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‘‘SEC. 2244. RECONCILIATION OF PREMIUM ASSISTANCE
THROUGH USE OF INCOME STATEMENTS.
‘‘(a) REQUIREMENT FOR FILING OF INCOME STATE-
MENT.—Subject to section 2245, in the case of a family
which is receiving low-income assistance under this part
for any month in a year, a member of the family shall
file with the State plan, by not later than April 15 of the
following year, a statement that verifies the family’s total
adjusted family income for the taxable year ending during
the previous year. Such a statement shall provide informa-
tion necessary to determine the family adjusted total in-
come during the year and the number of family members
in the family as of the last day of the year.
‘‘(b) RECONCILIATION
OF PREMIUM ASSISTANCE
BASED ON ACTUAL INCOME.—Based on and using the in-
come reported in the statement filed under subsection (a)
with respect to a family or individual, subject to section
2245, each State plan shall compute the amount of assist-
ance that should have been provided under this part with
respect to premiums for the family in the year involved.
If the amount of such assistance computed is—
‘‘(1) greater than the amount of premium as-
sistance provided, the State plan shall provide for
payment (directly or through a credit against future
premiums owed) to the family or individual involved
of an amount equal to the amount of the deficit, or
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‘‘(2) less than the amount of assistance pro-
vided, the State plan shall require the family or indi-
vidual to pay (directly or through an increase in fu-
ture premiums owed) to the plan an amount equal
to the amount of the excess payment.
‘‘(c) DISQUALIFICATION FOR FAILURE TO FILE.—
Subject to section 2245, in the case of any family that
is required to file an information statement under sub-
section (a) in a year and that fails to file such a statement
by the deadline specified in such subsection, no member
of the family shall be eligible for assistance under this part
after May 1 of such year. A State plan shall waive the
application of this subsection if the family establishes, to
the satisfaction of the State, good cause for the failure
to file the statement on a timely basis.
‘‘(d) PENALTIES FOR FALSE INFORMATION.—Any
individual that provides false information in a statement
under subsection (a) is subject to a criminal penalty to
the same extent as a criminal penalty may be imposed
under section 1128B(a) with respect to a person described
in clause (ii) of such section.
‘‘(e) NOTICE OF REQUIREMENT.—Each State plan
shall provide for written notice, in March of each year,
of the requirement of subsection (a) to each family which
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received assistance under this part in any month during
the preceding year and to which such requirement applies.
‘‘(f) TRANSMITTAL
OF INFORMATION.—The Sec-
retary of the Treasury shall transmit annually to the Sec-
retary such information relating to the adjusted total in-
come of individuals for the taxable year ending in the pre-
vious year as may be necessary for State plans to verify
the reconciliation of assistance under this section. The
Secretary shall provide for transmission of such informa-
tion to State plans for their use in performing such rec-
onciliation.
‘‘(g) CONSTRUCTION.—Nothing in this section shall
be construed as authorizing reconciliation of assistance
provided with respect to deductibles and coinsurance.
‘‘SEC. 2245. TREATMENT OF CERTAIN CASH ASSISTANCE
RECIPIENTS.
‘‘In the case of a family that has been determined
to be eligible for aid under part A or E of title IV or an
individual who has been determined to be eligible for sup-
plemental security income benefits under title XVI—
‘‘(1) the family or individual is deemed, without
the need to file an application for assistance under
section 2243, to have adjusted total income below
100 percent of the official poverty line applicable to
a family of the size involved,
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‘‘(2) the family or individual need not file a
statement under section 2244(a), and
‘‘(3) the assistance received by the family or in-
dividual is not subject to reconciliation under section
2244(b).
‘‘SEC. 2246. COMPUTATION OF FAMILY ADJUSTED TOTAL
INCOME.
‘‘In this part:
‘‘(1) ADJUSTED
TOTAL
INCOME.—The term
‘adjusted total income’ means—
‘‘(A) adjusted gross income (as defined in
section 62(a) of the Internal Revenue Code of
1986), determined without the application of
paragraphs (6) and (7) of such section and
without the application of section 162(l) of such
Code, plus
‘‘(B) the amount of social security benefits
(described in section 86(d) of such Code) which
is not includable in gross income under section
86 of such Code.
