[Senate Report 107-233]
[From the U.S. Government Publishing Office]
Calendar No. 541
107th Congress Report
SENATE
2d Session 107-233
======================================================================
MOTHERS AND NEWBORNS HEALTH INSURANCE ACT OF 2002
_______
August 1, 2002.--Ordered to be printed
_______
Mr. Baucus, from the Committee on Finance, submitted the following
R E P O R T
[To accompany S. 724]
The Committee on Finance, to which was referred the bill
(S. 724) to amend title XXI of the Social Security Act to
provide for coverage of pregnancy-related assistance for
targeted low-income pregnant women, reports favorably thereon
and refers the bill to the full Senate with a recommendation
that the bill pass.
I. BACKGROUND
Lack of health insurance is a significant barrier to
receiving prenatal care, and contributes greatly to America's
high levels of infant and maternal mortality. With 4.3 million
uninsured mothers living below 200 percent of the Federal
poverty level, the United States currently ranks 21st in the
world in infant mortality and 26th in maternal mortality. These
are the worst rates of any developed nation.
In recent years, the United States has made significant
progress toward extending health insurance coverage to children
in low-income families. Unfortunately, the mothers of these
children remain at high risk of going uninsured. Mothers in
low-income families account for nearly three of every four
uninsured mothers in the country. These women often lack access
to affordable, employer-based health insurance coverage and are
excluded from public programs such as Medicaid and the State
Children's Health Insurance Program (SCHIP).
While a majority of states provide health insurance
coverage through Medicaid or SCHIP to children in families up
to 200 percent of the Federal poverty level, or about $24,000
for a family of two, the same level of coverage generally does
not apply to their mothers. Current law only requires states to
cover pregnant women under Medicaid if they are under 133
percent of poverty, which is approximately $16,000 per year for
afamily of two. States also have the option to extend this
coverage up to 185 percent of poverty, or about $22,000 a year, for
that same family. Pregnant women are not eligible to receive coverage
under SCHIP, unless a state is granted a Section 1115 waiver of current
law to do so.
There is no valid policy rationale for the existing
disparities in health insurance coverage between mothers and
their children. Current law essentially dictates that low-
income children receive health insurance coverage only after
their mothers have gone through nine months of pregnancy
without crucial prenatal coverage. This disparity in coverage
levels exposes both mothers and children to unnecessary health
risks. Moreover, it is not cost-effective. Recent studies have
shown that infants born to mothers receiving late or no
prenatal care are more likely to face complications--which can
result in hospitalization, expensive medical treatments, and
increased costs to public programs. Closing the gap in coverage
between mothers and their children will improve the health of
both, while reducing costs for taxpayers.
II. DESCRIPTION OF THE BILL
The legislation reported by the Finance Committee consists
of the following provisions:
Section 1. Short title
Section 2. State option to expand or add coverage of certain pregnant
women under Medicaid and SCHIP
(a) Medicaid
PRESENT LAW
States are required to provide Medicaid coverage to
pregnant women with no other children who have family income up
to 133 percent of the Federal poverty level (FPL), and have the
option to extend such coverage to pregnant women with no other
children who have family income above 133 percent FPL up to 185
percent FPL. Both of these eligibility categories are commonly
referred to as ``poverty-related pregnant women.'' These
pregnant women are entitled only to pregnancy-related services
(e.g., prenatal, delivery and postpartum care up to 60 days
after delivery). States may increase the effective income level
above these standards by modifying applicable income and
resource methodologies. In addition, states may seek waivers of
program rules to extend Medicaid to pregnant women at higher
income levels.
The State Children's Health Insurance Program (SCHIP)
allows states to cover uninsured children under age 19 in
families with income above applicable Medicaid financial
standards. States may choose from among three benefit options
when designing their SCHIP programs. They may expand Medicaid,
create a new separate state program that must meet minimum
benefit requirements, or devise a combination of both
approaches. Among the many services available under SCHIP are
prenatal care and hospital services. Pregnant women ages 19 and
above are eligible for SCHIP only through special waivers of
program rules, or when employer-sponsored family coverage
subsidized by SCHIP includes adults in families with eligible
children.
The Federal share of Medicaid costs is equal to the Federal
medical assistance percentage (FMAP) of those costs. The FMAP
is determined annually according to a formula designed to pay a
higher Federal matching rate to states with lower per capita
incomes relative to the national average. The law establishes a
minimum FMAP of 50 percent and a maximum FMAP of 83 percent.
Under SCHIP, an enhanced FMAP (E-FMAP) is available. The E-FMAP
is defined as the FMAP under Medicaid increased by 30 percent
of the number of percentage points by which the FMAP for the
state is less than 100 percent. E-FMAP ranges from 65 percent
to 85 percent (the statutory upper limit).
Under Medicaid presumptive eligibility rules, states are
allowed to temporarily enroll children whose family income
appears to be below applicable Medicaid income standards, until
a formal determination of eligibility is made. Payments made on
behalf of Medicaid children during periods of presumptive
eligibility are matched at the regular Medicaid FMAP, but are
paid out of state SCHIP allotments.
