SECTION 1. SHORT TITLE; AMENDMENTS TO SOCIAL SECU-
RITY ACT; REFERENCES; TABLE OF CON-
TENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Children’s Health Insurance Program Reauthorization 
Act of 2009’’. 
(b) AMENDMENTS TO SOCIAL SECURITY ACT.—Ex-
cept as otherwise specifically provided, whenever in this 
Act an amendment 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 that section or other 
provision of the Social Security Act. 
(c) REFERENCES
TO
CHIP; MEDICAID; SEC-
RETARY.—In this Act: 
(1) CHIP.—The term ‘‘CHIP’’ means the 
State Children’s Health Insurance Program estab-
lished under title XXI of the Social Security Act (42 
U.S.C. 1397aa et seq.). 
(2) MEDICAID.—The term ‘‘Medicaid’’ means 
the program for medical assistance established under 
title XIX of the Social Security Act (42 U.S.C. 1396 
et seq.). 
(3) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
(d) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows:
Sec. 1. Short title; amendments to Social Security Act; references; table of con-
tents. 
Sec. 2. Purpose. 
Sec. 3. General effective date; exception for State legislation; contingent effec-
tive date; reliance on law. 
TITLE I—FINANCING 
Subtitle A—Funding 
Sec. 101. Extension of CHIP. 
Sec. 102. Allotments for States and territories for fiscal years 2009 through 
2013. 
Sec. 103. Child Enrollment Contingency Fund. 
Sec. 104. CHIP performance bonus payment to offset additional enrollment 
costs resulting from enrollment and retention efforts. 
Sec. 105. Two-year initial availability of CHIP allotments. 
Sec. 106. Redistribution of unused allotments. 
Sec. 107. Option for qualifying States to receive the enhanced portion of the 
CHIP matching rate for Medicaid coverage of certain children. 
Sec. 108. One-time appropriation. 
Sec. 109. Improving funding for the territories under CHIP and Medicaid. 
Subtitle B—Focus on Low-Income Children and Pregnant Women 
Sec. 111. State option to cover low-income pregnant women under CHIP 
through a State plan amendment. 
Sec. 112. Phase-out of coverage for nonpregnant childless adults under CHIP; 
conditions for coverage of parents. 
Sec. 113. Elimination of counting Medicaid child presumptive eligibility costs 
against title XXI allotment. 
Sec. 114. Limitation on matching rate for States that propose to cover children 
with effective family income that exceeds 300 percent of the 
poverty line. 
Sec. 115. State authority under Medicaid. 
TITLE II—OUTREACH AND ENROLLMENT 
Subtitle A—Outreach and Enrollment Activities 
Sec. 201. Grants and enhanced administrative funding for outreach and enroll-
ment. 
Sec. 202. Increased outreach and enrollment of Indians. 
Sec. 203. State option to rely on findings from an Express Lane agency to con-
duct simplified eligibility determinations. 
Subtitle B—Reducing Barriers to Enrollment 
Sec. 211. Verification of declaration of citizenship or nationality for purposes 
of eligibility for Medicaid and CHIP. 
Sec. 212. Reducing administrative barriers to enrollment. 
Sec. 213. Model of Interstate coordinated enrollment and coverage process. 
Sec. 214. Permitting States to ensure coverage without a 5-year delay of cer-
tain children and pregnant women under the Medicaid program 
and CHIP.
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. 
Sec. 302. Outreach, education, and enrollment assistance. 
Subtitle B—Coordinating Premium Assistance With Private Coverage 
Sec. 311. Special enrollment period under group health plans in case of termi-
nation of Medicaid or CHIP coverage or eligibility for assist-
ance in purchase of employment-based coverage; coordination 
of coverage. 
TITLE IV—STRENGTHENING QUALITY OF CARE AND HEALTH 
OUTCOMES 
Sec. 401. Child health quality improvement activities for children enrolled in 
Medicaid or CHIP. 
Sec. 402. Improved availability of public information regarding enrollment of 
children in CHIP and Medicaid. 
Sec. 403. Application of certain managed care quality safeguards to CHIP. 
TITLE V—IMPROVING ACCESS TO BENEFITS 
Sec. 501. Dental benefits. 
Sec. 502. Mental health parity in CHIP plans. 
Sec. 503. Application of prospective payment system for services provided by 
Federally-qualified health centers and rural health clinics. 
Sec. 504. Premium grace period. 
Sec. 505. Clarification of coverage of services provided through school-based 
health centers. 
TITLE VI—PROGRAM INTEGRITY AND OTHER MISCELLANEOUS 
PROVISIONS 
Subtitle A—Program Integrity and Data Collection 
Sec. 601. Payment error rate measurement (‘‘PERM’’). 
Sec. 602. Improving data collection. 
Sec. 603. Updated Federal evaluation of CHIP. 
Sec. 604. Access to records for IG and GAO audits and evaluations. 
Sec. 605. No Federal funding for illegal aliens. 
Subtitle B—Miscellaneous Health Provisions 
Sec. 611. Deficit Reduction Act technical corrections. 
Sec. 612. References to title XXI. 
Sec. 613. Prohibiting initiation of new health opportunity account demonstra-
tion programs. 
Sec. 614. Adjustment in computation of Medicaid FMAP to disregard an ex-
traordinary employer pension contribution. 
Sec. 615. Clarification treatment of regional medical center. 
Sec. 616. Extension of Medicaid DSH allotments for Tennessee and Hawaii. 
Subtitle C—Other Provisions 
Sec. 621. Outreach regarding health insurance options available to children.
Sec. 622. Sense of the Senate regarding access to affordable and meaningful 
health insurance coverage. 
Sec. 623. Limitation on Medicare exception to the prohibition on certain physi-
cian referrals for hospitals. 
TITLE VII—REVENUE PROVISIONS 
Sec. 701. Increase in excise tax rate on tobacco products. 
Sec. 702. Administrative improvements. 
Sec. 703. Treasury study concerning magnitude of tobacco smuggling in the 
United States. 
Sec. 704. Time for payment of corporate estimated taxes. 
SEC. 2. PURPOSE. 
It is the purpose of this Act to provide dependable 
and stable funding for children’s health insurance under 
titles XXI and XIX of the Social Security Act in order 
to enroll all six million uninsured children who are eligible, 
but not enrolled, for coverage today through such titles. 
SEC. 3. GENERAL EFFECTIVE DATE; EXCEPTION FOR STATE 
LEGISLATION; 
CONTINGENT 
EFFECTIVE 
DATE; RELIANCE ON LAW. 
(a) GENERAL EFFECTIVE DATE.—Unless otherwise 
provided in this Act, subject to subsections (b) through 
(d), this Act (and the amendments made by this Act) shall 
take effect on April 1, 2009, and shall apply to child 
health assistance and medical assistance provided on or 
after that date. 
(b) EXCEPTION FOR STATE LEGISLATION.—In the 
case of a State plan under title XIX or State child health 
plan under XXI of the Social Security Act, which the Sec-
retary of Health and Human Services determines requires 
State legislation in order for the respective plan to meet
one or more additional requirements imposed by amend-
ments made by this Act, the respective plan shall not be 
regarded as failing to comply with the requirements of 
such title solely on the basis of its failure to meet such 
an additional requirement before the first day of the first 
calendar quarter beginning after the close of the first reg-
ular session of the State legislature that begins after the 
date of enactment of this Act. For purposes of the pre-
vious sentence, in the case of a State that has a 2-year 
legislative session, each year of the session shall be consid-
ered to be a separate regular session of the State legisla-
ture. 
