in section 2105(a)(4) for such fiscal year; 
or 
‘‘(iii) has submitted a specific plan for 
outreach for such fiscal year. 
‘‘(B) 
HIGH-PERFORMING
STATE.—The 
State, on the basis of the most timely and accu-
rate published estimates of the Bureau of the 
Census, ranks in the lowest 1⁄3 of States in 
terms of the State’s percentage of low-income 
children without health insurance. 
‘‘(C) STATE INCREASING ENROLLMENT OF 
LOW-INCOME
CHILDREN.—The State qualified 
for a performance bonus payment under section 
2105(a)(3)(B) for the most recent fiscal year 
applicable under such section. 
‘‘(4) RULES
OF
CONSTRUCTION.—Nothing in 
this subsection shall be construed as prohibiting a 
State from submitting an application to the Sec-
retary for a waiver under section 1115 of the State 
plan under title XIX to provide medical assistance to 
a parent of a targeted low-income child that was 
provided child health assistance or health benefits 
coverage under an applicable existing waiver. 
‘‘(c) APPLICABLE EXISTING WAIVER.—For purposes 
of this section—
‘‘(1) IN GENERAL.—The term ‘applicable exist-
ing waiver’ means a waiver, experimental, pilot, or 
demonstration project under section 1115, grand-
fathered under section 6102(c)(3) of the Deficit Re-
duction Act of 2005, or otherwise conducted under 
authority that— 
‘‘(A) would allow funds made available 
under this title to be used to provide child 
health assistance or other health benefits cov-
erage to— 
‘‘(i) a parent of a targeted low-income 
child; 
‘‘(ii) a nonpregnant childless adult; or 
‘‘(iii) individuals described in both 
clauses (i) and (ii); and 
‘‘(B) was in effect during fiscal year 2009. 
‘‘(2) DEFINITIONS.— 
‘‘(A) PARENT.—The term ‘parent’ includes 
a caretaker relative (as such term is used in 
carrying out section 1931) and a legal guard-
ian. 
‘‘(B) NONPREGNANT CHILDLESS ADULT.— 
The term ‘nonpregnant childless adult’ has the 
meaning given such term by section 2107(f).’’. 
(2) CONFORMING AMENDMENTS.—
(A) Section 2107(f) (42 U.S.C. 1397gg(f)) 
is amended— 
(i) by striking ‘‘, the Secretary’’ and 
inserting ‘‘: 
‘‘(1) The Secretary’’; 
(ii) in the first sentence, by inserting 
‘‘or a parent (as defined in section 
2111(c)(2)(A)), who is not pregnant, of a 
targeted low-income child’’ before the pe-
riod; 
(iii) by striking the second sentence; 
and 
(iv) by adding at the end the following 
new paragraph: 
‘‘(2) The Secretary may not approve, extend, 
renew, or amend a waiver, experimental, pilot, or 
demonstration project with respect to a State after 
the date of enactment of the Children’s Health In-
surance Program Reauthorization Act of 2009 that 
would waive or modify the requirements of section 
2111.’’. 
(B) Section 6102(c) of the Deficit Reduc-
tion Act of 2005 (Public Law 109–171; 120 
Stat. 131) is amended by striking ‘‘Nothing’’ 
and inserting ‘‘Subject to section 2111 of the
Social Security Act, as added by section 112 of 
the Children’s Health Insurance Program Re-
authorization Act of 2009, nothing’’. 
(b) GAO STUDY AND REPORT.— 
(1) IN GENERAL.—The Comptroller General of 
the United States shall conduct a study of wheth-
er— 
(A) the coverage of a parent, a caretaker 
relative (as such term is used in carrying out 
section 1931), or a legal guardian of a targeted 
low-income child under a State health plan 
under title XXI of the Social Security Act in-
creases the enrollment of, or the quality of care 
for, children, and 
(B) such parents, relatives, and legal 
guardians who enroll in such a plan are more 
likely to enroll their children in such a plan or 
in a State plan under title XIX of such Act. 
(2) REPORT.—Not later than 2 years after the 
date of the enactment of this Act, the Comptroller 
General shall report the results of the study to the 
Committee on Finance of the Senate and the Com-
mittee on Energy and Commerce of the House of 
Representatives, including recommendations (if any) 
for changes in legislation.
SEC. 113. ELIMINATION OF COUNTING MEDICAID CHILD 
PRESUMPTIVE ELIGIBILITY COSTS AGAINST 
TITLE XXI ALLOTMENT. 
(a) IN GENERAL.—Section 2105(a)(1) (42 U.S.C. 
1397ee(a)(1)) is amended— 
(1) in the matter preceding subparagraph (A), 
by striking ‘‘(or, in the case of expenditures de-
scribed in subparagraph (B), the Federal medical 
assistance percentage (as defined in the first sen-
tence of section 1905(b)))’’; and 
(2) by striking subparagraph (B) and inserting 
the following new subparagraph: 
‘‘(B) [reserved]’’. 
(b) AMENDMENTS TO MEDICAID.— 
(1) ELIGIBILITY
OF
A
NEWBORN.—Section 
1902(e)(4) (42 U.S.C. 1396a(e)(4)) is amended in 
the first sentence by striking ‘‘so long as the child 
is a member of the woman’s household and the 
woman remains (or would remain if pregnant) eligi-
ble for such assistance’’. 
(2) APPLICATION OF QUALIFIED ENTITIES TO 
PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN 
UNDER
MEDICAID.—Section 1920(b) (42 U.S.C. 
1396r–1(b)) is amended by adding after paragraph 
(2) the following flush sentence:
‘‘The term ‘qualified provider’ also includes a qualified en-
tity, as defined in section 1920A(b)(3).’’. 
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. 
(a) FMAP APPLIED TO EXPENDITURES.—Section 
2105(c) (42 U.S.C. 1397ee(c)) is amended by adding at 
the end the following new paragraph: 
‘‘(8) LIMITATION ON MATCHING RATE FOR EX-
PENDITURES FOR CHILD HEALTH ASSISTANCE PRO-
VIDED TO CHILDREN WHOSE EFFECTIVE FAMILY IN-
COME
EXCEEDS
300
PERCENT
OF
THE
POVERTY 
LINE.— 
‘‘(A) 
FMAP 
APPLIED
TO
EXPENDI-
TURES.—Except as provided in subparagraph 
(B), for fiscal years beginning with fiscal year 
2009, the Federal medical assistance percent-
age (as determined under section 1905(b) with-
out regard to clause (4) of such section) shall 
be substituted for the enhanced FMAP under 
subsection (a)(1) with respect to any expendi-
tures for providing child health assistance or 
health benefits coverage for a targeted low-in-
come child whose effective family income would
exceed 300 percent of the poverty line but for 
the application of a general exclusion of a block 
of income that is not determined by type of ex-
pense or type of income. 
‘‘(B) 
EXCEPTION.—Subparagraph 
(A) 
shall not apply to any State that, on the date 
of enactment of the Children’s Health Insur-
ance Program Reauthorization Act of 2009, has 
an approved State plan amendment or waiver to 
provide, or has enacted a State law to submit 
a State plan amendment to provide, expendi-
tures described in such subparagraph under the 
State child health plan.’’. 
(b) RULE
OF
CONSTRUCTION.—Nothing in the 
amendments made by this section shall be construed as— 
(1) changing any income eligibility level for chil-
dren under title XXI of the Social Security Act; or 
(2) changing the flexibility provided States 
under such title to establish the income eligibility 
level for targeted low-income children under a State 
child health plan and the methodologies used by the 
State to determine income or assets under such 
plan.
SEC. 115. STATE AUTHORITY UNDER MEDICAID. 
Notwithstanding any other provision of law, including 
the fourth sentence of subsection (b) of section 1905 of 
the Social Security Act (42 U.S.C. 1396d) or subsection 
(u) of such section, at State option, the Secretary shall 
provide the State with the Federal medical assistance per-
centage determined for the State for Medicaid with respect 
to expenditures described in section 1905(u)(2)(A) of such 
Act or otherwise made to provide medical assistance under 
Medicaid to a child who could be covered by the State 
under CHIP. 
TITLE II—OUTREACH AND 
ENROLLMENT 
Subtitle A—Outreach and 
Enrollment Activities 
SEC. 201. GRANTS AND ENHANCED ADMINISTRATIVE FUND-
ING FOR OUTREACH AND ENROLLMENT. 
(a) GRANTS.—Title XXI (42 U.S.C. 1397aa et seq.), 
as amended by section 111, is amended by adding at the 
end the following: 
‘‘SEC. 2113. GRANTS TO IMPROVE OUTREACH AND ENROLL-
MENT. 
‘‘(a) OUTREACH AND ENROLLMENT GRANTS; NA-
TIONAL CAMPAIGN.— 
‘‘(1) IN GENERAL.—From the amounts appro-
priated under subsection (g), subject to paragraph
(2), the Secretary shall award grants to eligible enti-
ties during the period of fiscal years 2009 through 
2013 to conduct outreach and enrollment efforts 
that are designed to increase the enrollment and 
participation of eligible children under this title and 
title XIX. 
‘‘(2) TEN PERCENT SET ASIDE FOR NATIONAL 
ENROLLMENT CAMPAIGN.—An amount equal to 10 
percent of such amounts shall be used by the Sec-
retary for expenditures during such period to carry 
out a national enrollment campaign in accordance 
with subsection (h). 
‘‘(b) PRIORITY FOR AWARD OF GRANTS.— 
‘‘(1) IN GENERAL.—In awarding grants under 
subsection (a), the Secretary shall give priority to el-
igible entities that— 
‘‘(A) propose to target geographic areas 
with high rates of— 
‘‘(i) eligible but unenrolled children, 
including such children who reside in rural 
areas; or 
‘‘(ii) racial and ethnic minorities and 
health disparity populations, including 
those proposals that address cultural and 
linguistic barriers to enrollment; and
‘‘(B) submit the most demonstrable evi-
dence required under paragraphs (1) and (2) of 
subsection (c). 
‘‘(2) TEN PERCENT SET ASIDE FOR OUTREACH 
TO INDIAN CHILDREN.—An amount equal to 10 per-
cent of the funds appropriated under subsection (g) 
shall be used by the Secretary to award grants to 
Indian Health Service providers and urban Indian 
organizations receiving funds under title V of the In-
dian Health Care Improvement Act (25 U.S.C. 1651 
et seq.) for outreach to, and enrollment of, children 
who are Indians. 
‘‘(c) APPLICATION.—An eligible entity that desires to 
receive a grant under subsection (a) shall submit an appli-
cation to the Secretary in such form and manner, and con-
taining such information, as the Secretary may decide. 
Such application shall include— 
‘‘(1) evidence demonstrating that the entity in-
cludes members who have access to, and credibility 
with, ethnic or low-income populations in the com-
munities in which activities funded under the grant 
are to be conducted; 
‘‘(2) evidence demonstrating that the entity has 
the ability to address barriers to enrollment, such as 
lack of awareness of eligibility, stigma concerns and
punitive fears associated with receipt of benefits, 
and other cultural barriers to applying for and re-
ceiving child health assistance or medical assistance; 
‘‘(3) specific quality or outcomes performance 
measures to evaluate the effectiveness of activities 
funded by a grant awarded under this section; and 
‘‘(4) an assurance that the eligible entity 
shall— 
‘‘(A) conduct an assessment of the effec-
tiveness of such activities against the perform-
ance measures; 
‘‘(B) cooperate with the collection and re-
porting of enrollment data and other informa-
tion in order for the Secretary to conduct such 
assessments; and 
‘‘(C) in the case of an eligible entity that 
is not the State, provide the State with enroll-
ment data and other information as necessary 
for the State to make necessary projections of 
eligible children and pregnant women. 
