‘(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 Rec-
onciliation 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 preg-
nancy (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).
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† HR 2 EAS 
‘‘(B) In the case of a State that has elected to provide 
medical assistance to a category of aliens under subpara-
graph (A), no debt shall accrue under an affidavit of sup-
port 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. 
‘‘(C) As part of the State’s ongoing eligibility redeter-
mination requirements and procedures for an individual 
provided medical assistance as a result of an election by 
the State under subparagraph (A), a State shall verify that 
the individual continues to lawfully reside in the United 
States using the documentation presented 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 documenta-
tion or other evidence to verify that the individual is law-
fully 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 redesignating subparagraphs (E) 
and (F) as subparagraphs (F) and (G), respectively and 
by inserting after subparagraph (D) the following new sub-
paragraph:
133 
† HR 2 EAS 
‘‘(E) Paragraph (4) of section 1903(v) (re-
lating to optional coverage of categories of law-
fully residing immigrant children or pregnant 
women), but only if the State has elected to 
apply such paragraph with respect to such cat-
egory of children or pregnant women under title 
XIX.’’. 
TITLE III—REDUCING BARRIERS 
TO PROVIDING PREMIUM AS-
SISTANCE 
Subtitle A—Additional State Option 
for Providing Premium Assistance 
SEC. 301. ADDITIONAL STATE OPTION FOR PROVIDING PRE-
MIUM 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 AS-
SISTANCE.— 
‘‘(A) IN GENERAL.—A State may elect to 
offer a premium 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
134 
† HR 2 EAS 
eligible for child health assistance under the plan 
and have access to such coverage in accordance 
with the requirements of this paragraph. No sub-
sidy shall be provided 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 
assistance. 
‘‘(B) 
QUALIFIED
EMPLOYER-SPONSORED 
COVERAGE.— 
‘‘(i) IN
GENERAL.—Subject to clause 
(ii), in this paragraph, the term ‘qualified 
employer-sponsored 
coverage’ 
means 
a 
group health plan or health insurance cov-
erage offered through an employer— 
‘‘(I) that qualifies as creditable 
coverage as a group health plan under 
section 2701(c)(1) of the Public Health 
Service Act; 
‘‘(II) for which the employer con-
tribution toward any premium for 
such coverage is at least 40 percent; 
and
135 
† HR 2 EAS 
‘‘(III) that is offered to all indi-
viduals in a manner that would be 
considered a nondiscriminatory eligi-
bility classification for purposes of 
paragraph (3)(A)(ii) of section 105(h) 
of the Internal Revenue Code of 1986 
(but determined without regard to 
clause (i) of subparagraph (B) of such 
paragraph). 
‘‘(ii) EXCEPTION.—Such term does not 
include coverage consisting of— 
‘‘(I) benefits provided under a 
health flexible spending arrangement 
(as defined in section 106(c)(2) of the 
Internal Revenue Code of 1986); or 
‘‘(II) a high deductible health 
plan (as defined in section 223(c)(2) of 
such Code), without regard to whether 
the plan is purchased in conjunction 
with a health savings account (as de-
fined under section 223(d) of such 
Code). 
‘‘(C) PREMIUM ASSISTANCE SUBSIDY.— 
‘‘(i) IN GENERAL.—In this paragraph, 
the term ‘premium assistance subsidy’
136 
† HR 2 EAS 
means, with respect to a targeted low-in-
come child, the amount equal to the dif-
ference between the employee contribution 
required for enrollment only of the employee 
under qualified employer-sponsored coverage 
and the employee contribution required for 
enrollment of the employee and the child in 
such coverage, less any applicable premium 
cost-sharing applied under the State child 
health plan (subject to the limitations im-
posed under section 2103(e), including the 
requirement to count the total amount of the 
employee contribution required for enroll-
ment of the employee and the child in such 
coverage toward the annual aggregate cost- 
sharing limit applied under paragraph 
(3)(B) of such section). 
‘‘(ii) STATE
PAYMENT
OPTION.—A 
State may provide a premium assistance 
subsidy either as reimbursement to an em-
ployee for out-of-pocket expenditures or, sub-
ject to clause (iii), directly to the employee’s 
employer. 