(c) COORDINATION OF CHIP FUNDING FOR FISCAL 
YEAR 2009.—Notwithstanding any other provision of law, 
insofar as funds have been appropriated under section 
2104(a)(11), 2104(k), or 2104(l) of the Social Security 
Act, as amended by section 201 of Public Law 110–173, 
to provide allotments to States under CHIP for fiscal year 
2009— 
(1) any amounts that are so appropriated that 
are not so allotted and obligated before April 1, 
2009, are rescinded; and 
(2) any amount provided for CHIP allotments 
to a State under this Act (and the amendments 
made by this Act) for such fiscal year shall be re-
duced by the amount of such appropriations so allot-
ted and obligated before such date. 
(d) RELIANCE ON LAW.—With respect to amend-
ments made by this Act (other than title VII) that become 
effective as of a date— 
(1) such amendments are effective as of such 
date whether or not regulations implementing such 
amendments have been issued; and 
(2) Federal financial participation for medical 
assistance or child health assistance furnished under 
title XIX or XXI, respectively, of the Social Security 
Act on or after such date by a State in good faith 
reliance on such amendments before the date of pro-
mulgation of final regulations, if any, to carry out 
such amendments (or before the date of guidance, if 
any, regarding the implementation of such amend-
ments) shall not be denied on the basis of the 
State’s failure to comply with such regulations or 
guidance. 
TITLE I—FINANCING 
Subtitle A—Funding 
SEC. 101. EXTENSION OF CHIP. 
Section 2104(a) (42 U.S.C. 1397dd(a)) is amended— 
(1) in paragraph (10), by striking ‘‘and’’ at the 
end;
(2) by amending paragraph (11), by striking 
‘‘each of fiscal years 2008 and 2009’’ and inserting 
‘‘fiscal year 2008’’; and 
(3) by adding at the end the following new 
paragraphs: 
‘‘(12) for fiscal year 2009, $10,562,000,000; 
‘‘(13) for fiscal year 2010, $12,520,000,000; 
‘‘(14) for fiscal year 2011, $13,459,000,000; 
‘‘(15) for fiscal year 2012, $14,982,000,000; 
and 
‘‘(16) for fiscal year 2013, for purposes of mak-
ing 2 semi-annual allotments— 
‘‘(A) $3,000,000,000 for the period begin-
ning on October 1, 2012, and ending on March 
31, 2013, and 
‘‘(B) $3,000,000,000 for the period begin-
ning on April 1, 2013, and ending on Sep-
tember 30, 2013.’’. 
SEC. 102. ALLOTMENTS FOR STATES AND TERRITORIES 
FOR FISCAL YEARS 2009 THROUGH 2013. 
Section 2104 (42 U.S.C. 1397dd) is amended— 
(1) in subsection (b)(1), by striking ‘‘subsection 
(d)’’ and inserting ‘‘subsections (d) and (m)’’;
(2) in subsection (c)(1), by striking ‘‘subsection 
(d)’’ and inserting ‘‘subsections (d) and (m)(4)’’; 
and 
(3) by adding at the end the following new sub-
section: 
‘‘(m) ALLOTMENTS
FOR
FISCAL
YEARS
2009 
THROUGH 2013.— 
‘‘(1) FOR FISCAL YEAR 2009.— 
‘‘(A) FOR THE 50 STATES AND THE DIS-
TRICT
OF
COLUMBIA.—Subject to the suc-
ceeding provisions of this paragraph and para-
graph (4), the Secretary shall allot for fiscal 
year 2009 from the amount made available 
under subsection (a)(12), to each of the 50 
States and the District of Columbia 110 per-
cent of the highest of the following amounts for 
such State or District: 
‘‘(i) The total Federal payments to 
the State under this title for fiscal year 
2008, multiplied by the allotment increase 
factor determined under paragraph (5) for 
fiscal year 2009. 
‘‘(ii) The amount allotted to the State 
for fiscal year 2008 under subsection (b), 
multiplied by the allotment increase factor
determined under paragraph (5) for fiscal 
year 2009. 
‘‘(iii) The projected total Federal pay-
ments to the State under this title for fis-
cal year 2009, as determined on the basis 
of the February 2009 projections certified 
by the State to the Secretary by not later 
than March 31, 2009. 
‘‘(B) FOR
THE
COMMONWEALTHS
AND 
TERRITORIES.—Subject to the succeeding provi-
sions of this paragraph and paragraph (4), the 
Secretary shall allot for fiscal year 2009 from 
the amount made available under subsection 
(a)(12) to each of the commonwealths and ter-
ritories described in subsection (c)(3) an 
amount equal to the highest amount of Federal 
payments to the commonwealth or territory 
under this title for any fiscal year occurring 
during the period of fiscal years 1999 through 
2008, multiplied by the allotment increase fac-
tor determined under paragraph (5) for fiscal 
year 2009, except that subparagraph (B) there-
of shall be applied by substituting ‘the United 
States’ for ‘the State’.
‘‘(C) 
ADJUSTMENT
FOR
QUALIFYING 
STATES.—In the case of a qualifying State de-
scribed in paragraph (2) of section 2105(g), the 
Secretary shall permit the State to submit a re-
vised projection described in subparagraph 
(A)(iii) in order to take into account changes in 
such projections attributable to the application 
of paragraph (4) of such section. 
‘‘(2) FOR FISCAL YEARS 2010 THROUGH 2012.— 
‘‘(A) IN GENERAL.—Subject to paragraphs 
(4) and (6), from the amount made available 
under paragraphs (13) through (15) of sub-
section (a) for each of fiscal years 2010 
through 2012, respectively, the Secretary shall 
compute a State allotment for each State (in-
cluding the District of Columbia and each com-
monwealth and territory) for each such fiscal 
year as follows: 
‘‘(i) GROWTH
FACTOR
UPDATE
FOR 
FISCAL YEAR 2010.—For fiscal year 2010, 
the allotment of the State is equal to the 
sum of— 
‘‘(I) the amount of the State al-
lotment under paragraph (1) for fiscal 
year 2009; and
‘‘(II) the amount of any pay-
ments made to the State under sub-
section (k), (l), or (n) for fiscal year 
2009, 
multiplied by the allotment increase factor 
under paragraph (5) for fiscal year 2010. 
‘‘(ii) REBASING
IN
FISCAL
YEAR 
2011.—For fiscal year 2011, the allotment 
of the State is equal to the Federal pay-
ments to the State that are attributable to 
(and countable towards) the total amount 
of allotments available under this section 
to the State in fiscal year 2010 (including 
payments made to the State under sub-
section (n) for fiscal year 2010 as well as 
amounts redistributed to the State in fiscal 
year 2010), multiplied by the allotment in-
crease factor under paragraph (5) for fis-
cal year 2011. 
‘‘(iii) GROWTH FACTOR UPDATE FOR 
FISCAL YEAR 2012.—For fiscal year 2012, 
the allotment of the State is equal to the 
sum of—
‘‘(I) the amount of the State al-
lotment under clause (ii) for fiscal 
year 2011; and 
‘‘(II) the amount of any pay-
ments made to the State under sub-
section (n) for fiscal year 2011, 
multiplied by the allotment increase factor 
under paragraph (5) for fiscal year 2012. 
‘‘(3) FOR FISCAL YEAR 2013.— 
‘‘(A) FIRST HALF.—Subject to paragraphs 
(4) and (6), from the amount made available 
under subparagraph (A) of paragraph (16) of 
subsection (a) for the semi-annual period de-
scribed in such paragraph, increased by the 
amount of the appropriation for such period 
under section 108 of the Children’s Health In-
surance Program Reauthorization Act of 2009, 
the Secretary shall compute a State allotment 
for each State (including the District of Colum-
bia and each commonwealth and territory) for 
such semi-annual period in an amount equal to 
the first half ratio (described in subparagraph 
(D)) of the amount described in subparagraph 
(C).
