‘‘(B) SECOND YEAR.—As of the first day 
of the second year in which this title is effec-
tive, the individual has not attained 11 years of 
age. 
‘‘(C) THIRD YEAR.—As of the first day of 
the third year in which this title is effective, the 
individual has not attained 16 years of age. 
‘‘(D) FOURTH YEAR.—As of the first day 
of the fourth year in which this title is effective, 
the individual has not attained 21 years of age. 
‘‘(E) FIFTH AND SUBSEQUENT YEARS.—
As of the first day of the fifth year in which 
this title is effective and each subsequent year, 
the individual has not attained 23 years of age. 
‘‘(2) CITIZENSHIP.—The individual is a citizen 
or national of the United States or is permanently 
residing in the United States under color of law. 
‘‘(b) ENROLLMENT PROCESS.—An individual may 
enroll in the program established under this title only in 
such manner and form as may be prescribed by regula-
tions, and only during an enrollment period prescribed by 
the Secretary consistent with the provisions of this section. 
Such regulations shall provide a process under which—
‘‘(1) individuals who are born in the United 
States after December 31, 2006, are deemed to be
enrolled at the time of birth and a parent or guard-
ian of such an individual is permitted to pre-enroll 
in the month prior to the expected month of birth; 
‘‘(2) individuals who are born outside the 
United States after such date and who become eligi-
ble to enroll by virtue of immigration into (or an ad-
justment of immigration status in) the United 
States are deemed enrolled at the time of entry or 
adjustment of status; 
‘‘(3) eligible individuals may otherwise be en-
rolled at such other times and manner as the Sec-
retary shall specify, including the use of outstationed 
eligibility 
sites 
as 
described 
in 
section 
1902(a)(55)(A) and the use of presumptive eligi-
bility provisions like those described in section 
1920A; and 
‘‘(4) at the time of automatic enrollment of a 
child, the Secretary provides for issuance to a parent 
or custodian of the individual a card evidencing cov-
erage under this title and for a description of such 
coverage. 
The provisions of section 1837(h) apply with respect to 
enrollment under this title in the same manner as they 
apply to enrollment under part B of title XVIII. An indi-
vidual who is enrolled under this title is not eligible to
be enrolled under an MA or MA–PD plan under part C 
of title XVIII. 
‘‘(c) DATE COVERAGE BEGINS.—
‘‘(1) IN GENERAL.—The period during which 
an individual is entitled to benefits under this title 
shall begin as follows, but in no case earlier than 
January 1, 2007: 
‘‘(A) In the case of an individual who is 
enrolled under paragraph (1) or (2) of sub-
section (b), the date of birth or date of obtain-
ing appropriate citizenship or immigration sta-
tus, as the case may be. 
‘‘(B) In the case of another individual who 
enrolls (including pre-enrolls) before the month 
in which the individual satisfies eligibility for 
enrollment under subsection (a), the first day of 
such month of eligibility. 
‘‘(C) In the case of another individual who 
enrolls during or after the month in which the 
individual first satisfies eligibility for enrollment 
under such subsection, the first day of the fol-
lowing month. 
‘‘(2) AUTHORITY
TO
PROVIDE
FOR
PARTIAL 
MONTHS
OF
COVERAGE.—Under regulations, the 
Secretary may, in the Secretary’s discretion, provide
for coverage periods that include portions of a 
month in order to avoid lapses of coverage. 
‘‘(3) LIMITATION ON PAYMENTS.—No payments 
may be made under this title with respect to the ex-
penses of an individual enrolled under this title un-
less such expenses were incurred by such individual 
during a period which, with respect to the individual, 
is a coverage period under this section. 
‘‘(d) EXPIRATION OF ELIGIBILITY.—An individual’s 
coverage period under this section shall continue until the 
individual’s enrollment has been terminated because the 
individual no longer meets the requirements of subsection 
(a) (whether because of age or change in immigration sta-
tus). 
‘‘(e) ENTITLEMENT TO MEDIKIDS BENEFITS FOR 
ENROLLED INDIVIDUALS.—An individual enrolled under 
this title is entitled to the benefits described in section 
2202. 