‘‘(d) DISSEMINATION OF ENROLLMENT DATA AND 
INFORMATION DETERMINED FROM EFFECTIVENESS AS-
SESSMENTS; ANNUAL REPORT.—The Secretary shall—
‘‘(1) make publicly available the enrollment 
data and information collected and reported in ac-
cordance with subsection (c)(4)(B); and 
‘‘(2) submit an annual report to Congress on 
the outreach and enrollment activities conducted 
with funds appropriated under this section. 
‘‘(e) MAINTENANCE
OF
EFFORT
FOR
STATES 
AWARDED GRANTS; NO STATE MATCH REQUIRED.—In 
the case of a State that is awarded a grant under this 
section— 
‘‘(1) the State share of funds expended for out-
reach and enrollment activities under the State child 
health plan shall not be less than the State share of 
such funds expended in the fiscal year preceding the 
first fiscal year for which the grant is awarded; and 
‘‘(2) no State matching funds shall be required 
for the State to receive a grant under this section. 
‘‘(f) DEFINITIONS.—In this section: 
‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible en-
tity’ means any of the following: 
‘‘(A) A State with an approved child health 
plan under this title. 
‘‘(B) A local government. 
‘‘(C) An Indian tribe or tribal consortium, 
a tribal organization, an urban Indian organiza-
tion receiving funds under title V of the Indian 
Health Care Improvement Act (25 U.S.C. 1651 
et seq.), or an Indian Health Service provider. 
‘‘(D) A Federal health safety net organiza-
tion. 
‘‘(E) A national, State, local, or commu-
nity-based public or nonprofit private organiza-
tion, including organizations that use commu-
nity health workers or community-based doula 
programs. 
‘‘(F) A faith-based organization or con-
sortia, to the extent that a grant awarded to 
such an entity is consistent with the require-
ments of section 1955 of the Public Health 
Service Act (42 U.S.C. 300x–65) relating to a 
grant award to nongovernmental entities. 
‘‘(G) An elementary or secondary school. 
‘‘(2) FEDERAL HEALTH SAFETY NET ORGANI-
ZATION.—The term ‘Federal health safety net orga-
nization’ means— 
‘‘(A) a Federally-qualified health center (as 
defined in section 1905(l)(2)(B)); 
‘‘(B) a hospital defined as a dispropor-
tionate share hospital for purposes of section 
1923;
‘‘(C) a covered entity described in section 
340B(a)(4) of the Public Health Service Act 
(42 U.S.C. 256b(a)(4)); and 
‘‘(D) any other entity or consortium that 
serves children under a federally funded pro-
gram, including the special supplemental nutri-
tion program for women, infants, and children 
(WIC) established under section 17 of the Child 
Nutrition Act of 1966 (42 U.S.C. 1786), the 
Head Start and Early Head Start programs 
under the Head Start Act (42 U.S.C. 9801 et 
seq.), the school lunch program established 
under the Richard B. Russell National School 
Lunch Act, and an elementary or secondary 
school. 
‘‘(3) INDIANS; INDIAN TRIBE; TRIBAL ORGANI-
ZATION; URBAN INDIAN ORGANIZATION.—The terms 
‘Indian’, ‘Indian tribe’, ‘tribal organization’, and 
‘urban Indian organization’ have the meanings given 
such terms in section 4 of the Indian Health Care 
Improvement Act (25 U.S.C. 1603). 
‘‘(4) COMMUNITY HEALTH WORKER.—The term 
‘community health worker’ means an individual who 
promotes health or nutrition within the community 
in which the individual resides—
‘‘(A) by serving as a liaison between com-
munities and health care agencies; 
‘‘(B) by providing guidance and social as-
sistance to community residents; 
‘‘(C) by enhancing community residents’ 
ability to effectively communicate with health 
care providers; 
‘‘(D) by providing culturally and linguis-
tically appropriate health or nutrition edu-
cation; 
‘‘(E) by advocating for individual and com-
munity health or nutrition needs; and 
‘‘(F) by providing referral and followup 
services. 
‘‘(g) APPROPRIATION.—There is appropriated, out of 
any money in the Treasury not otherwise appropriated, 
$100,000,000 for the period of fiscal years 2009 through 
2013, for the purpose of awarding grants under this sec-
tion. Amounts appropriated and paid under the authority 
of this section shall be in addition to amounts appro-
priated under section 2104 and paid to States in accord-
ance with section 2105, including with respect to expendi-
tures for outreach activities in accordance with subsections 
(a)(1)(D)(iii) and (c)(2)(C) of that section.
‘‘(h) NATIONAL ENROLLMENT CAMPAIGN.—From 
the amounts made available under subsection (a)(2), the 
Secretary shall develop and implement a national enroll-
ment campaign to improve the enrollment of underserved 
child populations in the programs established under this 
title and title XIX. Such campaign may include— 
‘‘(1) the establishment of partnerships with the 
Secretary of Education and the Secretary of Agri-
culture to develop national campaigns to link the eli-
gibility and enrollment systems for the assistance 
programs each Secretary administers that often 
serve the same children; 
‘‘(2) the integration of information about the 
programs established under this title and title XIX 
in public health awareness campaigns administered 
by the Secretary; 
‘‘(3) increased financial and technical support 
for enrollment hotlines maintained by the Secretary 
to ensure that all States participate in such hotlines; 
‘‘(4) the establishment of joint public awareness 
outreach initiatives with the Secretary of Education 
and the Secretary of Labor regarding the impor-
tance of health insurance to building strong commu-
nities and the economy;
‘‘(5) the development of special outreach mate-
rials for Native Americans or for individuals with 
limited English proficiency; and 
‘‘(6) such other outreach initiatives as the Sec-
retary determines would increase public awareness of 
the programs under this title and title XIX. 
‘‘(i) GRANTS FOR OUTREACH AND ENROLLMENT OF 
NATIVE AMERICAN BENEFICIARIES.— 
‘‘(1) IN GENERAL.—To overcome language and 
cultural barriers to program access by Native Ameri-
cans, the Secretary shall establish grant programs to 
conduct outreach and enrollment efforts to increase 
the enrollment and participation of eligible individ-
uals in programs of the Social Security Act (42 
U.S.C. 1397aa et seq.) and other Federal health and 
social service programs. 
‘‘(2) USE
OF
TRIBAL
BENEFITS-COUNSELORS 
MODEL.—The grant program under this subsection 
shall incorporate expansion and stabilization of the 
tribal benefits-counselors model developed in the 
State of Washington to overcome language and cul-
tural barriers to Federal programs. 
‘‘(3) RECIPIENTS.—In order to qualify for a 
grant under this subsection, an applicant shall be a 
national, nonprofit organization with successful and
verifiable experience in assisting Native Americans 
access Federal programs. 
‘‘(4) REPORT.—At the end of the period of 
funding provided under subsection (f), the Secretary 
shall submit to Congress a report on the grants 
made under this subsection, including the efficacy of 
outreach efforts and the cost effectiveness of 
projects funded by such grants in improving access 
to Federal programs by Native Americans.’’. 
(b) ENHANCED
ADMINISTRATIVE
FUNDING
FOR 
TRANSLATION
OR INTERPRETATION SERVICES UNDER 
CHIP AND MEDICAID.— 
(1) CHIP.—Section 2105(a)(1) (42 U.S.C. 
1397ee(a)(1)), as amended by section 113, is 
amended— 
(A) in the matter preceding subparagraph 
(A), by inserting ‘‘(or, in the case of expendi-
tures described in subparagraph (D)(iv), the 
higher of 75 percent or the sum of the en-
hanced FMAP plus 5 percentage points)’’ after 
‘‘enhanced FMAP’’; and 
(B) in subparagraph (D)— 
(i) in clause (iii), by striking ‘‘and’’ at 
the end;
(ii) by redesignating clause (iv) as 
clause (v); and 
(iii) by inserting after clause (iii) the 
following new clause: 
‘‘(iv) for translation or interpretation 
services in connection with the enrollment 
of, retention of, and use of services under 
this title by, individuals for whom English 
is not their primary language (as found 
necessary by the Secretary for the proper 
and efficient administration of the State 
plan); and’’. 
(2) MEDICAID.— 
(A) USE
OF
MEDICAID
FUNDS.—Section 
1903(a)(2) (42 U.S.C. 1396b(a)(2)) is amended 
by adding at the end the following new sub-
paragraph: 
‘‘(E) an amount equal to 75 percent of so much 
of the sums expended during such quarter (as found 
necessary by the Secretary for the proper and effi-
cient administration of the State plan) as are attrib-
utable to translation or interpretation services in 
connection with the enrollment of, retention of, and 
use of services under this title by, children of fami-
lies for whom English is not the primary language; 
plus’’. 
(B) USE OF COMMUNITY HEALTH WORK-
ERS FOR OUTREACH ACTIVITIES.— 
(i) IN GENERAL.—Section 2102(c)(1) 
of such Act (42 U.S.C. 1397bb(c)(1)) is 
amended by inserting ‘‘(through commu-
nity health workers and others)’’ after 
‘‘Outreach’’. 
(ii) IN FEDERAL EVALUATION.—Sec-
tion 2108(c)(3)(B) of such Act (42 U.S.C. 
1397hh(c)(3)(B)) is amended by inserting 
‘‘(such as through community health work-
ers and others)’’ after ‘‘including prac-
tices’’. 
SEC. 202. INCREASED OUTREACH AND ENROLLMENT OF IN-
DIANS. 
(a) IN GENERAL.—Section 1139 (42 U.S.C. 1320b– 
9) is amended to read as follows: 
‘‘SEC. 1139. IMPROVED ACCESS TO, AND DELIVERY OF, 
HEALTH CARE FOR INDIANS UNDER TITLES 
XIX AND XXI. 
‘‘(a) AGREEMENTS WITH STATES
FOR MEDICAID 
AND CHIP OUTREACH ON OR NEAR RESERVATIONS TO
INCREASE
THE ENROLLMENT
OF INDIANS
IN THOSE 
PROGRAMS.— 
‘‘(1) IN GENERAL.—In order to improve the ac-
cess of Indians residing on or near a reservation to 
obtain benefits under the Medicaid and State chil-
dren’s health insurance programs established under 
titles XIX and XXI, the Secretary shall encourage 
the State to take steps to provide for enrollment on 
or near the reservation. Such steps may include out-
reach efforts such as the outstationing of eligibility 
workers, entering into agreements with the Indian 
Health Service, Indian Tribes, Tribal Organizations, 
and Urban Indian Organizations to provide out-
reach, education regarding eligibility and benefits, 
enrollment, and translation services when such serv-
ices are appropriate. 
‘‘(2) CONSTRUCTION.—Nothing in paragraph 
(1) shall be construed as affecting arrangements en-
tered into between States and the Indian Health 
Service, Indian Tribes, Tribal Organizations, or 
Urban Indian Organizations for such Service, 
Tribes, or Organizations to conduct administrative 
activities under such titles. 
‘‘(b) REQUIREMENT
TO
FACILITATE
COOPERA-
TION.—The Secretary, acting through the Centers for
Medicare & Medicaid Services, shall take such steps as are 
necessary to facilitate cooperation with, and agreements 
between, States and the Indian Health Service, Indian 
Tribes, Tribal Organizations, or Urban Indian Organiza-
tions with respect to the provision of health care items 
and services to Indians under the programs established 
under title XIX or XXI. 