‘‘(B) SECOND
HALF.—Subject to para-
graphs (4) and (6), from the amount made 
available under subparagraph (B) of paragraph 
(16) of subsection (a) for the semi-annual pe-
riod described in such paragraph, the Secretary 
shall compute a State allotment for each State 
(including the District of Columbia and each 
commonwealth and territory) for such semi-an-
nual period in an amount equal to the amount 
made available under such subparagraph, multi-
plied by the ratio of— 
‘‘(i) the amount of the allotment to 
such State under subparagraph (A); to 
‘‘(ii) the total of the amount of all of 
the allotments made available under such 
subparagraph. 
‘‘(C) FULL
YEAR
AMOUNT
BASED
ON 
REBASED AMOUNT.—The amount described in 
this subparagraph for a State is equal to the 
Federal payments to the State that are attrib-
utable to (and countable towards) the total 
amount of allotments available under this sec-
tion to the State in fiscal year 2012 (including 
payments made to the State under subsection 
(n) for fiscal year 2012 as well as amounts re-
distributed to the State in fiscal year 2012), 
multiplied by the allotment increase factor 
under paragraph (5) for fiscal year 2013. 
‘‘(D) FIRST HALF RATIO.—The first half 
ratio described in this subparagraph is the ratio 
of— 
‘‘(i) the sum of— 
‘‘(I) the amount made available 
under subsection (a)(16)(A); and 
‘‘(II) the amount of the appro-
priation for such period under section 
108 of the Children’s Health Insur-
ance Program Reauthorization Act of 
2009; to 
‘‘(ii) the sum of the— 
‘‘(I) amount described in clause 
(i); and 
‘‘(II) the amount made available 
under subsection (a)(16)(B). 
‘‘(4) PRORATION RULE.—If, after the applica-
tion of this subsection without regard to this para-
graph, the sum of the allotments determined under 
paragraph (1), (2), or (3) for a fiscal year (or, in 
the case of fiscal year 2013, for a semi-annual pe-
riod in such fiscal year) exceeds the amount avail-
able under subsection (a) for such fiscal year or pe-
riod, the Secretary shall reduce each allotment for 
any State under such paragraph for such fiscal year 
or period on a proportional basis. 
‘‘(5) ALLOTMENT INCREASE FACTOR.—The al-
lotment increase factor under this paragraph for a 
fiscal year is equal to the product of the following: 
‘‘(A) PER CAPITA HEALTH CARE GROWTH 
FACTOR.—1 plus the percentage increase in the 
projected per capita amount of National Health 
Expenditures from the calendar year in which 
the previous fiscal year ends to the calendar 
year in which the fiscal year involved ends, as 
most recently published by the Secretary before 
the beginning of the fiscal year. 
‘‘(B) CHILD
POPULATION
GROWTH
FAC-
TOR.—1 plus the percentage increase (if any) in 
the population of children in the State from 
July 1 in the previous fiscal year to July 1 in 
the fiscal year involved, as determined by the 
Secretary based on the most recent published 
estimates of the Bureau of the Census before 
the beginning of the fiscal year involved, plus 1 
percentage point.
‘‘(6) INCREASE
IN
ALLOTMENT
TO
ACCOUNT 
FOR APPROVED PROGRAM EXPANSIONS.—In the case 
of one of the 50 States or the District of Columbia 
that— 
‘‘(A) has submitted to the Secretary, and 
has approved by the Secretary, a State plan 
amendment or waiver request relating to an ex-
pansion of eligibility for children or benefits 
under this title that becomes effective for a fis-
cal year (beginning with fiscal year 2010 and 
ending with fiscal year 2013); and 
‘‘(B) has submitted to the Secretary, be-
fore the August 31 preceding the beginning of 
the fiscal year, a request for an expansion allot-
ment adjustment under this paragraph for such 
fiscal year that specifies— 
‘‘(i) the additional expenditures that 
are attributable to the eligibility or benefit 
expansion provided under the amendment 
or waiver described in subparagraph (A), 
as certified by the State and submitted to 
the Secretary by not later than August 31 
preceding the beginning of the fiscal year; 
and
‘‘(ii) the extent to which such addi-
tional expenditures are projected to exceed 
the allotment of the State or District for 
the year, 
subject to paragraph (4), the amount of the allot-
ment of the State or District under this subsection 
for such fiscal year shall be increased by the excess 
amount described in subparagraph (B)(i). A State or 
District may only obtain an increase under this 
paragraph for an allotment for fiscal year 2010 or 
fiscal year 2012. 
‘‘(7) AVAILABILITY OF AMOUNTS FOR SEMI-AN-
NUAL PERIODS IN FISCAL YEAR 2013.—Each semi- 
annual allotment made under paragraph (3) for a 
period in fiscal year 2013 shall remain available for 
expenditure under this title for periods after the end 
of such fiscal year in the same manner as if the al-
lotment had been made available for the entire fiscal 
year.’’. 
SEC. 103. CHILD ENROLLMENT CONTINGENCY FUND. 
Section 2104 (42 U.S.C. 1397dd), as amended by 
section 102, is amended by adding at the end the following 
new subsection: 
‘‘(n) CHILD ENROLLMENT CONTINGENCY FUND.—
‘‘(1) ESTABLISHMENT.—There is hereby estab-
lished in the Treasury of the United States a fund 
which shall be known as the ‘Child Enrollment Con-
tingency Fund’ (in this subsection referred to as the 
‘Fund’). Amounts in the Fund shall be available 
without further appropriations for payments under 
this subsection. 
‘‘(2) DEPOSITS INTO FUND.— 
‘‘(A) INITIAL
AND
SUBSEQUENT
APPRO-
PRIATIONS.—Subject to subparagraphs (B) and 
(D), out of any money in the Treasury of the 
United States not otherwise appropriated, there 
are appropriated to the Fund— 
‘‘(i) for fiscal year 2009, an amount 
equal to 20 percent of the amount made 
available under paragraph (12) of sub-
section (a) for the fiscal year; and 
‘‘(ii) for each of fiscal years 2010 
through 2012 (and for each of the semi- 
annual allotment periods for fiscal year 
2013), such sums as are necessary for 
making payments to eligible States for 
such fiscal year or period, but not in excess 
of the aggregate cap described in subpara-
graph (B).
‘‘(B) AGGREGATE CAP.—The total amount 
available for payment from the Fund for each 
of fiscal years 2010 through 2012 (and for each 
of the semi-annual allotment periods for fiscal 
year 2013), taking into account deposits made 
under subparagraph (C), shall not exceed 20 
percent of the amount made available under 
subsection (a) for the fiscal year or period. 
‘‘(C) INVESTMENT
OF
FUND.—The Sec-
retary of the Treasury shall invest, in interest 
bearing securities of the United States, such 
currently available portions of the Fund as are 
not immediately required for payments from the 
Fund. The income derived from these invest-
ments constitutes a part of the Fund. 
‘‘(D) AVAILABILITY
OF
EXCESS
FUNDS 
FOR
PERFORMANCE
BONUSES.—Any amounts 
in excess of the aggregate cap described in sub-
paragraph (B) for a fiscal year or period shall 
be made available for purposes of carrying out 
section 2105(a)(3) for any succeeding fiscal 
year and the Secretary of the Treasury shall re-
duce the amount in the Fund by the amount so 
made available.