‘‘(2) FAMILY ADJUSTED TOTAL INCOME.—The
term ‘family adjusted total income’ means, with re-
spect to an individual, the sum of the adjusted total
income for the individual and all the other family
members.
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‘‘PART F—ADMINISTRATIVE PROVISIONS
‘‘SEC. 2261. GENERAL ADMINISTRATION THROUGH INSUR-
ANCE COMPANIES.
‘‘(a) IN GENERAL.—Except as otherwise provided in
this part, each State shall provide, to the maximum extent
practicable, for the administration of the State plan under
this title through arrangements with at least 2 insurance
companies, or, if there are not 2 qualified insurance com-
panies able to administer the plan in the State, 1 such
insurance company. Nothing in this section shall be con-
strued as preventing or prohibiting States in a region from
jointly contracting with 2 or more insurance companies
to administer the State plans of the several States in the
region.
‘‘(b) OUTREACH AND OPTIONAL SERVICES.—Each
State shall provide directly for the administration of the
State plan with respect to—
‘‘(1) the provision of, or payment for, outreach
services under section 2212(b), and
‘‘(2) the provision of, or payment for, optional
services under section 2212(c).
‘‘(c) LOW INCOME ASSISTANCE.—Each State shall
provide for the determination of low-income assistance
under part E to be made by entities, specifically des-
ignated by the State, that are independent of such insur-
111
ance companies and that will assure the confidentiality of
information provided in conjunction with obtaining such
assistance.
‘‘SEC. 2262. QUALITY ASSURANCE.
‘‘(a) IN GENERAL.—Each State plan shall provide for
the application of methods that assure the quality of the
services provided under the plan.
‘‘(b) PEER REVIEW.—Such methods shall include—
‘‘(1) peer review of professional services, and
‘‘(2) such other methods as the Secretary finds
cost-effective in order to reduce unnecessary tests
and procedures.
‘‘SEC. 2263. BENEFICIARY CLAIMS SAFEGUARDS.
‘‘(a) NOTICE OF CLAIMS DENIALS.—Each State plan
shall provide an individual with written notice concerning
the denial of a claim submitted by the individual under
the plan. Such notice shall include the reasons for the de-
nial.
‘‘(b) PROCESS FOR REVIEW.—Each State plan shall
use a fair process for the timely review of claims denied
under the plan.
‘‘(c) CLAIM FOR CARE NEEDED FOR LIFE-THREAT-
ENING ILLNESS.—In cases in which the failure to provide
required health services promptly would be life-threatening
or result in a risk of permanent disability of an individual
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enrolled under a State plan, the individual is entitled to
a decision as to whether benefits are available under the
plan with respect to such services not later than 1 day
after supplying the State plan with all requested informa-
tion. In the event of a denial of coverage for such services,
the individual shall be entitled to an expedited review of
an appeal of such denial within 5 days.
‘‘(d) APPEALS.—Each individual is entitled to appeal
the denial of a claim submitted by the individual under
the State plan. The Secretary shall promulgate regulations
establishing procedures to be utilized for appealing denials
of claims under this title that are similar to the procedures
established under title XVIII for appealing denials of
claims under such title.
‘‘SEC. 2264. ADMINISTRATIVE EFFICIENCY STANDARDS.
‘‘Each State plan shall be administered in a manner
consistent with administrative efficiency and simplicity, in
accordance with standards specified by the Secretary.
Such standards shall incorporate goals for the reduction
of administrative waste and duplication.
‘‘SEC. 2265. HEALTH MAINTENANCE ORGANIZATIONS.
‘‘(a) IN GENERAL.—Except as provided in this sec-
tion, section 1876 shall apply to individuals enrolled under
a State plan in the same manner as such section applies
113
to individuals entitled to benefits under part A, and en-
rolled under part B, of title XVIII.