‘‘(f) LOW-INCOME INFORMATION.—
‘‘(1) INQUIRY OF INCOME.—At the time of en-
rollment of a child under this title, the Secretary 
shall make an inquiry as to whether the family in-
come (as determined for purposes of section 
1905(p)) of the family that includes the child is 
within any of the following income ranges:
‘‘(A) UP TO 150 PERCENT OF POVERTY.—
The income of the family does not exceed 150 
percent of the poverty line for a family of the 
size involved. 
‘‘(B) BETWEEN 150 AND 200 PERCENT OF 
POVERTY.—The income of the family exceeds 
150 percent, but does not exceed 200 percent, 
of such poverty line. 
‘‘(C) BETWEEN 200 AND 300 PERCENT OF 
POVERTY.—The income of the family exceeds 
200 percent, but does not exceed 300 percent, 
of such poverty line. 
‘‘(2) CODING.—If the family income is within a 
range described in paragraph (1), the Secretary 
shall encode in the identification card issued in con-
nection with eligibility under this title a code indi-
cating the range applicable to the family of the child 
involved. 
‘‘(3) PROVIDER VERIFICATION THROUGH ELEC-
TRONIC SYSTEM.—The Secretary also shall provide 
for an electronic system through which providers 
may verify which income range described in para-
graph (1), if any, is applicable to the family of the 
child involved.
‘‘(g) CONSTRUCTION.—Nothing in this title shall be 
construed as requiring (or preventing) an individual who 
is enrolled under this title from seeking medical assistance 
under a State medicaid plan under title XIX or child 
health assistance under a State child health plan under 
title XXI. 
‘‘SEC. 2202. BENEFITS. 
‘‘(a) SECRETARIAL
SPECIFICATION
OF
BENEFIT 
PACKAGE.—
‘‘(1) IN GENERAL.—The Secretary shall specify 
the benefits to be made available under this title 
consistent with the provisions of this section and in 
a manner designed to meet the health needs of en-
rollees. 
‘‘(2) UPDATING.—The Secretary shall update 
the specification of benefits over time to ensure the 
inclusion of age-appropriate benefits to reflect the 
enrollee population. 
‘‘(3) ANNUAL UPDATING.—The Secretary shall 
establish procedures for the annual review and up-
dating of such benefits to account for changes in 
medical practice, new information from medical re-
search, and other relevant developments in health 
science.
‘‘(4) INPUT.—The Secretary shall seek the 
input of the pediatric community in specifying and 
updating such benefits. 
‘‘(5) LIMITATION ON UPDATING.—In no case 
shall updating of benefits under this subsection re-
sult in a failure to provide benefits required under 
subsection (b). 
‘‘(b) INCLUSION OF CERTAIN BENEFITS.—
‘‘(1) MEDICARE CORE BENEFITS.—Such bene-
fits shall include (to the extent consistent with other 
provisions of this section) at least the same benefits 
(including coverage, access, availability, duration, 
and beneficiary rights) that are available under 
parts A and B of title XVIII. 
‘‘(2) ALL
REQUIRED
MEDICAID
BENEFITS.—
Such benefits shall also include all items and serv-
ices for which medical assistance is required to be 
provided under section 1902(a)(10)(A) to individuals 
described in such section, including early and peri-
odic screening, diagnostic services, and treatment 
services. 
‘‘(3) INCLUSION
OF
PRESCRIPTION
DRUGS.—
Such benefits also shall include (as specified by the 
Secretary) benefits for prescription drugs and 
biologicals which are not less than the benefits for
such drugs and biologicals under the standard op-
tion for the service benefit plan described in section 
8903(1) of title 5, United States Code, offered dur-
ing 2005. 
‘‘(4) COST-SHARING.—
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), such benefits also shall include the 
cost-sharing (in the form of deductibles, coin-
surance, and copayments) which is substantially 
similar to such cost-sharing under the health 
benefits coverage in any of the four largest 
health benefits plans (determined by enroll-
ment) offered under chapter 89 of title 5, 
United States Code, and including an out-of-
pocket limit for catastrophic expenditures for 
covered benefits, except that no cost-sharing 
shall be imposed with respect to early and peri-
odic screening and diagnostic services included 
under paragraph (2). 