‘‘(3) CHILD ENROLLMENT CONTINGENCY FUND 
PAYMENTS.— 
‘‘(A) IN GENERAL.—If a State’s expendi-
tures under this title in fiscal year 2009, fiscal 
year 2010, fiscal year 2011, fiscal year 2012, or 
a semi-annual allotment period for fiscal year 
2013, exceed the total amount of allotments 
available under this section to the State in the 
fiscal year or period (determined without regard 
to any redistribution it receives under sub-
section (f) that is available for expenditure dur-
ing such fiscal year or period, but including any 
carryover from a previous fiscal year) and if the 
average monthly unduplicated number of chil-
dren enrolled under the State plan under this 
title (including children receiving health care 
coverage through funds under this title pursu-
ant to a waiver under section 1115) during 
such fiscal year or period exceeds its target av-
erage number of such enrollees (as determined 
under subparagraph (B)) for that fiscal year or 
period, subject to subparagraph (D), the Sec-
retary shall pay to the State from the Fund an 
amount equal to the product of—
‘‘(i) the amount by which such aver-
age monthly caseload exceeds such target 
number of enrollees; and 
‘‘(ii) the projected per capita expendi-
tures under the State child health plan (as 
determined under subparagraph (C) for 
the fiscal year), multiplied by the enhanced 
FMAP (as defined in section 2105(b)) for 
the State and fiscal year involved (or in 
which the period occurs). 
‘‘(B) TARGET AVERAGE NUMBER OF CHILD 
ENROLLEES.—In this paragraph, the target av-
erage number of child enrollees for a State— 
‘‘(i) for fiscal year 2009 is equal to 
the monthly average unduplicated number 
of children enrolled in the State child 
health plan under this title (including such 
children receiving health care coverage 
through funds under this title pursuant to 
a waiver under section 1115) during fiscal 
year 2008 increased by the population 
growth for children in that State for the 
year ending on June 30, 2007 (as esti-
mated by the Bureau of the Census) plus 
1 percentage point; or
subsection in the same manner as they apply to 
payments under such section. 
‘‘(F) CONTINUED
REPORTING.—For pur-
poses of this paragraph and subsection (f), the 
State shall submit to the Secretary the State’s 
projected Federal expenditures, even if the 
amount of such expenditures exceeds the total 
amount of allotments available to the State in 
such fiscal year or period. 
‘‘(G) APPLICATION
TO
COMMONWEALTHS 
AND TERRITORIES.—No payment shall be made 
under this paragraph to a commonwealth or 
territory described in subsection (c)(3) until 
such time as the Secretary determines that 
there are in effect methods, satisfactory to the 
Secretary, for the collection and reporting of re-
liable data regarding the enrollment of children 
described in subparagraphs (A) and (B) in 
order to accurately determine the common-
wealth’s or territory’s eligibility for, and 
amount of payment, under this paragraph.’’.
SEC. 104. CHIP PERFORMANCE BONUS PAYMENT TO OFF-
SET ADDITIONAL ENROLLMENT COSTS RE-
SULTING FROM ENROLLMENT AND RETEN-
TION EFFORTS. 
Section 2105(a) (42 U.S.C. 1397ee(a)) is amended 
by adding at the end the following new paragraphs: 
‘‘(3) PERFORMANCE BONUS PAYMENT TO OFF-
SET ADDITIONAL MEDICAID AND CHIP CHILD EN-
ROLLMENT COSTS RESULTING FROM ENROLLMENT 
AND RETENTION EFFORTS.— 
‘‘(A) IN
GENERAL.—In addition to the 
payments made under paragraph (1), for each 
fiscal year (beginning with fiscal year 2009 and 
ending with fiscal year 2013), the Secretary 
shall pay from amounts made available under 
subparagraph (E), to each State that meets the 
condition under paragraph (4) for the fiscal 
year, an amount equal to the amount described 
in subparagraph (B) for the State and fiscal 
year. The payment under this paragraph shall 
be made, to a State for a fiscal year, as a single 
payment not later than the last day of the first 
calendar quarter of the following fiscal year. 
‘‘(B) AMOUNT FOR ABOVE BASELINE MED-
ICAID CHILD ENROLLMENT COSTS.—Subject to 
subparagraph (E), the amount described in this
subparagraph for a State for a fiscal year is 
equal to the sum of the following amounts: 
‘‘(i) FIRST
TIER
ABOVE
BASELINE 
MEDICAID ENROLLEES.—An amount equal 
to the number of first tier above baseline 
child enrollees (as determined under sub-
paragraph (C)(i)) under title XIX for the 
State and fiscal year, multiplied by 15 per-
cent of the projected per capita State Med-
icaid expenditures (as determined under 
subparagraph (D)) for the State and fiscal 
year under title XIX. 
‘‘(ii) SECOND TIER ABOVE BASELINE 
MEDICAID ENROLLEES.—An amount equal 
to the number of second tier above baseline 
child enrollees (as determined under sub-
paragraph (C)(ii)) under title XIX for the 
State and fiscal year, multiplied by 62.5 
percent of the projected per capita State 
Medicaid 
expenditures 
(as 
determined 
under subparagraph (D)) for the State and 
fiscal year under title XIX. 
‘‘(C) NUMBER OF FIRST AND SECOND TIER 
ABOVE BASELINE CHILD ENROLLEES; BASELINE
NUMBER OF CHILD ENROLLEES.—For purposes 
of this paragraph: 
‘‘(i) FIRST
TIER
ABOVE
BASELINE 
CHILD ENROLLEES.—The number of first 
tier above baseline child enrollees for a 
State for a fiscal year under title XIX is 
equal to the number (if any, as determined 
by the Secretary) by which— 
‘‘(I) 
the 
monthly 
average 
unduplicated number of qualifying 
children (as defined in subparagraph 
(F)) enrolled during the fiscal year 
under the State plan under title XIX, 
respectively; exceeds 
‘‘(II) the baseline number of en-
rollees described in clause (iii) for the 
State and fiscal year under title XIX, 
respectively; 
but not to exceed 10 percent of the base-
line number of enrollees described in sub-
clause (II). 
‘‘(ii) SECOND TIER ABOVE BASELINE 
CHILD ENROLLEES.—The number of sec-
ond tier above baseline child enrollees for 
a State for a fiscal year under title XIX is
equal to the number (if any, as determined 
by the Secretary) by which— 
‘‘(I) 
the 
monthly 
average 
unduplicated number of qualifying 
children (as defined in subparagraph 
(F)) enrolled during the fiscal year 
under title XIX as described in clause 
(i)(I); exceeds 
‘‘(II) the sum of the baseline 
number of child enrollees described in 
clause (iii) for the State and fiscal 
year under title XIX, as described in 
clause (i)(II), and the maximum num-
ber of first tier above baseline child 
enrollees for the State and fiscal year 
under title XIX, as determined under 
clause (i). 
‘‘(iii) BASELINE
NUMBER
OF
CHILD 
ENROLLEES.—Subject 
to 
subparagraph 
(H), the baseline number of child enrollees 
for a State under title XIX— 
‘‘(I) for fiscal year 2009 is equal 
to the monthly average unduplicated 
number of qualifying children enrolled 
in the State plan under title XIX dur-
ing fiscal year 2007 increased by the 
population growth for children in that 
State from 2007 to 2008 (as esti-
mated by the Bureau of the Census) 
plus 4 percentage points, and further 
increased by the population growth 
for children in that State from 2008 
to 2009 (as estimated by the Bureau 
of the Census) plus 4 percentage 
points; 
‘‘(II) for each of fiscal years 
2010, 2011, and 2012, is equal to the 
baseline number of child enrollees for 
the State for the previous fiscal year 
under title XIX, increased by the pop-
ulation growth for children in that 
State from the calendar year in which 
the respective fiscal year begins to the 
succeeding calendar year (as esti-
mated by the Bureau of the Census) 
plus 3.5 percentage points; 
‘‘(III) for each of fiscal years 
2013, 2014, and 2015, is equal to the 
baseline number of child enrollees for 
the State for the previous fiscal year
under title XIX, increased by the pop-
ulation growth for children in that 
State from the calendar year in which 
the respective fiscal year begins to the 
succeeding calendar year (as esti-
mated by the Bureau of the Census) 
plus 3 percentage points; and 
‘‘(IV) for a subsequent fiscal year 
is equal to the baseline number of 
child enrollees for the State for the 
previous fiscal year under title XIX, 
increased by the population growth 
for children in that State from the 
calendar year in which the fiscal year 
involved begins to the succeeding cal-
endar year (as estimated by the Bu-
reau of the Census) plus 2 percentage 
points. 