Federal funds for SCHIP were appropriated in the original
enacting statute for FY1998 through FY2007. From each year's
appropriation, a state is allotted an amount as determined by a
formula set in law. Expenditures associated with presumptive
eligibility for children under Medicaid are counted against a
state's SCHIP allotment.
EXPLANATION OF PROVISION
The bill allows states meeting two conditions to cover
under Medicaid additional pregnant women (up to 60 days
postpartum) with no other children in families with income
exceeding 185 percent FPL, up to the SCHIP income level for
children in effect as of January 1, 2002. The two conditions
include: (1) the state must cover under Medicaid and SCHIP such
pregnant women in lower income families before or in addition
to pregnant women in higher income families, and (2) the state
must apply an income level to the new group of pregnant women
that is no lower than the effective income level in place for
pregnant women already covered under the state Medicaid plan as
of January 1, 2002.
For states expanding coverage to additional pregnant women
with incomes exceeding 185 percent FPL, the SCHIP enhanced FMAP
applies and all payments are counted against the state's SCHIP
allotment.
Finally, the bill eliminates the requirement that
expenditures associated with presumptive eligibility for
children under Medicaid be counted against a state's SCHIP
allotment.
REASONS FOR CHANGE
The Committee bill includes provisions based on S. 724,
introduced by Senator Breaux, and S. 1016, introduced by
Senator Bingaman, to extend Medicaid and SCHIP coverage to
pregnant women. The provisions attempt to restore balance in
eligibility levels between mothers and their children by
allowing states to cover pregnant women in these programs up to
the income eligibility level available for their children. The
provision offers an incentive to states to raise income
eligibility levels for pregnant women byproviding the enhanced
SCHIP matching rate to states that expand coverage above the current
limit of 185 percent of poverty.
(b) SCHIP
PRESENT LAW
In general, SCHIP allows states to cover uninsured children
under age 19 in families with incomes that are either: (1)
above the state's Medicaid financial eligibility standard but
less than 200 percent of the federal poverty level, or (2) in
states with Medicaid income levels for children already at or
above 200 percent FPL, within 50 percentage points over the
state's Medicaid income eligibility limit for children in
effect on March 31, 1997.
Generally, states cover SCHIP-eligible kids by either
enrolling them into Medicaid expansion programs, or into
separate state health insurance plans that meet specific
standards for benefits and cost-sharing, or through a
combination of both.
States covering SCHIP-eligible children through Medicaid
must provide the full range of mandatory Medicaid benefits,
including maternity care, and all optional services specified
in their state Medicaid plans. Coverage for pregnant women
under Medicaid is limited to services related to the pregnancy
(e.g., prenatal, delivery, and postpartum care up to 60 days
after delivery); complications of pregnancy; and family
planning services. Alternatively, states operating separate
state insurance plans may choose any one of three other benefit
options: (1) a benchmark benefit package, (2) benchmark
equivalent coverage, or (3) any other health benefits plan that
the Secretary determines will provide appropriate coverage for
the targeted population of uninsured children. These three
additional benefit options may include maternity care. However,
apart from requiring coverage of inpatient and outpatient
hospital services, and physicians' surgical and medical
services, there is no specific language in the federal statute
that requires provision of prenatal, delivery and postpartum
services with these non-Medicaid benefit plan options.
The SCHIP program does not include pregnancy status among
its eligibility criteria, and does not cover individuals over
age 18. There are two circumstances under which uninsured
pregnant women over 18 years would be eligible for SCHIP.
First, SCHIP has a ``family coverage option'' that allows
states to provide coverage under a group health plan that may
include maternity care to adult females in eligible families.
States may cover entire families including parents if the
purchase of family coverage is cost effective when compared
with the cost of covering only the targeted low-income children
in the families involved, and would not substitute for other
health insurance coverage. Alternatively, states may apply for
waivers of program rules to extend coverage to adults such as
parents and pregnant women.
Cost sharing refers to the out-of-pocket payments made by
beneficiaries of a health insurance plan. States that chose to
implement SCHIP as a Medicaid expansion must follow the nominal
cost sharing rules of the Medicaid program. Under separate
state programs, total annual aggregate cost-sharing (including
premiums, enrollment fees, deductibles, copayments,
coinsurance, and other similar charges) for any family may not
exceed 5 percent of total income in a year. Preventive services
are exempt from cost-sharing.
For each fiscal year, the states and the District of
Columbia are allotted a proportion of the total amount of
Federal SCHIP dollars available. From that amount, Federal
matching funds are disbursed quarterly to each state by a
formula set in statute. The original authorizing legislation
for SCHIP requires that 0.25 percent of the program's total
authorization be set-aside for five territories. This total is
distributed among these territories based on specific
percentages defined in statute.
