[Senate Report 108-157]
[From the U.S. Government Publishing Office]
Calendar No. 295
108th Congress Report
SENATE
1st Session 108-157
======================================================================
FAMILY OPPORTUNITY ACT OF 2003
_______
September 30 (legislative day, September 29), 2003.--Ordered to be
printed
Mr. Grassley, from the Committee on Finance, submitted the following
R E P O R T
[To accompany S. 622]
The Committee on Finance, to which was referred the bill
(S. 622) to amend title XIX of the Social Security Act to
provide families of disabled children with the opportunity to
purchase coverage under the Medicaid program for such children,
and for other purposes, reports favorably thereon with an
amendment in the nature of a substitute and refers the bill to
the full Senate with a recommendation that the bill do pass.
I. BACKGROUND
Health care research shows that children with significant
disabilities face multiple barriers to accessing critical
health care services. In their efforts to obtain high quality
health care services for their child, parents with children
with disabilities often face financial difficulties. Many are
forced to stay impoverished, become impoverished, put their
children in out of home placements, or simply give up custody
of their children--so that their child can maintain eligibility
for health coverage through Medicaid.
Not all employer sponsored health plans or State Children's
Health Insurance Programs (S-CHIP) cover essential services
that children with severe disabilities need to maintain their
health status or to prevent deterioration of their health
status. Medicaid often provides access to more comprehensive
services, including respite care, day treatment services,
mental health services, personal care services, and durable
medical equipment.
In a health care survey of 20 States, families with special
needs children report they are turning down jobs, turning down
raises, refusing overtime, and are unable to save money for the
future of their children and family--so that they can stay in
an income bracket low enough to qualify their child for SSI
and/or Medicaid.
The committee bill is intended to address the two greatest
barriers preventing families from staying together and staying
employed: (1) Lack of access to appropriate health care
services, and (2) lack of access to information and resources
to help parents navigate the system.
The sponsors of the Family Opportunity Act first introduced
the legislation in the second session of the 106th Congress.
The bill had wide bi-partisan support in both the House and
Senate. By the close of the 106th Congress, the House bill,
sponsored by Representatives Pete Sessions (R-TX) and Henry
Waxman (D-CA), had 142 co-sponsors and the Senate bill,
sponsored by Senators Chuck Grassley (R-IA) and Edward Kennedy
(D-MA), had 77 co-sponsors.
The introduction of the Family Opportunity Act (also called
the ``Dylan Lee James Family Opportunity Act'') was motivated
by the circumstance of individual families--the Melissa Arnold
family and the Dylan Lee James family. Both families relied on
Medicaid health services for their child with disabilities, and
both families risked losing eligibility to Medicaid as a result
of financial eligibility rules that created disincentives for
the parents to work and/or to seek better employment
opportunities. Sadly, Dylan Lee James, who suffered from Downs
Syndrome, died at young age from complications.
The FY 2001 Budget Resolution included a reserve fund for
the Family Opportunity Act, and on July 12, 2000, the Senate
Budget Committee held a hearing to examine the Family
Opportunity Act. The nature of the hearing was to highlight the
need for the Family Opportunity Act. The first panel of
witnesses consisted of three elected representatives, including
Senator Edward Kennedy (D-MA), Governor Mike Huckabee (R-AR),
and Representative Pete Sessions (R-TX). The second panel
consisted of health experts and family members, including
William Scanlon, Ph.D., Director of Health, Education, and
Human Services at the General Accounting Office in Washington,
D.C.; Gordon Fay, a staff sergeant in the U.S. Air Force and a
parent of a 9-year-old daughter with Angelman's Syndrome;
Rebecca Eichorn, a parent of a teenager with mental health
needs from Newberg, Oregon; Tanya Baker-McCue, a parent of a
teenager with cystic fibrosis from Albuquerque, New Mexico; and
Dr. David Alexander, medical director of Raymond Blank
Children's Hospital in Des Moines, Iowa.
The sponsors re-introduced the Family Opportunity Act in
the 107th Congress and again achieved broad bi-partisan
support. It was voice voted out of the Finance Committee. The
House bill, H.R. 600, had 236 co-sponsors and the Senate bill,
S. 321, had 75 co-sponsors.
At the time of the Finance Committee mark up of the Family
Opportunity Act in 108th Congress, there were 63 co-sponsors of
the Senate bill, S. 622.
For 3 consecutive years, the sponsors of the legislation
have secured support from congressional budget committees. The
FY 2003 Congressional Budget Resolution includes a $7.46
billion budget reserve fund for the Family Opportunity Act
legislation.
II. DESCRIPTION OF THE BILL
The legislation reported by the Finance Committee consists
of the following provisions:
Section 1. Short title
Section 2. Opportunity for families of disabled children to purchase
medicaid coverage for such children
PRESENT LAW
(a) State Option To Allow Families of Disabled Children To
Purchase Medicaid Coverage for Such Children.--Federal law
establishes the categories or groups of individuals that can be
covered under Medicaid and, in many cases, defines specific
eligibility rules for these categories. Some groups must be
covered under Medicaid (called mandatory groups), while others
may be covered at state option. In general, Medicaid is
available to low-income persons who are aged, blind or
disabled, members of families with dependent children, and
certain other pregnant women and children. Applicants' income
and resources must be within certain limits, most of which are
determined by States, again within Federal statutory
parameters. States have considerable flexibility in defining
countable income and assets for determining eligibility.
For disabled children, there are several potentially
applicable Medicaid eligibility groups, some mandatory but most
optional. Some of these children could qualify for Medicaid
through more than one pathway in any given State. There are
four primary coverage groups for which disability status or
medical need is directly related to eligibility.
First, subject to one important exception, States are
required to cover all children receiving Supplemental Security
Income (SSI). Because SSI is a Federal program, income and
resource standards do not vary by . In determining financial
eligibility, parents' income is deemed available to
noninstitutionalized children (but the need of household
members is taken into account). If family income is higher than
the SSI threshold, the child will not qualify for SSI or
Medicaid.
The major exception to the required coverage under Medicaid
of SSI recipients occurs in so called ``209(b)'' States. Such
states can apply more restrictive income and resources
standards and/or methodologies in determining Medicaid
eligibility than the standards applicable under SSI. States
that offer State Supplemental Payments (SSP) may also offer
Medicaid coverage to SSP recipients who would be eligible for
SSI, except that their income is too high.
Second, States may offer medically needy coverage under
Medicaid. The medically needy are persons who fall into one of
the other categories of eligibility (e.g., is a dependent
child) but whose income exceeds applicable financial standards.
Income standards for the medically needy can be no higher than
133\1/3\ percent of the State's former Aid to Families with
Dependent Children (AFDC) payment standard in effect on July
16, 1996. Individuals can meet these financial criteria by
having income that falls below the medically needy standard, or
by incurring medical expenses that when subtracted from income,
result in an amount that is lower than the medically needy
income standard. Resource standards correspond to those
applicable under SSI. Older children or those with very large
medical expenses may qualify for medically needy coverage.
(Other eligibility pathways for younger children are described
below.)
Third, States may extend Medicaid to certain disabled
children under 18 who are living at home and who would be
eligible for Medicaid via the SSI pathway if they were in a
hospital, nursing facility, or intermediate care facility for
the mentally retarded, as long as the cost of care at home is
no more than institutional care. (This group is called the
``Katie Beckett'' category.) The law allows States to consider
only the child's income and resources when determining
eligibility for this group. That is, States may ignore parents'
income.
