II 114th CONGRESS 1st Session S. 522 IN THE SENATE OF THE UNITED STATES February 12, 2015 Mr. Brown (for himself, Ms. Stabenow , Mr. Wyden , Mr. Casey , Mr. Reid , Mr. Durbin , Ms. Baldwin , Mr. Bennet , Mr. Blumenthal , Mr. Booker , Mrs. Boxer , Ms. Cantwell , Mr. Cardin , Mr. Carper , Mr. Coons , Mr. Donnelly , Mr. Franken , Mrs. Gillibrand , Mr. Heinrich , Ms. Heitkamp , Ms. Hirono , Mr. Kaine , Mr. King , Ms. Klobuchar , Mr. Leahy , Mr. Markey , Mr. Manchin , Mrs. McCaskill , Mr. Menendez , Mr. Merkley , Ms. Mikulski , Mr. Murphy , Mrs. Murray , Mr. Nelson , Mr. Peters , Mr. Reed , Mr. Sanders , Mr. Schatz , Mr. Schumer , Mrs. Shaheen , Mr. Tester , Mr. Udall , Mr. Warner , Ms. Warren , Mr. Whitehouse , and Mrs. Feinstein ) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend title XXI of the Social Security Act to extend the Children's Health Insurance Program, and for other purposes.

1. Short title This Act may be cited as the Protecting And Retaining Our Children's Health Insurance Program Act of 2015 . 2. 4-year extension of CHIP funding (a) Funding (1) In general Section 2104(a) of the Social Security Act ( 42 U.S.C. 1397dd(a) ) is amended— (A) in paragraph (17), by striking and at the end; and (B) by striking paragraph (18) and inserting the following new paragraphs: (18) for fiscal year 2015, $21,061,000,000; (19) for fiscal year 2016, $19,300,000,000; (20) for fiscal year 2017, $20,300,000,000; (21) for fiscal year 2018, $21,300,000,000; and (22) for fiscal year 2019, for purposes of making 2 semi-annual allotments— (A) $2,850,000,000 for the period beginning on October 1, 2018, and ending on March 31, 2019; and (B) $2,850,000,000 for the period beginning on April 1, 2019, and ending on September 30, 2019. . (2) Prevention of duplicate appropriations for fiscal year 2015 Notwithstanding any other provision of law, insofar as funds have been appropriated under subsection (a)(18) or (m) of section 2104 of the Social Security Act ( 42 U.S.C. 1397dd ), or under section 108 of the Children's Health Insurance Program Reauthorization Act of 2009 ( Public Law 111–3 ), as such subsections and section are in effect on the day before the date of the enactment of this Act, to provide allotments to States under the State Children’s Health Insurance Program established under title XXI of the Social Security Act ( 42 U.S.C. 1397aa et seq. ) (whether implemented under title XIX, XXI, or both, of the Social Security Act) for fiscal year 2015— (A) any amounts that are so appropriated that are not so allotted and obligated before the date of the enactment of this Act, are rescinded; and (B) any amount provided for CHIP allotments to a State under this section (and the amendments made by this section) for such fiscal year shall be reduced by the amount of such appropriations so allotted and obligated before such date. (b) Allotments (1) In general Section 2104(m) of the Social Security Act ( 42 U.S.C. 1397dd(m) ) is amended— (A) in the subsection heading, by striking Through 2015 and inserting and Thereafter ; (B) in paragraph (2)— (i) in the paragraph heading, by striking 2014 and inserting 2018 ; and (ii) by striking subparagraph (B) and inserting the following new subparagraph: (B) Fiscal year 2013 through 2018 Subject to paragraphs (4) and (6), from the amount made available under paragraphs (16) through (21) of subsection (a) for each of fiscal years 2013 through 2018, respectively, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for each such fiscal year as follows: (i) Rebasing in fiscal year 2013 and each succeeding odd-numbered fiscal year For fiscal year 2013 and each succeeding odd-numbered fiscal year, the allotment of the State is equal to the Federal payments to the State that are attributable to (and countable toward) the total amount of allotments available under this section to the State in the preceding fiscal year (including payments made to the State under subsection (n) for such preceding fiscal year as well as amounts redistributed to the State in such preceding fiscal year), multiplied by the allotment increase factor under paragraph (5) for such odd-numbered fiscal year. (ii) Growth factor update for fiscal year 2014 and each succeeding even-numbered fiscal year Except as provided in clause (iii), for fiscal year 2014 and each succeeding even-numbered fiscal year, the allotment of the State is equal to the sum of— (I) the amount of the State allotment under clause (i) for the preceding fiscal year; and (II) the amount of any payments made to the State under subsection (n) for such preceding fiscal year, multiplied by the allotment increase factor under paragraph (5) for such even-numbered fiscal year. (iii) Special rule for fiscal year 2016 For fiscal year 2016, the allotment of the State is equal to the Federal payments to the State that are attributable to (and countable toward) the total amount of allotments available under this section to the State in the preceding fiscal year (including payments made to the State under subsection (n) for such preceding fiscal year as well as amounts redistributed to the State in such preceding fiscal year), but determined