‘‘(c) DEFINITION OF INDIAN; INDIAN TRIBE; INDIAN 
HEALTH PROGRAM; TRIBAL ORGANIZATION; URBAN IN-
DIAN ORGANIZATION.—In this section, the terms ‘Indian’, 
‘Indian Tribe’, ‘Indian Health Program’, ‘Tribal Organi-
zation’, and ‘Urban Indian Organization’ have the mean-
ings given those terms in section 4 of the Indian Health 
Care Improvement Act.’’. 
(b) NONAPPLICATION
OF 10 PERCENT LIMIT
ON 
OUTREACH AND CERTAIN OTHER EXPENDITURES.—Sec-
tion 2105(c)(2) (42 U.S.C. 1397ee(c)(2)) is amended by 
adding at the end the following: 
‘‘(C) NONAPPLICATION
TO
CERTAIN
EX-
PENDITURES.—The limitation under subpara-
graph (A) shall not apply with respect to the 
following expenditures: 
‘‘(i) EXPENDITURES
TO
INCREASE 
OUTREACH TO, AND THE ENROLLMENT OF, 
INDIAN CHILDREN UNDER THIS TITLE AND
TITLE xix.—Expenditures for outreach ac-
tivities to families of Indian children likely 
to be eligible for child health assistance 
under the plan or medical assistance under 
the State plan under title XIX (or under 
a waiver of such plan), to inform such 
families of the availability of, and to assist 
them in enrolling their children in, such 
plans, including such activities conducted 
under grants, contracts, or agreements en-
tered into under section 1139(a).’’. 
SEC. 203. STATE OPTION TO RELY ON FINDINGS FROM AN 
EXPRESS LANE AGENCY TO CONDUCT SIM-
PLIFIED ELIGIBILITY DETERMINATIONS. 
(a) APPLICATION UNDER MEDICAID AND CHIP PRO-
GRAMS.— 
(1) MEDICAID.—Section 1902(e) (42 U.S.C. 
1396a(e)) is amended by adding at the end the fol-
lowing: 
‘‘(13) EXPRESS LANE OPTION.— 
‘‘(A) IN GENERAL.— 
‘‘(i) OPTION TO USE A FINDING FROM AN 
EXPRESS LANE AGENCY.—At the option of the 
State, the State plan may provide that in deter-
mining eligibility under this title for a child (as
defined in subparagraph (G)), the State may 
rely on a finding made within a reasonable pe-
riod (as determined by the State) from an Ex-
press Lane agency (as defined in subparagraph 
(F)) when it determines whether a child satis-
fies one or more components of eligibility for 
medical assistance under this title. The State 
may rely on a finding from an Express Lane 
agency notwithstanding any differences in 
budget unit, disregard, deeming or other meth-
odology, if the following requirements are met: 
‘‘(I) PROHIBITION ON DETERMINING 
CHILDREN INELIGIBLE FOR COVERAGE.— 
If a finding from an Express Lane agency 
would result in a determination that a 
child does not satisfy an eligibility require-
ment for medical assistance under this title 
and for child health assistance under title 
XXI, the State shall determine eligibility 
for assistance using its regular procedures. 
‘‘(II) NOTICE
REQUIREMENT.—For 
any child who is found eligible for medical 
assistance under the State plan under this 
title or child health assistance under title 
XXI and who is subject to premiums based
on an Express Lane agency’s finding of 
such child’s income level, the State shall 
provide notice that the child may qualify 
for lower premium payments if evaluated 
by the State using its regular policies and 
of the procedures for requesting such an 
evaluation. 
‘‘(III) COMPLIANCE
WITH
SCREEN 
AND
ENROLL
REQUIREMENT.—The State 
shall satisfy the requirements under sub-
paragraphs 
(A) 
and 
(B) 
of 
section 
2102(b)(3) (relating to screen and enroll) 
before enrolling a child in child health as-
sistance under title XXI. At its option, the 
State may fulfill such requirements in ac-
cordance with either option provided under 
subparagraph (C) of this paragraph. 
‘‘(IV) VERIFICATION OF CITIZENSHIP, 
NATIONALITY
STATUS, 
OR
QUALIFIED 
ALIEN
STATUS.—The State shall satisfy 
the requirements of sections 1137(d) and 
1902(a)(46)(B) for verifications of citizen-
ship, nationality status, or qualified alien 
status.
‘‘(V) CODING.—The State meets the 
requirements of subparagraph (E). 
‘‘(ii) OPTION TO APPLY TO RENEWALS AND 
REDETERMINATIONS.—The State may apply the 
provisions of this paragraph when conducting 
initial determinations of eligibility, redetermina-
tions of eligibility, or both, as described in the 
State plan. 
‘‘(B) RULES OF CONSTRUCTION.—Nothing in 
this paragraph shall be construed— 
‘‘(i) to relieve a State of the obligation to 
determine components of eligibility that are not 
the subject of an Express Lane agency’s find-
ing, as described in subparagraph (A); 
‘‘(ii) to limit or prohibit a State from tak-
ing any actions otherwise permitted under this 
title or title XXI in determining eligibility for 
or enrolling children into medical assistance 
under this title or child health assistance under 
title XXI; or 
‘‘(iii) to modify the limitations in section 
1902(a)(5) concerning the agencies that may 
make a determination of eligibility for medical 
assistance under this title.
‘‘(C) OPTIONS FOR SATISFYING THE SCREEN 
AND ENROLL REQUIREMENT.— 
‘‘(i) IN GENERAL.—With respect to a child 
whose eligibility for medical assistance under 
this title or for child health assistance under 
title XXI has been evaluated by a State agency 
using an income finding from an Express Lane 
agency, a State may carry out its duties under 
subparagraphs 
(A) 
and 
(B) 
of 
section 
2102(b)(3) (relating to screen and enroll) in ac-
cordance with either clause (ii) or clause (iii). 
‘‘(ii) 
ESTABLISHING
A
SCREENING 
THRESHOLD.— 
‘‘(I) IN GENERAL.—Under this clause, 
the State establishes a screening threshold 
set as a percentage of the Federal poverty 
level that exceeds the highest income 
threshold applicable under this title to the 
child by a minimum of 30 percentage 
points or, at State option, a higher number 
of percentage points that reflects the value 
(as determined by the State and described 
in the State plan) of any differences be-
tween income methodologies used by the 
program administered by the Express Lane
100 
agency and the methodologies used by the 
State in determining eligibility for medical 
assistance under this title. 
‘‘(II) CHILDREN
WITH
INCOME
NOT 
ABOVE THRESHOLD.—If the income of a 
child does not exceed the screening thresh-
old, the child is deemed to satisfy the in-
come eligibility criteria for medical assist-
ance under this title regardless of whether 
such child would otherwise satisfy such cri-
teria. 
‘‘(III) 
CHILDREN
WITH
INCOME 
ABOVE THRESHOLD.—If the income of a 
child exceeds the screening threshold, the 
child shall be considered to have an income 
above the Medicaid applicable income level 
described in section 2110(b)(4) and to sat-
isfy 
the 
requirement 
under 
section 
2110(b)(1)(C) (relating to the requirement 
that CHIP matching funds be used only 
for children not eligible for Medicaid). If 
such a child is enrolled in child health as-
sistance under title XXI, the State shall 
provide the parent, guardian, or custodial 
relative with the following:
101 
‘‘(aa) Notice that the child may 
be eligible to receive medical assist-
ance under the State plan under this 
title if evaluated for such assistance 
under the State’s regular procedures 
and notice of the process through 
which a parent, guardian, or custodial 
relative can request that the State 
evaluate the child’s eligibility for med-
ical assistance under this title using 
such regular procedures. 
‘‘(bb) A description of differences 
between the medical assistance pro-
vided under this title and child health 
assistance under title XXI, including 
differences in cost-sharing require-
ments and covered benefits. 
‘‘(iii) TEMPORARY ENROLLMENT IN CHIP 
PENDING SCREEN AND ENROLL.— 
‘‘(I) IN GENERAL.—Under this clause, 
a State enrolls a child in child health as-
sistance under title XXI for a temporary 
period if the child appears eligible for such 
assistance based on an income finding by 
an Express Lane agency.
102 
‘‘(II) 
DETERMINATION
OF
ELIGI-
BILITY.—During such temporary enroll-
ment period, the State shall determine the 
child’s eligibility for child health assistance 
under title XXI or for medical assistance 
under this title in accordance with this 
clause. 
‘‘(III) PROMPT FOLLOW UP.—In mak-
ing such a determination, the State shall 
take prompt action to determine whether 
the child should be enrolled in medical as-
sistance under this title or child health as-
sistance under title XXI pursuant to sub-
paragraphs 
(A) 
and 
(B) 
of 
section 
2102(b)(3) (relating to screen and enroll). 
‘‘(IV) REQUIREMENT FOR SIMPLIFIED 
DETERMINATION.—In making such a de-
termination, the State shall use procedures 
that, to the maximum feasible extent, re-
duce the burden imposed on the individual 
of such determination. Such procedures 
may not require the child’s parent, guard-
ian, or custodial relative to provide or 
verify information that already has been 
provided to the State agency by an Ex-
103 
press Lane agency or another source of in-
formation unless the State agency has rea-
son to believe the information is erroneous. 
‘‘(V) AVAILABILITY OF CHIP MATCH-
ING FUNDS DURING TEMPORARY ENROLL-
MENT
PERIOD.—Medical assistance for 
items and services that are provided to a 
child enrolled in title XXI during a tem-
porary enrollment period under this clause 
shall be treated as child health assistance 
under such title. 
‘‘(D) OPTION FOR AUTOMATIC ENROLLMENT.— 
‘‘(i) IN GENERAL.—The State may initiate 
and determine eligibility for medical assistance 
under the State Medicaid plan or for child 
health assistance under the State CHIP plan 
without a program application from, or on be-
half of, the child based on data obtained from 
sources other than the child (or the child’s fam-
ily), but a child can only be automatically en-
rolled in the State Medicaid plan or the State 
CHIP plan if the child or the family affirma-
tively consents to being enrolled through affir-
mation and signature on an Express Lane
104 
agency application, if the requirement of clause 
(ii) is met. 
‘‘(ii) INFORMATION
REQUIREMENT.—The 
requirement of this clause is that the State in-
forms the parent, guardian, or custodial relative 
of the child of the services that will be covered, 
appropriate methods for using such services, 
premium or other cost sharing charges (if any) 
that apply, medical support obligations (under 
section 1912(a)) created by enrollment (if appli-
cable), and the actions the parent, guardian, or 
relative must take to maintain enrollment and 
renew coverage. 
‘‘(E) CODING; APPLICATION TO ENROLLMENT 
ERROR RATES.— 
‘‘(i) IN GENERAL.—For purposes of sub-
paragraph (A)(iv), the requirement of this sub-
paragraph for a State is that the State agrees 
to— 
‘‘(I) assign such codes as the Sec-
retary shall require to the children who are 
enrolled in the State Medicaid plan or the 
State CHIP plan through reliance on a 
finding made by an Express Lane agency
105 
for the duration of the State’s election 
under this paragraph; 
‘‘(II) annually provide the Secretary 
with a statistically valid sample (that is ap-
proved by Secretary) of the children en-
rolled in such plans through reliance on 
such a finding by conducting a full Med-
icaid eligibility review of the children iden-
tified for such sample for purposes of de-
termining an eligibility error rate (as de-
scribed in clause (iv)) with respect to the 
enrollment of such children (and shall not 
include such children in any data or sam-
ples used for purposes of complying with a 
Medicaid 
Eligibility 
Quality 
Control 
(MEQC) review or a payment error rate 
measurement (PERM) requirement); 
‘‘(III) submit the error rate deter-
mined under subclause (II) to the Sec-
retary; 
‘‘(IV) if such error rate exceeds 3 per-
cent for either of the first 2 fiscal years in 
which the State elects to apply this para-
graph, demonstrate to the satisfaction of 
the Secretary the specific corrective actions
106 
implemented by the State to improve upon 
such error rate; and 
‘‘(V) if such error rate exceeds 3 per-
cent for any fiscal year in which the State 
elects to apply this paragraph, a reduction 
in the amount otherwise payable to the 
State under section 1903(a) for quarters 
for that fiscal year, equal to the total 
amount of erroneous excess payments de-
termined for the fiscal year only with re-
spect to the children included in the sam-
ple for the fiscal year that are in excess of 
a 3 percent error rate with respect to such 
children. 