‘‘(D) PROJECTED PER CAPITA STATE MED-
ICAID EXPENDITURES.—For purposes of sub-
paragraph (B), the projected per capita State 
Medicaid expenditures for a State and fiscal 
year under title XIX is equal to the average per 
capita expenditures (including both State and 
Federal financial participation) for children
under the State plan under such title, including 
under waivers but not including such children 
eligible for assistance by virtue of the receipt of 
benefits under title XVI, for the most recent 
fiscal year for which actual data are available 
(as determined by the Secretary), increased (for 
each subsequent fiscal year up to and including 
the fiscal year involved) by the annual percent-
age increase in per capita amount of National 
Health Expenditures (as estimated by the Sec-
retary) for the calendar year in which the re-
spective subsequent fiscal year ends and multi-
plied by a State matching percentage equal to 
100 percent minus the Federal medical assist-
ance percentage (as defined in section 1905(b)) 
for the fiscal year involved. 
‘‘(E) AMOUNTS
AVAILABLE
FOR
PAY-
MENTS.— 
‘‘(i) INITIAL APPROPRIATION.—Out of 
any money in the Treasury not otherwise 
appropriated, 
there 
are 
appropriated 
$3,225,000,000 for fiscal year 2009 for 
making payments under this paragraph, to 
be available until expended.
‘‘(ii) 
TRANSFERS.—Notwithstanding 
any other provision of this title, the fol-
lowing amounts shall also be available, 
without fiscal year limitation, for making 
payments under this paragraph: 
‘‘(I) 
UNOBLIGATED
NATIONAL 
ALLOTMENT.— 
‘‘(aa) FISCAL
YEARS
2009 
THROUGH 2012.—As of December 
31 of fiscal year 2009, and as of 
December 31 of each succeeding 
fiscal year through fiscal year 
2012, the portion, if any, of the 
amount appropriated under sub-
section (a) for such fiscal year 
that is unobligated for allotment 
to a State under subsection (m) 
for such fiscal year or set aside 
under subsection (a)(3) or (b)(2) 
of section 2111 for such fiscal 
year. 
‘‘(bb) FIRST HALF OF FIS-
CAL YEAR 2013.—As of December 
31 of fiscal year 2013, the por-
tion, if any, of the sum of the
amounts appropriated under sub-
section (a)(16)(A) and under sec-
tion 108 of the Children’s Health 
Insurance Reauthorization Act of 
2009 for the period beginning on 
October 1, 2012, and ending on 
March 31, 2013, that is unobli-
gated for allotment to a State 
under subsection (m) for such 
fiscal year or set aside under 
subsection (b)(2) of section 2111 
for such fiscal year. 
‘‘(cc) SECOND HALF OF FIS-
CAL YEAR 2013.—As of June 30 
of fiscal year 2013, the portion, 
if any, of the amount appro-
priated 
under 
subsection 
(a)(16)(B) for the period begin-
ning on April 1, 2013, and end-
ing on September 30, 2013, that 
is unobligated for allotment to a 
State under subsection (m) for 
such fiscal year or set aside 
under subsection (b)(2) of section 
2111 for such fiscal year.
‘‘(II) 
UNEXPENDED
ALLOT-
MENTS NOT USED FOR REDISTRIBU-
TION.—As of November 15 of each of 
fiscal years 2010 through 2013, the 
total amount of allotments made to 
States under section 2104 for the sec-
ond preceding fiscal year (third pre-
ceding fiscal year in the case of the 
fiscal year 2006, 2007, and 2008 al-
lotments) that is not expended or re-
distributed under section 2104(f) dur-
ing the period in which such allot-
ments are available for obligation. 
‘‘(III) EXCESS
CHILD
ENROLL-
MENT
CONTINGENCY
FUNDS.—As of 
October 1 of each of fiscal years 2010 
through 2013, any amount in excess 
of the aggregate cap applicable to the 
Child Enrollment Contingency Fund 
for the fiscal year under section 
2104(n). 
‘‘(IV) 
UNEXPENDED
TRANSI-
TIONAL COVERAGE BLOCK GRANT FOR 
NONPREGNANT CHILDLESS ADULTS.— 
As of October 1, 2011, any amounts
set aside under section 2111(a)(3) 
that are not expended by September 
30, 2011. 
‘‘(iii) PROPORTIONAL REDUCTION.—If 
the sum of the amounts otherwise payable 
under this paragraph for a fiscal year ex-
ceeds the amount available for the fiscal 
year under this subparagraph, the amount 
to be paid under this paragraph to each 
State shall be reduced proportionally. 
‘‘(F) QUALIFYING CHILDREN DEFINED.— 
For purposes of this subsection, the term 
‘qualifying children’ means children who meet 
the eligibility criteria (including income, cat-
egorical eligibility, age, and immigration status 
criteria) in effect as of July 1, 2008, for enroll-
ment under title XIX, taking into account cri-
teria applied as of such date under title XIX 
pursuant to a waiver under section 1115. Such 
term does not include any children for whom 
the State has made an election to provide med-
ical assistance under section 1903(v)(4). 
‘‘(G) APPLICATION
TO
COMMONWEALTHS 
AND TERRITORIES.—The provisions of subpara-
graph (G) of section 2104(n)(3) shall apply
with respect to payment under this paragraph 
in the same manner as such provisions apply to 
payment under such section. 
‘‘(H) APPLICATION TO STATES THAT IM-
PLEMENT A MEDICAID EXPANSION FOR CHIL-
DREN AFTER FISCAL YEAR 2008.—In the case of 
a State that provides coverage under section 
115 of the Children’s Health Insurance Pro-
gram Reauthorization Act of 2009 for any fis-
cal year after fiscal year 2008— 
‘‘(i) any child enrolled in the State 
plan under title XIX through the applica-
tion of such an election shall be dis-
regarded from the determination for the 
State of the monthly average unduplicated 
number of qualifying children enrolled in 
such plan during the first 3 fiscal years in 
which such an election is in effect; and 
‘‘(ii) in determining the baseline num-
ber of child enrollees for the State for any 
fiscal year subsequent to such first 3 fiscal 
years, the baseline number of child enroll-
ees for the State under title XIX for the 
third of such fiscal years shall be the 
monthly average unduplicated number of
qualifying children enrolled in the State 
plan under title XIX for such third fiscal 
year. 
‘‘(4) ENROLLMENT
AND
RETENTION
PROVI-
SIONS FOR CHILDREN.—For purposes of paragraph 
(3)(A), a State meets the condition of this para-
graph for a fiscal year if it is implementing at least 
4 of the following enrollment and retention provi-
sions (treating each subparagraph as a separate en-
rollment and retention provision) throughout the en-
tire fiscal year: 
‘‘(A) 
CONTINUOUS
ELIGIBILITY.—The 
State has elected the option of continuous eligi-
bility for a full 12 months for all children de-
scribed in section 1902(e)(12) under title XIX 
under 19 years of age, as well as applying such 
policy under its State child health plan under 
this title. 
‘‘(B) LIBERALIZATION OF ASSET REQUIRE-
MENTS.—The State meets the requirement 
specified in either of the following clauses: 
‘‘(i) ELIMINATION OF ASSET TEST.— 
The State does not apply any asset or re-
source test for eligibility for children under 
title XIX or this title.
