II 117th CONGRESS 1st Session S. 646 IN THE SENATE OF THE UNITED STATES March 9, 2021 Mr. Brown (for himself, Ms. Baldwin , Ms. Warren , and Mr. Whitehouse ) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend titles XIX and XXI of the Social Security Act to provide for 12-month continuous enrollment under Medicaid and the Children's Health Insurance Program, and for other purposes.

1. Short title This Act may be cited as the Stabilize Medicaid and CHIP Coverage Act of 2021 . 2. Findings Congress finds the following: (1) Every year millions of people are enrolled in Medicaid and the Children’s Health Insurance Program (in this section referred to as CHIP ), but subsequently lose their coverage, despite still being eligible, because of inefficient and cumbersome paperwork and logistical requirements. (2) Data show that the typical enrollee receives Medicaid coverage for about ¾ of the year and that coverage periods are lower for non-elderly, non-disabled adults than for those with disabilities, seniors, and children. (3) Medicaid enrollees with coverage disruption are more likely to be hospitalized for illnesses, like asthma, diabetes, or cardiovascular disease, that can be effectively managed through ongoing primary medical care and medication, are less likely to be screened for breast cancer, and may have poorer cancer outcomes. (4) Children enrolled in CHIP also experience disruptions in health coverage and care. For example, during just a 1-year period, over 1/3 of CHIP enrollees were also enrolled in a State’s Medicaid program. Transitions between Medicaid and CHIP can cause disruptions in care because the health care coverage and participating providers vary between the two programs. (5) Interruptions in coverage can impair the receipt of effective primary care and lead to expensive hospitalizations or emergency room visits. (6) Unnecessary enrollment, disenrollment, and reenrollment in Medicaid and CHIP result in higher administrative expenses for reenrollment and result in more people uninsured at any given time. (7) Stable coverage under Medicaid and CHIP lowers average monthly medical costs. Continuous enrollment also permits better prevention and disease management, leading to fewer serious illnesses and hospitalizations. (8) Children with stable coverage are less likely to have unmet medical needs, allowing children to receive the preventive care that is necessary to help them grow into healthy adults. 3. 12-month continuous enrollment (a) Requirement of 12-Month continuous enrollment under medicaid (1) In general Section 1902(e)(12) of the Social Security Act ( 42 U.S.C. 1396a(e) ), is amended to read as follows: (12) 12-month continuous enrollment (A) In general Notwithstanding any other provision of this title, a State plan approved under this title or under any waiver of such plan approved pursuant to section 1115 or section 1915, shall provide that an individual who is determined to be eligible for benefits under such plan (or waiver) shall be considered to meet the eligibility requirements met on the date of application and shall remain eligible and enrolled for such benefits through the end of the month in which the 12-month period (beginning on the date of determination of eligibility) ends. (B) Promoting retention of eligible and enrolled persons beyond 12 months The Secretary shall— (i) identify methods that promote the retention of individuals who are enrolled under the State plan or under a waiver of such plan and who remain eligible for medical assistance beyond the 12-month period described in subparagraph (A); and (ii) actively promote the adoption of such enrollment retention methods by States, which shall include, but not be limited to, issuing guidance and developing resources on State best practices. (C) Enrollment and retention reporting (i) In general Not later than 1 year after the date of enactment of the Stabilize Medicaid and CHIP Coverage Act of 2021 , the Secretary shall publish the procedures that States are expected to use to provide annual enrollment and retention reports beginning not later than 2 years after the date of enactment of such Act. (ii) State reporting requirements At a minimum, the reporting procedures published under clause (i) shall include a description of State eligibility criteria and enrollment procedures under this title and data regarding enrollment and retention using standardized reporting formats determined by the Secretary. (iii) Secretary report and publication (I) In general The Secretary annually shall publish enrollment and retention performance results for all States not later than 6 months after the deadline for each annual State enrollment and retention reporting period. (II) Estimated enrollment continuity ratios Each annual report published by the Secretary under subclause (I) shall include estimates of Medicaid enrollment continuity ratios for each State in accordance with the requirements of subclause (III). (III) Requirements The Secretary shall develop both overall enrollment continuity ratios for all enrollees and separate enrollment continuity ratios for each of the following categories: (aa) Children. (bb) Individuals whose eligibility category is related to having attained age 