‘‘(ii) NO
PUNITIVE
ACTION
BASED
ON 
ERROR RATE.—The Secretary shall not apply 
the error rate derived from the sample under 
clause (i) to the entire population of children 
enrolled in the State Medicaid plan or the State 
CHIP plan through reliance on a finding made 
by an Express Lane agency, or to the popu-
lation of children enrolled in such plans on the 
basis of the State’s regular procedures for de-
termining eligibility, or penalize the State on 
the basis of such error rate in any manner
107 
other than the reduction of payments provided 
for under clause (i)(V). 
‘‘(iii) RULE OF CONSTRUCTION.—Nothing 
in this paragraph shall be construed as relieving 
a State that elects to apply this paragraph from 
being subject to a penalty under section 
1903(u), for payments made under the State 
Medicaid plan with respect to ineligible individ-
uals and families that are determined to exceed 
the error rate permitted under that section (as 
determined without regard to the error rate de-
termined under clause (i)(II)). 
‘‘(iv) ERROR RATE DEFINED.—In this sub-
paragraph, the term ‘error rate’ means the rate 
of erroneous excess payments for medical as-
sistance (as defined in section 1903(u)(1)(D)) 
for the period involved, except that such pay-
ments shall be limited to individuals for which 
eligibility determinations are made under this 
paragraph and except that in applying this 
paragraph under title XXI, there shall be sub-
stituted for references to provisions of this title 
corresponding provisions within title XXI. 
‘‘(F) EXPRESS LANE AGENCY.—
108 
‘‘(i) IN GENERAL.—In this paragraph, the 
term ‘Express Lane agency’ means a public 
agency that— 
‘‘(I) is determined by the State Med-
icaid agency or the State CHIP agency (as 
applicable) to be capable of making the de-
terminations of one or more eligibility re-
quirements 
described 
in 
subparagraph 
(A)(i); 
‘‘(II) is identified in the State Med-
icaid plan or the State CHIP plan; and 
‘‘(III) notifies the child’s family— 
‘‘(aa) of the information which 
shall be disclosed in accordance with 
this paragraph; 
‘‘(bb) that the information dis-
closed will be used solely for purposes 
of determining eligibility for medical 
assistance under the State Medicaid 
plan or for child health assistance 
under the State CHIP plan; and 
‘‘(cc) that the family may elect to 
not have the information disclosed for 
such purposes; and
110 
‘‘(ii) The Child Care and Devel-
opment Block Grant Act of 1990 (42 
U.S.C. 9858 et seq.). 
‘‘(jj) The Stewart B. McKinney 
Homeless Assistance Act (42 U.S.C. 
11301 et seq.). 
‘‘(kk) The United States Housing 
Act of 1937 (42 U.S.C. 1437 et seq.). 
‘‘(ll) The Native American Hous-
ing Assistance and Self-Determination 
Act of 1996 (25 U.S.C. 4101 et seq.). 
‘‘(II) A State-specified governmental 
agency that has fiscal liability or legal re-
sponsibility for the accuracy of the eligi-
bility determination findings relied on by 
the State. 
‘‘(III) A public agency that is subject 
to an interagency agreement limiting the 
disclosure and use of the information dis-
closed for purposes of determining eligi-
bility under the State Medicaid plan or the 
State CHIP plan. 
‘‘(iii) EXCLUSIONS.—Such term does not 
include an agency that determines eligibility for 
a program established under the Social Services
111 
Block Grant established under title XX or a 
private, for-profit organization. 
‘‘(iv) RULES OF CONSTRUCTION.—Nothing 
in this paragraph shall be construed as— 
‘‘(I) exempting a State Medicaid 
agency from complying with the require-
ments of section 1902(a)(4) relating to 
merit-based personnel standards for em-
ployees of the State Medicaid agency and 
safeguards against conflicts of interest); or 
‘‘(II) authorizing a State Medicaid 
agency that elects to use Express Lane 
agencies under this subparagraph to use 
the Express Lane option to avoid com-
plying with such requirements for purposes 
of making eligibility determinations under 
the State Medicaid plan. 
‘‘(v) ADDITIONAL
DEFINITIONS.—In this 
paragraph: 
‘‘(I) STATE.—The term ‘State’ means 
1 of the 50 States or the District of Co-
lumbia. 
‘‘(II) 
STATE
CHIP
AGENCY.—The 
term ‘State CHIP agency’ means the State
112 
agency responsible for administering the 
State CHIP plan. 
‘‘(III) STATE CHIP PLAN.—The term 
‘State CHIP plan’ means the State child 
health plan established under title XXI 
and includes any waiver of such plan. 
‘‘(IV) STATE
MEDICAID
AGENCY.— 
The term ‘State Medicaid agency’ means 
the State agency responsible for admin-
istering the State Medicaid plan. 
‘‘(V) STATE
MEDICAID
PLAN.—The 
term ‘State Medicaid plan’ means the 
State plan established under title XIX and 
includes any waiver of such plan. 
‘‘(G) CHILD DEFINED.—For purposes of this 
paragraph, the term ‘child’ means an individual 
under 19 years of age, or, at the option of a State, 
such higher age, not to exceed 21 years of age, as 
the State may elect. 
‘‘(H) APPLICATION.—This paragraph shall not 
apply to with respect to eligibility determinations 
made after September 30, 2013.’’. 
(2) CHIP.—Section 2107(e)(1) (42 U.S.C. 
1397gg(e)(1)) is amended by redesignating subpara-
graphs (B), (C), and (D) as subparagraphs (C), (D),
113 
and (E), respectively, and by inserting after sub-
paragraph (A) the following new subparagraph: 
‘‘(B) Section 1902(e)(13) (relating to the 
State option to rely on findings from an Ex-
press Lane agency to help evaluate a child’s eli-
gibility for medical assistance).’’. 
(b) EVALUATION AND REPORT.— 
(1) EVALUATION.—The Secretary shall con-
duct, by grant, contract, or interagency agreement, 
a comprehensive, independent evaluation of the op-
tion provided under the amendments made by sub-
section (a). Such evaluation shall include an analysis 
of the effectiveness of the option, and shall include— 
(A) obtaining a statistically valid sample of 
the children who were enrolled in the State 
Medicaid plan or the State CHIP plan through 
reliance on a finding made by an Express Lane 
agency and determining the percentage of chil-
dren who were erroneously enrolled in such 
plans; 
(B) determining whether enrolling children 
in such plans through reliance on a finding 
made by an Express Lane agency improves the 
ability of a State to identify and enroll low-in-
114 
come, uninsured children who are eligible but 
not enrolled in such plans; 
(C) evaluating the administrative costs or 
savings related to identifying and enrolling chil-
dren in such plans through reliance on such 
findings, and the extent to which such costs dif-
fer from the costs that the State otherwise 
would have incurred to identify and enroll low- 
income, uninsured children who are eligible but 
not enrolled in such plans; and 
(D) any recommendations for legislative or 
administrative changes that would improve the 
effectiveness of enrolling children in such plans 
through reliance on such findings. 
(2) REPORT
TO
CONGRESS.—Not later than 
September 30, 2012, the Secretary shall submit a 
report to Congress on the results of the evaluation 
under paragraph (1). 
(3) FUNDING.— 
(A) IN GENERAL.—Out of any funds in the 
Treasury not otherwise appropriated, there is 
appropriated to the Secretary to carry out the 
evaluation under this subsection $5,000,000 for 
the period of fiscal years 2009 through 2012.
115 
(B) BUDGET AUTHORITY.—Subparagraph 
(A) constitutes budget authority in advance of 
appropriations Act and represents the obliga-
tion of the Federal Government to provide for 
the payment of such amount to conduct the 
evaluation under this subsection. 
(c) ELECTRONIC TRANSMISSION OF INFORMATION.— 
Section 1902 (42 U.S.C. 1396a) is amended by adding 
at the end the following new subsection: 
‘‘(dd) ELECTRONIC TRANSMISSION
OF INFORMA-
TION.—If the State agency determining eligibility for med-
ical assistance under this title or child health assistance 
under title XXI verifies an element of eligibility based on 
information from an Express Lane Agency (as defined in 
subsection (e)(13)(F)), or from another public agency, 
then the applicant’s signature under penalty of perjury 
shall not be required as to such element. Any signature 
requirement for an application for medical assistance may 
be satisfied through an electronic signature, as defined in 
section 1710(1) of the Government Paperwork Elimi-
nation Act (44 U.S.C. 3504 note). The requirements of 
subparagraphs (A) and (B) of section 1137(d)(2) may be 
met through evidence in digital or electronic form.’’. 
(d) AUTHORIZATION
OF
INFORMATION
DISCLO-
SURE.—
116 
(1) IN GENERAL.—Title XIX is amended by 
adding at the end the following new section: 
‘‘SEC. 1942. AUTHORIZATION TO RECEIVE RELEVANT IN-
FORMATION. 
‘‘(a) IN GENERAL.—Notwithstanding any other pro-
vision of law, a Federal or State agency or private entity 
in possession of the sources of data directly relevant to 
eligibility determinations under this title (including eligi-
bility files maintained by Express Lane agencies described 
in section 1902(e)(13)(F), information described in para-
graph (2) or (3) of section 1137(a), vital records informa-
tion about births in any State, and information described 
in sections 453(i) and 1902(a)(25)(I)) is authorized to 
convey such data or information to the State agency ad-
ministering the State plan under this title, to the extent 
such conveyance meets the requirements of subsection (b). 
‘‘(b) REQUIREMENTS FOR CONVEYANCE.—Data or 
information may be conveyed pursuant to subsection (a) 
only if the following requirements are met: 
‘‘(1) The individual whose circumstances are 
described in the data or information (or such indi-
vidual’s parent, guardian, caretaker relative, or au-
thorized representative) has either provided advance 
consent to disclosure or has not objected to disclo-
117 
sure after receiving advance notice of disclosure and 
a reasonable opportunity to object. 
‘‘(2) Such data or information are used solely 
for the purposes of— 
‘‘(A) identifying individuals who are eligi-
ble or potentially eligible for medical assistance 
under this title and enrolling or attempting to 
enroll such individuals in the State plan; and 
‘‘(B) verifying the eligibility of individuals 
for medical assistance under the State plan. 
‘‘(3) An interagency or other agreement, con-
sistent with standards developed by the Secretary— 
‘‘(A) prevents the unauthorized use, disclo-
sure, or modification of such data and other-
wise meets applicable Federal requirements 
safeguarding privacy and data security; and 
‘‘(B) requires the State agency admin-
istering the State plan to use the data and in-
formation obtained under this section to seek to 
enroll individuals in the plan. 
‘‘(c) PENALTIES FOR IMPROPER DISCLOSURE.— 
‘‘(1) CIVIL MONEY PENALTY.—A private entity 
described in the subsection (a) that publishes, dis-
closes, or makes known in any manner, or to any ex-
tent not authorized by Federal law, any information
118 
obtained under this section is subject to a civil 
money penalty in an amount equal to $10,000 for 
each such unauthorized publication or disclosure. 