Fourth, States have an option to cover persons needing home
and community based services, if these persons would otherwise
require institutional care covered by Medicaid. These services
are provided under waiver programs authorized by Section
1915(c) of Title XIX of the Social Security Act. Unlike the
Katie Beckett option, which requires all disabled children
within a State to be covered, such programs may be limited to
specific geographic areas, and/or may target specific disabled
groups and/or specific individuals within a group. States may
apply institutional deeming rules which allow them to ignore
parents' income in determining a child's eligibility for waiver
services.
Disabled children can also qualify for Medicaid via other
eligibility pathways for which disability status and medical
need are irrelevant. These additional pathways cover children
at higher income levels than those applicable to most of the
disability-related eligibility categories described above. For
example, States are required to provide Medicaid coverage to
children under age 6 (and pregnant women) in families with
incomes below 133 percent of the Federal poverty level (FPL),
and in FY2002, for children between ages 6 and 18 in families
with income below 100 percent of FPL. States may cover infants
under age one (and pregnant women) in families with income
between 133 and 185 percent of FPL. Similarly, under the State
Children's Health Insurance Program (SCHIP), States may extend
Medicaid (or provide other health insurance) to certain
children under age 19 who are not otherwise eligible for
Medicaid in families with income that is above the applicable
Medicaid standard but less than 200 percent of FPL, or in
States that already exceed the 200 percent of FPL level for
Medicaid children, within 50 percentage points over that
existing level.
(b) Interaction With Employer Sponsored Family Coverage.--
States may require Medicaid eligibles to apply for coverage in
certain employer-sponsored group health plans (for which such
persons are eligible) when it is cost-effective to do so. This
requirement may be imposed as a condition of continuing
Medicaid eligibility, except that failure of a parent to enroll
a child must not affect the child's continuing eligibility for
Medicaid.
If all members of the family are not eligible for Medicaid,
and the group health plan requires enrollment of the entire
family, Medicaid will pay associated premiums for full family
coverage if doing so is cost-effective. However, Medicaid will
not pay deductibles, coinsurance or other cost-sharing for
family members ineligible for Medicaid. Third, party liability
rules apply to coverage in a group health plan. That is, such
plans, not Medicaid, must pay for all covered services under
the plan.
Under current law, cost-effectiveness means that the
reduction in Medicaid expenditures for Medicaid beneficiaries
enrolled in a group health plan is likely to be greater than
the additional costs for premiums and cost-sharing required
under the group health plan. Group health plan means a plan of
(or contributed to by) an employer or employee organization to
provide health care (directly or otherwise) for employees and
their families.
In sum, when it is cost-effective, Medicaid pays the
premiums and other cost-sharing under certain group health
plans for Medicaid eligibles, as well as for Medicaid services
not covered under the group health plan. This includes payment
of any premium and cost-sharing amounts that exceed limits
placed on such payments in Medicaid law.
(c) State Option To Impose Income-Related Premiums.--
Generally, for certain eligibility categories, States may not
impose enrollment fees, premiums or similar charges. Further,
States are specifically prohibited from requiring payment of
deductions, cost-sharing or similar charges for services
furnished to persons under 18 years of age (up to age 21, or
any reasonable subcategory of such persons between 18 and 21
years of age, at State option).
In certain circumstances, States may impose monthly
premiums for enrollment in Medicaid. For example, States may
require certain qualified severely impaired persons ages 16 and
above who but for earnings would be eligible for SSI to pay
premiums and other cost-sharing charges set on a sliding scale
based on income. Further, States may require such persons with
income between 250 to 450 percent of FPL to pay the full
premium. However, the sum of such payments may not exceed 7.5
percent of income.
For other groups, States may not require prepayment of
premiums and may not terminate eligibility due to failure to
pay premiums, unless such failure continues for at least 60
days. States can also waive premiums when such payments would
cause undue hardship.
EXPLANATION OF PROVISION
(a) Effective October 1, 2005, the Committee mark would add
a new optional eligibility group for disabled children to
Medicaid. The new group includes children under 18 years of age
who meet the disability definition for children under the
Supplemental Security Income (SSI) program and whose family
income is above the financial standards for SSI but not more
than 250 percent of FPL. States may exceed 250 percent of FPL,
but Federal financial participation is not available for
coverage of disabled children in families with income above
that level.
(b) As part of the optional Medicaid ``buy-in,'' the
Committee mark would allow States to require parents of
disabled children who are eligible for the newly defined
coverage group to enroll in employer-sponsored family coverage
under certain circumstances. Specifically, when the employer of
a parent of a disabled child offers family coverage under a
group health plan, the parent is eligible for such coverage,
and the employer contributes at least 50 percent of the annual
premium costs, States shall require participation in such
employer-sponsored family coverage plan as a condition of
continuing Medicaid eligibility for the targeted child under
the proposed optional eligibility category. In addition, if
such coverage is obtained, States may elect to have families
pay an amount that reasonably reflects the premium contribution
made by the parent for this coverage on behalf of the disabled
child. States may pay any portion of a required premium for
family coverage under an employer-sponsored plan; for families
with income that does not exceed 250 percent of FPL, the
Federal Government will share in the cost of these payments.
In addition, States that use employer-sponsored family
coverage for the new optional eligibility group must insure
that these plans, not Medicaid, pay for all covered services
under the plan, as is the case with all other third party
liability situations.
(c) The Committee mark also adds a new section to Medicaid
law governing premiums applicable to the new optional
eligibility group. It would allow States to require families
with disabled children eligible for Medicaid under the new
optional eligibility group to pay monthly premiums for
enrollment in Medicaid on a sliding scale based on family
income. Aggregate payments for premiums paid by families for
employer-sponsored family coverage may not exceed 5 percent of
income.
Consistent with current law, States may not require
prepayment of premiums, nor are States allowed to terminate
eligibility of a targeted child for failure to pay premiums
unless lack of payment continues for a minimum of 60 days
beyond the payment due date. States may waive payment of
premiums when such payment would cause undue hardship.
The mark does not change current law with respect to other
cost-sharing by beneficiaries (e.g., deductibles, co-insurance,
co-payments), which is not permitted for children under 18
years of age. Thus, Medicaid would pay such cost sharing
obligations rather than the families of qualifying children
under the new optional group.
REASONS FOR CHANGE
The provisions in Section 2 of the Committee mark provide
similar work incentives as those included in the successful
Ticket to Work and Work Incentives Improvement Act (TWWIIA;
P.L. 106-170), which encouraged disabled adults to enter the
workforce without risk of losing their Medicare (Part A only)
and Medicaid benefits.
Before P.L. 106-170 took effect, adults who made more than
$500 a month lost SSI eligibility and therefore became
ineligible for Medicaid. As a result, many adults with
disabilities were reluctant to enter into the workforce and
purposely kept their incomes under the cap to remain eligible
for Medicaid via the SSI pathway. TWWIIA reversed the
disincentive to work by allowing these adults to enter the
workforce without the threat of losing the health care they
needed.
Parents of children with disabilities should have the same
opportunities as was granted to adults with disabilities
TWWIIA. The provisions in Section 2 of the Committee mark
provide a similar incentive to work for parents of a disabled
child. Currently, low-income parents of severely disabled
children who work are at risk of jeopardizing Medicaid
eligibility for their disabled children if they have income and
resources above the poverty level. The Committee mark allows
parents to go to work and earn above-poverty wages while
maintaining health care for their disabled children by
purchasing Medicaid. Right now, in too many cases, parents are
forced to stay poor so that they can maintain Medicaid
eligibility for a disabled child. Specifically, by providing
States an option to allow families with disabled children to
``buy into'' Medicaid if the family income falls between 100
and 250 percent of the Federal poverty level ($37,550 for a
family of three and $45,250 for a family of four), parents can
go back to work and increase wages without worrying about
losing access to critical health care services for their
disabled child. In short, parents won't have to choose between
work and health care for their child.