as if the last two sentences of section 2105(b) were in effect in such preceding fiscal year and then multiplying the result by the allotment increase factor under paragraph (5) for fiscal year 2016. ; (C) in paragraph (3)— (i) in the heading, by striking 2015 and inserting 2019 ; (ii) in subparagraph (A)— (I) by striking paragraph (18) and inserting paragraph (22) ; and (II) by striking section 108 of the Children's Health Insurance Program Reauthorization Act of 2009 and inserting section 2(b)(2) of the Protecting And Retaining Our Children's Health Insurance Program Act of 2015 ; (iii) in subparagraph (B), by striking paragraph (18) and inserting paragraph (22) ; (iv) in subparagraph (C)— (I) by striking 2014 each place it appears and inserting 2018 ; and (II) by striking 2015 and inserting 2019 ; and (v) in subparagraph (D)— (I) in clause (i)— (aa) in subclause (I), by striking subsection (a)(18)(A) and inserting subsection (a)(22)(A) ; and (bb) in subclause (II), by striking section 108 of the Children's Health Insurance Program Reauthorization Act of 2009 and inserting section 2(b)(2) of the Protecting And Retaining Our Children's Health Insurance Program Act of 2015 ; and (II) in clause (ii)(II), by striking subsection (a)(18)(B) and inserting subsection (a)(22)(B) ; (D) in paragraph (4), by striking 2015 and inserting 2019 ; (E) in paragraph (6)— (i) in subparagraph (A), by striking 2015 and inserting 2019 ; and (ii) in the second sentence, by striking or fiscal year 2014 and inserting fiscal year 2014, fiscal year 2016, or fiscal year 2018 ; and (F) in paragraph (8)— (i) in the paragraph heading, by striking 2015 and inserting 2019 ; and (ii) by striking for a period in fiscal year 2015 and inserting for a period in fiscal year 2019 . (2) One-time appropriation for fiscal year 2019 There is appropriated to the Secretary of Health and Human Services, out of any money in the Treasury not otherwise appropriated, $16,700,000,000 to accompany the allotment made for the period beginning on October 1, 2018, and ending on March 31, 2019, under section 2104(a)(22)(A) of the Social Security Act ( 42 U.S.C. 1397dd(a)(22)(A) ) (as added by subsection (a)(1)), to remain available until expended. Such amount shall be used to provide allotments to States under paragraph (3) of section 2104(m) of such Act ( 42 U.S.C. 1397dd(m) ) (as amended by paragraph (1)(C)) for the first 6 months of fiscal year 2019 in the same manner as allotments are provided under subsection (a)(22)(A) of such section 2104 and subject to the same terms and conditions as apply to the allotments provided from such subsection (a)(22)(A). (c) Child enrollment contingency fund (1) In general Section 2104(n) of the Social Security Act ( 42 U.S.C. 1397dd(n) ) is amended— (A) in paragraph (2)— (i) in subparagraph (A)— (I) in the matter preceding clause (i), by striking and (D) and inserting , (D), and (E) ; and (II) by striking clause (ii) and inserting the following: (ii) for each of— (I) fiscal years 2010 through 2014, such sums as are necessary for making payments to eligible States for such fiscal year, but not in excess of the aggregate cap described in subparagraph (B); and (II) fiscal years 2015 through 2018 (and for each of the semi-annual allotment periods for fiscal year 2019), such sums as are necessary for making payments to eligible States for such fiscal year or period. ; and (ii) by striking subparagraph (B) and inserting the following: (B) Aggregate cap The total amount available for payment from the Fund for each of fiscal years 2010 through 2014, taking into account deposits made under subparagraph (C), shall not exceed 20 percent of the amount made available under subsection (a) for the fiscal year. In the case of fiscal years 2015 through 2018 (and for each of the semi-annual allotment periods for fiscal year 2019), there shall be no limit on the amount available for payment from the Fund. ; (iii) in subparagraph (D)— (I) by inserting before fiscal year 2015 after fiscal year or period ; and (II) by striking for any succeeding fiscal year ; and (iv) by adding at the end the following subparagraph: (E) Transfers Notwithstanding any other provision of this title, the following amounts shall also be available, without fiscal year limitation, for making payments from the Fund: (i) Unobligated national allotment for fiscal years beginning with fiscal year 2014 (I) Fiscal year 2014 allotment As of December 31 of fiscal year 2015, the portion, if any, of the amount appropriated under subsection (a) for fiscal year 2014 that is unobligated for allotment to a State under subsection (m) for such fiscal year. (II) Succeeding fiscal year allotments As of December 31 of fiscal year 2016, and each succeeding fiscal year, the portion, if any, of the amount appropriated under subsection (a) for the preceding fiscal year that is unobligated for allotment to a State under subsection (m) for such preceding fiscal year. (ii) Unexpended allotments not used for redistribution As of December 31 of fiscal year 2015, and as of November 15 of each succeeding fiscal year, the total amount of allotments made to States under