‘‘(b) APPLICATION.—In applying section 1876 under
this section—
‘‘(1) the provisions of such section relating only
to individuals enrolled under part B of title XVIII
shall not apply;
‘‘(2) any reference to a Trust Fund established
under title XVIII and to benefits with respect to any
services under such title is deemed a reference to the
Federal Children and Pregnant Women Health In-
surance Trust Fund and to health insurance benefits
with respect to required health services under this
title;
‘‘(3) the adjusted average per capita cost shall
be determined on the basis of benefits under this
title;
‘‘(4) subsections (f) and (h) of such section
shall not apply;
‘‘(5) in applying subsection (c)(3)(B) of such
section, an eligible organization may require a mini-
mum period of enrollment (of not greater than 6
months) during which an individual may not
disenroll other than for cause or unless enrollment
under this title is terminated; and
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‘‘(6) the Secretary shall establish such rules as
may be necessary to apply such section to different
State plans.
‘‘SEC. 2266. PROGRAM INTEGRITY; MISCELLANEOUS PROVI-
SIONS.
‘‘Sections 1124, 1124A, 1126, and 1128 through
1128B (relating to fraud and abuse) shall apply to this
title in the same manner as they apply to title XIX.
‘‘SEC. 2267. DEMONSTRATION PROJECT AUTHORITY.
‘‘(a) DEMONSTRATION PROJECT AUTHORITY.—
‘‘(1) IN GENERAL.—Subject to the approval of
the Secretary, States are authorized to conduct dem-
onstration projects—
‘‘(A) to improve the delivery and quality of
health care services under this title, and
‘‘(B) to increase the efficiency and effec-
tiveness of methods of payment for such serv-
ices.
Subject to paragraph (2), the Secretary may waive
such requirements of this title as may be necessary
to carry out such demonstration projects.
‘‘(2) LIMITATION.—The Secretary does not
have the authority under paragraph (1)—
‘‘(A) to reduce the benefits available under
part B, or
115
‘‘(B) to increase the deductible or coinsur-
ance under part C.
‘‘(3) FUNDING.—Grants, payments under con-
tracts, and other expenditures made for demonstra-
tion projects under this subsection—
‘‘(A) shall be made from the Federal Chil-
dren and Pregnant Women Health Insurance
Trust Fund,
‘‘(B) may be made either in advance or by
way of reimbursement, as may be determined
by the Secretary, and
‘‘(C) shall be made in such installments
and on such conditions as the Secretary finds
necessary to carry out the purpose of this sub-
section.
‘‘(b) CONSTRUCTION.—Except as provided in sub-
section (a), the Secretary is not authorized to waive any
requirement of this title.
‘‘PART G—DEFINITIONS AND MISCELLANEOUS
‘‘SEC. 2281. INCORPORATION OF CERTAIN DEFINITIONS
USED IN OTHER HEALTH-RELATED TITLES.
‘‘(a) INCORPORATION OF MEDICARE DEFINITIONS.—
In this title, the definitions contained in section 1861
apply for purposes of this title in the same manner as they
apply for purposes of title XVIII.
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‘‘(b) INCORPORATION
OF CERTAIN EMPLOYMENT-
RELATED DEFINITIONS IN TITLE XXI.—In this title, ex-
cept as otherwise provided, the definitions of the following
terms contained in title XXI apply for purposes of this
title:
‘‘(1) EMPLOYEE.—The term ‘employee’ as de-
fined in section 2181(a)(3).
‘‘(2) FULL-TIME EMPLOYEE.—The term ‘full-
time employee’ as defined in section 2181(b)(1).
‘‘(3) PART-TIME EMPLOYEE.—The term ‘part-
time employee’ as defined in section 2181(b)(2).
‘‘(4) QUALIFIED EMPLOYER HEALTH PLAN.—
The term ‘qualified employer health plan’ as defined
in section 2121(a).
‘‘(5) SEASONAL OR TEMPORARY EMPLOYEE.—
The term ‘seasonal or temporary employee’ as de-
fined in section 2181(b)(3).
‘‘(6) WAGES.—The term ‘wages’ as defined in
section 2181(a)(1).
‘‘SEC. 2282. OTHER DEFINITIONS.
‘‘In this title:
‘‘(1) CHILD.—The term ‘child’ means, with re-
spect to a person who is not a child, an individual—
‘‘(A) who under 22 years of age;