Medicaid services are important to children with
disabilities because Medicaid offers access to medically
necessary services such as physical therapy, mental health
services, and customized durable medical equipment, to list a
few. Many children with severe disabilities need these services
in order to have a chance to grow and develop into contributing
members of their community.
Children with significant disabilities who come from
families that have an annual income above the eligibility level
for Medicaid are at risk of not receiving these medically
necessary services unless their parents choose to remain in
poverty or to move into poverty in order to keep Medicaid.
The provisions in Section 2 regarding employer-sponsored
insurance are intended to promote the take-up and utilization
of private market insurance. For instance, a participating
family could have private insurance through an employer and
still need to purchase certain Medicaid services that aren't
offered through the private plan. In this case, Medicaid serves
as a ``wrap around'' only--meaning that if a parent has access
to employer-sponsored insurance (ESI), the ESI coverage would
pay first and Medicaid would cover only the cost of the
benefits not available through the employer's plan.
The Committee mark only provides access to Medicaid for
children with a severe disability. The child must meet the
level of disability required for SSI. The legislation does not
make SSI available to additional children; the legislation
references SSI for purposes of disability criteria.
To be disabled under SSI, a child under age 18 must have a
``medically determinable physical or mental impairment which
results in marked and severe functional limitations, and which
can be expected to result in death or which has lasted or can
be expected to last for a continuous period of not less than 12
months.'' Depending on the determination process, an example of
a child who qualifies could be a child with one of the
following disabilities or chronic conditions: cerebral palsy,
blindness, neurologic impairments (spina bifida),
musculoskeletal (juvenile rheumatoid arthritis or muscular
dystrophy) incapacity, Downs Syndrome, Autism, or pervasive
developmental disorder.
Section 3. Treatment of inpatient psychiatric hospital services for
individuals under 21 in home or community-based services
waivers
(a) Medicaid.--
PRESENT LAW
Medicaid home and community-based service (HCBS) waivers
authorized by Section 1915(c) of Title XIX of the Social
Security Act give States the flexibility to develop and
implement alternatives to placing Medicaid beneficiaries in
hospitals, nursing facilities, or intermediate care facilities
for the mentally retarded (ICF-MRs). These waivers allow such
individuals to be cared for in their homes and communities as
long as the cost is no higher than that of institutional care.
Federal regulations permit HCBS programs to serve the
elderly, persons with physical disabilities, developmental
disabilities, mental retardation or mental illness. States may
also target waiver programs to persons with specific illnesses
or conditions, such as technology-dependent children or
individuals with AIDS.
Services that may be provided under HCBS waiver programs
include: case management, homemaker/home health aide services,
personal care services, adult day health, habilitation, and
respite care. Other services needed by waiver participants to
avoid institutionalization, such as non-medical transportation,
in-home support services, special communication services, minor
home modifications, and adult day care may also be provided,
subject to approval by Centers for Medicare and Medicaid
Services (CMS). The law further permits day treatment or other
partial hospitalization services, psychosocial rehabilitation,
and clinic services for persons with chronic mental illness.
Room and board are excluded from coverage except under limited
circumstances.
Under HCBS wavier programs, States may select the mix of
services that best meets the needs of the targeted population
to be served. Programs may be Statewide or limited to a
specific geographic area.
EXPLANATION OF PROVISION
The Committee mark adds to the list of persons eligible for
HCBS waiver programs individuals under 21 years of age
requiring inpatient psychiatric hospital services, effective
for medical assistance provided on or after October 1, 2004.
REASON FOR CHANGE
Home and community services are an attractive option to
disabled and elderly individuals who prefer to receive services
in the home or community as an alternative to institutional
care. Additionally, many States design HCBS services as a cost-
effective approach to providing long term care health services.
It is often less costly to provide targeted home and community
services than it is to cover institutional care. At the present
time, States are operating nearly 264 home and community based
waivers.
The provisions in Section 3(a) of the Committee mark aim to
improve mental health parity for children with mental health
illnesses. Under current law, States can offer home and
community based services as an alternative to one of three
institutional settings, including (1) hospitals, (2) nursing
facilities, or (3) intermediate care facilities for the
mentally retarded (ICFMRs). Current law does not allow States
to offer home and community based services as an alternative to
inpatient psychiatric hospitals.
This provision corrects this omission by including
inpatient psychiatric hospitals to the list of institutions for
which alternative care through home and community based waivers
may be available.
Unfortunately, some parents have been faced with the
impossible decision of relinquishing custody of a child to a
State institution so that the child can get necessary, life-
saving services. This problem presents itself most often when
the child suffers from a mental health illness. Medical and
health care experts report on the benefits and effectiveness of
community based care for children with serious mental health
disorders. Residential treatments centers offer an important
alternative to psychiatric hospitals. Improving access to
community-based mental health services for children with
serious mental health needs should lead to improved health
outcomes in mental health.
Section 4. Development and support of family-to-family health
information centers
(a) Maternal and Child Services Block Grant.--
PRESENT LAW
Title V of the Social Security Act authorizes the Maternal
and Child Services Block Grant program, which provides grants
to States for improving the health of mothers and children. The
program has three components: (1) Formula block grants to 59
States and territories; (2) Special Projects of Regional and
National Significance (SPRANS); and (3) Community Integrated
Service Systems (CISS) grants.
Activities supported under SPRANS include Maternal and
Child Health (MCH) research, training, genetic services,
hemophilia diagnostic and treatment centers and maternal and
child health improvement projects that support a broad range of
innovative strategies.
By law, 15 percent of the amount appropriated for the
Maternal and Child Health Block Grant Program up to $600
million, is awarded to public and private not-for-profit
organizations for SPRANS. SPRANS also receive 15 percent of
funds remaining above $600 million after CISS funds are set
aside. The CISS programs are initiated when the MCH
appropriation exceeds $600 million. Of any amount appropriated
over $600 million, 12.75 percent must be for CISS. The
remaining amounts are allocated to the block grant program and
to SPRANS.
EXPLANATION OF PROVISION
The Committee mark would increase funding for SPRANS for
the development and support of new family-to-family health
information centers. The mark would appropriate to the
Secretary out of any money in the Treasury not otherwise
appropriated, for this new purpose an additional $3 million for
FY2005; $4 million for FY2006; and $5 million for FY2007. For
each of fiscal years 2008 and 2009, the bill authorizes to be
appropriated to the Secretary $5 million for this purpose.
Funds would remain available until expended.
The family-to-family health information centers would: (1)
Assist families of children with disabilities or special health
care needs to make informed choices about health care so as to
promote good treatment decisions, cost-effectiveness, and
improved health outcomes for such children; (2) provide
information regarding the health care needs of, and resources
available for children with disabilities or special health care
needs; (3) identify successful health delivery models; (4)
develop a model for collaboration between such children and
health professionals; (5) provide training and guidance with
regard to the care of such children; and (6) conduct outreach
activities to the families of such children, health
professionals, schools, and other appropriate entities and
individuals. The family-to-family health information centers
would be staffed by families of children with disabilities or
special health care needs who have expertise in Federal and
State public and private health care systems, and health
professionals.