‘‘(iii) EMPLOYER
OPT-OUT.—An em-
ployer may notify a State that it elects to
137 
† HR 2 EAS 
opt-out of being directly paid a premium 
assistance subsidy on behalf of an employee. 
In the event of such a notification, an em-
ployer shall withhold the total amount of 
the employee contribution required for en-
rollment of the employee and the child in 
the qualified employer-sponsored coverage 
and the State shall pay the premium assist-
ance subsidy directly to the employee. 
‘‘(iv) TREATMENT AS CHILD HEALTH 
ASSISTANCE.—Expenditures for the provi-
sion of premium assistance subsidies shall 
be considered child health assistance de-
scribed in paragraph (1)(C) of subsection 
(a) for purposes of making payments under 
that subsection. 
‘‘(D) APPLICATION
OF
SECONDARY
PAYOR 
RULES.—The State shall be a secondary payor 
for any items or services provided under the 
qualified employer-sponsored coverage for which 
the State provides child health assistance under 
the State child health plan. 
‘‘(E) REQUIREMENT TO PROVIDE SUPPLE-
MENTAL
COVERAGE
FOR
BENEFITS
AND
COST-
138 
† HR 2 EAS 
SHARING
PROTECTION
PROVIDED
UNDER
THE 
STATE CHILD HEALTH PLAN.— 
‘‘(i) IN
GENERAL.—Notwithstanding 
section 2110(b)(1)(C), the State shall pro-
vide for each targeted low-income child en-
rolled in qualified employer-sponsored cov-
erage, supplemental coverage consisting of— 
‘‘(I) items or services that are not 
covered, or are only partially covered, 
under the qualified employer-sponsored 
coverage; and 
‘‘(II) cost-sharing protection con-
sistent with section 2103(e). 
‘‘(ii) 
RECORD
KEEPING
REQUIRE-
MENTS.—For purposes of carrying out 
clause (i), a State may elect to directly pay 
out-of-pocket expenditures for cost-sharing 
imposed under the qualified employer-spon-
sored coverage and collect or not collect all 
or any portion of such expenditures from 
the parent of the child. 
‘‘(F) APPLICATION OF WAITING PERIOD IM-
POSED UNDER THE STATE.—Any waiting period 
imposed under the State child health plan prior 
to the provision of child health assistance to a
139 
† HR 2 EAS 
targeted low-income child under the State plan 
shall apply to the same extent to the provision 
of a premium assistance subsidy for the child 
under this paragraph. 
‘‘(G) 
OPT-OUT
PERMITTED
FOR
ANY 
MONTH.—A State shall establish a process for 
permitting the parent of a targeted low-income 
child receiving a premium assistance subsidy to 
disenroll the child from the qualified employer- 
sponsored coverage and enroll the child in, and 
receive child health assistance under, the State 
child health plan, effective on the first day of 
any month for which the child is eligible for such 
assistance and in a manner that ensures con-
tinuity of coverage for the child. 
‘‘(H) APPLICATION
TO
PARENTS.—If a 
State provides child health assistance or health 
benefits coverage to parents of a targeted low-in-
come child in accordance with section 2111(b), 
the State may elect to offer a premium assistance 
subsidy to a parent of a targeted low-income 
child who is eligible for such a subsidy under 
this paragraph in the same manner as the State 
offers such a subsidy for the enrollment of the
140 
† HR 2 EAS 
child in qualified employer-sponsored coverage, 
except that— 
‘‘(i) the amount of the premium assist-
ance subsidy shall be increased to take into 
account the cost of the enrollment of the 
parent in the qualified employer-sponsored 
coverage or, at the option of the State if the 
State determines it cost-effective, the cost of 
the enrollment of the child’s family in such 
coverage; and 
‘‘(ii) any reference in this paragraph 
to a child is deemed to include a reference 
to the parent or, if applicable under clause 
(i), the family of the child. 