‘‘(ii) ADMINISTRATIVE
VERIFICATION 
OF ASSETS.—The State— 
‘‘(I) permits a parent or care-
taker relative who is applying on be-
half of a child for medical assistance 
under title XIX or child health assist-
ance under this title to declare and 
certify by signature under penalty of 
perjury information relating to family 
assets for purposes of determining 
and redetermining financial eligibility; 
and 
‘‘(II) takes steps to verify assets 
through means other than by requir-
ing documentation from parents and 
applicants except in individual cases 
of discrepancies or where otherwise 
justified. 
‘‘(C) ELIMINATION OF IN-PERSON INTER-
VIEW REQUIREMENT.—The State does not re-
quire an application of a child for medical as-
sistance under title XIX (or for child health as-
sistance under this title), including an applica-
tion for renewal of such assistance, to be made 
in person nor does the State require a face-to-
face interview, unless there are discrepancies or 
individual circumstances justifying an in-person 
application or face-to-face interview. 
‘‘(D) USE
OF
JOINT
APPLICATION
FOR 
MEDICAID
AND
CHIP.—The application form 
and supplemental forms (if any) and informa-
tion verification process is the same for pur-
poses of establishing and renewing eligibility for 
children for medical assistance under title XIX 
and child health assistance under this title. 
‘‘(E) AUTOMATIC RENEWAL (USE OF AD-
MINISTRATIVE RENEWAL).— 
‘‘(i) IN
GENERAL.—The State pro-
vides, in the case of renewal of a child’s 
eligibility for medical assistance under title 
XIX or child health assistance under this 
title, a pre-printed form completed by the 
State based on the information available to 
the State and notice to the parent or care-
taker relative of the child that eligibility of 
the child will be renewed and continued 
based on such information unless the State 
is provided other information. Nothing in 
this clause shall be construed as preventing 
a State from verifying, through electronic
and other means, the information so pro-
vided. 
‘‘(ii) SATISFACTION
THROUGH
DEM-
ONSTRATED USE OF EX PARTE PROCESS.— 
A State shall be treated as satisfying the 
requirement of clause (i) if renewal of eli-
gibility of children under title XIX or this 
title is determined without any require-
ment for an in-person interview, unless 
sufficient information is not in the State’s 
possession and cannot be acquired from 
other sources (including other State agen-
cies) without the participation of the appli-
cant or the applicant’s parent or caretaker 
relative. 
‘‘(F) 
PRESUMPTIVE
ELIGIBILITY
FOR 
CHILDREN.—The State is implementing section 
1920A under title XIX as well as, pursuant to 
section 2107(e)(1), under this title. 
‘‘(G) EXPRESS LANE.—The State is imple-
menting 
the 
option 
described 
in 
section 
1902(e)(13) under title XIX as well as, pursu-
ant to section 2107(e)(1), under this title.’’.
SEC. 105. TWO-YEAR INITIAL AVAILABILITY OF CHIP AL-
LOTMENTS. 
Section 2104(e) (42 U.S.C. 1397dd(e)) is amended 
to read as follows: 
‘‘(e) AVAILABILITY OF AMOUNTS ALLOTTED.— 
‘‘(1) IN GENERAL.—Except as provided in para-
graph (2), amounts allotted to a State pursuant to 
this section— 
‘‘(A) for each of fiscal years 1998 through 
2008, shall remain available for expenditure by 
the State through the end of the second suc-
ceeding fiscal year; and 
‘‘(B) for fiscal year 2009 and each fiscal 
year thereafter, shall remain available for ex-
penditure by the State through the end of the 
succeeding fiscal year. 
‘‘(2) AVAILABILITY
OF
AMOUNTS
REDISTRIB-
UTED.—Amounts redistributed to a State under sub-
section (f) shall be available for expenditure by the 
State through the end of the fiscal year in which 
they are redistributed.’’. 
SEC. 106. REDISTRIBUTION OF UNUSED ALLOTMENTS. 
(a) BEGINNING WITH FISCAL YEAR 2007.— 
(1) IN GENERAL.—Section 2104(f) (42 U.S.C. 
1397dd(f)) is amended—
(A) by striking ‘‘The Secretary’’ and in-
serting the following: 
‘‘(1) IN GENERAL.—The Secretary’’; 
(B) by striking ‘‘States that have fully ex-
pended the amount of their allotments under 
this section.’’ and inserting ‘‘States that the 
Secretary determines with respect to the fiscal 
year for which unused allotments are available 
for redistribution under this subsection, are 
shortfall States described in paragraph (2) for 
such fiscal year, but not to exceed the amount 
of the shortfall described in paragraph (2)(A) 
for each such State (as may be adjusted under 
paragraph (2)(C)).’’; and 
(C) by adding at the end the following new 
paragraph: 
‘‘(2) SHORTFALL STATES DESCRIBED.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1), with respect to a fiscal year, a short-
fall State described in this subparagraph is a 
State with a State child health plan approved 
under this title for which the Secretary esti-
mates on the basis of the most recent data 
available to the Secretary, that the projected ex-
penditures under such plan for the State for the 
fiscal year will exceed the sum of— 
‘‘(i) the amount of the State’s allot-
ments for any preceding fiscal years that 
remains available for expenditure and that 
will not be expended by the end of the im-
mediately preceding fiscal year; 
‘‘(ii) the amount (if any) of the child 
enrollment 
contingency 
fund 
payment 
under subsection (n); and 
‘‘(iii) the amount of the State’s allot-
ment for the fiscal year. 
‘‘(B) PRORATION RULE.—If the amounts 
available for redistribution under paragraph (1) 
for a fiscal year are less than the total amounts 
of the estimated shortfalls determined for the 
year under subparagraph (A), the amount to be 
redistributed under such paragraph for each 
shortfall State shall be reduced proportionally. 
‘‘(C) RETROSPECTIVE ADJUSTMENT.—The 
Secretary may adjust the estimates and deter-
minations made under paragraph (1) and this 
paragraph with respect to a fiscal year as nec-
essary on the basis of the amounts reported by 
States not later than November 30 of the suc-
ceeding fiscal year, as approved by the Sec-
retary.’’. 
(2) EFFECTIVE DATE.—The amendments made 
by paragraph (1) shall apply to redistribution of al-
lotments made for fiscal year 2007 and subsequent 
fiscal years. 
(b) REDISTRIBUTION OF UNUSED ALLOTMENTS FOR 
FISCAL
YEAR
2006.—Section 2104(k) (42 U.S.C. 
1397dd(k)) is amended— 
(1) in the subsection heading, by striking ‘‘THE 
FIRST 2 QUARTERS OF’’; 
(2) in paragraph (1), by striking ‘‘the first 2 
quarters of’’; and 
(3) in paragraph (6)— 
(A) by striking ‘‘the first 2 quarters of’’; 
and 
(B) by striking ‘‘March 31’’ and inserting 
‘‘September 30’’. 
SEC. 107. OPTION FOR QUALIFYING STATES TO RECEIVE 
THE ENHANCED PORTION OF THE CHIP 
MATCHING RATE FOR MEDICAID COVERAGE 
OF CERTAIN CHILDREN. 
(a) IN
GENERAL.—Section 2105(g) (42 U.S.C. 