The provisions of section 1128A (other than sub-
sections (a) and (b) and the second sentence of sub-
section (f)) shall apply to a civil money penalty 
under this paragraph in the same manner as such 
provisions apply to a penalty or proceeding under 
section 1128A(a). 
‘‘(2) CRIMINAL PENALTY.—A private entity de-
scribed in the subsection (a) that willfully publishes, 
discloses, or makes known in any manner, or to any 
extent not authorized by Federal law, any informa-
tion obtained under this section shall be fined not 
more than $10,000 or imprisoned not more than 1 
year, or both, for each such unauthorized publication 
or disclosure. 
‘‘(d) RULE OF CONSTRUCTION.—The limitations and 
requirements that apply to disclosure pursuant to this sec-
tion shall not be construed to prohibit the conveyance or 
disclosure of data or information otherwise permitted 
under Federal law (without regard to this section).’’. 
(2) CONFORMING AMENDMENT TO TITLE XXI.— 
Section 2107(e)(1) (42 U.S.C. 1397gg(e)(1)), as
119 
amended by subsection (a)(2), is amended by adding 
at the end the following new subparagraph: 
‘‘(F) Section 1942 (relating to authoriza-
tion to receive data directly relevant to eligi-
bility determinations).’’. 
(3) CONFORMING AMENDMENT TO PROVIDE AC-
CESS TO DATA ABOUT ENROLLMENT IN INSURANCE 
FOR PURPOSES OF EVALUATING APPLICATIONS AND 
FOR
CHIP.—Section 1902(a)(25)(I)(i) (42 U.S.C. 
1396a(a)(25)(I)(i)) is amended— 
(A) by inserting ‘‘(and, at State option, in-
dividuals who apply or whose eligibility for med-
ical assistance is being evaluated in accordance 
with section 1902(e)(13)(D))’’ after ‘‘with re-
spect to individuals who are eligible’’; and 
(B) by inserting ‘‘under this title (and, at 
State option, child health assistance under title 
XXI)’’ after ‘‘the State plan’’. 
(e) AUTHORIZATION
FOR STATES ELECTING EX-
PRESS LANE OPTION TO RECEIVE CERTAIN DATA DI-
RECTLY RELEVANT TO DETERMINING ELIGIBILITY AND 
CORRECT AMOUNT OF ASSISTANCE.—The Secretary shall 
enter into such agreements as are necessary to permit a 
State that elects the Express Lane option under section 
1902(e)(13) of the Social Security Act to receive data di-
120 
rectly relevant to eligibility determinations and deter-
mining the correct amount of benefits under a State child 
health plan under CHIP or a State plan under Medicaid 
from the following: 
(1) The National Directory of New Hires estab-
lished under section 453(i) of the Social Security 
Act (42 U.S.C. 653(i)). 
(2) Data regarding enrollment in insurance that 
may help to facilitate outreach and enrollment under 
the State Medicaid plan, the State CHIP plan, and 
such other programs as the Secretary may specify. 
(f) EFFECTIVE DATE.—The amendments made by 
this section are effective on the date of the enactment of 
this Act. 
Subtitle B—Reducing Barriers to 
Enrollment 
SEC. 211. VERIFICATION OF DECLARATION OF CITIZENSHIP 
OR NATIONALITY FOR PURPOSES OF ELIGI-
BILITY FOR MEDICAID AND CHIP. 
(a) 
ALTERNATIVE
STATE
PROCESS
FOR 
VERIFICATION OF DECLARATION OF CITIZENSHIP OR NA-
TIONALITY FOR PURPOSES OF ELIGIBILITY FOR MED-
ICAID.— 
(1) ALTERNATIVE
TO
DOCUMENTATION
RE-
QUIREMENT.—
121 
(A) IN
GENERAL.—Section 1902 (42 
U.S.C. 1396a), as amended by section 203(c), 
is amended— 
(i) in subsection (a)(46)— 
(I) by inserting ‘‘(A)’’ after 
‘‘(46)’’; 
(II) by adding ‘‘and’’ after the 
semicolon; and 
(III) by adding at the end the 
following new subparagraph: 
‘‘(B) provide, with respect to an individual de-
claring to be a citizen or national of the United 
States for purposes of establishing eligibility under 
this title, that the State shall satisfy the require-
ments of— 
‘‘(i) section 1903(x); or 
‘‘(ii) subsection (ee);’’; and 
(ii) by adding at the end the following 
new subsection: 
‘‘(ee)(1) For purposes of subsection (a)(46)(B)(ii), 
the requirements of this subsection with respect to an indi-
vidual declaring to be a citizen or national of the United 
States for purposes of establishing eligibility under this 
title, are, in lieu of requiring the individual to present sat-
isfactory documentary evidence of citizenship or nation-
122 
ality under section 1903(x) (if the individual is not de-
scribed in paragraph (2) of that section), as follows: 
‘‘(A) The State submits the name and social se-
curity number of the individual to the Commissioner 
of Social Security as part of the program established 
under paragraph (2). 
‘‘(B) If the State receives notice from the Com-
missioner of Social Security that the name or social 
security number, or the declaration of citizenship or 
nationality, of the individual is inconsistent with in-
formation in the records maintained by the Commis-
sioner— 
‘‘(i) the State makes a reasonable effort to 
identify and address the causes of such incon-
sistency, including through typographical or 
other clerical errors, by contacting the indi-
vidual to confirm the accuracy of the name or 
social security number submitted or declaration 
of citizenship or nationality and by taking such 
additional actions as the Secretary, through 
regulation or other guidance, or the State may 
identify, and continues to provide the individual 
with medical assistance while making such ef-
fort; and
123 
‘‘(ii) in the case such inconsistency is not 
resolved under clause (i), the State— 
‘‘(I) notifies the individual of such 
fact; 
‘‘(II) provides the individual with a 
period of 90 days from the date on which 
the notice required under subclause (I) is 
received by the individual to either present 
satisfactory documentary evidence of citi-
zenship or nationality (as defined in sec-
tion 1903(x)(3)) or resolve the inconsist-
ency with the Commissioner of Social Se-
curity (and continues to provide the indi-
vidual with medical assistance during such 
90-day period); and 
‘‘(III) disenrolls the individual from 
the State plan under this title within 30 
days after the end of such 90-day period if 
no such documentary evidence is presented 
or if such inconsistency is not resolved. 
‘‘(2)(A) Each State electing to satisfy the require-
ments of this subsection for purposes of section 
1902(a)(46)(B) shall establish a program under which the 
State submits at least monthly to the Commissioner of So-
cial Security for comparison of the name and social secu-
124 
rity number, of each individual newly enrolled in the State 
plan under this title that month who is not described in 
section 1903(x)(2) and who declares to be a United States 
citizen or national, with information in records maintained 
by the Commissioner. 
‘‘(B) In establishing the State program under this 
paragraph, the State may enter into an agreement with 
the Commissioner of Social Security— 
‘‘(i) to provide, through an on-line system or 
otherwise, for the electronic submission of, and re-
sponse to, the information submitted under subpara-
graph (A) for an individual enrolled in the State 
plan under this title who declares to be citizen or na-
tional on at least a monthly basis; or 
‘‘(ii) to provide for a determination of the con-
sistency of the information submitted with the infor-
mation maintained in the records of the Commis-
sioner through such other method as agreed to by 
the State and the Commissioner and approved by 
the Secretary, provided that such method is no more 
burdensome for individuals to comply with than any 
burdens that may apply under a method described in 
clause (i). 
‘‘(C) The program established under this paragraph 
shall provide that, in the case of any individual who is
125 
required to submit a social security number to the State 
under subparagraph (A) and who is unable to provide the 
State with such number, shall be provided with at least 
the reasonable opportunity to present satisfactory docu-
mentary evidence of citizenship or nationality (as defined 
in section 1903(x)(3)) as is provided under clauses (i) and 
(ii) of section 1137(d)(4)(A) to an individual for the sub-
mittal to the State of evidence indicating a satisfactory 
immigration status. 
‘‘(3)(A) The State agency implementing the plan ap-
proved under this title shall, at such times and in such 
form as the Secretary may specify, provide information on 
the percentage each month that the inconsistent submis-
sions bears to the total submissions made for comparison 
for such month. For purposes of this subparagraph, a 
name, social security number, or declaration of citizenship 
or nationality of an individual shall be treated as incon-
sistent and included in the determination of such percent-
age only if— 
‘‘(i) the information submitted by the individual 
is not consistent with information in records main-
tained by the Commissioner of Social Security; 
‘‘(ii) the inconsistency is not resolved by the 
State;
126 
‘‘(iii) the individual was provided with a reason-
able period of time to resolve the inconsistency with 
the Commissioner of Social Security or provide satis-
factory documentation of citizenship status and did 
not successfully resolve such inconsistency; and 
‘‘(iv) payment has been made for an item or 
service furnished to the individual under this title. 
‘‘(B) If, for any fiscal year, the average monthly per-
centage determined under subparagraph (A) is greater 
than 3 percent— 
‘‘(i) the State shall develop and adopt a correc-
tive plan to review its procedures for verifying the 
identities of individuals seeking to enroll in the State 
plan under this title and to identify and implement 
changes in such procedures to improve their accu-
racy; and 
‘‘(ii) pay to the Secretary an amount equal to 
the amount which bears the same ratio to the total 
payments under the State plan for the fiscal year for 
providing medical assistance to individuals who pro-
vided inconsistent information as the number of in-
dividuals with inconsistent information in excess of 
3 percent of such total submitted bears to the total 
number of individuals with inconsistent information.
127 
‘‘(C) The Secretary may waive, in certain limited 
cases, all or part of the payment under subparagraph 
(B)(ii) if the State is unable to reach the allowable error 
rate despite a good faith effort by such State. 
‘‘(D) Subparagraphs (A) and (B) shall not apply to 
a State for a fiscal year if there is an agreement described 
in paragraph (2)(B) in effect as of the close of the fiscal 
year that provides for the submission on a real-time basis 
of the information described in such paragraph. 
‘‘(4) Nothing in this subsection shall affect the rights 
of any individual under this title to appeal any 
disenrollment from a State plan.’’. 
(B) COSTS OF IMPLEMENTING AND MAIN-
TAINING
SYSTEM.—Section 
1903(a)(3) 
(42 
U.S.C. 1396b(a)(3)) is amended— 
(i) by striking ‘‘plus’’ at the end of 
subparagraph (E) and inserting ‘‘and’’, 
and 
(ii) by adding at the end the following 
new subparagraph: 
‘‘(F)(i) 90 percent of the sums expended 
during the quarter as are attributable to the de-
sign, development, or installation of such 
mechanized verification and information re-
trieval systems as the Secretary determines are
128 
necessary to implement section 1902(ee) (in-
cluding a system described in paragraph (2)(B) 
thereof), and 
‘‘(ii) 75 percent of the sums expended dur-
ing the quarter as are attributable to the oper-
ation of systems to which clause (i) applies, 
plus’’. 
(2) LIMITATION ON WAIVER AUTHORITY.—Not-
withstanding any provision of section 1115 of the 
Social Security Act (42 U.S.C. 1315), or any other 
provision of law, the Secretary may not waive the re-
quirements of section 1902(a)(46)(B) of such Act 
(42 U.S.C. 1396a(a)(46)(B)) with respect to a 
State. 
(3) CONFORMING AMENDMENTS.—Section 1903 
(42 U.S.C. 1396b) is amended— 
(A) in subsection (i)(22), by striking ‘‘sub-
section 
(x)’’ 
and 
inserting 
‘‘section 
1902(a)(46)(B)’’; and 
(B) in subsection (x)(1), by striking ‘‘sub-
section 
(i)(22)’’ 
and 
inserting 
‘‘section 
1902(a)(46)(B)(i)’’. 