‘‘(I) ADDITIONAL STATE OPTION FOR PRO-
VIDING PREMIUM ASSISTANCE.— 
‘‘(i) IN GENERAL.—A State may estab-
lish an employer-family premium assistance 
purchasing pool for employers with less 
than 250 employees who have at least 1 em-
ployee who is a pregnant woman eligible for 
assistance under the State child health plan 
(including through the application of an 
option described in section 2112(f)) or a 
member of a family with at least 1 targeted
141 
† HR 2 EAS 
low-income child and to provide a premium 
assistance subsidy under this paragraph for 
enrollment in coverage made available 
through such pool. 
‘‘(ii) ACCESS
TO
CHOICE
OF
COV-
ERAGE.—A State that elects the option 
under clause (i) shall identify and offer ac-
cess to not less than 2 private health plans 
that are health benefits coverage that is 
equivalent to the benefits coverage in a 
benchmark benefit package described in sec-
tion 2103(b) or benchmark-equivalent cov-
erage that meets the requirements of section 
2103(a)(2) for employees described in clause 
(i). 
‘‘(iii) CLARIFICATION OF PAYMENT FOR 
ADMINISTRATIVE
EXPENDITURES.—Nothing 
in this subparagraph shall be construed as 
permitting payment under this section for 
administrative expenditures attributable to 
the establishment or operation of such pool, 
except to the extent that such payment 
would otherwise be permitted under this 
title.
142 
† HR 2 EAS 
‘‘(J) NO EFFECT ON PREMIUM ASSISTANCE 
WAIVER PROGRAMS.—Nothing in this paragraph 
shall be construed as limiting the authority of a 
State to offer premium assistance under section 
1906 or 1906A, a waiver described in paragraph 
(2)(B) or (3), a waiver approved under section 
1115, or other authority in effect prior to the 
date of enactment of the Children’s Health Insur-
ance Program Reauthorization Act of 2009. 
‘‘(K) NOTICE OF AVAILABILITY.—If a State 
elects to provide premium assistance subsidies in 
accordance with this paragraph, the State 
shall— 
‘‘(i) include on any application or en-
rollment form for child health assistance a 
notice of the availability of premium assist-
ance subsidies for the enrollment of targeted 
low-income children in qualified employer- 
sponsored coverage; 
‘‘(ii) provide, as part of the applica-
tion and enrollment process under the State 
child health plan, information describing 
the availability of such subsidies and how to 
elect to obtain such a subsidy; and
143 
† HR 2 EAS 
‘‘(iii) establish such other procedures as 
the State determines necessary to ensure 
that parents are fully informed of the 
choices for receiving child health assistance 
under the State child health plan or through 
the receipt of premium assistance subsidies. 
‘‘(L) APPLICATION
TO
QUALIFIED
EM-
PLOYER-SPONSORED BENCHMARK COVERAGE.—If 
a group health plan or health insurance coverage 
offered through an employer is certified by an 
actuary as health benefits coverage that is equiv-
alent to the benefits coverage in a benchmark 
benefit package described in section 2103(b) or 
benchmark-equivalent coverage that meets the re-
quirements of section 2103(a)(2), the State may 
provide premium assistance subsidies for enroll-
ment of targeted low-income children in such 
group health plan or health insurance coverage 
in the same manner as such subsidies are pro-
vided under this paragraph for enrollment in 
qualified employer-sponsored coverage, but with-
out regard to the requirement to provide supple-
mental coverage for benefits and cost-sharing 
protection provided under the State child health 
plan under subparagraph (E).
144 
† HR 2 EAS 
‘‘(M) SATISFACTION
OF
COST-EFFECTIVE-
NESS TEST.—Premium assistance subsidies for 
qualified employer-sponsored coverage offered 
under this paragraph shall be deemed to meet the 
requirement of subparagraph (A) of paragraph 
(3). 
‘‘(N) COORDINATION
WITH
MEDICAID.—In 
the case of a targeted low-income child who re-
ceives child health assistance through a State 
plan under title XIX and who voluntarily elects 
to receive a premium assistance subsidy under 
this section, the provisions of section 1906A shall 
apply and shall supersede any other provisions 
of this paragraph that are inconsistent with such 
section.’’. 