The Committee mark would require the Secretary to develop
such centers in: (1) Not less than 25 States in FY2005; (2) not
less than 40 States in FY2006; and (3) all States in FY2007.
States would be defined as the 50 States and the District of
Columbia.
REASON FOR CHANGE
The family-to-family health information centers authorized
by this provision are modeled after successful demonstration
programs that provide important information and outreach
centers for parents with disabled children. The complexity of
the health care system poses challenges to even the most
informed parent. Health information centers can guide and
assist a parent through the maze and promote efficiency.
Families report that they spend extraordinary amounts of time
and energy investigating resources and coordinating their
child's care.
Family to family health information centers would be run by
trained parents and professionals and would provide technical
assistance and accurate information to otherfamilies about
local health care programs and services. For instance, a mother of a
newborn infant with serious medical problems could turn to one of these
centers for guidance, such as information about local doctors who
specialize in certain disease management, information about parent
training courses, information about day care centers in the area that
care for disabled infants, etc.
The family-to-family health information centers will not
only assist parents, but they will also provide information to
health care insurers, providers, and purchasers. The successful
demonstrations of these centers are proof that the medical and
provider community rely on family members for their expertise
in certain decision-making.
Section 5. Restoration of Medicaid eligibility for certain SSI
beneficiaries
(a) Medicaid.--
PRESENT LAW
Except in the case of ``209(b)'' States, States are
required to provide Medicaid benefits to all individuals who
are receiving Supplemental Security Income (SSI). Persons
eligible for SSI are low-income aged, blind, and disabled
individuals. (Under the 209(b) provision, States may apply more
restrictive income and resources standards and/or methodologies
for determining Medicaid eligibility than the standards under
SSI.) For disability purposes, two groups of disabled children
exist: Those under the age of 18 and those age 18 through 21
(if a full time student). Eligibility for SSI is effective on
the later of: (1) The first day of the month following the date
the application was filed, or (2) the first day of the month
following the date that the individual became eligible.
EXPLANATION OF PROVISION
The Committee mark confers Medicaid eligibility to persons
who are under age 21 and who are eligible for SSI, effective on
the later of: (1) The date the application was filed, or (2)
the date the individual became eligible for SSI.
The Committee's provision would apply to medical assistance
for items and services furnished on October 1, 2004.
REASON FOR CHANGE
This provision addresses a technical matter that resulted
inadvertently in previous legislation. It addresses the
interaction between Medicaid and SSI. Most States are required
to make Medicaid available to persons receiving SSI. Persons
eligible for SSI are low-income, AND aged, blind, or disabled.
Eligibility for SSI is effective on the first day of the
month following the date the individual was determined
eligible. Medicaid for SSI eligible individuals would therefore
also become available on the first day of the month following
the date the individual was determined eligible for SSI.
An example can help to clarify: A woman has a child on
December 3; the child is born with a disabling condition and is
placed in a neonatal intensive care unit for 6 weeks. On
December 4, the child's mother applies for SSI with the help of
a hospital aide. SSI is established for the child based on the
disability that exists on December 4. Due to the administration
of the program, SSI would not begin until January 1, and
therefore Medicaid would begin on Jan. 1. Under this example,
28 days of hospital bills will likely go unpaid by the family.
The hospital would assume the costs.
This provision removes the arbitrary ``first date of the
following month'' rule as it applies to Medicaid without
changing SSI in any way. This provision allows Medicaid
coverage to apply upon the date that SSI disability
determination is made--which is December 4 in example above.
This provision will assist low-income families as well as
hospitals.
States who are considered to be 209(b) States have more
restrictive policies and therefore this provision does not
apply to those States.
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 Family
Opportunity Act of 2002.
IMPACT ON INDIVIDUALS AND BUSINESSES
The bill as reported would expand eligibility and benefits
for children with disabilities under the Medicaid program. The
mark would give States the option of providing coverage to
certain children who meet the disability standard used in the
Supplemental Security Income program but are ineligible for SSI
because they do not meet that program's income or asset
requirements. The bill would also allow States to provide home
and community-based services to individuals under age 21 who
need inpatient psychiatric hospital services, and would extend
eligibility to SSI recipients under age 21 during the month
that they apply for SSI benefits
Specifically, Section 2(a) creates a State option to allow
families of disabled children to purchase Medicaid coverage.
Section 3(a) expands authority under Medicaid for the
development of 1915(c) waivers, also known as home and
community-based waivers. Section 4(a) provides increased
funding under Title V of the Social Security Act for the
development of new family-to-family health information centers.
None of the aforementioned provisions poses a mandate on
States; each provision provides new options for States to
consider. If a State takes up an option, the program would be
utilized on a voluntary basis by disabled children and their
families. Therefore, no provision imposes any additional
paperwork or regulatory burdens on State governments or
individuals.
Section 2(b) includes a provision that requires States to
require participating parents to take up employer-sponsored
coverage if the parent of a disabled child is offered family
coverage under a group health plan and the employer contributes
at least 50 percent of the annual premium costs. This
requirement is a condition of eligibility for the participating
parent; however, since the requirement only applies to parents
who are offered employer-sponsored coverage, it is implicit
that the employer is already offering employer-sponsored
coverage to employees. Therefore, this provision does not
impose any additional paperwork or regulatory burden on
businesses.
Section 2(c) establishes a new section to Medicaid law
governing premiums applicable to the new optional eligibility
group. It would allow States to require families with disabled
children eligible for Medicaid under the new optional
eligibility group to pay monthly premiums for enrollment in
Medicaid on a sliding scale based on family income. Aggregate
payments for premiums paid by families for employer-sponsored
family coverage may not exceed 5 percent of income. Because
participation in the program is voluntary, no individual is
subject to this provision unless one opts to participate.
Section 5(a) addresses a technical correction in Medicaid
by conferring Medicaid and SSI eligibility to persons under age
21 and who are eligible for SSI. This provision does not impose
additional paperwork or regulatory burdens on businesses or
individuals.
IMPACT ON PERSONAL PRIVACY
The Committee mark permits States to provide new pathways
for Medicaid eligibility to children with disabilities who are
not presently eligible. To establish eligibility for coverage
in States that take up a new option, parents of children with
disabilities 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 parents must provide.
B. Unfunded Mandates Statement
According to the Congressional Budget Office, the bill as
reported contains no intergovernmental or private sector
mandates as defined by the Unfunded Mandates Reform Act (UMRA).
IV. BUDGET EFFECTS
In total, the Congressional Budget Office estimates that
enacting the bill as reported would increase mandatory spending
(primarily for expanded Medicaid assistance) by $0 in 2004 and
by $7.03 billion over the 2004-2013 period. CBO also estimates
that appropriation of the authorized amounts for the health
information centers would cost $10 million over the 2005-2010
period. CBO estimates that total State spending for Medicaid
would increase by $5.5 billion over the 2004-2013 period and
that State spending for the State Children's Health Insurance
Program (SCHIP) would decrease by $110 million over the same
period.
Following is the Congressional Budget Office's full
statement on this bill:
S. 622--Family Opportunity Act of 2003
Summary: S. 622 would expand eligibility and benefits for
disabled children under the Medicaid program. The bill would
give states the option of providing coverage to certain
children who meet the disability standard used in the
Supplemental Security Income (SSI) program but are ineligible
for SSI because they do not meet that program's income or asset
requirements. The bill also would allow states to provide home
and community-based services to individuals under age 21 who
need inpatient psychiatric hospital services, and would extend
eligibility to SSI recipients under age 21 during the month
that they apply for SSI benefits.