1397ee(g)) is amended—
(1) in paragraph (1)(A), as amended by section 
201(b)(1) of Public Law 110–173— 
(A) by inserting ‘‘subject to paragraph 
(4),’’ after ‘‘Notwithstanding any other provi-
sion of law,’’; and 
(B) by striking ‘‘2008, or 2009’’ and in-
serting ‘‘or 2008’’; and 
(2) by adding at the end the following new 
paragraph: 
‘‘(4) OPTION
FOR
ALLOTMENTS
FOR
FISCAL 
YEARS 2009 THROUGH 2013.— 
‘‘(A) PAYMENT OF ENHANCED PORTION OF 
MATCHING
RATE
FOR
CERTAIN
EXPENDI-
TURES.—In the case of expenditures described 
in subparagraph (B), a qualifying State (as de-
fined in paragraph (2)) may elect to be paid 
from the State’s allotment made under section 
2104 for any of fiscal years 2009 through 2013 
(insofar as the allotment is available to the 
State under subsections (e) and (m) of such 
section) an amount each quarter equal to the 
additional amount that would have been paid to 
the State under title XIX with respect to such 
expenditures if the enhanced FMAP (as deter-
mined under subsection (b)) had been sub-
stituted for the Federal medical assistance per-
centage (as defined in section 1905(b)). 
‘‘(B) EXPENDITURES
DESCRIBED.—For 
purposes of subparagraph (A), the expenditures 
described in this subparagraph are expenditures 
made after the date of the enactment of this 
paragraph and during the period in which funds 
are available to the qualifying State for use 
under subparagraph (A), for the provision of 
medical assistance to individuals residing in the 
State who are eligible for medical assistance 
under the State plan under title XIX or under 
a waiver of such plan and who have not at-
tained age 19 (or, if a State has so elected 
under the State plan under title XIX, age 20 
or 21), and whose family income equals or ex-
ceeds 133 percent of the poverty line but does 
not exceed the Medicaid applicable income 
level.’’. 
(b) REPEAL OF LIMITATION ON AVAILABILITY OF 
FISCAL YEAR 2009 ALLOTMENTS.—Paragraph (2) of sec-
tion 201(b) of the Medicare, Medicaid, and SCHIP Exten-
sion Act of 2007 (Public Law 110-173) is repealed.
SEC. 108. ONE-TIME APPROPRIATION. 
There is appropriated to the Secretary, out of any 
money in the Treasury not otherwise appropriated, 
$11,406,000,000 to accompany the allotment made for the 
period beginning on October 1, 2012, and ending on 
March 31, 2013, under section 2104(a)(16)(A) of the So-
cial Security Act (42 U.S.C. 1397dd(a)(16)(A)) (as added 
by section 101), to remain available until expended. Such 
amount shall be used to provide allotments to States under 
paragraph (3) of section 2104(m) of the Social Security 
Act (42 U.S.C. 1397dd(i)), as added by section 102, for 
the first 6 months of fiscal year 2013 in the same manner 
as allotments are provided under subsection (a)(16)(A) of 
such section 2104 and subject to the same terms and con-
ditions as apply to the allotments provided from such sub-
section (a)(16)(A). 
SEC. 109. IMPROVING FUNDING FOR THE TERRITORIES 
UNDER CHIP AND MEDICAID. 
(a) REMOVAL OF FEDERAL MATCHING PAYMENTS 
FOR DATA REPORTING SYSTEMS FROM THE OVERALL 
LIMIT ON PAYMENTS TO TERRITORIES UNDER TITLE 
XIX.—Section 1108(g) (42 U.S.C. 1308(g)) is amended 
by adding at the end the following new paragraph: 
‘‘(4) EXCLUSION OF CERTAIN EXPENDITURES 
FROM
PAYMENT
LIMITS.—With respect to fiscal 
years beginning with fiscal year 2009, if Puerto
Rico, the Virgin Islands, Guam, the Northern Mar-
iana Islands, or American Samoa qualify for a pay-
ment under subparagraph (A)(i), (B), or (F) of sec-
tion 1903(a)(3) for a calendar quarter of such fiscal 
year, the payment shall not be taken into account in 
applying subsection (f) (as increased in accordance 
with paragraphs (1), (2), and (3) of this subsection) 
to such commonwealth or territory for such fiscal 
year.’’. 
(b) GAO STUDY AND REPORT.—Not later than Sep-
tember 30, 2010, the Comptroller General of the United 
States shall submit a report to the Committee on Finance 
of the Senate and the Committee on Energy and Com-
merce of the House of Representatives regarding Federal 
funding under Medicaid and CHIP for Puerto Rico, the 
United States Virgin Islands, Guam, American Samoa, 
and the Northern Mariana Islands. The report shall in-
clude the following: 
(1) An analysis of all relevant factors with re-
spect to— 
(A) eligible Medicaid and CHIP popu-
lations in such commonwealths and territories; 
(B) historical and projected spending needs 
of such commonwealths and territories and the
ability of capped funding streams to respond to 
those spending needs; 
(C) the extent to which Federal poverty 
guidelines are used by such commonwealths and 
territories to determine Medicaid and CHIP eli-
gibility; and 
(D) the extent to which such common-
wealths and territories participate in data col-
lection and reporting related to Medicaid and 
CHIP, including an analysis of territory partici-
pation in the Current Population Survey versus 
the American Community Survey. 
(2) Recommendations regarding methods for 
the collection and reporting of reliable data regard-
ing the enrollment under Medicaid and CHIP of 
children in such commonwealths and territories. 
(3) Recommendations for improving Federal 
funding under Medicaid and CHIP for such com-
monwealths and territories.
Subtitle B—Focus on Low-Income 
Children and Pregnant Women 
SEC. 111. STATE OPTION TO COVER LOW-INCOME PREG-
NANT WOMEN UNDER CHIP THROUGH A 
STATE PLAN AMENDMENT. 
(a) IN GENERAL.—Title XXI (42 U.S.C. 1397aa et 
seq.), as amended by section 112(a), is amended by adding 
at the end the following new section: 
‘‘SEC. 2112. OPTIONAL COVERAGE OF TARGETED LOW-IN-
COME PREGNANT WOMEN THROUGH A STATE 
PLAN AMENDMENT. 
‘‘(a) IN GENERAL.—Subject to the succeeding provi-
sions of this section, a State may elect through an amend-
ment to its State child health plan under section 2102 to 
provide pregnancy-related assistance under such plan for 
targeted low-income pregnant women. 
‘‘(b) CONDITIONS.—A State may only elect the option 
under subsection (a) if the following conditions are satis-
fied: 
‘‘(1) MINIMUM
INCOME
ELIGIBILITY
LEVELS 
FOR PREGNANT WOMEN AND CHILDREN.—The State 
has established an income eligibility level— 
‘‘(A) for pregnant women under subsection 
(a)(10)(A)(i)(III), 
(a)(10)(A)(i)(IV), 
or 
(l)(1)(A) of section 1902 that is at least 185
percent (or such higher percent as the State 
has in effect with regard to pregnant women 
under this title) of the poverty line applicable to 
a family of the size involved, but in no case 
lower than the percent in effect under any such 
subsection as of July 1, 2008; and 
‘‘(B) for children under 19 years of age 
under this title (or title XIX) that is at least 
200 percent of the poverty line applicable to a 
family of the size involved. 
‘‘(2) NO CHIP INCOME ELIGIBILITY LEVEL FOR 
PREGNANT WOMEN LOWER THAN THE STATE’S MED-
ICAID LEVEL.—The State does not apply an effective 
income level for pregnant women under the State 
plan amendment that is lower than the effective in-
come level (expressed as a percent of the poverty line 
and considering applicable income disregards) speci-
fied 
under 
subsection 
(a)(10)(A)(i)(III), 
(a)(10)(A)(i)(IV), or (l)(1)(A) of section 1902, on 
the date of enactment of this paragraph to be eligi-
ble for medical assistance as a pregnant woman. 
‘‘(3) NO COVERAGE FOR HIGHER INCOME PREG-
NANT WOMEN WITHOUT COVERING LOWER INCOME 
PREGNANT
WOMEN.—The State does not provide 
coverage for pregnant women with higher family in-
come without covering pregnant women with a lower 
family income. 