EXPLANATION OF PROVISION
The Committee bill allows states to cover additional
pregnant women under SCHIP. The SCHIP expansion group includes
pregnant women with family income above the state's Medicaid
financial eligibility standard for pregnant women in effect on
January 1, 2002, up to the income eligibility for SCHIP
children in effect as of January 1, 2002. The provision also
requires states to meet the following conditions before they
are permitted to expand their eligibility. First, the state
must have already expanded Medicaid eligibility for pregnant
women up to at least 185 percent FPL. Second, the same two
conditions required of states choosing to expand coverage to
pregnant women under Medicaid must also be met: (1) the state
must cover under Medicaid and SCHIP pregnant women in lower
income families before or in addition to pregnant women in
higher income families, and (2) the state must apply an income
level to the new group of pregnant women that is no lower than
the effective income level in place for pregnant women covered
under the state Medicaid plan as of January 1, 2002. Coverage
for pregnant women is limited to services related to the
pregnancy (e.g., prenatal, delivery, and postpartum care up to
60 days after delivery); complications of pregnancy; and family
planning services.
The provision prohibits: (1) excluding pregnancy-related
services based on a preexisting condition; (2) imposing a
waiting period for the purpose of minimizing substitution; and
(3) cost sharing for pregnancy-related services.
Children born to women receiving pregnancy-related services
under SCHIP Medicaid expansions or separate state plans are
automatically enrolled in such program at the time of birth and
remain eligible for such assistance until the child attains 1
year of age. Unless the state issues a separate eligibility
number for the child, such child retains the medical assistance
eligibility identification number of the mother during this
eligibility period.
For each of fiscal years 2003 through 2006, the Committee's
provision adds an additional appropriation, in the amount of
$200 million, out of funds not otherwise appropriated from the
Treasury. A total of 98.95 percent of such funds are
distributed among the states in the same manner as SCHIP funds
are distributed under current law. The remaining funds are
distributed among the territories also in the same manner as
defined in current law. Funds added to the SCHIP program may be
used for child health assistance for targeted low-income
children, as well as for pregnancy-related assistance for
pregnant women. Funds are available to states that expand
coverage to pregnant woman under title XXI (SCHIP), or title
XIX (Medicaid) beyond those covered as of January 1, 2002.
Additional funds are not available to the states before October
1, 2002.
REASONS FOR CHANGE
Current Federal law enables low-income pregnant women to
receive coverage under SCHIP through age 18, but it does not
provide such coverage to women ages 19 andabove. While states
have the ability to add SCHIP coverage for pregnant women over age 18
through Section 1115 waivers, states find this process to be both time-
consuming and administratively burdensome. The Committee bill allows
states to cover pregnant women under SCHIP regardless of age and gives
states the flexibility to expand coverage to pregnant women through the
simpler state plan amendment process. The committee bill also
eliminates the disparity in coverage levels between pregnant women and
infants that has been created through SCHIP, enabling both mothers and
their newborn children to immediately receive health coverage under the
program.
(c)(1) Other amendments to Medicaid: Eligibility of a
newborn
PRESENT LAW
A child born to a woman eligible for and receiving medical
assistance under a Medicaid state plan on the date of the
child's birth, is deemed to have applied for, and to have been
found eligible for such assistance. The child remains eligible
for such assistance until that child attains 1 year of age as
long as the child is a member of the woman's household, and the
woman remains (or would remain if pregnant) eligible for
Medicaid.
EXPLANATION OF PROVISION
For a child born to a woman eligible for and receiving
medical assistance under a Medicaid state plan on the date of
the child's birth, the Committee's bill removes current law
requirements that the child remain a member of the woman's
household; and the woman continues to be eligible (or would
remain eligible if pregnant) for Medicaid.
REASONS FOR CHANGE
The Committee bill ensures that children born to women
enrolled in Medicaid or SCHIP are immediately enrolled in the
program for which they are eligible, regardless of the
eligibility status of the mother. The provision prevents
newborns eligible for SCHIP from being subject to enrollment
waiting periods that may apply to other, older children
eligible for the program and helps ensure that infants receive
appropriate health care in their first year of life.
(c)(2) Other amendments to Medicaid: Application of
qualified entities to presumptive eligibility for
pregnant women under Medicaid
PRESENT LAW
Under Medicaid presumptive eligibility rules, states are
allowed to temporarily enroll children whose family income
appears to be below Medicaid income standards, until a final
formal determination of eligibility is made. Entities qualified
to make presumptive eligibility determinations include Medicaid
providers, agencies that determine eligibility for Head Start,
subsidized child care, or the Special Supplemental Food Program
for Women, Infants and Children (WIC). BIPA 2000 added several
entities to the list of those qualified to make Medicaid
presumptive eligibility determinations. These include agencies
that determine eligibility for Medicaid or the State Children's
Health Insurance Program (SCHIP); certain elementary and
secondary schools; state or tribal child support enforcement
agencies; certain organizations providing food and shelter to
the homeless; entities involved in enrollment under Medicaid,
TANF, SCHIP, or that determine eligibility for federally funded
housing assistance; or any other entity deemed by a state, as
approved by the Secretary of HHS.
EXPLANATION OF PROVISION
For purposes of presumptive eligibility determinations, the
Committee bill clarifies that qualified providers be included
under qualified entities as defined in current law. The bill
further clarifies that qualified entities be permitted to make
presumptive eligibility determinations for pregnant women in
addition to children.