In addition, the bill would appropriate $12 million in
funding over the 2005-2007 period for health information
centers for families with disabled children, and would
authorize the appropriation of an additional $10 million for
those centers for fiscal years 2008 and 2009.
In total, CBO estimates that enacting S. 622 would increase
mandatory spending (primarily for expanded Medicaid assistance)
by $52 million in 2005 and by $7 billion over the 2004-2013
period. The bill would not affect spending in 2004. CBO also
estimates that appropriation of the authorized amounts for the
health information centers would cost $10 million over the
2008-2012 period.
The bill contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
CBO estimates that total state spending for Medicaid would
increase by $5.5 billion over the 2004-2013 period, and that
state spending for the State Children's Health Insurance
Program (SCHIP) would decrease by $110 million over the same
period.
Estimated cost to the Federal Government: The estimated
budgetary impact of S. 622 is shown in the following table. The
costs of this legislation fall within budget function 550
(health).
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------------------------------------------
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2004-13
----------------------------------------------------------------------------------------------------------------
CHANGES IN DIRECT SPENDING
Medicaid coverage for
disabled children:
Medicaid:
Estimated budget 0 0 90 260 490 670 790 840 900 970 5,010
authority..........
Estimated outlays... 0 0 90 260 490 670 790 840 900 970 5,010
State Children's Health
Insurance Program:
Budget authority.... 0 0 0 0 0 0 0 0 0 0 0
Estimated outlays... 0 0 -10 -25 -45 -35 -60 -60 -60 45 -250
Medicaid interaction
with SCHIP:
Estimated budget 0 0 0 -10 -20 -45 -40 -50 -50 -25 -240
authority..........
Estimated outlays... 0 0 0 -10 -20 -45 -40 -50 -50 -25 -240
Medicaid home and community-
based services:
Estimated budget 0 25 90 170 230 260 295 335 375 425 2,205
authority..............
Estimated outlays....... 0 25 90 170 230 260 295 335 375 425 2,205
Medicaid eligibility for
certain SSI recipients:
Estimated budget 0 25 25 25 30 30 35 40 40 45 295
authority..............
Estimated outlays....... 0 25 25 25 30 30 35 40 40 45 295
Health information centers:
Budget authority........ 0 3 4 5 0 0 0 0 0 0 12
Estimated outlays....... 0 2 3 4 2 * * 0 0 0 12
Total changes in direct
spending:
Estimated budget 0 53 209 450 730 915 1,080 1,165 1,265 1,415 7,282
authority..............
Estimated outlays....... 0 52 198 424 687 880 1,020 1,105 1,205 1,460 7,032
CHANGES IN SPENDING SUBJECT TO APPROPRIATION
Health information centers:
Authorization level..... 0 0 0 0 5 5 0 0 0 0 10
Estimated outlays....... 0 0 0 0 3 5 2 1 * 0 10
----------------------------------------------------------------------------------------------------------------
Note.--Components may not sum to totals because of rounding. * = less than $500,000.
Basis of estimate: Enacting S. 622 would have significant
effects on direct spending over the next 10 years, as well as a
small effect on discretionary spending beginning in 2008.
Direct spending
CBO estimates that S. 622 would increase direct spending by
a total of $7 billion over the 2004-2013 period. Those costs
would be due primarily to expanded Medicaid coverage of
disabled children and the increased use of Medicaid home and
community-based services.
Medicaid Coverage for Certain Disabled Children. Section 2
of the bill would allow state Medicaid programs to cover
individuals under age 18 who meet the disability standard used
for children in the SSI program but do not meet the program's
income or asset restrictions. Eligibility would be limited to
children with family income below a specified amount, set by
each state, that could not exceed 250 percent of the federal
poverty level. The parents of those children would be required
to purchase private health insurance through their employer if
the employer offers family coverage and subsidizes at least 50
percent of the cost of premiums. States also would be able to
impose premiums on a sliding sale for the Medicaid coverage.
This provision would take effect on October 1, 2005.
CBO estimates that this provision would lead to a net
increase in direct spending of $4.5 billion over the 2006-2013
period. Additional Medicaid spending for disabled children
would cost $5.0 billion over that period, but those costs would
be offset by savings of $0.3 billion in SCHIP and $0.2 billion
in Medicaid because of interactions between Medicaid and SCHIP.
The provision's effects are discussed in greater detailed
below.
Number of Disabled Children. CBO relied on data from the
National Health Interview Survey (NHIS) on the number of people
with disabilities in 1994 and population projections from the
Social Security Administration to estimate the number of
children that have a disability that meets the SSI standard. We
made several adjustments to the number of children that the
NHIS estimated had a ``specific, chronic, and life-limiting''
disability--the most severe definition used in the survey. We
accounted for underreporting (the NHIS did not assess all forms
of disability) and excluded 18-year-olds, who would not be
eligible under the bill.
The SSI disability standard for children is quite
stringent, requiring a child to have a medically determinable
condition that results in ``marked and severe functional
limitations'' and will either last at least 12 months or result
in death. For this reason, CBO assumed that only 90 percent of
those children would qualify as disabled under the bill. After
those adjustments, CBO estimated that 2.6 million children--
about 3.4 percent of U.S. children--would meet the SSI
disability standard in fiscal year 2006, the year the provision
would take effect.
CBO anticipates that about 1.7 million of those children
would be receiving Medicaid under current law, either as SSI
recipients (who are automatically eligible for Medicaid in most
states) or under other eligibility categories. The remaining
900,000 children, who have a disability that meets the SSI
standard but are not enrolled in Medicaid, form the starting
point in estimating the number of new Medicaid recipients under
the bill. We estimate that the number of children in this
category would gradually decline to about 800,000 by 2013,
mainly because of continued growth in the number of SSI
recipients.
Number of New Enrollees. CBO classified the disabled
children not enrolled in Medicaid by family income and health
insurance status using research from the NHIS, the General
Accounting Office, the Economic and Social Research Institute,
and other sources. (We estimate that about half of those
children have family incomes below 250 percent of the poverty
level and a majority of them have private health insurance.) We
then estimated the additional Medicaid enrollment under the
bill by making assumptions about the eligibility limits that
participating states would set and the premium amounts that
they would charge.
CBO anticipates that most of the states that expand
Medicaid coverage under the bill would set their eligibility
limits around 200 percent of the poverty level and that only a
minority of participating states would set their limits above
that level. We also expect that states would require the new
enrollees to pay premiums on a sliding scale, as allowed under
the bill. We assume that the premiums charged would range from
zero for families with incomes below the poverty level to 2.5
percent of income for families with income equal to 250 percent
of the poverty level.
CBO estimated the number of children that would enroll
under the bill based on research from several sources on
participation rates in SCHIP, where premiums are commonly
charged. (Medicaid generally does not allow states to charge
premiums.) We assumed that the participation rate under the
bill would be on the high end of rates found in the studies.
Families with disabled children are less likely than SCHIP
families to view premiums as a deterrent because disabled
children frequently have high medical expenses.
Overall, CBO estimates that Medicaid enrollment in 2006
would increase by about 90,000 children on a full-year
equivalent basis, if all states decide to provide coverage
under the bill. (Projected state participation is discussed
below.) After 2009, the additional enrollment would range
between 140,000 and 150,000 annually.
Based on research on health insurance coverage, we estimate
that most of the additional enrollees--about 65 percent--also
would have private health insurance from an employer that pays
at least 50 percent of the cost of premiums. Another 15 percent
otherwise would have private health insurance from an employer
that pays less than 50 percent of the cost of premiums; CBO
assumes that this group would substitute coverage under the
bill for family coverage. The remaining 20 percent would be
uninsured.