‘‘(B) REDUCED
COST-SHARING
FOR
LOW 
INCOME CHILDREN.—Such benefits shall pro-
vide that—
‘‘(i) there shall be no cost-sharing for 
children in families the income of which is
within the range described in section 
2201(f)(1)(A); 
‘‘(ii) the cost-sharing otherwise appli-
cable shall be reduced by 75 percent for 
children in families the income of which is 
within the range described in section 
2201(f)(1)(B); or 
‘‘(iii) the cost-sharing otherwise appli-
cable shall be reduced by 50 percent for 
children in families the income of which is 
within the range described in section 
2201(f)(1)(C). 
‘‘(C) CATASTROPHIC LIMIT ON COST-SHAR-
ING.—For a refundable credit for cost-sharing 
in the case of cost-sharing in excess of a per-
centage of the individual’s adjusted gross in-
come, see section 36 of the Internal Revenue 
Code of 1986. 
‘‘(c) PAYMENT SCHEDULE.—The Secretary, with the 
assistance of the Medicare Payment Advisory Commission, 
shall develop and implement a payment schedule for bene-
fits covered under this title. To the extent feasible, such 
payment schedule shall be consistent with comparable pay-
ment schedules and reimbursement methodologies applied 
under parts A and B of title XVIII.
‘‘(d) INPUT.—The Secretary shall specify such bene-
fits and payment schedules only after obtaining input from 
appropriate child health providers and experts. 
‘‘(e) ENROLLMENT IN HEALTH PLANS.—The Sec-
retary shall provide for the offering of benefits under this 
title through enrollment in a health benefit plan that 
meets the same (or similar) requirements as the require-
ments that apply to Medicare Advantage plans under part 
C of title XVIII (other than any such requirements that 
relate to part D of such title). In the case of individuals 
enrolled under this title in such a plan, the payment rate 
shall be based on payment rates provided for under section 
1853(c) in effect before the date of the enactment of the 
Medicare Prescription Drug, Modernization, and Improve-
ment Act of 2003 (Public Law 108–173), except that such 
payment rates shall be adjusted in an appropriate manner 
to reflect differences between the population served under 
this title and the population under title XVIII. 
‘‘SEC. 2203. PREMIUMS. 
‘‘(a) AMOUNT OF MONTHLY PREMIUMS.—
‘‘(1) IN GENERAL.—The Secretary shall, during 
September of each year (beginning with 2006), es-
tablish a monthly MediKids premium for the fol-
lowing year. Subject to paragraph (2), the monthly 
MediKids premium for a year is equal to 1⁄12 of the
annual premium rate computed under subsection 
(b). 
‘‘(2) ELIMINATION OF MONTHLY PREMIUM FOR 
DEMONSTRATION
OF
EQUIVALENT
COVERAGE
(IN-
CLUDING
COVERAGE
UNDER
LOW-INCOME
PRO-
GRAMS).—The amount of the monthly premium im-
posed under this section for an individual for a 
month shall be zero in the case of an individual who 
demonstrates to the satisfaction of the Secretary 
that the individual has basic health insurance cov-
erage for that month. For purposes of the previous 
sentence enrollment in a medicaid plan under title 
XIX, a State child health insurance plan under title 
XXI, or under the medicare program under title 
XVIII is deemed to constitute basic health insurance 
coverage described in such sentence. 
‘‘(b) ANNUAL PREMIUM.—
‘‘(1) NATIONAL
PER
CAPITA
AVERAGE.—The 
Secretary shall estimate the average, annual per 
capita amount that would be payable under this title 
with respect to individuals residing in the United 
States who meet the requirement of section 
2201(a)(1) as if all such individuals were eligible for 
(and enrolled) under this title during the entire year
(and assuming that section 1862(b)(2)(A)(i) did not 
apply). 
‘‘(2) ANNUAL PREMIUM.—Subject to subsection 
(d), the annual premium under this subsection for 
months in a year is equal to 25 percent of the aver-
age, annual per capita amount estimated under 
paragraph (1) for the year. 
‘‘(c) PAYMENT OF MONTHLY PREMIUM.—
‘‘(1) PERIOD OF PAYMENT.—In the case of an 
individual who participates in the program estab-
lished by this title, subject to subsection (d), the 
monthly premium shall be payable for the period 
commencing with the first month of the individual’s 
coverage period and ending with the month in which 
the individual’s coverage under this title terminates. 