subsection (a) for the second preceding fiscal year that is not expended or redistributed under subsection (f) during the period in which such allotments are available for obligation. (iii) Unexpended performance incentive funds As of January 1, 2016, and as of January 1 of each succeeding calendar year, the portion, if any, of the amount appropriated under section 2105(a)(3)(E)(iii) for the preceding fiscal year that is not expended or obligated under such section. ; and (B) in paragraph (3)— (i) in subparagraph (A)— (I) by redesignating clauses (i) and (ii) as subclauses (I) and (II), respectively, and realigning the left margins accordingly; (II) by striking If a State's and all that follows through 2015, and inserting the following: (i) For fiscal years 2009 through 2014 If a State's expenditures under this title in fiscal year 2009, fiscal year 2010, fiscal year 2011, fiscal year 2012, fiscal year 2013, or fiscal year 2014 ; (III) by striking or period each place it appears; (IV) in subclause (II) (as so redesignated), by striking (or in which the period occurs) ; and (V) by adding at the end the following clause: (ii) For fiscal years after 2014 (I) In general For each of fiscal years 2015 through 2018 (and for each of the semi-annual allotment periods for fiscal year 2019), if the Secretary determines that a State is a shortfall State described in subclause (II) for that fiscal year or period, the Secretary shall pay to the State from the Fund, in addition to any other payments made to the State under this title for the fiscal year or period, an amount equal to the amount described in subclause (III). (II) Shortfall States described For purposes of this clause, with respect to a fiscal year or semi-annual allotment period, a shortfall State is a State for which the Secretary estimates, on the basis of the most recent data available to the Secretary, that the projected expenditures for the State and fiscal year or period under this title (including in the form of coverage described in paragraph (1) or (2) of section 2101, or both) will exceed the sum of— (aa) the amount of the State's allotments for any preceding fiscal year that remains available for expenditure and that will not be expended by the end of the immediately preceding fiscal year; (bb) the amount (if any) that will be redistributed to the State under subsection (f) for the fiscal year or period; (cc) the amount (if any) to be paid to the State in the first quarter of the fiscal year under section 2105(a)(3); and (dd) the amount of the State's allotment for the fiscal year or period. (III) Amount described With respect to a State and fiscal year or period, the amount described in this subclause is equal to the amount by which the projected expenditures for the State under this title for the fiscal year or period (estimated by the Secretary on the basis of the most recent data available to the Secretary) exceed the sum determined under subclause (II) for the State and fiscal year or period. (IV) Retrospective adjustment The Secretary may adjust the determinations made under this clause with respect to a State and fiscal year or period as necessary on the basis of the amounts reported by States not later than November 30 of the succeeding fiscal year, as approved by the Secretary. ; (ii) in subparagraph (B)(ii), by striking (or semi-annual period occurring in a fiscal year) ; (iii) in subparagraph (C)— (I) in the matter preceding clause (i), by striking subparagraph (A)(ii) and inserting subparagraph (A)(i)(II) ; and (II) in clause (ii), by striking (or semi-annual period occurring in a fiscal year) ; and (iv) in subparagraph (G), by inserting the expenditures under the State child health plan and after regarding . (2) Conforming amendment Section 2104(f)(2)(A)(ii) of the Social Security Act ( 42 U.S.C. 13957dd(f)(2)(A)(ii) ) is amended by inserting only in the case of a fiscal year before fiscal year 2015, before the amount . (d) Extension and update of performance incentive payments (1) Extension through fiscal year 2019 Section 2105(a)(3) of the Social Security Act ( 42 U.S.C. 1397ee(a)(3) ) is amended— (A) in subparagraph (A)— (i) by striking 2013 and inserting 2019 ; and (ii) in the second sentence, by inserting , except that payment under this paragraph may be made to a State for fiscal year 2014 as a single payment not later than December 31, 2015 before the period; (B) in subparagraph (E)— (i) in clause (ii)— (I) by striking subclause (I) and inserting the following: (I) Unobligated national allotment for fiscal years 2009 through 2013 As of December 31 of fiscal year 2009, and as of December 31 of each succeeding fiscal year through fiscal year 2013, the portion, if any, of the amount appropriated under section 2104(a) for such fiscal year that is unobligated for allotment to a State under section 2104(m) for such fiscal year or set aside under subsection (a)(3) or (b)(2) of section 2111 for such fiscal year. ; (II) in subclause (III), by striking 2013 and inserting 2014 ; (ii) by redesignating clause (iii) as clause (iv); and (iii) by inserting after clause (ii) the following new clause: (iii) Appropriation for