REASON FOR CHANGE
Given the established value of early prenatal care for
ensuring the health of both mother and child, it is important
to clarify and extend presumptive eligibility rules to pregnant
women.
(d) Effective date
Section 2 of the Committee bill applies to items and
services furnished on or after October 1, 2002, regardless of
whether implementing regulations have been issued.
Section 3. Review of State agency blindness and disability
determinations
PRESENT LAW
State agencies are required to conduct blindness and
disability determinations to establish an individual's
eligibility for: (1) Title II, (Federal Old-Age, Survivors, and
Disability Insurance (OASDI) benefits); and (2) Title XVI
(Supplemental Security Income, (SSI)). Disability
determinations are made in accordance with disability criteria
defined in statute as well as standards promulgated under
regulations or other guidance.
Under current law, the Commissioner of Social Security is
required to review the state agency's Title II initial
blindness and disability determinations in advance of awarding
payment to individuals determined eligible under such
requirements. This requirement for review is met when: (1) at
least 50 percent of all such determinations have been reviewed,
or (2) other such determinations have been reviewed as
necessary to ensure a high level of accuracy.
EXPLANATION OF PROVISION
After a 1-year phase-in, the bill aligns the initial review
requirements for Title XVI with those currently required under
Title II. As under Title II, the Commissioner of Social
Security is required to review initial Title XVI SSI blindness
and disability determinations made by state agencies in advance
awarding payments. For FY2003, the SSI review is required for
25 percent of all state-determined allowances. In FY2004 and
thereafter, review is required for at least 50 percent of
state-determined allowances. To the extent feasible, the
Committee's bill requires the Commissioner to select for
review, determinations that are most likely to be incorrect.
REASON FOR CHANGE
The Committee bill includes a requirement that
determinations in the SSI program be reviewed to improve
program integrity.
EFFECTIVE DATE
Section 3 of the Committee bill is effective at the time of
enactment of such Act.
III. REGULATORY IMPACT STATEMENT AND RELATED MATTERS
A. Regulatory Impact
In accordance with paragraph 11(b) of rule XXVI of the
Standing Rules of the Senate, the Committee makes the following
statement concerning the regulatory impact of the Mothers and
Newborns Health Insurance Act of 2002.
IMPACT ON INDIVIDUALS AND BUSINESSES
Section 2(a) creates a state option for states to cover
additional pregnant women under Medicaid. Because the provision
merely creates an option for states to consider, it does not
impose any additional paperwork or regulatory burdens on
individuals or businesses.
Section 2(b) creates a state option for states to cover
additional pregnant women under the State Children's Health
Insurance Program (SCHIP), and it appropriates additional funds
for the SCHIP allotment of states that chose to take up the
option. Because the provision merely creates an option for
states to consider enacting, it does not impose any additional
paperwork or regulatory burdens on individuals or businesses.
For a child born to a woman receiving Medicaid on the date
of the child's birth, Section 2(c)(1) removes current law
requirements that the child remain eligible only as long as the
child is a member of the woman's household and the woman
remains eligible for Medicaid. Because it removes requirements
for eligibility for infants, the provision reduces paperwork
and regulatory burdens on individuals, and does not impose
additional paperwork or regulatory burdens on businesses.
Section 2(c)(2) clarifies that qualified providers are
qualified entities for purposes of determining presumptive
eligibility for children for Medicaid. It also allows qualified
entities to make presumptive determinations of eligibility for
pregnant women. This provision reduces the paperwork and
regulatory burdens on qualified providers and qualified
entities, and it does not impose additional paperwork and
regulatory burdens on other businesses or individuals.
IMPACT ON PERSONAL PRIVACY
The Committee bill permits states to provide health
coverage through Medicaid or SCHIP to pregnant women who are
not presently eligible. To establish their eligibility for
coverage in states that take up the new options, pregnant women
may be required to provide information regarding their income,
their assets, and their medical condition, but they would not
be required to provide any more information than presently
eligible pregnant women would have to provide. Infants who were
born to mothers eligible for and receiving Medicaid would have
to provide less information about household and income to
maintain their Medicaid coverage for one year. Finally, because
the law clarifies that certain private entities may make
presumptive eligibility determinations, it would give children
and pregnant women the option to obtain eligibility by sharing
income, asset, and medical condition information with private
and public entities. However, no child or pregnant woman would
be required to share the information.
B. Unfunded Mandates Statement
Due to time constraints, the Congressional Budget Office
estimate was not included in the report. When received by the
Committee, it will appear in the Congressional Record at a
later time.
IV. BUDGET EFFECTS
Due to time constraints, the Congressional Budget Office
estimate was not included in the report. When received by the
Committee, it will appear in the Congressional Record at a
later time.
V. VOTES
On July 11, 2002, a substitute for S. 724, entitled, the
``Mothers and Newborns Health Insurance Act of 2002,'' was
ordered favorably reported by a voice vote. A quorum was
present.
No amendments were offered.