‘‘(4) APPLICATION
OF
REQUIREMENTS
FOR 
COVERAGE OF TARGETED LOW-INCOME CHILDREN.— 
The State provides pregnancy-related assistance for 
targeted low-income pregnant women in the same 
manner, and subject to the same requirements, as 
the State provides child health assistance for tar-
geted low-income children under the State child 
health plan, and in addition to providing child health 
assistance for such women. 
‘‘(5) NO PREEXISTING CONDITION EXCLUSION 
OR WAITING PERIOD.—The State does not apply any 
exclusion of benefits for pregnancy-related assistance 
based on any preexisting condition or any waiting 
period (including any waiting period imposed to 
carry out section 2102(b)(3)(C)) for receipt of such 
assistance. 
‘‘(6) APPLICATION OF COST-SHARING PROTEC-
TION.—The State provides pregnancy-related assist-
ance to a targeted low-income woman consistent 
with the cost-sharing protections under section 
2103(e) and applies the limitation on total annual 
aggregate cost sharing imposed under paragraph
(3)(B) of such section to the family of such a 
woman. 
‘‘(7) NO WAITING LIST FOR CHILDREN.—The 
State does not impose, with respect to the enroll-
ment under the State child health plan of targeted 
low-income children during the quarter, any enroll-
ment cap or other numerical limitation on enroll-
ment, any waiting list, any procedures designed to 
delay the consideration of applications for enroll-
ment, or similar limitation with respect to enroll-
ment. 
‘‘(c) OPTION TO PROVIDE PRESUMPTIVE ELIGI-
BILITY.—A State that elects the option under subsection 
(a) and satisfies the conditions described in subsection (b) 
may elect to apply section 1920 (relating to presumptive 
eligibility for pregnant women) to the State child health 
plan in the same manner as such section applies to the 
State plan under title XIX. 
‘‘(d) 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) with respect to an individual during the pe-
riod described in paragraph (2)(A).
‘‘(2) 
TARGETED
LOW-INCOME
PREGNANT 
WOMAN.—The term ‘targeted low-income pregnant 
woman’ means an individual— 
‘‘(A) during pregnancy and through the 
end of the month in which the 60-day period 
(beginning on the last day of her pregnancy) 
ends; 
‘‘(B) whose family income exceeds 185 per-
cent (or, if higher, the percent applied under 
subsection (b)(1)(A)) of the poverty line appli-
cable to a family of the size involved, but does 
not exceed the income eligibility level estab-
lished under the State child health plan under 
this title for a targeted low-income child; and 
‘‘(C) who satisfies the requirements of 
paragraphs (1)(A), (1)(C), (2), and (3) of sec-
tion 2110(b) in the same manner as a child ap-
plying for child health assistance would have to 
satisfy such requirements. 
‘‘(e) AUTOMATIC
ENROLLMENT
FOR
CHILDREN 
BORN TO WOMEN RECEIVING PREGNANCY-RELATED AS-
SISTANCE.—If a child is born to a targeted low-income 
pregnant woman who was receiving pregnancy-related as-
sistance under this section on the date of the child’s birth, 
the child shall be deemed to have applied for child health
assistance under the State child health plan and to have 
been found eligible for such assistance under such plan 
or to have applied for medical assistance under title XIX 
and to have been found eligible for such assistance under 
such title, as appropriate, on the date of such birth and 
to remain eligible for such assistance until the child at-
tains 1 year of age. During the period in which a child 
is deemed under the preceding sentence to be eligible for 
child health or medical assistance, the child health or med-
ical assistance eligibility identification number of the 
mother shall also serve as the identification number of the 
child, and all claims shall be submitted and paid under 
such number (unless the State issues a separate identifica-
tion number for the child before such period expires). 
‘‘(f) STATES
PROVIDING
ASSISTANCE
THROUGH 
OTHER OPTIONS.— 
‘‘(1) CONTINUATION OF OTHER OPTIONS FOR 
PROVIDING ASSISTANCE.—The option to provide as-
sistance in accordance with the preceding sub-
sections of this section shall not limit any other op-
tion for a State to provide— 
‘‘(A) child health assistance through the 
application of sections 457.10, 457.350(b)(2), 
457.622(c)(5), and 457.626(a)(3) of title 42, 
Code of Federal Regulations (as in effect after
the final rule adopted by the Secretary and set 
forth at 67 Fed. Reg. 61956–61974 (October 2, 
2002)), or 
‘‘(B) pregnancy-related services through 
the application of any waiver authority (as in 
effect on June 1, 2008). 
‘‘(2) CLARIFICATION OF AUTHORITY TO PRO-
VIDE POSTPARTUM SERVICES.—Any State that pro-
vides child health assistance under any authority de-
scribed in paragraph (1) may continue to provide 
such assistance, as well as postpartum services, 
through the end of the month in which the 60-day 
period (beginning on the last day of the pregnancy) 
ends, in the same manner as such assistance and 
postpartum services would be provided if provided 
under the State plan under title XIX, but only if the 
mother would otherwise satisfy the eligibility re-
quirements that apply under the State child health 
plan (other than with respect to age) during such 
period. 
‘‘(3) NO
INFERENCE.—Nothing in this sub-
section shall be construed— 
‘‘(A) to infer congressional intent regard-
ing the legality or illegality of the content of the 
sections specified in paragraph (1)(A); or
‘‘(B) to modify the authority to provide 
pregnancy-related services under a waiver speci-
fied in paragraph (1)(B).’’. 
(b) ADDITIONAL CONFORMING AMENDMENTS.— 
(1) NO
COST
SHARING
FOR
PREGNANCY-RE-
LATED BENEFITS.—Section 2103(e)(2) (42 U.S.C. 
1397cc(e)(2)) is amended— 
(A) in the heading, by inserting ‘‘OR 
PREGNANCY-RELATED
ASSISTANCE’’ after 
‘‘PREVENTIVE SERVICES’’; and 
(B) by inserting before the period at the 
end the following: ‘‘or for pregnancy-related as-
sistance’’. 
(2) 
NO
WAITING
PERIOD.—Section 
2102(b)(1)(B) (42 U.S.C. 1397bb(b)(1)(B)) is 
amended— 
(A) in clause (i), by striking ‘‘, and’’ at the 
end and inserting a semicolon; 
(B) in clause (ii), by striking the period at 
the end and inserting ‘‘; and’’; and 
(C) by adding at the end the following new 
clause: 
‘‘(iii) may not apply a waiting period 
(including a waiting period to carry out 
paragraph (3)(C)) in the case of a targeted
low-income pregnant woman provided preg-
nancy-related 
assistance 
under 
section 
2112.’’. 
SEC. 112. PHASE-OUT OF COVERAGE FOR NONPREGNANT 
CHILDLESS ADULTS UNDER CHIP; CONDI-
TIONS FOR COVERAGE OF PARENTS. 
(a) PHASE-OUT RULES.— 
(1) IN
GENERAL.—Title XXI (42 U.S.C. 
1397aa et seq.) is amended by adding at the end the 
following new section: 
‘‘SEC. 2111. PHASE-OUT OF COVERAGE FOR NONPREGNANT 
CHILDLESS ADULTS; CONDITIONS FOR COV-
ERAGE OF PARENTS. 
‘‘(a) TERMINATION OF COVERAGE FOR NONPREG-
NANT CHILDLESS ADULTS.— 
‘‘(1) NO NEW CHIP WAIVERS; AUTOMATIC EX-
TENSIONS AT STATE OPTION THROUGH FISCAL YEAR 
2010.—Notwithstanding section 1115 or any other 
provision of this title, except as provided in this sub-
section— 
‘‘(A) the Secretary shall not on or after the 
date of the enactment of the Children’s Health 
Insurance Program Reauthorization Act of 
2009, approve or renew a waiver, experimental, 
pilot, or demonstration project that would allow