fiscal years 2015 through 2019 Out of any money in the Treasury not otherwise appropriated, there are appropriated $500,000,000 for each of fiscal years 2015 through 2019 for making payments under this paragraph. Amounts appropriated for a fiscal year under this clause shall remain available for making payments under this paragraph until January 1 of the following fiscal year. Any amounts of such appropriations that remain unexpended or unobligated as of such date shall be transferred and made available for making payments under section 2104(n). ; and (C) in subparagraph (F)(iii), by striking 2013 and inserting 2019 . (2) Updated performance incentive criteria for fiscal years 2015 through 2019 Section 2105(a) of the Social Security Act ( 42 U.S.C. 1397ee(a) ) is amended— (A) in paragraph (3)(A), by inserting or (5) after paragraph (4) ; (B) in paragraph (4)— (i) in the heading, by inserting fiscal years 2009 through 2014 after for children ; and (ii) in the matter preceding subparagraph (A), by striking for a fiscal year if and inserting for fiscal years 2009 through 2014 if ; and (C) by adding at the end the following new paragraph: (5) Enrollment and retention provisions for children for fiscal year 2015 and succeeding fiscal years (A) In general For purposes of paragraph (3)(A), a State meets the condition of this paragraph for fiscal year 2015 and any succeeding fiscal year if it is implementing at least 4 of the enrollment and retention provisions specified in subparagraph (B) (treating each clause as a separate enrollment and retention provision) throughout the entire fiscal year. (B) Enrollment and retention provisions The enrollment and retention provisions specified in this subparagraph are the following: (i) Continuous eligibility The State has elected the option of continuous eligibility for a full 12 months for all children described in section 1902(e)(12) under title XIX under 19 years of age, as well as applying such policy under its State child health plan under this title. (ii) Express Lane eligibility The State is implementing the option described in section 1902(e)(13) under title XIX as well as, pursuant to section 2107(e)(1), under this title. (iii) Presumptive eligibility The State provides medical assistance to children during a presumptive eligibility period by implementing section 1920A under title XIX as well as, pursuant to section 2107(e)(1), under this title, and ensures that such period begins with the determination by any qualified entity that the family income of the child does not exceed the applicable level of income eligibility under the State plan. A State shall not satisfy this provision if the only type of entity recognized by the State as a qualified entity is a hospital that has elected to be a qualified entity under section 1902(a)(47)(B). (iv) Premium assistance for employer-sponsored plans The State has opted to offer a premium assistance subsidy for qualified employer-sponsored coverage by implementing section 1906A under title XIX or the option described in section 2105(c)(10) under this title. (v) Elimination of waiting periods The State does not impose a waiting period for coverage of any individual under the State child health plan and ensures that no waiting period applies in the case of coverage provided to any individual eligible for coverage under the State child health plan through coverage purchased by the State under section 2105(c)(3) or employer-sponsored coverage subsidized by the State under section 1906A of title XIX or section 2105(c)(10) of this title. (vi) Automated tracking of cost sharing or lower cap on cost sharing In the case of a State child health plan that imposes premiums, deductibles, cost sharing, or similar charges that could (as determined by the Secretary) cause families that include an individual receiving assistance under the plan to have out-of-pocket expenses that exceed the limit imposed under section 2103(e)(3)(B), the State has either— (I) established, or, in the case of a State child health plan that provides child health assistance through managed care entities or organizations, required such entities or organizations to coordinate with the State agency responsible for implementing the State child health plan under this title in establishing— (aa) an electronic process for tracking such expenses that does not rely on documentation provided by the individual or the family; and (bb) a system for notifying each such family of the aggregate monthly or quarterly limits on out-of-pocket expenses applicable to the family under section 2103(e)(3)(B) and explaining to each such family that no such expenses shall be imposed on any individual in the family for the remainder of any month or quarter with respect to which the family has reached the applicable aggregate monthly or quarterly family limit imposed under such section; or (II) elected to eliminate deductibles, copayments, coinsurance, or other forms of cost-sharing (other than premiums) imposed under this title with respect to any individual receiving coverage under the State child health plan. (vii) Real-time eligibility determinations through the