169 
MATERIALS
TO
EMPLOYEE.—An em-
ployer may provide the model notice 
applicable to the State in which an 
employee resides concurrent with the 
furnishing of materials notifying the 
employee of health plan eligibility, 
concurrent with materials provided to 
the employee in connection with an 
open season or election process con-
ducted under the plan, or concurrent 
with the furnishing of the summary 
plan description as provided in section 
104(b). 
‘‘(ii) 
DISCLOSURE
ABOUT
GROUP 
HEALTH PLAN BENEFITS TO STATES FOR 
MEDICAID
AND
CHIP
ELIGIBLE
INDIVID-
UALS.—In the case of a participant or ben-
eficiary of a group health plan who is cov-
ered under a Medicaid plan of a State 
under title XIX of the Social Security Act 
or under a State child health plan under 
title XXI of such Act, the plan adminis-
trator of the group health plan shall dis-
close to the State, upon request, informa-
tion about the benefits available under the 
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170 
group health plan in sufficient specificity, 
as determined under regulations of the 
Secretary of Health and Human Services 
in consultation with the Secretary that re-
quire use of the model coverage coordina-
tion disclosure form developed under sec-
tion 311(b)(1)(C) of the Children’s Health 
Insurance Program Reauthorization Act of 
2009, so as to permit the State to make a 
determination (under paragraph (2)(B), 
(3), or (10) of section 2105(c) of the So-
cial Security Act or otherwise) concerning 
the cost-effectiveness of the State pro-
viding medical or child health assistance 
through premium assistance for the pur-
chase of coverage under such group health 
plan and in order for the State to provide 
supplemental benefits required under para-
graph (10)(E) of such section or other au-
thority.’’. 
(B) CONFORMING
AMENDMENT.—Section 
102(b) of the Employee Retirement Income Se-
curity Act of 1974 (29 U.S.C. 1022(b)) is 
amended— 
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171 
(i) by striking ‘‘and the remedies’’ 
and inserting ‘‘, the remedies’’; and 
(ii) by inserting before the period the 
following: ‘‘, and if the employer so elects 
for purposes of complying with section 
701(f)(3)(B)(i), the model notice applicable 
to the State in which the participants and 
beneficiaries reside’’. 
(C) WORKING GROUP TO DEVELOP MODEL 
COVERAGE
COORDINATION
DISCLOSURE 
FORM.— 
(i) MEDICAID, CHIP, AND EMPLOYER- 
SPONSORED
COVERAGE
COORDINATION 
WORKING GROUP.— 
(I) IN GENERAL.—Not later than 
60 days after the date of enactment of 
this Act, the Secretary of Health and 
Human Services and the Secretary of 
Labor shall jointly establish a Med-
icaid, CHIP, and Employer-Sponsored 
Coverage 
Coordination 
Working 
Group (in this subparagraph referred 
to as the ‘‘Working Group’’). The 
purpose of the Working Group shall 
be to develop the model coverage co-
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172 
ordination disclosure form described 
in subclause (II) and to identify the 
impediments to the effective coordina-
tion of coverage available to families 
that include employees of employers 
that maintain group health plans and 
members who are eligible for medical 
assistance under title XIX of the So-
cial Security Act or child health as-
sistance or other health benefits cov-
erage under title XXI of such Act. 
(II) MODEL COVERAGE COORDI-
NATION
DISCLOSURE
FORM
DE-
SCRIBED.—The model form described 
in this subclause is a form for plan 
administrators of group health plans 
to complete for purposes of permitting 
a State to determine the availability 
and cost-effectiveness of the coverage 
available under such plans to employ-
ees who have family members who are 
eligible for premium assistance offered 
under a State plan under title XIX or 
XXI of such Act and to allow for co-
ordination of coverage for enrollees of 
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173 
such plans. Such form shall provide 
the following information in addition 
to such other information as the 
Working Group determines appro-
priate: 
(aa) 
A 
determination 
of 
whether the employee is eligible 
for coverage under the group 
health plan. 
(bb) The name and contract 
information of the plan adminis-
trator of the group health plan. 
(cc) The benefits offered 
under the plan. 
(dd) The premiums and 
cost-sharing required under the 
plan. 
(ee) Any other information 
relevant to coverage under the 
plan. 
(ii) 
MEMBERSHIP.—The 
Working 
Group shall consist of not more than 30 
members and shall be composed of rep-
resentatives of— 
(I) the Department of Labor; 
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174 
(II) the Department of Health 
and Human Services; 
(III) State directors of the Med-
icaid program under title XIX of the 
Social Security Act; 
(IV) State directors of the State 
Children’s Health Insurance Program 
under title XXI of the Social Security 
Act; 
(V) employers, including owners 
of small businesses and their trade or 
industry representatives and certified 
human resource and payroll profes-
sionals; 
(VI) plan administrators and 
plan sponsors of group health plans 
(as defined in section 607(1) of the 
Employee Retirement Income Security 
Act of 1974); 
(VII) health insurance issuers; 
and 
(VIII) children and other bene-
ficiaries of medical assistance under 
title XIX of the Social Security Act or 
child health assistance or other health 
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