Effect on the Medically Needy. In addition to new
enrollees, the bill also would affect some children who receive
Medicaid under current law through what is known as a
``medically needy'' program. About 35 states currently have
medically needy programs that allow individuals to receive
Medicaid after first spending a specified portion of their
income on medical expenses. CBO anticipates that some of those
states also would cover disabled children under the bill. In
those states, some children who now receive Medicaid through a
medically needy program would be able to qualify under the new
eligibility category for disabled children. Medicaid spending
for those children would increase because the program would now
provide benefits without first requiring the children's
families to pay some costs themselves.
CBO estimates that about 2,000 medically needy children in
2006 would qualify under the new eligibility category for
disabled children. This figure would rise to about 10,000 in
later years. Those estimates are based on enrollment data from
the Centers for Medicare & Medicaid Services (CMS) and reflect
CBO's assumptions about the number of states that would provide
Medicaid coverage under the bill.
Per Capita Costs. CBO used two sets of per capita costs for
newly enrolled disabled children--one for children with
Medicaid only and another for those with both Medicaid and
private health insurance. We estimate that the federal costs
per full-year equivalent for children with Medicaid only would
be about $7,300 in 2006, rising to $12,700 in 2013. For
children with private health insurance, the Medicaid costs
would be about $4,000 in 2006 and increase to $7,200 in 2013.
Costs for children with private health coverage would be lower
than for children with Medicaid only because private insurance
would cover some costs that Medicaid would otherwise pay. Those
estimates are based on Medicaid spending data from CMS and
research on the value of private health insurance under the
Federal Employees Health Benefits Program.
As noted above, the bill also would increase Medicaid
spending for some children who currently qualify through
medically needy programs. CBO estimates that the additional
federal spending for those children would be about $1,200 in
2006 and rise to $1,900 by 2013.
State Participation. CBO anticipates that under the bill
states with about 10 percent of potential Medicaid costs would
choose to cover disabled children in 2006. We expect that
proportion to reach two-thirds by 2009 and remain at that level
in subsequent years.
CBO believes that state participation eventually would be
relatively high because the bill would give states another way
to pay for services for children who are covered by the
Individuals with Disabilities Education Act (IDEA), which
requires states to provide special education services to all
eligible students. States pay most of the costs of IDEA;
federal funding for the program is subject to appropriation and
represents less than 20 percent of the program's total cost.
Because the bill expands Medicaid to more disabled children,
states would be able to use Medicaid to pay for some of the
services, such as transportation and physical therapy, that
states currently provide to IDEA-eligible students. Medicaid
would be an attractive funding source because the federal
government pays at least 50 percent of the program's total cost
and funding for the program is open-ended (i.e., it is not
limited by appropriation or any other programmatic cap).
Premiums. The bill would allow states to charge premiums
set on a sliding scale for Medicaid coverage for the newly
eligible disabled children. Those premiums could not exceed 5
percent of family income and would be reduced to account for
any premiums that families would be required to pay for private
health insurance. CBO assumes that states would impose premiums
only on families with incomes above the federal poverty level,
and that the maximum premium would be 2.5 percent of income for
families with income equal to 250 percent of the federal
poverty level. (Using current poverty guidelines, the maximum
premium would be about $100 per month for a family of four.)
CBO estimates that the federal share of premium receipts
would be about $2 million in 2006 and would rise to $20 million
by 2013. Those receipts would offset only a small portion of
the bill's costs because premiums would be based on family
income rather than actual costs, which would be high for the
children covered under the bill. The share of costs offset by
the premiums also would decline over time because family income
is expected to grow more slowly than the costs of medical care.
Additional Administrative Costs. CBO estimates that the
bill would increase spending on Medicaid administrative costs
by about $40 million in 2006, rising to $100 million by 2013.
We anticipate that about 25 percent of those costs would be for
eligibility determinations, claims processing, and collection
of premiums. We assume that costs for eligibility
determinations would be similar to those for disabled SSI
applicants. The remainder would be administrative costs for
disabled children that are currently paid by local school
systems.
Effect on SCHIP. CBO anticipates that some of the disabled
children who would receive Medicaid under the bill would be
enrolled in SCHIP under current law. Because children who are
eligible for Medicaid cannot receive SCHIP, the bill would lead
to savings in SCHIP.
CBO estimates that about 2,000 children would lose their
SCHIP eligibility in 2006 under the bill. That figure would
rise to about 21,000 children by 2010, before declining
slightly in later years. Those figures are based on the NHIS
disability survey and account for state participation. The
number of affected children would decline in later years
because CBO's baseline projections assume that annual SCHIP
funding will remain constant after 2007. (Unlike Medicaid,
which is an open-ended entitlement program, annual funding
levels for SCHIP are set at specific amounts.) Since we expect
the cost of medical care to continue growing in those years, we
assume that one of the ways that states will respond will be to
trim enrollment.
CBO varied the per capita savings for those children by
type of SCHIP program. (A state can administer its SCHIP
program either as an expansion of its Medicaid program or as a
completely separate program.) Federal savings per capita in
states with Medicaid expansions, which provide the
comprehensive Medicaid package of benefits, would rise from
$8,900 in 2006 to $15,600 in 2013. For states with separate
programs, which provide less generous benefits, the
corresponding savings would be $4,000 in 2006 and $6,800 in
2013. CBO assumes that about 80 percent of affected children
would come from states that administer their SCHIP programs
separately from Medicaid.
Based on those assumptions, CBO estimates that moving SCHIP
disabled children to Medicaid would reduce SCHIP spending by
$900 million over the 2004-2013 period. However, states would
use some of those savings to cover other children under SCHIP,
particularly in later years as constraints on spending grow
tighter. On net, estimated savings would be $250 million over
the 10-year period.
Medicaid Interaction with SCHIP. Under current law, CBO
expects that states will adopt a variety of measures to respond
to the limited availability of SCHIP funds. One response--
trimming enrollment--has already been discussed. We also
anticipate that states will react by expanding Medicaid
eligibility and shifting some children from SCHIP to Medicaid.
That approach would enable states to continue receiving federal
matching funds (albeit at a less-favorable match rate) and
avoid cutting enrollment.
Since S. 622 would free up SCHIP funds to cover more
nondisabled children states would not need to rely on Medicaid
to cover those children. As a result, CBO estimates that this
effect would lead to savings in Medicaid totaling $240 million
over the 2004-2013 period.
Medicaid Home and Community-Based Services. Under Medicaid,
states can establish programs--known as 1915(c) waiver programs
after the section of the Social Security Act that authorizes
them--that provide coverage for home and community-based
services for individuals who otherwise would need services in
an institution. Current law limits eligibility for 1915(c)
waiver programs to individuals who otherwise would need
services in a hospital, nursing home, or intermediate care
facility for the mentally retarded. Section 3 of the bill would
allow 1915(c) waiver programs to cover individuals under age 21
who would otherwise need services in an inpatient psychiatric
hospital. This provision would take effect on October 1, 2004.
CBO estimates that this provision would increase net
federal spending on Medicaid by $25 million in 2005 and by $2.2
billion over the 2004-2013 period. Spending on home and
community-based services would increase by about $3.3 billion
over that period, and be offset by $1.1 billion in savings on
spending for institutional services.