use of enhanced data sources With respect to applications and renewals for medical assistance under title XIX or child health assistance under this title for a fiscal year, the State meets the following criteria for all income determinations made using modified adjusted gross income under section 1902(e)(14)(A): (I) The State relies on enhanced data sources (which may include, but shall not be limited to, the data sources available under section 1137 or the federal Data Services Hub) to make the determinations. (II) In the case of initial applications, the State makes at least 50 percent of the determinations within 24 hours of receiving the application. If a State successfully makes the required minimum percentage of timely determinations for a fiscal year, such State shall not receive credit for meeting this provision in any subsequent fiscal year unless the State makes a percentage of timely income determinations that is at least 5 percentage points higher (or, if at least 75 percent of the State's determinations in a previous fiscal year were timely, 1 percentage point higher) than the percentage that the State achieved in the last fiscal year in which the State received credit for meeting this provision. (III) In the case of renewals, the State makes at least 50 percent of the determinations within 24 hours of receiving the renewal. If a State successfully makes the required minimum percentage of timely determinations for a fiscal year, such State shall not receive credit for meeting this provision in any subsequent fiscal year unless the State makes a percentage of timely income determinations that is at least 5 percentage points higher (or, if at least 75 percent of the State's determinations in a previous fiscal year were timely, 1 percentage point higher) than the percentage that the State achieved in the last fiscal year in which the State received credit for meeting this provision. (viii) Elimination of premiums or retroactive reinstatement upon premium payment The State has elected to either— (I) impose no premiums for coverage under the State child health plan; or (II) in the case of an individual whose coverage under the State child health plan has been terminated for failure to make premium payments, provide assistance to such individual for purposes of immediate reenrollment of the individual upon payment of outstanding premiums, with coverage retroactive to the beginning of the most recent month for which an outstanding premium has been paid, and shall not impose any waiting period or fee as a condition of such reenrollment. . (e) Extension of qualifying states option Section 2105(g)(4) of the Social Security Act ( 42 U.S.C. 1397ee(g)(4) ) is amended— (1) in the paragraph heading, by striking 2015 and inserting 2019 ; and (2) in subparagraph (A), by striking 2015 and inserting 2019 . (f) Extension of certain programs and demonstration projects (1) Quality care for children demonstration project Section 1139A(d)(1) of the Social Security Act (42 U.S.C. 1320b–9a(d)(1)) is amended in the matter before subparagraph (A) by inserting , and during the period of fiscal years 2016 through 2019, the Secretary shall award not more than 10 grants, before to States . (2) Childhood obesity demonstration project Section 1139A(e)(8) of the Social Security Act (42 U.S.C. 1320b–9a(e)(8)) is amended by inserting , and $25,000,000 for the period of fiscal years 2015 though 2019 after 2014 . (3) Pediatric quality measures program Section 1139A(i) of the Social Security Act (42 U.S.C. 1320b–9a(i)) is amended in the first sentence by inserting before the period at the end the following: , and there is appropriated for each of fiscal years 2016 through 2019, $45,000,000 for the purpose of carrying out this section (other than subsections (e), (f), and (g)). . (4) Outreach and enrollment grants; national campaign Section 2113 of the Social Security Act ( 42 U.S.C. 1397mm ) is amended— (A) in subsection (a)(1), by striking 2015 and inserting 2019 ; and (B) in subsection (g), by inserting , and $80,000,000 for the period of fiscal years 2016 through 2019, to remain available until expended, after 2015 . (g) Express lane eligibility Section 1902(e)(13)(I) of the Social Security Act ( 42 U.S.C. 1396a(e)(13)(I) ) is amended by striking September 30, 2015 and inserting September 30, 2019 . (h) Authority To use income determination made under certain programs Section 1902(e)(14) of the Social Security Act ( 42 U.S.C. 1396a(e)(14) ) is amended— (1) in subparagraph (A), in the first sentence, by striking subparagraph (D) and inserting subparagraphs (D) and (J) ; and (2) by adding at the end the following new subparagraph: (J) Use of income determination made under certain other programs (i) In general For purposes of determining income eligibility for medical assistance under the State plan or under any waiver of such plan, a State may use a determination of income made by— (I) the State program funded under part A of title IV; or (II) the supplemental nutrition assistance program established under the Food and Nutrition Act of 2008. (ii) Sunset Clause (i) shall not apply after September 30, 2019. .