VI. CHANGES IN EXISTING LAW
In compliance with paragraph 12 of the rule XXVI of the
Standing Rules of the Senate, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, existing law in which no changes
is proposed is shown in roman):
SOCIAL SECURITY ACT
* * * * * * *
TITLE XVI--GRANTS TO STATES FOR AID TO THE AGED, BLIND, OR DISABLED
* * * * * * *
ADMINISTRATION
Sec. 1633. (a) Subject to subsection (b), the Commissioner
of Social Security may make such administrative and other
arrangements (including arrangements for the determination of
blindness and disability under section 1614(a)(2) and (3) in
the same manner and subject to the same conditions as provided
with respect to disability determinations under section 221) as
may be necessary or appropriate to carry out the Commissioner's
functions under this title.
* * * * * * *
(e)(1) The Commissioner of Social Security shall review
determinations, made by State agencies pursuant to subsection
(a) in connection with applications for benefits under this
title on the basis of blindness or disability, that individuals
who have attained 18 years of age are blind or disabled as of a
specified onset date. The Commissioner of Social Security shall
review such a determination before any action is taken to
implement the determination.
(2)(A) In carrying out paragraph (1), the
Commissioner of Social Security shall review--
(i) at least 25 percent of all determinations
referred to in paragraph (1) that are made in
fiscal year 2003; and
(ii) at least 50 percent of all such
determinations that are made in fiscal year
2004 or thereafter.
(B) In carrying out subparagraph (A), the
Commissioner of Social Security shall, to the extent
feasible, select for review the determinations which
the Commissioner of Social Security identifies as being
the most likely to be incorrect.
* * * * * * *
TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
STATE PLANS FOR MEDICAL ASSISTANCE
Sec. 1902. (a) A State plan for medical assistance must--
* * * * * * *
(e)(1)(A) * * *
* * * * * * *
(4) A child born to a woman eligible for and receiving
medical assistance under a State plan on the date of the
child's birth shall be deemed to have applied for medical
assistance and to have been found eligible for such assistance
under such plan on the date of such birth and to remain
eligible for such assistance for a period of one year [so long
as the child is a member of the woman's household and the woman
remains (or would remain if pregnant) eligible for such
assistance]. During the period in which a child is deemed under
the preceding sentence to be eligible for medical assistance,
the medical assistance eligibility identification number of the
mother shall also serve as the identification number of the
child, and all claims shall be submitted and paid under such
number (unless the State issues a separate identification
number for the child before such period expires).
* * * * * * *
(l)(1) Individuals described in this paragraph are--
(A) women during pregnancy (and during the 60-day
period beginning on the last day of the pregnancy),
(B) infants under one year of age,
(C) children who have attained one year of age but
have not attained 6 years of age, and
(D) children born after September 30, 1983 (or, at
the option of a State, after any earlier date), who
have attained 6 years of age but have not attained 19
years of age,
who are not described in any of subclauses (I) through (III) of
subsection (a)(10)(A)(i) and whose family income does not
exceed the income level established by the State under
paragraph (2) for a family size equal to the size of the
family, including the woman, infant, or child.
(2)(A)(i) For purposes of paragraph (1) with respect to
individuals described in subparagraph (A) or (B) of that
paragraph, the State shall establish an income level which is a
percentage (not less than the percentage provided under clause
(ii) and not more than 185 percent (or such higher percent as
the State may elect for purposes of expenditures for medical
assistance for pregnant women described in section
1905(u)(4)(A)) of the income official poverty line (as defined
by the Office of Management and Budget and Budget, and revised
annually in accordance with section 673(2) of the Omnibus
Budget Reconciliation Act of 1981) applicable to a family of
the size involved.
* * * * * * *
DEFINITIIONS
Sec. 1905. * * *
(b) Subject to section 1933(d), the term ``Federal medical
assistance percentage'' for any State shall be 100 per centum
less the State percentage; and the State percentage shall be
that percentage which bears the same ratio to 45 per centum as
the square of the per capita income of such State bears to the
square of the per capita income of the continental United
States (including Alaska) and Hawaii; except that (1) the
Federal medical assistance percentage shall in no case be less
than 50 per centum or more than 83 per centum, (2) the Federal
medical assistance percentage for Puerto Rico, the Virgin
Islands, Guam, the Northern Mariana Islands, and American Samoa
shall be 50 per centum. The Federal medical assistance
percentage for any State shall be determined and promulgated in
accordance with the provisions of section 1101(a)(8)(B).
Notwithstanding the first sentence of this section, the Federal
medical assistance percentage shall be 100 per centum with
respect to amounts expended as medical assistance for services
which are received through an Indian Health Service facility
whether operated by the Indian Health Service or by an Indian
tribe or tribal organization (as defined in section 4 of the
Indian Health Care Improvement Act). Notwithstanding the first
sentence of this subsection, in the case of a State plan that
meets the condition described in subsection (u)(1), with
respect to expenditures (other than expenditures under section
1923) described in subsection (u)(2)(A) [or subsection (u)(3)],
(u)(3), or (u)(4) for the State for a fiscal year, and that do
not exceed the amount of the State's available allotment under
section 2104, the Federal medical assistance percentage is
equal to the enhanced FMAP described in section 2105(b), for
purpose of this title and title XXI, the Federal medical
assistance percentage for the District of Columbia shall be 70
percent and (4) the Federal medical assistance percentage shall
be equal to the enhanced FMAP described in section 2105(b) with
respect to medical assistance provided to individuals who are
eligible for such assistance only on the basis of section
1902(a)(10)(A)(ii)(XVIII).