(4) APPROPRIATION.—Out of any money in the 
Treasury of the United States not otherwise appro-
priated, there are appropriated to the Commissioner
129 
of Social Security $5,000,000 to remain available 
until expended to carry out the Commissioner’s re-
sponsibilities under section 1902(ee) of the Social 
Security Act, as added by subsection (a). 
(b) CLARIFICATION OF REQUIREMENTS RELATING 
TO PRESENTATION
OF SATISFACTORY DOCUMENTARY 
EVIDENCE OF CITIZENSHIP OR NATIONALITY.— 
(1) ACCEPTANCE OF DOCUMENTARY EVIDENCE 
ISSUED
BY
A
FEDERALLY
RECOGNIZED
INDIAN 
TRIBE.—Section 
1903(x)(3)(B) 
(42 
U.S.C. 
1396b(x)(3)(B)) is amended— 
(A) by redesignating clause (v) as clause 
(vi); and 
(B) by inserting after clause (iv), the fol-
lowing new clause: 
‘‘(v)(I) Except as provided in subclause (II), a 
document issued by a federally recognized Indian 
tribe evidencing membership or enrollment in, or af-
filiation with, such tribe (such as a tribal enrollment 
card or certificate of degree of Indian blood). 
‘‘(II) With respect to those federally recognized 
Indian tribes located within States having an inter-
national border whose membership includes individ-
uals who are not citizens of the United States, the 
Secretary shall, after consulting with such tribes,
130 
issue regulations authorizing the presentation of 
such other forms of documentation (including tribal 
documentation, if appropriate) that the Secretary 
determines to be satisfactory documentary evidence 
of citizenship or nationality for purposes of satis-
fying the requirement of this subsection.’’. 
(2) REQUIREMENT
TO
PROVIDE
REASONABLE 
OPPORTUNITY
TO
PRESENT
SATISFACTORY
DOCU-
MENTARY EVIDENCE.—Section 1903(x) (42 U.S.C. 
1396b(x)) is amended by adding at the end the fol-
lowing new paragraph: 
‘‘(4) In the case of an individual declaring to be a 
citizen or national of the United States with respect to 
whom a State requires the presentation of satisfactory 
documentary evidence of citizenship or nationality under 
section 1902(a)(46)(B)(i), the individual shall be provided 
at least the reasonable opportunity to present satisfactory 
documentary evidence of citizenship or nationality under 
this subsection as is provided under clauses (i) and (ii) 
of section 1137(d)(4)(A) to an individual for the submittal 
to the State of evidence indicating a satisfactory immigra-
tion status.’’. 
(3) CHILDREN BORN IN THE UNITED STATES 
TO MOTHERS ELIGIBLE FOR MEDICAID.—
131 
(A) CLARIFICATION
OF
RULES.—Section 
1903(x) (42 U.S.C. 1396b(x)), as amended by 
paragraph (2), is amended— 
(i) in paragraph (2)— 
(I) in subparagraph (C), by strik-
ing ‘‘or’’ at the end; 
(II) by redesignating subpara-
graph (D) as subparagraph (E); and 
(III) by inserting after subpara-
graph (C) the following new subpara-
graph: 
‘‘(D) pursuant to the application of section 
1902(e)(4) (and, in the case of an individual who is 
eligible for medical assistance on such basis, the in-
dividual shall be deemed to have provided satisfac-
tory documentary evidence of citizenship or nation-
ality and shall not be required to provide further 
documentary evidence on any date that occurs dur-
ing or after the period in which the individual is eli-
gible for medical assistance on such basis); or’’; and 
(ii) by adding at the end the following 
new paragraph: 
‘‘(5) Nothing in subparagraph (A) or (B) of section 
1902(a)(46), the preceding paragraphs of this subsection, 
or the Deficit Reduction Act of 2005, including section
132 
6036 of such Act, shall be construed as changing the re-
quirement of section 1902(e)(4) that a child born in the 
United States to an alien mother for whom medical assist-
ance for the delivery of such child is available as treatment 
of an emergency medical condition pursuant to subsection 
(v) shall be deemed eligible for medical assistance during 
the first year of such child’s life.’’. 
(B) STATE REQUIREMENT TO ISSUE SEPA-
RATE
IDENTIFICATION
NUMBER.—Section 
1902(e)(4) (42 U.S.C. 1396a(e)(4)) is amended 
by adding at the end the following new sen-
tence: ‘‘Notwithstanding the preceding sentence, 
in the case of a child who is born in the United 
States to an alien mother for whom medical as-
sistance for the delivery of the child is made 
available pursuant to section 1903(v), the State 
immediately shall issue a separate identification 
number for the child upon notification by the 
facility at which such delivery occurred of the 
child’s birth.’’. 
(4) 
TECHNICAL
AMENDMENTS.—Section 
1903(x)(2) (42 U.S.C. 1396b(x)) is amended— 
(A) in subparagraph (B)—
133 
(i) by realigning the left margin of the 
matter preceding clause (i) 2 ems to the 
left; and 
(ii) by realigning the left margins of 
clauses (i) and (ii), respectively, 2 ems to 
the left; and 
(B) in subparagraph (C)— 
(i) by realigning the left margin of the 
matter preceding clause (i) 2 ems to the 
left; and 
(ii) by realigning the left margins of 
clauses (i) and (ii), respectively, 2 ems to 
the left. 
(c) APPLICATION OF DOCUMENTATION SYSTEM TO 
CHIP.— 
(1) IN GENERAL.—Section 2105(c) (42 U.S.C. 
1397ee(c)), as amended by section 114(a), is amend-
ed by adding at the end the following new para-
graph: 
‘‘(9) CITIZENSHIP DOCUMENTATION REQUIRE-
MENTS.— 
‘‘(A) IN GENERAL.—No payment may be 
made under this section with respect to an indi-
vidual who has, or is, declared to be a citizen 
or national of the United States for purposes of
134 
establishing eligibility under this title unless the 
State meets the requirements of section 
1902(a)(46)(B) with respect to the individual. 
‘‘(B) ENHANCED
PAYMENTS.—Notwith-
standing subsection (b), the enhanced FMAP 
with respect to payments under subsection (a) 
for expenditures described in clause (i) or (ii) of 
section 1903(a)(3)(F) necessary to comply with 
subparagraph (A) shall in no event be less than 
90 percent and 75 percent, respectively.’’. 
(2) NONAPPLICATION OF ADMINISTRATIVE EX-
PENDITURES
CAP.—Section 
2105(c)(2)(C) 
(42 
U.S.C. 1397ee(c)(2)(C)), as amended by section 
202(b), is amended by adding at the end the fol-
lowing: 
‘‘(ii) 
EXPENDITURES
TO
COMPLY 
WITH
CITIZENSHIP
OR
NATIONALITY 
VERIFICATION
REQUIREMENTS.—Expendi-
tures necessary for the State to comply 
with paragraph (9)(A).’’. 
(d) EFFECTIVE DATE.— 
(1) IN GENERAL.— 
(A) IN GENERAL.—Except as provided in 
subparagraph (B), the amendments made by
135 
this section shall take effect on October 1, 
2009. 
(B) 
TECHNICAL
AMENDMENTS.—The 
amendments made by— 
(i) paragraphs (1), (2), and (3) of 
subsection (b) shall take effect as if in-
cluded in the enactment of section 6036 of 
the Deficit Reduction Act of 2005 (Public 
Law 109–171; 120 Stat. 80); and 
(ii) paragraph (4) of subsection (b) 
shall take effect as if included in the enact-
ment of section 405 of division B of the 
Tax Relief and Health Care Act of 2006 
(Public Law 109–432; 120 Stat. 2996). 
(2) RESTORATION
OF
ELIGIBILITY.—In the 
case of an individual who, during the period that 
began on July 1, 2006, and ends on October 1, 
2009, was determined to be ineligible for medical as-
sistance under a State Medicaid plan, including any 
waiver of such plan, solely as a result of the applica-
tion of subsections (i)(22) and (x) of section 1903 
of the Social Security Act (as in effect during such 
period), but who would have been determined eligible 
for such assistance if such subsections, as amended 
by subsection (b), had applied to the individual, a
136 
State may deem the individual to be eligible for such 
assistance as of the date that the individual was de-
termined to be ineligible for such medical assistance 
on such basis. 
(3) SPECIAL TRANSITION RULE FOR INDIANS.— 
During the period that begins on July 1, 2006, and 
ends on the effective date of final regulations issued 
under subclause (II) of section 1903(x)(3)(B)(v) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1396b(x)(3)(B)(v)) 
(as 
added 
by 
subsection 
(b)(1)(B)), an individual who is a member of a fed-
erally-recognized Indian tribe described in subclause 
(II) of that section who presents a document de-
scribed in subclause (I) of such section that is issued 
by such Indian tribe, shall be deemed to have pre-
sented satisfactory evidence of citizenship or nation-
ality for purposes of satisfying the requirement of 
subsection (x) of section 1903 of such Act. 
SEC. 212. REDUCING ADMINISTRATIVE BARRIERS TO EN-
ROLLMENT. 
Section 2102(b) (42 U.S.C. 1397bb(b)) is amended— 
(1) by redesignating paragraph (4) as para-
graph (5); and 
(2) by inserting after paragraph (3) the fol-
lowing new paragraph:
137 
‘‘(4) REDUCTION
OF
ADMINISTRATIVE
BAR-
RIERS TO ENROLLMENT.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the plan shall include a description 
of the procedures used to reduce administrative 
barriers to the enrollment of children and preg-
nant women who are eligible for medical assist-
ance under title XIX or for child health assist-
ance or health benefits coverage under this title. 
Such procedures shall be established and re-
vised as often as the State determines appro-
priate to take into account the most recent in-
formation available to the State identifying 
such barriers. 
‘‘(B) DEEMED COMPLIANCE IF JOINT AP-
PLICATION AND RENEWAL PROCESS THAT PER-
MITS APPLICATION OTHER THAN IN PERSON.— 
A State shall be deemed to comply with sub-
paragraph (A) if the State’s application and re-
newal forms and supplemental forms (if any) 
and information verification process is the same 
for purposes of establishing and renewing eligi-
bility for children and pregnant women for 
medical assistance under title XIX and child 
health assistance under this title, and such
138 
process does not require an application to be 
made in person or a face-to-face interview.’’. 
SEC. 213. MODEL OF INTERSTATE COORDINATED ENROLL-
MENT AND COVERAGE PROCESS. 
(a) IN GENERAL.—In order to assure continuity of 
coverage of low-income children under the Medicaid pro-
gram and the State Children’s Health Insurance Program 
(CHIP), not later than 18 months after the date of the 
enactment of this Act, the Secretary of Health and 
Human Services, in consultation with State Medicaid and 
CHIP directors and organizations representing program 
beneficiaries, shall develop a model process for the coordi-
nation of the enrollment, retention, and coverage under 
such programs of children who, because of migration of 
families, emergency evacuations, natural or other disas-
ters, public health emergencies, educational needs, or oth-
erwise, frequently change their State of residency or other-
wise are temporarily located outside of the State of their 
residency. 
(b) REPORT TO CONGRESS.—After development of 
such model process, the Secretary of Health and Human 
Services shall submit to Congress a report describing addi-
tional steps or authority needed to make further improve-
ments to coordinate the enrollment, retention, and cov-
139 
erage under CHIP and Medicaid of children described in 
subsection (a). 
SEC. 214. PERMITTING STATES TO ENSURE COVERAGE 
WITHOUT A 5-YEAR DELAY OF CERTAIN CHIL-
DREN AND PREGNANT WOMEN UNDER THE 
MEDICAID PROGRAM AND CHIP. 