(2) DETERMINATION
OF
COST-EFFECTIVENESS 
FOR PREMIUM ASSISTANCE OR PURCHASE OF FAMILY 
COVERAGE.— 
(A) IN
GENERAL.—Section 2105(c)(3)(A) 
(42 U.S.C. 1397ee(c)(3)(A)) is amended by strik-
ing ‘‘relative to’’ and all that follows through the 
comma and inserting ‘‘relative to 
‘‘(i) the amount of expenditures under 
the State child health plan, including ad-
ministrative expenditures, that the State
145 
† HR 2 EAS 
would have made to provide comparable 
coverage of the targeted low-income child in-
volved or the family involved (as applica-
ble); or 
‘‘(ii) the aggregate amount of expendi-
tures that the State would have made under 
the State child health plan, including ad-
ministrative expenditures, for providing 
coverage under such plan for all such chil-
dren or families.’’. 
(B) NONAPPLICATION TO PREVIOUSLY AP-
PROVED COVERAGE.—The amendment made by 
subparagraph (A) shall not apply to coverage the 
purchase of which has been approved by the Sec-
retary under section 2105(c)(3) of the Social Se-
curity Act prior to the date of enactment of this 
Act. 
(b) MEDICAID.—Title XIX is amended by inserting 
after section 1906 the following new section: 
‘‘PREMIUM ASSISTANCE OPTION FOR CHILDREN 
‘‘SEC. 1906A. (a) IN GENERAL.—A State may elect to 
offer a premium assistance subsidy (as defined in subsection 
(c)) for qualified employer-sponsored coverage (as defined 
in subsection (b)) to all individuals under age 19 who are 
entitled to medical assistance under this title (and to the
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† HR 2 EAS 
parent of such an individual) who have access to such cov-
erage if the State meets the requirements of this section. 
‘‘(b) QUALIFIED EMPLOYER-SPONSORED COVERAGE.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2)), 
in this paragraph, the term ‘qualified employer-spon-
sored coverage’ means a group health plan or health 
insurance coverage offered through an employer— 
‘‘(A) that qualifies as creditable coverage as 
a group health plan under section 2701(c)(1) of 
the Public Health Service Act; 
‘‘(B) for which the employer contribution 
toward any premium for such coverage is at 
least 40 percent; and 
‘‘(C) that is offered to all individuals in a 
manner that would be considered a nondiscrim-
inatory eligibility classification for purposes of 
paragraph (3)(A)(ii) of section 105(h) of the In-
ternal Revenue Code of 1986 (but determined 
without regard to clause (i) of subparagraph (B) 
of such paragraph). 
‘‘(2) EXCEPTION.—Such term does not include 
coverage consisting of— 
‘‘(A) benefits provided under a health flexi-
ble spending arrangement (as defined in section
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† HR 2 EAS 
106(c)(2) of the Internal Revenue Code of 1986); 
or 
‘‘(B) a high deductible health plan (as de-
fined in section 223(c)(2) of such Code), without 
regard to whether the plan is purchased in con-
junction with a health savings account (as de-
fined under section 223(d) of such Code). 
‘‘(3) TREATMENT AS THIRD PARTY LIABILITY.— 
The State shall treat the coverage provided under 
qualified employer-sponsored coverage as a third 
party liability under section 1902(a)(25). 
‘‘(c) PREMIUM ASSISTANCE SUBSIDY.—In this section, 
the term ‘premium assistance subsidy’ means the amount 
of the employee contribution for enrollment in the qualified 
employer-sponsored coverage by the individual under age 
19 or by the individual’s family. Premium assistance sub-
sidies under this section shall be considered, for purposes 
of section 1903(a), to be a payment for medical assistance. 
‘‘(d) VOLUNTARY PARTICIPATION.— 
‘‘(1) EMPLOYERS.—Participation by an em-
ployer in a premium assistance subsidy offered by a 
State under this section shall be voluntary. An em-
ployer may notify a State that it elects to opt-out of 
being directly paid a premium assistance subsidy on 
behalf of an employee.