65. (cc) Individuals whose eligibility category is related to disability or blindness. (dd) Individuals whose eligibility category is related to their status as parents and caretaker relatives of children under 19 or who are otherwise not elderly, blind or disabled adults. . (b) Requirement of 12-Month continuous enrollment under CHIP (1) In general Section 2102(b) of the Social Security Act ( 42 U.S.C. 1397bb(b) ) is amended by adding at the end the following new paragraph: (6) Requirement for 12-month continuous enrollment Notwithstanding any other provision of this title, a State child health plan that provides child health assistance under this title through a means other than that described in section 2101(a)(2), shall provide that an individual who is determined to be eligible for benefits under such plan shall be considered to meet the eligibility requirements met on the date of application and shall remain eligible and enrolled for such benefits through the end of the month in which the 12-month period (beginning on the date of determination of eligibility) ends. . (2) Conforming amendments (A) Enrollment and retention provisions Section 2105(a)(4)(A) of the Social Security Act ( 42 U.S.C. 1397ee(a)(4)(A) ) is amended— (i) by striking has elected the option of and inserting is in compliance with the requirement for ; and (ii) by striking applying such policy under its State child health plan under this title and inserting in compliance with section 2102(b) . (B) Application of medicaid retention and reporting requirements Section 2107(e)(1) of the Social Security Act ( 42 U.S.C. 1397gg(e)(1) ) is amended— (i) by redesignating subparagraphs (H) through (S) as subparagraphs (I) through (T), respectively; and (ii) by inserting after subparagraph (G), the following: (H) Subparagraphs (B) and (C) of section 1902(e)(12) (relating to promotion of enrollment beyond 12 months and reporting requirements)(without regard to items (bb), (cc), and (dd) of subparagraph (C)(iii)(III) of that section). . (c) Effective date (1) In general Except as provided in paragraph (2) or (3), the amendments made by subsections (a) and (b) shall apply to determinations (and redeterminations) of eligibility made on or after the date that is 18 months after the date of the enactment of this Act. (2) Extension of effective date for state law amendment In the case of a State plan under title XIX or State child health plan under title XXI of the Social Security Act ( 42 U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.) which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the respective plan to meet the additional requirements imposed by the amendments made by subsections (a) or (b), respectively, the respective plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such applicable additional requirements before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of the session is considered to be a separate regular session of the State legislature. (3) Option to implement 12-month continuous eligibility prior to effective date A State may elect through a State plan amendment under title XIX or XXI of the Social Security Act ( 42 U.S.C. 1396 et seq.; 42 U.S.C. 1397aa et seq.) to apply the amendments made by subsection (a) or (b), respectively, on any date prior to the 18-month date specified in paragraph (1), but not sooner than the date of the enactment of this Act. 4. Preventing the application under chip of coverage waiting periods (a) In general Section 2102(b)(1)(B) of the Social Security Act ( 42 U.S.C. 1397bb(b)(1)(B) ) is amended— (1) in clause (iii)— (A) by striking in the case of and inserting in the case of a targeted low-income child (including a child provided dental-only supplemental coverage under section 2110(b)(5)) or in the case of ; and (B) by adding and after the semicolon; (2) by striking clause (iv); and (3) by redesignating clause (v) as clause (iv). (b) Conforming amendments Section 2105(c)(10) of the Social Security Act ( 42 U.S.C. 1397ee(c)(10) ) is amended by striking subparagraph (F) and redesignating subparagraphs (G) through (M) as subparagraphs (F) through (L), respectively. (c) Effective date The amendments made by this section shall take effect on the date of enactment of this Act. 5. Medicaid performance bonuses for enrollment and retention improvements for certain individuals Section 1903 of the Social Security Act ( 42 U.S.C. 1396b ) is amended by adding at the end the following new subsection: (cc) Performance bonuses for enrollment and retention of low-Income individuals (1) In general A State may qualify for performance bonuses related to the enrollment and retention of individuals (including children) described in section 1902(e)(12)(C)(iii)(III). For purposes of this paragraph, a State meets the condition of this paragraph for such individuals if, for each category of individuals specified in section 1902(e)(12)(C)(iii)(III), the State is implementing at least 3 of the following enrollment and retention provisions (treating each subparagraph as a separate enrollment and retention provision) throughout the entire fiscal year: (A) Aligning treatment of income under medicaid with that of other insurance affordability programs The State implements policies, including