(a) PURPOSE.—In order to promote the health of 
needy children and pregnant women residing lawfully in 
the United States, States should be permitted to waive 
certain restrictions which result in a 5-year delay for cov-
erage of necessary health services for such children and 
women under the Medicaid program and CHIP. 
(b) MEDICAID PROGRAM.—Section 1903(v) of the 
Social Security Act (42 U.S.C. 1396b(v)) is amended— 
(1) in paragraph (1), by striking ‘‘paragraph 
(2)’’ and inserting ‘‘paragraphs (2) and (4)’’; and 
(2) by adding at the end the following new 
paragraph: 
‘‘(4)(A) A State may elect (in a plan amendment 
under this title) to provide, notwithstanding sections 
401(a), 402(b), 403, and 421 of Public Law 104–193, 
medical assistance under a State plan under this title to 
children and pregnant women who are lawfully residing 
in the United States (including battered individuals de-
140 
scribed in section 431(c) of such Act) and are otherwise 
eligible for such assistance. 
‘‘(B) Such election may be made only with respect 
to either or both of the following categories of individuals: 
‘‘(i) Children. 
‘‘(ii) Pregnant women. 
‘‘(C) In this paragraph: 
‘‘(i) The term ‘pregnant women’ means 
women during pregnancy (and during the 60- 
day period beginning on the last day of the 
pregnancy). 
‘‘(ii) The term ‘children’ means individuals 
under age 19 (or such higher age as the State 
has elected under section 1902(l)(1)(D)), in-
cluding optional targeted low-income children 
described in section 1905(u)(2)(B).’’. 
(c) CHIP.—Section 2107(e)(1) of such Act (42 
U.S.C. 1397gg(e)(1)), as amended by section 203(a)(2) 
and 203(d)(2), is amended by redesignating subpara-
graphs (E) and (F) as subparagraphs (F) and (G), respec-
tively and by inserting after subparagraph (D) the fol-
lowing new subparagraph: 
‘‘(E) Paragraph (4) of section 1903(v), in-
sofar as it relates to the category of children or 
pregnant women (as such terms are defined in
141 
such paragraph), but only if the State has elect-
ed to apply such paragraph with respect to such 
category of children or pregnant women under 
title XIX and only if, in the case of pregnant 
women, the State has elected the option under 
section 2111 to provide assistance for pregnant 
women under this title.’’. 
(d) CONFORMING AMENDMENT.—Section 423(d)(1) 
of Public Law 104-193 is amended by inserting before the 
period the following: ‘‘and medical or child health assist-
ance furnished under section 1903(v)(4) or 2107(e)(1)(E), 
respectively, of the Social Security Act’’. 
(e) EFFECTIVE DATE.—The amendments made by 
this section take effect on the date of the enactment of 
this Act. 
TITLE III—REDUCING BARRIERS 
TO PROVIDING PREMIUM AS-
SISTANCE 
Subtitle A—Additional State Op-
tion for Providing Premium As-
sistance 
SEC. 301. ADDITIONAL STATE OPTION FOR PROVIDING 
PREMIUM ASSISTANCE. 
(a) CHIP.—
142 
(1) IN GENERAL.—Section 2105(c) (42 U.S.C. 
1397ee(c)), as amended by sections 114(a) and 
211(c), is amended by adding at the end the fol-
lowing: 
‘‘(10) STATE OPTION TO OFFER PREMIUM AS-
SISTANCE.— 
‘‘(A) IN GENERAL.—A State may elect to 
offer a premium assistance subsidy (as defined 
in subparagraph (C)) for qualified employer- 
sponsored coverage (as defined in subparagraph 
(B)) to all targeted low-income children who are 
eligible for child health assistance under the 
plan and have access to such coverage in ac-
cordance with the requirements of this para-
graph. No subsidy shall be provided to a tar-
geted low-income child under this paragraph 
unless the child (or the child’s parent) volun-
tarily elects to receive such a subsidy. A State 
may not require such an election as a condition 
of receipt of child health assistance. 
‘‘(B) QUALIFIED
EMPLOYER-SPONSORED 
COVERAGE.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), in this paragraph, the term ‘qualified 
employer-sponsored coverage’ means a
143 
group health plan or health insurance cov-
erage offered through an employer— 
‘‘(I) that qualifies as creditable 
coverage as a group health plan under 
section 2701(c)(1) of the Public 
Health Service Act; 
‘‘(II) for which the employer con-
tribution toward any premium for 
such coverage is at least 40 percent; 
and 
‘‘(III) that is offered to all indi-
viduals in a manner that would be 
considered a nondiscriminatory eligi-
bility classification for purposes of 
paragraph (3)(A)(ii) of section 105(h) 
of the Internal Revenue Code of 1986 
(but determined without regard to 
clause (i) of subparagraph (B) of such 
paragraph). 
‘‘(ii) EXCEPTION.—Such term does 
not include coverage consisting of— 
‘‘(I) benefits provided under a 
health flexible spending arrangement 
(as defined in section 106(c)(2) of the 
Internal Revenue Code of 1986); or
144 
‘‘(II) a high deductible health 
plan (as defined in section 223(c)(2) 
of such Code), without regard to 
whether the plan is purchased in con-
junction with a health savings account 
(as defined under section 223(d) of 
such Code). 
‘‘(C) PREMIUM ASSISTANCE SUBSIDY.— 
‘‘(i) IN GENERAL.—In this paragraph, 
the term ‘premium assistance subsidy’ 
means, with respect to a targeted low-in-
come child, the amount equal to the dif-
ference between the employee contribution 
required for enrollment only of the em-
ployee under qualified employer-sponsored 
coverage and the employee contribution re-
quired for enrollment of the employee and 
the child in such coverage, less any appli-
cable premium cost-sharing applied under 
the State child health plan (subject to the 
limitations imposed under section 2103(e), 
including the requirement to count the 
total amount of the employee contribution 
required for enrollment of the employee 
and the child in such coverage toward the
145 
annual aggregate cost-sharing limit applied 
under paragraph (3)(B) of such section). 
‘‘(ii) STATE
PAYMENT
OPTION.—A 
State may provide a premium assistance 
subsidy either as reimbursement to an em-
ployee for out-of-pocket expenditures or, 
subject to clause (iii), directly to the em-
ployee’s employer. 
‘‘(iii) EMPLOYER OPT-OUT.—An em-
ployer may notify a State that it elects to 
opt-out of being directly paid a premium 
assistance subsidy on behalf of an em-
ployee. In the event of such a notification, 
an employer shall withhold the total 
amount of the employee contribution re-
quired for enrollment of the employee and 
the child in the qualified employer-spon-
sored coverage and the State shall pay the 
premium assistance subsidy directly to the 
employee. 
‘‘(iv) TREATMENT AS CHILD HEALTH 
ASSISTANCE.—Expenditures for the provi-
sion of premium assistance subsidies shall 
be considered child health assistance de-
scribed in paragraph (1)(C) of subsection
146 
(a) for purposes of making payments 
under that subsection. 
‘‘(D) APPLICATION OF SECONDARY PAYOR 
RULES.—The State shall be a secondary payor 
for any items or services provided under the 
qualified employer-sponsored coverage for which 
the State provides child health assistance under 
the State child health plan. 
‘‘(E) REQUIREMENT TO PROVIDE SUPPLE-
MENTAL COVERAGE FOR BENEFITS AND COST- 
SHARING PROTECTION PROVIDED UNDER THE 
STATE CHILD HEALTH PLAN.— 
‘‘(i) IN
GENERAL.—Notwithstanding 
section 2110(b)(1)(C), the State shall pro-
vide for each targeted low-income child en-
rolled in qualified employer-sponsored cov-
erage, supplemental coverage consisting 
of— 
‘‘(I) items or services that are 
not covered, or are only partially cov-
ered, under the qualified employer- 
sponsored coverage; and 
‘‘(II) cost-sharing protection con-
sistent with section 2103(e).
147 
‘‘(ii) RECORD
KEEPING
REQUIRE-
MENTS.—For purposes of carrying out 
clause (i), a State may elect to directly pay 
out-of-pocket expenditures for cost-sharing 
imposed under the qualified employer-spon-
sored coverage and collect or not collect all 
or any portion of such expenditures from 
the parent of the child. 
‘‘(F) APPLICATION
OF
WAITING
PERIOD 
IMPOSED UNDER THE STATE.—Any waiting pe-
riod imposed under the State child health plan 
prior to the provision of child health assistance 
to a targeted low-income child under the State 
plan shall apply to the same extent to the provi-
sion of a premium assistance subsidy for the 
child under this paragraph. 
‘‘(G) 
OPT-OUT
PERMITTED
FOR
ANY 
MONTH.—A State shall establish a process for 
permitting the parent of a targeted low-income 
child receiving a premium assistance subsidy to 
disenroll the child from the qualified employer- 
sponsored coverage and enroll the child in, and 
receive child health assistance under, the State 
child health plan, effective on the first day of 
any month for which the child is eligible for
149 
‘‘(I) ADDITIONAL STATE OPTION FOR PRO-
VIDING PREMIUM ASSISTANCE.— 
‘‘(i) IN GENERAL.—A State may es-
tablish an employer-family premium assist-
ance purchasing pool for employers with 
less than 250 employees who have at least 
1 employee who is a pregnant woman eligi-
ble for assistance under the State child 
health plan (including through the applica-
tion of an option described in section 
2112(f)) or a member of a family with at 
least 1 targeted low-income child and to 
provide a premium assistance subsidy 
under this paragraph for enrollment in 
coverage made available through such pool. 
‘‘(ii) ACCESS
TO
CHOICE
OF
COV-
ERAGE.—A State that elects the option 
under clause (i) shall identify and offer ac-
cess to not less than 2 private health plans 
that are health benefits coverage that is 
equivalent to the benefits coverage in a 
benchmark benefit package described in 
section 2103(b) or benchmark-equivalent 
coverage that meets the requirements of
150 
section 2103(a)(2) for employees described 
in clause (i). 
‘‘(iii) CLARIFICATION
OF
PAYMENT 
FOR
ADMINISTRATIVE
EXPENDITURES.— 
Nothing in this subparagraph shall be con-
strued as permitting payment under this 
section for administrative expenditures at-
tributable to the establishment or oper-
ation of such pool, except to the extent 
that such payment would otherwise be per-
mitted under this title. 
‘‘(J) NO EFFECT ON PREMIUM ASSISTANCE 
WAIVER
PROGRAMS.—Nothing in this para-
graph shall be construed as limiting the author-
ity of a State to offer premium assistance under 
section 1906 or 1906A, a waiver described in 
paragraph (2)(B) or (3), a waiver approved 
under section 1115, or other authority in effect 
prior to the date of enactment of the Children’s 
Health Insurance Program Reauthorization Act 
of 2009. 
‘‘(K) NOTICE
OF
AVAILABILITY.—If a 
State elects to provide premium assistance sub-
sidies in accordance with this paragraph, the 
State shall—
151 
‘‘(i) include on any application or en-
rollment form for child health assistance a 
notice of the availability of premium assist-
ance subsidies for the enrollment of tar-
geted low-income children in qualified em-
ployer-sponsored coverage; 
‘‘(ii) provide, as part of the applica-
tion and enrollment process under the 
State child health plan, information de-
scribing the availability of such subsidies 
and how to elect to obtain such a subsidy; 
and 
‘‘(iii) establish such other procedures 
as the State determines necessary to en-
sure that parents are fully informed of the 
choices for receiving child health assistance 
under the State child health plan or 
through the receipt of premium assistance 
subsidies. 
