The Balanced Budget Act of 1997 (BBA 97; P.L. 105-33 ) established the State Children's Health Insurance Program (CHIP) under a new Title XXI of the Social Security Act and provided annual appropriations for CHIP through FY2007. The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA, H.R. 2 , P.L. 111-3 ), which was signed into law on February 4, 2009, provided CHIP appropriations through FY2013 and made other changes. CHIP offers federal matching funds to states and territories to provide health insurance to certain uninsured low-income children and pregnant women. Although specific requirements apply to eligibility, benefits, and beneficiary cost-sharing, as described below, these rules can be modified via waiver authority provided in Section 1115 of the Social Security Act. Eligibility for health benefits under CHIP is available to different groups via different federal authority and mechanisms. These groups have included children, pregnant women, parents and childless adults. Groups may be covered under the CHIP state plan or via special waiver authority. In general, Title XXI defines a targeted low-income child as one who is under age 19 with no health insurance, and who would not have been eligible for Medicaid under the rules in effect in the state on March 31, 1997. States can set the upper income level for targeted low-income children up to 200% of the federal poverty level (FPL), or 50 percentage points above the applicable pre-CHIP Medicaid income level. However, "(u)nder current statutory and regulatory authority, States are able to effectively expand eligibility of all children under 19 years of age to whatever level they choose." For states seeking CMS approval to expand eligibility, CHIPRA reduces federal CHIP payments for certain higher-income CHIP children. Specifically, the regular Medicaid federal matching rate (FMAP), which is lower than the CHIP enhanced matching rate, will be used for CHIP enrollees whose effective family income exceeds 300% of poverty using the state's policy of excluding "a block of income that is not determined by type of expense or type of income," with an exception for states that already had a federal approval plan (i.e., New Jersey) or that had enacted a state law to submit a plan for federal approval (i.e., New York). Within these general rules, states may provide assistance to qualifying children in two basic ways. They may cover such children under their Medicaid programs and/or they may create a separate CHIP program for this purpose. (More details on available benefits under each approach are described in the next section.) When states provide Medicaid coverage to targeted low-income children, Medicaid rules typically apply. When states provide coverage to targeted low-income children through separate CHIP programs, Title XXI rules typically apply. In both cases, the federal share of program costs comes from federal CHIP funds (also described in further detail below). Title XXI does not establish an individual entitlement to benefits. Instead, Title XXI entitles states with approved state CHIP plans to pre-determined federal allotments based on a distribution formula set in the law (explained further below). Targeted low-income children covered under a CHIP-financed expansion of Medicaid are, however, entitled to the benefits offered under that program as dictated by Medicaid law. No such individual entitlement exists for targeted low-income children covered in separate CHIP programs. States may cover targeted low-income children by expanding their Medicaid programs in the following ways: (1) by establishing a new optional eligibility group for such children as authorized in Title XXI, and/or (2) by liberalizing the financial rules for any of several existing Medicaid eligibility categories. Many states with Medicaid-expansion CHIP programs chose the latter, opting to cover targeted low-income children under existing Medicaid eligibility pathways, especially Medicaid's poverty-related child groups, rather than by establishing the Title XXI optional coverage group. Such a strategy reduces the administrative burden of creating and implementing a new coverage group. States may also provide coverage to targeted low-income children by creating a separate CHIP program. States define the group of targeted low-income children who may enroll in separate CHIP programs. Title XXI allows states to use the following factors in determining eligibility: geography (e.g., sub-state areas or statewide), age (e.g., subgroups under 19), income, resources (assets), residency, disability status (so long as any standard relating to that status does not restrict eligibility), access to or coverage under other health insurance (to establish whether such access/coverage precludes CHIP eligibility), and duration of CHIP eligibility. Prior to CHIPRA, states were able to cover adult pregnant women (ages 19 and older) in one of three ways: (1) states could apply for Section 1115 waivers to extend coverage to such pregnant women; (2) states could