prorating income over annual periods, so as to align its treatment of income for purposes of a determination of eligibility for medical assistance with that of other affordability insurance programs with the goal of eliminating inconsistent determinations among these programs. (B) Maintaining coverage for individuals during periods of transition The State implements the following policies: (i) In general Upon determination that an individual is no longer eligible for medical assistance, the State implements policies to maintain eligibility for medical assistance, including enrollment in the managed care organization in which the individual was enrolled at the time of the determination of ineligibility, during the period of time in which— (I) eligibility-related information is transmitted to the other insurance affordability programs; (II) a determination is made as to for which other insurance affordability program the individual is eligible, if any; and (III) coverage in such program and any related managed care organization becomes effective. (ii) Managed care organization continuity The State implements policies to enroll the individual in the managed care organization in which the individual was a member prior to the loss of medical assistance eligibility, if such managed care organization participates in the other insurance affordability program, unless the individual voluntarily selects a separate managed care organization. (C) Enhanced data-sharing between the state and an american health benefit exchange and agencies The State utilizes findings from an American Health Benefit Exchange, an Express Lane Agency (as identified by the State and as described in section 1902(e)(13)(F)), the Social Security Administration, or other agencies administering employment, educational, or social services programs as identified by the State, to document income, residency, age, or other relevant information in determining or renewing eligibility. (D) Eligibility based on pending status The State maintains eligibility for enrollees whose renewal status has not yet been determined and for whom eligibility based on alternative eligibility criteria has not yet been ruled out. (E) Default reenrollment in managed care organization In the case of individuals who are determined to be eligible for medical assistance under this title after the loss of eligibility for fewer than 6 months, and who previously had been members of a managed care organization, the State re-enrolls the individual in the managed care organization in which the individual was a member prior to the loss of eligibility, unless the individual voluntarily selects a separate managed care organization. (2) Performance bonus payment to support 12-month continuous enrollment for medicaid enrollees (A) Authority to make bonus payments (i) In general The Secretary shall make a bonus payment for fiscal years beginning with the first fiscal year that begins on or after the date that is 3 years after the date of enactment of the Stabilize Medicaid and CHIP Coverage Act of 2021 , and annually thereafter to the extent there are funds available under paragraph (3)(A), to each State that satisfies the requirements of subparagraph (B). (ii) Regulations Payments to States under this subsection for a fiscal year shall be allocated annually among eligible States in accordance with regulations promulgated by the Secretary not later than the date that is 6 months prior to October 1 of the first fiscal year for which payments are made under this paragraph. (iii) Timing A payment to a State under this subsection for a fiscal year shall be made as a single payment not later than the last day of the first calendar quarter of the succeeding fiscal year. (B) State eligibility for bonus payments A State shall be eligible for bonus payments under this subsection if— (i) the State has adopted at least 3 of the 5 policies described in subparagraphs (A) through (E) of paragraph (1) for each category of individuals specified in section 1902(e)(12)(C)(iii)(III); and (ii) the State is able to demonstrate improvement in the continuity of enrollment by child, aged, blind, and disabled, and adult populations, compared to the State’s baseline performance with respect to continuity of enrollment for such populations in fiscal year 2021 or such later year as the Secretary, by regulation, shall specify. (3) Amounts available for payments (A) In general The total amount of bonus payments made under this subsection for all fiscal years shall be equal to $500,000,000, to be available until expended. (B) Budget authority This paragraph constitutes budget authority in advance of appropriations Acts and represents the obligation of the Secretary to provide for the payment of amounts provided under this paragraph. (4) Uses of enrollment and retention performance bonuses Nothing in this subsection shall prohibit a State from establishing criteria which would permit the State to distribute a portion of the proceeds of any bonus payments received pursuant to this subsection to financially support providers and managed care entities participating under the State plan or under a waiver of such plan who have contributed to improved enrollment and retention activities. .