‘‘(L) APPLICATION
TO
QUALIFIED
EM-
PLOYER-SPONSORED BENCHMARK COVERAGE.— 
If a group health plan or health insurance cov-
erage offered through an employer is certified 
by an actuary as health benefits coverage that 
is equivalent to the benefits coverage in a
152 
benchmark benefit package described in section 
2103(b) or benchmark-equivalent coverage that 
meets the requirements of section 2103(a)(2), 
the State may provide premium assistance sub-
sidies for enrollment of targeted low-income 
children in such group health plan or health in-
surance coverage in the same manner as such 
subsidies are provided under this paragraph for 
enrollment in qualified employer-sponsored cov-
erage, but without regard to the requirement to 
provide supplemental coverage for benefits and 
cost-sharing protection provided under the 
State child health plan under subparagraph 
(E). 
‘‘(M) SATISFACTION OF COST-EFFECTIVE-
NESS TEST.—Premium assistance subsidies for 
qualified employer-sponsored coverage offered 
under this paragraph shall be deemed to meet 
the requirement of subparagraph (A) of para-
graph (3).’’. 
(2) DETERMINATION OF COST-EFFECTIVENESS 
FOR PREMIUM ASSISTANCE OR PURCHASE OF FAM-
ILY COVERAGE.— 
(A) IN GENERAL.—Section 2105(c)(3)(A) 
(42 U.S.C. 1397ee(c)(3)(A)) is amended by
153 
striking ‘‘relative to’’ and all that follows 
through the comma and inserting ‘‘relative to 
‘‘(i) the amount of expenditures under 
the State child health plan, including ad-
ministrative expenditures, that the State 
would have made to provide comparable 
coverage of the targeted low-income child 
involved or the family involved (as applica-
ble); or 
‘‘(ii) the aggregate amount of expendi-
tures that the State would have made 
under the State child health plan, includ-
ing administrative expenditures, for pro-
viding coverage under such plan for all 
such children or families.’’. 
(B) NONAPPLICATION TO PREVIOUSLY AP-
PROVED COVERAGE.—The amendment made by 
subparagraph (A) shall not apply to coverage 
the purchase of which has been approved by the 
Secretary under section 2105(c)(3) of the Social 
Security Act prior to the date of enactment of 
this Act. 
(b) MEDICAID.—Title XIX is amended by inserting 
after section 1906 the following new section:
154 
‘‘PREMIUM ASSISTANCE OPTION FOR CHILDREN 
‘‘SEC. 1906A. (a) IN GENERAL.—A State may elect 
to offer a premium assistance subsidy (as defined in sub-
section (c)) for qualified employer-sponsored coverage (as 
defined in subsection (b)) to all individuals under age 19 
who are entitled to medical assistance under this title (and 
to the parent of such an individual) who have access to 
such coverage if the State meets the requirements of this 
section. 
‘‘(b) 
QUALIFIED
EMPLOYER-SPONSORED
COV-
ERAGE.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2)), 
in this paragraph, the term ‘qualified employer-spon-
sored coverage’ means a group health plan or health 
insurance coverage offered through an employer— 
‘‘(A) that qualifies as creditable coverage 
as a group health plan under section 2701(c)(1) 
of the Public Health Service Act; 
‘‘(B) for which the employer contribution 
toward any premium for such coverage is at 
least 40 percent; and 
‘‘(C) that is offered to all individuals in a 
manner that would be considered a nondiscrim-
inatory eligibility classification for purposes of 
paragraph (3)(A)(ii) of section 105(h) of the
155 
Internal Revenue Code of 1986 (but determined 
without regard to clause (i) of subparagraph 
(B) of such paragraph). 
‘‘(2) EXCEPTION.—Such term does not include 
coverage consisting of— 
‘‘(A) benefits provided under a health flexi-
ble spending arrangement (as defined in section 
106(c)(2) of the Internal Revenue Code of 
1986); or 
‘‘(B) a high deductible health plan (as de-
fined in section 223(c)(2) of such Code), with-
out regard to whether the plan is purchased in 
conjunction with a health savings account (as 
defined under section 223(d) of such Code). 
‘‘(3) TREATMENT
AS
THIRD
PARTY
LIABIL-
ITY.—The State shall treat the coverage provided 
under qualified employer-sponsored coverage as a 
third party liability under section 1902(a)(25). 
‘‘(c) PREMIUM ASSISTANCE SUBSIDY.—In this sec-
tion, the term ‘premium assistance subsidy’ means the 
amount of the employee contribution for enrollment in the 
qualified employer-sponsored coverage by the individual 
under age 19 or by the individual’s family. Premium as-
sistance subsidies under this section shall be considered,
156 
for purposes of section 1903(a), to be a payment for med-
ical assistance. 
‘‘(d) VOLUNTARY PARTICIPATION.— 
‘‘(1) EMPLOYERS.—Participation by an em-
ployer in a premium assistance subsidy offered by a 
State under this section shall be voluntary. An em-
ployer may notify a State that it elects to opt-out of 
being directly paid a premium assistance subsidy on 
behalf of an employee. 
‘‘(2) BENEFICIARIES.—No subsidy shall be pro-
vided to an individual under age 19 under this sec-
tion unless the individual (or the individual’s parent) 
voluntarily elects to receive such a subsidy. A State 
may not require such an election as a condition of 
receipt of medical assistance. State may not require, 
as a condition of an individual under age 19 (or the 
individual’s parent) being or remaining eligible for 
medical assistance under this title, apply for enroll-
ment in qualified employer-sponsored coverage under 
this section. 
‘‘(3) OPT-OUT PERMITTED FOR ANY MONTH.— 
A State shall establish a process for permitting the 
parent of an individual under age 19 receiving a pre-
mium assistance subsidy to disenroll the individual 
from the qualified employer-sponsored coverage.
157 
‘‘(e) REQUIREMENT TO PAY PREMIUMS AND COST- 
SHARING AND PROVIDE SUPPLEMENTAL COVERAGE.—In 
the case of the participation of an individual under age 
19 (or the individual’s parent) in a premium assistance 
subsidy under this section for qualified employer-spon-
sored coverage, the State shall provide for payment of all 
enrollee premiums for enrollment in such coverage and all 
deductibles, coinsurance, and other cost-sharing obliga-
tions for items and services otherwise covered under the 
State plan under this title (exceeding the amount other-
wise permitted under section 1916 or, if applicable, section 
1916A). The fact that an individual under age 19 (or a 
parent) elects to enroll in qualified employer-sponsored 
coverage under this section shall not change the individ-
ual’s (or parent’s) eligibility for medical assistance under 
the State plan, except insofar as section 1902(a)(25) pro-
vides that payments for such assistance shall first be made 
under such coverage.’’. 
(c) GAO STUDY AND REPORT.—Not later than Janu-
ary 1, 2010, the Comptroller General of the United States 
shall study cost and coverage issues relating to any State 
premium assistance programs for which Federal matching 
payments are made under title XIX or XXI of the Social 
Security Act, including under waiver authority, and shall 
submit a report to the Committee on Finance of the Sen-
158 
ate and the Committee on Energy and Commerce of the 
House of Representatives on the results of such study. 
SEC. 302. OUTREACH, EDUCATION, AND ENROLLMENT AS-
SISTANCE. 
(a) REQUIREMENT TO INCLUDE DESCRIPTION OF 
OUTREACH, EDUCATION, AND ENROLLMENT EFFORTS 
RELATED TO PREMIUM ASSISTANCE SUBSIDIES IN STATE 
CHILD HEALTH PLAN.—Section 2102(c) (42 U.S.C. 
1397bb(c)) is amended by adding at the end the following 
new paragraph: 
‘‘(3) PREMIUM ASSISTANCE SUBSIDIES.—In the 
case of a State that provides for premium assistance 
subsidies under the State child health plan in ac-
cordance with paragraph (2)(B), (3), or (10) of sec-
tion 2105(c), or a waiver approved under section 
1115, outreach, education, and enrollment assistance 
for families of children likely to be eligible for such 
subsidies, to inform such families of the availability 
of, and to assist them in enrolling their children in, 
such subsidies, and for employers likely to provide 
coverage that is eligible for such subsidies, including 
the specific, significant resources the State intends 
to apply to educate employers about the availability 
of premium assistance subsidies under the State 
child health plan.’’.
159 
(b) NONAPPLICATION
OF 10 PERCENT LIMIT
ON 
OUTREACH AND CERTAIN OTHER EXPENDITURES.—Sec-
tion 2105(c)(2)(C) (42 U.S.C. 1397ee(c)(2)(C)), as 
amended by section 211(c)(2), is amended by adding at 
the end the following new clause: 
‘‘(iii) EXPENDITURES FOR OUTREACH 
TO INCREASE THE ENROLLMENT OF CHIL-
DREN UNDER THIS TITLE AND TITLE xix 
THROUGH
PREMIUM
ASSISTANCE
SUB-
SIDIES.—Expenditures for outreach activi-
ties to families of children likely to be eligi-
ble for premium assistance subsidies in ac-
cordance with paragraph (2)(B), (3), or 
(10), or a waiver approved under section 
1115, to inform such families of the avail-
ability of, and to assist them in enrolling 
their children in, such subsidies, and to 
employers likely to provide qualified em-
ployer-sponsored coverage (as defined in 
subparagraph (B) of such paragraph), but 
not to exceed an amount equal to 1.25 per-
cent of the maximum amount permitted to 
be expended under subparagraph (A) for 
items described in subsection (a)(1)(D).’’.
160 
Subtitle B—Coordinating Premium 
Assistance With Private Coverage 
SEC. 311. SPECIAL ENROLLMENT PERIOD UNDER GROUP 
HEALTH PLANS IN CASE OF TERMINATION OF 
MEDICAID OR CHIP COVERAGE OR ELIGI-
BILITY FOR ASSISTANCE IN PURCHASE OF 
EMPLOYMENT-BASED COVERAGE; COORDINA-
TION OF COVERAGE. 
(a) AMENDMENTS TO INTERNAL REVENUE CODE OF 
1986.—Section 9801(f) of the Internal Revenue Code of 
1986 (relating to special enrollment periods) is amended 
by adding at the end the following new paragraph: 
‘‘(3) SPECIAL RULES RELATING TO MEDICAID 
AND CHIP.— 
‘‘(A) IN GENERAL.—A group health plan 
shall permit an employee who is eligible, but 
not enrolled, for coverage under the terms of 
the plan (or a dependent of such an employee 
if the dependent is eligible, but not enrolled, for 
coverage under such terms) to enroll for cov-
erage under the terms of the plan if either of 
the following conditions is met: 
‘‘(i) TERMINATION OF MEDICAID OR 
CHIP
COVERAGE.—The employee or de-
pendent is covered under a Medicaid plan
167 
‘‘(B) COORDINATION WITH MEDICAID AND 
CHIP.— 
‘‘(i) OUTREACH TO EMPLOYEES RE-
GARDING AVAILABILITY OF MEDICAID AND 
CHIP COVERAGE.— 
‘‘(I) IN
GENERAL.—Each em-
ployer that maintains a group health 
plan in a State that provides medical 
assistance under a State Medicaid 
plan under title XIX of the Social Se-
curity Act, or child health assistance 
under a State child health plan under 
title XXI of such Act, in the form of 
premium assistance for the purchase 
of coverage under a group health 
plan, shall provide to each employee a 
written notice informing the employee 
of potential opportunities then cur-
rently available in the State in which 
the employee resides for premium as-
sistance under such plans for health 
coverage of the employee or the em-
ployee’s dependents. 
‘‘(II) MODEL NOTICE.—Not later 
than 1 year after the date of enact-