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† HR 2 EAS 
‘‘(2) BENEFICIARIES.—No subsidy shall be pro-
vided to an individual under age 19 under this sec-
tion unless the individual (or the individual’s parent) 
voluntarily elects to receive such a subsidy. A State 
may not require such an election as a condition of re-
ceipt of medical assistance. State may not require, as 
a condition of an individual under age 19 (or the in-
dividual’s parent) being or remaining eligible for 
medical assistance under this title, apply for enroll-
ment in qualified employer-sponsored coverage under 
this section. 
‘‘(3) OPT-OUT PERMITTED FOR ANY MONTH.—A 
State shall establish a process for permitting the par-
ent of an individual under age 19 receiving a pre-
mium assistance subsidy to disenroll the individual 
from the qualified employer-sponsored coverage. 
‘‘(e) REQUIREMENT TO PAY PREMIUMS AND COST- 
SHARING AND PROVIDE SUPPLEMENTAL COVERAGE.—In 
the case of the participation of an individual under age 
19 (or the individual’s parent) in a premium assistance 
subsidy under this section for qualified employer-sponsored 
coverage, the State shall provide for payment of all enrollee 
premiums for enrollment in such coverage and all 
deductibles, coinsurance, and other cost-sharing obligations 
for items and services otherwise covered under the State
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† HR 2 EAS 
plan under this title (exceeding the amount otherwise per-
mitted under section 1916 or, if applicable, section 1916A). 
The fact that an individual under age 19 (or a parent) 
elects to enroll in qualified employer-sponsored coverage 
under this section shall not change the individual’s (or par-
ent’s) eligibility for medical assistance under the State 
plan, except insofar as section 1902(a)(25) provides that 
payments for such assistance shall first be made under such 
coverage.’’. 
(c) GAO STUDY AND REPORT.—Not later than Janu-
ary 1, 2010, the Comptroller General of the United States 
shall study cost and coverage issues relating to any State 
premium assistance programs for which Federal matching 
payments are made under title XIX or XXI of the Social 
Security Act, including under waiver authority, and shall 
submit a report to the Committee on Finance of the Senate 
and the Committee on Energy and Commerce of the House 
of Representatives on the results of such study. 
SEC. 302. OUTREACH, EDUCATION, AND ENROLLMENT AS-
SISTANCE. 
(a) REQUIREMENT TO INCLUDE DESCRIPTION
OF 
OUTREACH, EDUCATION, AND ENROLLMENT EFFORTS RE-
LATED TO PREMIUM ASSISTANCE SUBSIDIES IN STATE 
CHILD
HEALTH
PLAN.—Section 2102(c) (42 U.S.C.
150 
† HR 2 EAS 
1397bb(c)) is amended by adding at the end the following 
new paragraph: 
‘‘(3) PREMIUM ASSISTANCE SUBSIDIES.—In the 
case of a State that provides for premium assistance 
subsidies under the State child health plan in accord-
ance with paragraph (2)(B), (3), or (10) of section 
2105(c), or a waiver approved under section 1115, 
outreach, education, and enrollment assistance for 
families of children likely to be eligible for such sub-
sidies, to inform such families of the availability of, 
and to assist them in enrolling their children in, such 
subsidies, and for employers likely to provide coverage 
that is eligible for such subsidies, including the spe-
cific, significant resources the State intends to apply 
to educate employers about the availability of pre-
mium assistance subsidies under the State child 
health plan.’’. 
(b) NONAPPLICATION OF 10 PERCENT LIMIT ON OUT-
REACH
AND CERTAIN OTHER EXPENDITURES.—Section 
2105(c)(2)(C) (42 U.S.C. 1397ee(c)(2)(C)), as amended by 
section 211(c)(2), is amended by adding at the end the fol-
lowing new clause: 
‘‘(iii) EXPENDITURES FOR OUTREACH 
TO INCREASE THE ENROLLMENT OF CHIL-
DREN UNDER THIS TITLE AND TITLE xix