‘‘(2) COLLECTION
THROUGH
TAX
RETURN.—
For provisions providing for the payment of monthly 
premiums under this subsection, see section 59B of 
the Internal Revenue Code of 1986. 
‘‘(3) 
PROTECTIONS
AGAINST
FRAUD
AND 
ABUSE.—The Secretary shall develop, in coordina-
tion with States and other health insurance issuers, 
administrative systems to ensure that claims which 
are submitted to more than one payor are coordi-
nated and duplicate payments are not made.
‘‘(d) REDUCTION IN PREMIUM FOR CERTAIN LOW-
INCOME FAMILIES.—For provisions reducing the premium 
under this section for certain low-income families, see sec-
tion 59B(d) of the Internal Revenue Code of 1986. 
‘‘SEC. 2204. MEDIKIDS TRUST FUND. 
‘‘(a) ESTABLISHMENT OF TRUST FUND.—
‘‘(1) IN GENERAL.—There is hereby created on 
the books of the Treasury of the United States a 
trust fund to be known as the ‘MediKids Trust 
Fund’ (in this section referred to as the ‘Trust 
Fund’). The Trust Fund shall consist of such gifts 
and bequests as may be made as provided in section 
201(i)(1) and such amounts as may be deposited in, 
or appropriated to, such fund as provided in this 
title. 
‘‘(2) PREMIUMS.—Premiums collected under 
section 59B of the Internal Revenue Code of 1986 
shall be periodically transferred to the Trust Fund. 
‘‘(3) TRANSITIONAL FUNDING BEFORE RECEIPT 
OF PREMIUMS.—In order to provide for funds in the 
Trust Fund to cover expenditures from the fund in 
advance of receipt of premiums under section 2203, 
there are transferred to the Trust Fund from the 
general fund of the United States Treasury such 
amounts as may be necessary.
‘‘(b) INCORPORATION OF PROVISIONS.—
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
subsection (b) (other than the last sentence) and 
subsections (c) through (i) of section 1841 shall 
apply with respect to the Trust Fund and this title 
in the same manner as they apply with respect to 
the Federal Supplementary Medical Insurance Trust 
Fund and part B, respectively. 
‘‘(2) MISCELLANEOUS REFERENCES.—In apply-
ing provisions of section 1841 under paragraph 
(1)—
‘‘(A) any reference in such section to ‘this 
part’ is construed to refer to title XXII; 
‘‘(B) any reference in section 1841(h) to 
section 1840(d) and in section 1841(i) to sec-
tions 1840(b)(1) and 1842(g) are deemed ref-
erences to comparable authority exercised under 
this title; 
‘‘(C) payments may be made under section 
1841(g) to the Trust Funds under sections 
1817 and 1841 as reimbursement to such funds 
for payments they made for benefits provided 
under this title; and 
‘‘(D) the Board of Trustees of the 
MediKids Trust Fund shall be the same as the
Board of Trustees of the Federal Supple-
mentary Medical Insurance Trust Fund. 
‘‘SEC. 2205. OVERSIGHT AND ACCOUNTABILITY. 
‘‘(a) PERIODIC GAO REPORTS.—The Comptroller 
General of the United States shall periodically submit to 
Congress reports on the operation of the program under 
this title, including on the financing of coverage provided 
under this title. 
‘‘(b) PERIODIC MEDPAC REPORTS.—The Medicare 
Payment Advisory Commission shall periodically report to 
Congress concerning the program under this title. 
‘‘SEC. 2206. INCLUSION OF CARE COORDINATION SERVICES. 
‘‘(a) IN GENERAL.—
‘‘(1) PROGRAM
AUTHORITY.—The Secretary, 
beginning in 2007, may implement a care coordina-
tion services program in accordance with the provi-
sions of this section under which, in appropriate cir-
cumstances, eligible individuals under section 2201 
may elect to have health care services covered under 
this title managed and coordinated by a designated 
care coordinator. 
‘‘(2) ADMINISTRATION
BY
CONTRACT.—The 
Secretary may administer the program under this 
section through a contract with an appropriate pro-
gram administrator.
‘‘(3) COVERAGE.—Care coordination services 
furnished in accordance with this section shall be 
treated under this title as if they were included in 
the definition of medical and other health services 
under section 1861(s) and benefits shall be available 
under this title with respect to such services without 
the application of any deductible or coinsurance. 