Spending on Home and Community-Based Services. CBO assumes
that this provision would affect the same population as section
2 of the bill--children who have a disability that meets the
SSI standard but are not enrolled in Medicaid. Based on
research by the General Accounting Office, CBO assumes that
about 25 percent of those children have a mental disorder. We
increased the number of disabled children with mental disorders
to account for those between the ages of 18 and 20, who are
ineligible under section 2. After those adjustments, CBO
anticipates that the number of children potentially affected by
the bill would be about 295,000 in 2005 and would decline to
about 250,000 by 2013.
CBO anticipates that this provision would increase
enrollment in 1915(c) waiver programs by about 2,400 children
in 2005, rising to 17,300 by 2013. About 80 percent of those
children would be new Medicaid enrollees; the remainder would
be existing enrollees that now receive institutional services.
The new enrollees would ultimately be about 5 percent of the
eligible population. Based on CMS data for current enrollees in
1915(c) waivers, CBO estimates that the per capita costs for
those children would be about $17,900 in 2005 and would rise to
$35,700 by 2013.
The additional spending for those children would represent
only a modest increase in spending on 1915(c) waiver programs.
The waivers are commonly use in Medicaid, partly because states
can limit total enrollment in the programs. Based on data from
CMS, we estimate that the number of people enrolled in 1915(c)
waiver programs under current law will increase from about
680,000 in 2005 to about 820,000 by 2013. During the same
period, federal spending on those waivers will jump from $12.8
billion to $30.8 billion. S. 622 would thus raise both the
number of enrollees and spending in 1915(c) waiver programs by
about 2 percent.
Spending on Institutional Services. Using data from CMS,
CBO estimates that under current law Medicaid covers about
50,000 children annually in inpatient psychiatric hospitals.
Under the bill, some of those children would be able to receive
services in the community instead of in an institution.
Services in an institution are extremely expensive, so the
shift to home and community-based services for those children
would reduce Medicaid spending.
As noted earlier, CBO estimates that about 20 percent of
the new enrollees in 1915(c) waivers under the bill would be
children that previously received institutional services.
Drawing on CMS data, we estimate that per capita savings for
those children would rise from about $69,000 in 2005 to
$110,000 in 2013. However, we anticipate that only 50 percent
of those savings would be realized because some of the newly
available capacity in psychiatric institutions would be used to
serve additional Medicaid enrollees.
Medicaid Eligibility for Certain SSI Recipients. Before the
enactment of welfare reform in 1996, applications for SSI
benefits were considered effective on the day that they were
submitted. The welfare reform law changed the effective date of
SSI applications to the first day of the following month and
delayed when applicants become eligible for SSI. Since most SSI
recipients are automatically eligible for Medicaid, the
provision also delayed the effective date of Medicaid
eligibility for new SSI recipients.
Section 5 of S. 622 would restore Medicaid eligibility for
SSI recipients under age 21 between the day they apply for
benefits and the first day of the following month. This
provision would take effect on October 1, 2004. CBO estimates
that this provision would increase federal Medicaid spending by
$25 million in 2005 and $295 million over the 2004-2013 period.
We estimate that about 210,000 people under age 21 would
become eligible for SSI in 2005, rising to about 220,000 by
2013. However, we anticipate that only about a third of those
individuals would be affected by the bill. The remainder would
be able under current law to offset the effects of the welfare
reform law by using other eligibility categories to receive
Medicaid between the day they apply for SSI benefits and the
first day of the following month.
CBO assumes that the individuals affected by this provision
would receive an additional two weeks of Medicaid benefits, on
average. Based on Medicaid spending for disabled recipients, we
estimate that the federal cost per capita of those additional
benefits would be about $320 in 2005 and increase to about $610
and 2013.
Health Information Centers. Section 4 would require the
Secretary of Health and Human Services to establish health
information centers that provide various types of assistance to
families with disabled children. Those services would include
providing information on available health care resources and
identifying successful ways to provide health care to disabled
children. The centers would be part of the Maternal and Child
Health grant program administered by the Health Resources and
Services Administration.
The bill would fund the health information centers by
appropriating $3 million in 2005, $4 million in 2006, and $5
million in 2007. CBO estimates that outlays from that funding
would be $2 million in 2005 and a total of $12 million over the
2005-2010 period. Our estimate is based on historical spending
patterns in the Maternal and Child Health grant program.
Spending subject to appropriation
The bill would make funding for the health information
centers subject to appropriation in 2008 and 2009, and would
authorize the appropriation of $5 million in each of those
years. Assuming appropriation of the authorized amounts, CBO
estimates that this provision would cost $10 million over the
2008-2012 period.
Intergovernmental and private-sector impact: The bill
contains no intergovernmental or private-sector mandates as
defined in UMRA. CBO estimates that, assuming states take
advantage of the options provided in the bill, total state
spending for Medicaid would increase by $5.5 billion over the
2004-2013 period, and that state spending for SCHIP would
decrease by $110 million over the same period.
Estimate prepared by: Federal Costs: Eric Rollins and
Jeanne De Sa. Impact on State, Local, and Tribal Governments:
Leo Lex. Impact on the Private Sector: Stuart Hagen.
Estimate approved by: Peter H. Fontaine, Deputy Assistant
Director for Budget Analysis.
V. VOTES OF THE COMMITTEE
On September 10, 2003, a substitute for S. 622, entitled
``The Family Opportunity 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, exiting law in which no change is
proposed is shown in roman):
SOCIAL SECURITY ACT
* * * * * * *
TITLE V--MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT
* * * * * * *
AUTHORIZATION OF APPROPRIATIONS
Sec. 501. * * *
* * * * * * *
(c)(1)(A) For the purpose of enabling the Secretary
(through grants, contracts, or otherwise) to provide for
special projects of regional and national significance for the
development and support of family-to-family health information
centers described in paragraph (2)--
(i) there is appropriated to the Secretary, out of
any money in the Treasury not otherwise appropriated--
(I) $3,000,000 for fiscal year 2005;
(II) $4,000,000 for fiscal year 2006; and
(III) 5,000,000 for fiscal year 2007; and
(ii) there is authorized to be appropriated to the
Secretary, $5,000,000 for each of fiscal years 2008 and
2009.
(B) Funds appropriated or authorized to be appropriated
under subparagraph (a) shall--
(i) be in addition to amounts appropriated under
subsection (a) and retained under section 502(a)(1) for
the purpose of carrying out activities described in
subsection (a)(2); and
(ii) remain available until expended.
(2) The family-to-family health information centers
described in this paragraph are centers that--
(A) assist families of children with disabilities or
special health care needs to make informed choices
about health care in order to promote good treatment
decisions, cost-effectiveness, and improved health
outcomes for such children;
(B) provide information regarding the health care
needs of, and resources available for, children with
disabilities or special health care needs;
(C) identify successful health delivery models for
such children;
(D) develop with representatives of health care
providers, managed care organizations, health care
purchasers, and appropriate State agencies a model for
collaboration between families of such children and
health professionals;
(E) provide training and guidance regarding caring
for such children;
(F) conduct outreach activities to the families of
such children, health professionals, schools, and other
appropriate entities and individuals; and
(G) are staffed by families of children with
disabilities or special health care needs who have
expertise in Federal and State public and private
health care systems and health professionals.
(3) The Secretary shall develop family-to-family health
information centers described in paragraph (2) in accordance
with the following:
(A) With respect to fiscal year 2004, such centers
shall be developed in not less than 25 States.
(B) With respect to fiscal year 2005, such centers
shall be developed in not less than 40 States.
(C) With respect to fiscal year 2006, such centers
shall be developed in all States.