* * * * * * *
(u)(1) The conditions described in this paragraph for a
State plan are as follows:
(A) The State is complying with the requirement of
section 2105(d)(1).
(B) The Plan provides for such reporting of
information about expenditures and payments
attributable to the operation of this subsection as the
Secretary deems necessary in order to carry out the
fourth sentence of subsection (b).
(2)(A) For purposes of subsection (b), the expenditures
described in this subparagraph are expenditures for medical
assistance for optional target low-income children described in
subparagraph (B).
(B) For purposes of this paragraph, the term ``optional
targeted low-income child'' means a targeted low-income child
as defined in section 2110(b)(1) (determined without regard to
that portion of subparagraph (C) of such section concerning
eligibility for medical assistance under this title) who would
not qualify for medical assistance under the State plan under
this title as in effect on March 31, 1997 (but taking into
account the expansion of age of eligibility effected through
the operation of section 1902(l)(1)(D)).
(3) For purposes of subsection (b), the expenditures
described in this paragraph are expenditures for medical
assistance for children who are born before October 1, 1983,
and who would be described in section 1902(l)(1)(D) if they had
been born on or after such date, and who are not eligible for
such assistance under the State plan under this title based on
such State plan as in effect as of March 31, 1997.
(4) For purposes of the fourth sentence of subsection (b)
and section 2105(a), the expenditures described in this
paragraph are the following:
(A) Certain pregnant women.--If the conditions
described in subparagraph (B) are met, expenditures for
medical assistance for pregnant women described in
subsection (n) or under section 1902(l)(1)(A) in a
family the income of which exceeds 185 percent of the
poverty line, but does not exceed the income
eligibility level established under title XXI for a
targeted low-income child.
(B) Conditions.--The conditions described in this
subparagraph are the following:
(i) The State plans under this title and
title XXI do not provide coverage for pregnant
women described in subparagraph (A) with higher
family income without covering such pregnant
women with a lower family income.
(ii) The State does not apply an effective
income level for pregnant women that is lower
than the effective income level (expressed as a
percent of the poverty line and considering
applicable income disregards) that has been
specified under the State plan under subsection
(a)(10)(A)(i)(III) or (l)(2)(A) of section
1902, as of January 1, 2002, to be eligible for
medical assistance as a pregnant woman.
(C) Definition of poverty line.--In this subsection,
the term ``poverty line'' has the meaning given such
term in section 2110(c)(5).
[(4)](5) The limitations on payment under subsections (f)
and (g) of section 1108 shall not apply to Federal payments
made under section 1903(a)(1) based on an enhanced FMAP
described in section 2105(b).
* * * * * * *
PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN
Sec. 1920. (a) A State plan approved under section 1902 may
provide for making ambulatory prenatal care available to a
pregnant woman during a presumptive eligibility period.
(b) For purposes of this section--
(1) the term ``presumptive eligibility period''
means, with respect to a pregnant woman, the period
that--
* * * * * * *
(2) the term ``qualified provider'' means any
provider that--
(A) is eligible for payments under a State
plan approved under this subchapter,
(B) provides services of the type described
in subparagraph (A) or (B) of section
1396d(a)(2) of this title or in section
1396b(a)(9) of this title,
(C) is determined by the State agency to be
capable of making determinations of the type
described in paragraph (1)(A), and
(D)(i) receives funds under--
(I) section 330 or 330A of the Public
Health Service Act
(II) title V of this Act, or
(III) title V of the Indian Health
Care Improvement Act;
(ii) participates in a program established
under--
(I) section 17 of the Child Nutrition
Act of 1966, or
(II) section 4(a) of the Agriculture
and Consumer Protection Act of 1973,
(iii) participates in a State perinatal
program; or
(iv) is the Indian Health Service or is a
health program or facility operated by a tribe
or tribal organization under the Indian Self-
Determination Act (Public Law 93-638).
The term ``qualified provider'' includes a qualified entity as
defined in section 1920A(b)(3).
* * * * * * *
TITLE XXI--STATE CHILDREN'S HEALTH INSURANCE PROGRAM
GENERAL CONTENTS OF STATE CHILD HEALTH PLAN; ELIGIBILITY; OUTREACH
Sec. 2102. (a) General Background and Description.--A State
child health plan shall include a description, consistent with
the requirements of this title, of--
* * * * * * *
(b) General Description of Eligibility Standards and
Methodology.--
(1) Eligibility standards.--
(A) In general.--The plan shall include a
description of the standard used to determine
the eligibility of targeted low-income children
for child health assistance under the plan.
such standards may include (to the extent
consistent with this title) those relating to
the geographic areas to be served by the plan,
age, income and resources (including any
standards relating to spenddowns and
disposition of resources), residency,
disability status (so long as any standard
relating to such status does not restrict
eligibility), access to or coverage under other
health coverage, and duration of eligibility.