‘‘(b) ELIGIBILITY CRITERIA; IDENTIFICATION AND 
NOTIFICATION OF ELIGIBLE INDIVIDUALS.—
‘‘(1) INDIVIDUAL ELIGIBILITY CRITERIA.—The 
Secretary shall specify criteria to be used in making 
a determination as to whether an individual may ap-
propriately be enrolled in the care coordination serv-
ices program under this section, which shall include 
at least a finding by the Secretary that for cohorts 
of individuals with characteristics identified by the 
Secretary, professional management and coordina-
tion of care can reasonably be expected to improve 
processes or outcomes of health care and to reduce 
aggregate costs to the programs under this title. 
‘‘(2) PROCEDURES
TO
FACILITATE
ENROLL-
MENT.—The Secretary shall develop and implement 
procedures designed to facilitate enrollment of eligi-
ble individuals in the program under this section. 
‘‘(c) ENROLLMENT OF INDIVIDUALS.—
‘‘(1) SECRETARY’S DETERMINATION OF ELIGI-
BILITY.—The Secretary shall determine the eligi-
bility for services under this section of individuals 
who are enrolled in the program under this section 
and who make application for such services in such 
form and manner as the Secretary may prescribe. 
‘‘(2) ENROLLMENT PERIOD.—
‘‘(A) EFFECTIVE DATE AND DURATION.—
Enrollment of an individual in the program 
under this section shall be effective as of the 
first day of the month following the month in 
which the Secretary approves the individual’s 
application under paragraph (1), shall remain 
in effect for one month (or such longer period 
as the Secretary may specify), and shall be 
automatically renewed for additional periods, 
unless terminated in accordance with such pro-
cedures as the Secretary shall establish by regu-
lation. Such procedures shall permit an indi-
vidual to disenroll for cause at any time and 
without cause at re-enrollment intervals. 
‘‘(B) LIMITATION
ON
REENROLLMENT.—
The Secretary may establish limits on an indi-
vidual’s eligibility to reenroll in the program 
under this section if the individual has
disenrolled from the program more than once 
during a specified time period. 
‘‘(d) PROGRAM.—The care coordination services pro-
gram under this section shall include the following ele-
ments: 
‘‘(1) BASIC CARE COORDINATION SERVICES.—
‘‘(A) IN GENERAL.—Subject to the cost-ef-
fectiveness criteria specified in subsection 
(b)(1), except as otherwise provided in this sec-
tion, enrolled individuals shall receive services 
described in section 1905(t)(1) and may receive 
additional items and services as described in 
subparagraph (B). 
‘‘(B) ADDITIONAL
BENEFITS.—The Sec-
retary may specify additional benefits for which 
payment would not otherwise be made under 
this title that may be available to individuals 
enrolled in the program under this section (sub-
ject to an assessment by the care coordinator of 
an individual’s circumstance and need for such 
benefits) in order to encourage enrollment in, or 
to improve the effectiveness of, such program. 
‘‘(2) CARE
COORDINATION
REQUIREMENT.—
Notwithstanding any other provision of this title, the 
Secretary may provide that an individual enrolled in
the program under this section may be entitled to 
payment under this title for any specified health 
care items or services only if the items or services 
have been furnished by the care coordinator, or co-
ordinated through the care coordination services pro-
gram. Under such provision, the Secretary shall pre-
scribe exceptions for emergency medical services as 
described in section 1852(d)(3), and other excep-
tions determined by the Secretary for the delivery of 
timely and needed care. 
‘‘(e) CARE COORDINATORS.—
‘‘(1) CONDITIONS OF PARTICIPATION.—In order 
to be qualified to furnish care coordination services 
under this section, an individual or entity shall—
‘‘(A) be a health care professional or entity 
(which may include physicians, physician group 
practices, or other health care professionals or 
entities the Secretary may find appropriate) 
meeting such conditions as the Secretary may 
specify; 
‘‘(B) have entered into a care coordination 
agreement; and 
‘‘(C) meet such criteria as the Secretary 
may establish (which may include experience in
the provision of care coordination or primary 
care physician’s services). 
‘‘(2) AGREEMENT TERM; PAYMENT.—
‘‘(A) DURATION AND RENEWAL.—A care 
coordination agreement under this subsection 
shall be for one year and may be renewed if the 
Secretary is satisfied that the care coordinator 
continues to meet the conditions of participa-
tion specified in paragraph (1). 