provide health benefits coverage, including prenatal care and delivery services, to unborn children of adult pregnant women through a CHIP state plan amendment (SPA) as permitted through regulation; or (3) states could offer a "family coverage option" through a group health plan that may include maternity care to adult females in eligible families. As of October 2007, 17 states offered pregnancy-related services to adults using CHIP funds. Of those, 6 states used the §1115 waiver authority, and 12 states extended coverage to unborn children of adult pregnant women through unborn child SPAs (Rhode Island extends coverage to adult pregnant women through both authorities). Of the 12 states that offered pregnancy-related services to unborn children under the CHIP SPAs, all but Tennessee extended coverage to the unborn children of undocumented aliens who otherwise would not have access to federally funded pregnancy-related services, except through emergency Medicaid. In FY2008, there were 364,161 unborn children enrolled in CHIP, nearly half of whom (176,822, 48.6%) were in California. CHIPRA added a new state option to cover pregnant women under CHIP through a state plan amendment. To implement this option, states must meet certain conditions (e.g., the Medicaid income standard for pregnant women must be at least 185% FPL but in no case lower than the percentage level in effect on July 1, 2008; no pre-existing conditions or waiting periods may be imposed; CHIP cost-sharing protections described below must apply). The upper income level for pregnant women may be as high as the standard applicable to CHIP children in the state. Other eligibility restrictions applicable to CHIP children (e.g., must be uninsured, ineligible for state employee health coverage) also apply. The period of coverage is during pregnancy through the postpartum period (through roughly 60 days after delivery). States are allowed to temporarily enroll pregnant women for up to two months until a formal determination of eligibility is made (referred to as presumptive eligibility). Benefits include all services available to CHIP children in the state as well as prenatal, delivery and postpartum care. Infants born to these pregnant women are deemed eligible for Medicaid or CHIP, as appropriate, and are covered up to age one year, at which point eligibility could be redetermined. States may continue to cover pregnant women through waivers and the unborn child regulation described above. For the latter case, CHIPRA clarified that states are allowed to offer postpartum services. Prior to CHIPRA, legal immigrants arriving in the United States after August 22, 1996, were ineligible for Medicaid or CHIP benefits for their first five years here. Coverage of such persons after the five-year bar was permitted at state option if they met other eligibility requirements for that program. For legal immigrants (but not refugees and asylees), the law requires that their sponsor's income and resources for those who have signed a legally binding affidavit of support would be taken into account in determining eligibility. Generally speaking, for federally means-tested programs (e.g., Medicaid, TANF), the affidavit of support required the sponsor to ensure that the new immigrant will not become a public charge and makes the sponsor financially responsible for the individual. CHIPRA permitted states to waive the five-year bar for Medicaid or CHIP coverage to pregnant women and children who are (1) lawfully residing in the United States and (2) are otherwise eligible for such coverage. The CHIP state plan option made available under this provision is available only to states that (1) elect this state plan option under Medicaid and (2) in the case of pregnant women coverage, elect the CHIP state plan option (described above) to provide assistance for pregnant women. For states that elect to extend such coverage, the provision assured that the cost of care will not be deemed under an affidavit of support against an individual's sponsor. In addition, as a part of states' redetermination processes (i.e., to redetermine eligibility at least every 12 months with respect to circumstances that may change and affect eligibility), individuals made eligible under this provision whose initial documentation showing legal residence is no longer valid will be required to show "further documentation or other evidence" that the individual continues to lawfully reside. Under current law, Section 1115 of the Social Security Act gives the Secretary of Health and Human Services (HHS) broad authority to modify many aspects of the CHIP programs including expanding eligibility to populations who are not otherwise eligible for CHIP (e.g., childless adults, and parents of Medicaid and CHIP-eligible children). Certain states that have covered adults with CHIP funds were permitted to do so almost entirely through the use of these waivers. Adult coverage waivers, which initially are effective for five years, are subject to renewal at least every three years.