Such standards may not discriminate on the
basis of diagnosis.
(B) Limitations on eligibility standards.--
Such eligibility standards--
(i) shall, within any defined group
of covered targeted low-income
children, not cover such children with
higher family income without covering
children with a lower family income[,
and ];
(ii) may not deny eligibility based
on a child having a preexisting medical
condition[.]; and
(iii) may not apply a waiting period
(including a waiting period to carry
out paragraph (3)(C)) in the case of a
targeted low-income pregnant woman.
COVERAGE REQUIREMENTS FOR CHILDREN'S HEALTH INSURANCE
Sec. 2103. (a) Required Scope of Health Insurance
Coverage.--The child health assistance provided to a targeted
low-income child under the plan in the form described in
paragraph (1) of section 2101(a) shall consist, consistent with
subsection (c)(5), of any of the following:
* * * * * * *
(e) Cost-Sharing.--
(1) Description; general conditions.--
(A) Description.--A State child health plan
shall include a description, consistent with
this subsection, of the amount (if any) of
premiums, deductibles, coinsurance, and other
cost sharing imposed. Any such charges shall be
imposed pursuant to a public schedule.
(B) Protection for lower income children.--
The State child health plan may only vary
premiums, deductibles, coinsurance, and other
cost sharing based on the family income of
targeted low-income children in a manner that
does not favor children from families with
higher income over children from families with
lower income.
(2) No cost sharing on benefits for preventive
services or pregnancy-related services.--The State
child health plan may not impose deductibles,
coinsurance, or other cost sharing with respect to
benefits for services within the category of services
described in subsection (c)(1)(D) or for pregnancy-
related services.
* * * * * * *
ALLOTMENTS
Sec. 2104. (a) Appropriation; Total Allotment.--For the
purpose of providing allotments to States under this section,
subject to subsection (d), there is appropriated, out of any
money in the Treasury not otherwise appropriated--
* * * * * * *
(b) Allotments to 50 States and District of Columbia.--
(1) In general.--Subject to paragraph (4) and
subsection (d), of the amount available for allotment
under subsection (a) for a fiscal year, reduced by the
amount of allotments made under subsection (c)
(determined without regard to paragraph (4) thereof)
for the fiscal year, the Secretary shall allot to each
State (other than a State described in such subsection)
with a State child health plan approved under this
title the same proportion as the ratio of--
* * * * * * *
(c) Allotments to Territories.--
(1) In general.--Of the amount available for
allotment under subsection (d) for a fiscal year
subject to subsection (d), the Secretary shall allot
0.25 percent among each of the commonwealths and
territories described in paragraph (3) in the same
proportion as the percentage specified in paragraph (2)
for such commonwealth or territory bears to the sum of
such percentages for all such commonwealths or
territories so described.
* * * * * * *
(d) Additional Allotments for Providing Coverage of
Pregnant Women.--
(1) Appropriation; total allotment.--For the purpose
of providing additional allotments to States under this
title, there is appropriated, out of any money in the
Treasury not otherwise appropriated, for each of fiscal
years 2003 through 2006, $200,000,000.
(2) State and territorial allotments.--In addition to
the allotments provided under subsections (b) and (c),
subject to paragraphs (3) and (4), of the amount
available for the additional allotments under paragraph
(1) for a fiscal year, the Secretary shall allot to
each State with a State child health plan approved
under this title--
(A) in the case of such a State other than a
commonwealth or territory described in
subparagraph (B), the same proportion as the
proportion of the State's allotment under
subsection (b) (determined without regard to
subsection (f)) to the total amount of the
allotments under subsection (b) for such States
eligible for an allotment under this paragraph
for such fiscal year; and
(B) in the case of a commonwealth or
territory described in subsection (c)(3), the
same proportion as the proportion of the
commonwealth's or territory's allotment under
subsection (c) (determined without regard to
subsection (f)) to the total amount of the
allotments under subsection (c) for
commonwealths and territories eligible for an
allotment under this paragraph for such fiscal
year.
(3) Use of additional allotment.--Additional
allotments provided under this subsection are not
available for amounts expended before October 1, 2002.
Such amounts are available for amounts expended on or
after such date for child health assistance for
targeted low-income children, as well as for pregnancy-
related assistance for targeted low-income pregnant
women.
(4) No payments unless election to expand coverage of
pregnant women.--No payments may be made to a State
under this title from an allotment provided under this
subsection unless the State provides pregnancy-related
assistance for targeted low-income pregnant women under
this title, or provides medical assistance for pregnant
women under title XIX, whose family income exceeds the
effective income level applicable under subsection
(a)(10)(A)(i)(III) or (l)(2)(A) of section 1902 to a
family of the size involved as of January 1, 2002.