‘‘(B) PAYMENT FOR SERVICES.—The Sec-
retary may negotiate or otherwise establish pay-
ment terms and rates for services described in 
subsection (d)(1). 
‘‘(C) LIABILITY.—Care coordinators shall 
be subject to liability for actual health damages 
which may be suffered by recipients as a result 
of the care coordinator’s decisions, failure or 
delay in making decisions, or other actions as 
a care coordinator. 
‘‘(D) TERMS.—In addition to such other 
terms as the Secretary may require, an agree-
ment under this section shall include the terms 
specified in subparagraphs (A) through (C) of 
section 1905(t)(3).
‘‘SEC. 2207. ADMINISTRATION AND MISCELLANEOUS. 
‘‘(a) IN GENERAL.—Except as otherwise provided in 
this title—
‘‘(1) the Secretary shall enter into appropriate 
contracts with providers of services, other health 
care providers, carriers, and fiscal intermediaries, 
taking into account the types of contracts used 
under title XVIII with respect to such entities, to 
administer the program under this title; 
‘‘(2) beneficiary protections for individuals en-
rolled under this title shall not be less than the ben-
eficiary protections (including limits on balance bill-
ing) provided medicare beneficiaries under title 
XVIII; 
‘‘(3) benefits described in section 2202 that are 
payable under this title to such individuals shall be 
paid in a manner specified by the Secretary (taking 
into account, and based to the greatest extent prac-
ticable upon, the manner in which they are provided 
under title XVIII); and 
‘‘(4) provider participation agreements under 
title XVIII shall apply to enrollees and benefits 
under this title in the same manner as they apply 
to enrollees and benefits under title XVIII. 
‘‘(b) 
COORDINATION
WITH
MEDICAID
AND 
SCHIP.—Notwithstanding any other provision of law, in-
dividuals entitled to benefits for items and services under 
this title who also qualify for benefits under title XIX or 
XXI or any other Federally funded health care program 
that provides basic health insurance coverage described in 
section 2203(a)(2) may continue to qualify and obtain 
benefits under such other title or program, and in such 
case such an individual shall elect either—
‘‘(1) such other title or program to be primary 
payor to benefits under this title, in which case no 
benefits shall be payable under this title and the 
monthly premium under section 2203 shall be zero; 
or 
‘‘(2) benefits under this title shall be primary 
payor to benefits provided under such title or pro-
gram, in which case the Secretary shall enter into 
agreements with States as may be appropriate to 
provide that, in the case of such individuals, the ben-
efits under titles XIX and XXI or such other pro-
gram (including reduction of cost-sharing) are pro-
vided on a ‘wrap-around’ basis to the benefits under 
this title.’’. 
(b) CONFORMING AMENDMENTS TO SOCIAL SECU-
RITY ACT PROVISIONS.—
(1) Section 201(i)(1) of the Social Security Act 
(42 U.S.C. 401(i)(1)) is amended by striking ‘‘or the
Federal Supplementary Medical Insurance Trust 
Fund’’ and inserting ‘‘the Federal Supplementary 
Medical Insurance Trust Fund, and the MediKids 
Trust Fund’’. 
(2) Section 201(g)(1)(A) of such Act (42 
U.S.C. 401(g)(1)(A)) is amended by striking ‘‘and 
the Federal Supplementary Medical Insurance Trust 
Fund established by title XVIII’’ and inserting ‘‘, 
the Federal Supplementary Medical Insurance Trust 
Fund, and the MediKids Trust Fund established by 
title XVIII’’. 
(c) MAINTENANCE OF MEDICAID ELIGIBILITY AND 
BENEFITS FOR CHILDREN.—
(1) IN GENERAL.—In order for a State to con-
tinue to be eligible for payments under section 
1903(a) of the Social Security Act (42 U.S.C. 
1396b(a))—
(A) the State may not reduce standards of 
eligibility, or benefits, provided under its State 
medicaid plan under title XIX of the Social Se-
curity Act or under its State child health plan 
under title XXI of such Act for individuals 
under 23 years of age below such standards of 
eligibility, and benefits, in effect on the date of 
the enactment of this Act; and