PAYMENTS TO STATES
Sec. 2105. (a) Payments.--
(1) In general.--Subject to the succeeding provisions
of this section, the Secretary shall pay to each State
with a plan approved under this title, from its
allotment under section 2104, an amount for each
quarter equal to the enhanced FMAP [(or, in the case of
expenditures described in subparagraph (B), the Federal
medical assistance percentage (as defined in the first
sentence of section 1905(b)))] of expenditures in the
quarter--
(A) for child health assistance under the
plan for targeted low-income children in the
form of providing medical assistance for which
payment is made on the basis of an enhanced
FMAP under the fourth sentence of section
1905(b);
[(B) for the provision of medical assistance
on behalf of a child during a presumptive
eligibility period under section 1920A;]
(B) for the provision of medical assistance
that is attributable to expenditures described
in section 1905(u)(4)(A);
* * * * * * *
SEC. 2111. OPTIONAL COVERAGE OF TARGETED LOW-INCOME PREGNANT WOMEN.
(a) Optional Coverage.--Notwithstanding any other provision
of this title, a State may provide for coverage, through an
amendment to its State child health plan under section 2102, of
pregnancy-related assistance for targeted low-income pregnant
women in accordance with this section, but only if--
(1) the State has established an income eligibility
level for pregnant women under subsection
(a)(10)(A)(i)(III) or (l)(2)(A) of section 1902 that is
at least 185 percent of the income official poverty
line; and
(2) the State meets the conditions described in
section 1905(u)(4)(B).
(b) Definitions.--For purposes of this title:
(1) Pregnancy-related assistance.--The term
``pregnancy-related assistance'' has the meaning given
the term child health assistance in section 2110(a) as
if any reference to targeted low-income children were a
reference to targeted low-income pregnant women, except
that the assistance shall be limited to services
related to pregnancy (which include prenatal, delivery,
and postpartum services and services described in
section 1905(a)(4)(C)) and to other conditions that may
complicate pregnancy.
(2) Targeted low-income pregnant woman.--The term
``targeted low-income pregnant woman'' means a woman--
(A) during pregnancy and through the end of
the month in which the 60-day period (beginning
on the last day of her pregnancy) ends;
(B) whose family income exceeds the effective
income level (expressed as a percent of the
poverty line and considering applicable income
disregards) that has been specified under
subsection (a)(10)(A)(i)(III) or (l)(2)(A) of
section 1902, as of January 1, 2002, to be
eligible for medical assistance as a pregnant
woman under title XIX but does not exceed the
income eligibility level established under the
State child health plan under this title for a
targeted low-income child; and
(C) who satisfies the requirement of
paragraphs (1)(A), (1)(C), (2), and (3) of
section 2110(b).
(c) References to Terms and Special Rules.--In the case of,
and with respect to, a State providing for coverage of
pregnancy-related assistance to targeted low-income pregnant
women under subsection (a), the following special rules apply:
(1) Any reference in this title (other than in
subsection (b)) to a targeted low-income child is
deemed to include a reference to a targeted low-income
pregnant woman.
(2) Any such reference to child health assistance
with respect to such women is deemed a reference to
pregnancy-related assistance.
(3) Any such reference to a child is deemed a
reference to a woman during pregnancy and the period
described in subsection (b)(2)(A).
(4) In applying section 2102(b)(3)(B), any reference
to children found through screening to be eligible for
medical assistance under the State medicaid plan under
title XIX is deemed a reference to pregnant women.
(5) There shall be no exclusion of benefits for
services described in subsection (b)(1) based on any
preexisting condition and no waiting period (including
any waiting period imposed to carry out section
2102(b)(3)(C)) shall apply.
(6) Subsection (a) of section 2103 (relating to
required scope of health insurance coverage) shall not
apply insofar as a State limits coverage to services
described in subsection (b)(1) and the reference to
such section in section 2105(a)(1)(C) is deemed not to
require, in such case, compliance with the requirements
of section 2103(a).
(7) In applying section 2103(e)(3)(B) in the case of
a pregnant woman provided coverage under this section,
the limitation on total annual aggregate cost-sharing
shall be applied to such pregnant woman.
(8) The reference in section 2107(e)(1)(D) to section
1920A (relating to presumptive eligibility for
children) is deemed a reference to section 1920
(relating to presumptive eligibility for pregnant
women).
(d) Automatic Enrollment for Children Born to Women
Receiving Pregnancy-Related Assistance.--If a child is born to
a targeted low-income pregnant woman who was receiving
pregnancy-related assistance under this section on the date of
the child's birth, the child shall be deemed to have applied
for child health assistance under the State child health plan
and to have been found eligible for such assistance under such
plan or to have applied for medical assistance under title XIX
and to have been found eligible for such assistance under such
title, as appropriate, on the date of such birth and to remain
eligible for such assistance until the child attains 1 year of
age. During the period in which a child is deemed under the
preceding sentence to be eligible for child health or medical
assistance, the child health or medical assistance eligibility
identification number of the mother shall also serve as the
identification number of the child, and all claims shall be
submitted and paid under such number (unless the State issues a
separate identification number for the child before such period
expires).