(4) The provisions of this title that are applicable to the
funds made available to the Secretary under section 502(a)(1)
apply in the same manner to funds made available to the
Secretary under paragraph (1)(A).
(5) For purposes of this subsection, the term ``State''
means each of the 50 States and the District of Columbia.
TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS \1\
* * * * * * *
STATE PLANS FOR MEDICAL ASSISTANCE
Sec. 1902. (a) A State plan for medical assistance must--
* * * * * * *
(10) provide--
(A) for making medical assistance available,
including at least the care and services listed
in paragraphs (1) through (5), (17) and (21) of
section 1905(a), to--
(i) all individuals--
(I) who are receiving aid or
assistance under any plan of
the State approved under title
I, X, XIV, or XVI, or part A or
part E of title IV (including
individuals eligible under this
title by reason of section
402(a)(37), 406(h), or 473(b),
or considered by the State to
be receiving such aid as
authorized under section
482(e)(6)),
(II) (aa) with respect to
whom supplemental security
income benefits are being paid
under title XVI (or were being
paid as of the date of the
enactment of section 211(a) of
the Personal Responsibility and
Work Opportunity Reconciliation
Act of 1996 (P.L. 104--193)
[and] and would continue to be
paid but for the enactment of
that [section or who are]
section), (bb) who are
qualified severely impaired
individuals (as defined in
section 1905(q)), or (cc) who
are under 21 years of age and
with respect to whom
supplemental security income
benefits would be paid under
title XVI if subparagraphs (A)
and (B) of section 1611(c)(7)
were applied without regard to
the phrase ``the first day of
the month following''.
* * * * * * *
(ii) * * *
* * * * * * *
(XVII) who are independent
foster care adolescents (as
defined in section 1905(w)(1)),
or who are within any
reasonable categories of such
adolescents specified by the
State; [or]
(XVIII) who are described in
subsection (aa) (relating to
certain breast or cervical
cancer patients); or
(XIX) who are disabled
children described in
subsection (cc)(1);
* * * * * * *
(cc)(1) Individuals described in this paragraph are
individuals--
(A) who have not attained 18 years of age;
(B) who would be considered disabled under section
1614(a)(3)(C) but for having earnings or deemed income
or resources (as determined under title XVI for
children) that exceed the requirements for receipt of
supplemental security income benefits; and
(C) whose family income does not exceed such income
level as the State establishes and does not exceed--
(i) 250 percent of the income official
poverty line (as defined by the Office of
Management 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; or
(ii) such higher percent of such poverty line
as a State may establish, except that--
(I) any medical assistance provided
to an individual whose family income
exceeds 250 percent of such poverty
line may only be provided with State
funds; and
(II) no Federal financial
participation shall be provided under
section 1903(a) for any medical
assistance provided to such an
individual.
(2)(A) If an employer of a parent of an individual
described in paragraph (1) offers family coverage under a group
health plan (as defined in section 2791(a) of the Public Health
Service Act), the State shall--
(i) require such parent to apply for, enroll in, and
pay premiums for, such coverage as a condition of such
parent's child being or remaining eligible for medical
assistance under subsection (a)(10)(A)(ii)(XIX) if the
parent is determined eligible for such coverage and the
employer contributes at least 50 percent of the total
cost of annual premiums for such coverage; and
(ii) if such coverage is obtained--
(I) subject to paragraph (2) of section
1916(h), reduce the premium imposed by the
State under that section in an amount that
reasonably reflects the premium contribution
made by the parent for private coverage on
behalf of a child with a disability; and
(II) treat such coverage as a third party
liability under subsection (a)(25).
(B) In the case of a parent to which subparagraph (A)
applies, a State, subject to paragraph (1)(C)(ii), may provide
for payment of any portion of the annual premium for such
family coverage that the parent is required to pay. Any
payments made by the State under this subparagraph shall be
considered, for purposes of section 1903(a), to be payments for
medical assistance.
* * * * * * *
PAYMENT TO STATES
Sect. 1903. * * *
* * * * * * *
(f)(1)(A) * * *
* * * * * * *
(4) The limitations on payment imposed by the preceding
provisions of this subsection shall not apply with respect to
any amount expended by a State as medical assistance for any
individual described in section 1902(a)(10)(A)(i)(III), ,
1902(a)(10)(A)(i)(IV), 1902(a)(10)(A)(i)(V),
1902(a)(10)(A)(i)(VI), 1902(a)(10)(A)(i)(VII),
1902(a)(10)(A)(ii)(IX), 1902(a)(10)(A)(ii)(X),
1902(a)(10)(A)(ii)(XIII), 1902(a)(10)(A)(ii)(XIV),
1902(a)(10)(A)(ii)(XV), 1902(a)(10)(A)(ii)(XVI),
1902(a)(10)(A)(ii)(XVII), 1902(a)(10)(A)(ii)(XVIII),
1902(a)(10)(A)(ii)(XIX), or 1905(p)(1) or for any individual--
* * * * * * *
PROVISIONS RESPECTING INAPPLICABILITY AND WAIVER OF CERTAIN
REQUIREMENTS OF THIS TITLE
Sec. 1915. * * *
* * * * * * *
(c)(1) The Secretary may by waiver provide that a State
plan approved under this title may include as ``medical
assistance'' under such plan payment for part or all of the
cost of home or community-based services (other than room and
board) approved by the Secretary which are provided pursuant to
a written plan of care to individuals with respect to whom
there has been a determination that but for the provision of
such services the individuals would require the level of care
provided in a hospital or a nursing facility or intermediate
care facility for the mentally retarded, or would require
inpatient psychiatric hospital services for individuals under
age 21, the cost of which could be reimbursed under the State
plan. For purposes of this subsection, the term ``room and
board'' shall not include an amount established under a method
determined by the State to reflect the portion of costs of rent
and food attributable to an unrelated personal caregiver who is
residing in the same household with an individual who, but for
the assistance of such caregiver, would require admission to a
hospital, nursing facility, or intermediate care facility for
the mentally retarded or would require inpatient psychiatric
hospital services for individuals under age 21.
(2) A waiver shall not be granted under this subsection
unless the State provides assurances satisfactory to the
Secretary that--
(A) necessary safeguards (including adequate
standards for provider participation) have been taken
to protect the health and welfare of individuals
provided services under the waiver and to assure
financial accountability for funds expended with
respect to such services;
(B) the State will provide, with respect to
individuals who--
(i) are entitled to medical assistance for
inpatient hospital services, nursing facility
services, [or services in an intermediate care
facility for the mentally retarded] services in
an intermediate care facility for the mentally
retarded, or inpatient psychiatric hospital
services for individuals under age 21 under the
State plan,
(ii) may require such services, and
(iii) may be eligible for such home or
community-based care under such waiver,
for an evaluation of the need for inpatient hospital
services, nursing facility services, [or services in an
intermediate care facility for the mentally retarded]
services in an intermediate care facility for the
mentally retarded, or inpatient psychiatric hospital
services for individuals under age 21;
(C) such individuals who are determined to be likely
to require the level of care provided in a hospital,
nursing facility, or intermediate care facility for the
mentally retarded, or who are determined to be likely
to require inpatient psychiatric hospital services for
individuals under age 21, are informed of the feasible
alternatives, if available under the waiver, at the
choice of such individuals, to the provision of
inpatient hospital services, nursing facility services,
[or services in an intermediate care facility for the
mentally retarded] services in an intermediate care
facility for the mentally retarded, or inpatient
psychiatric hospital services for individuals under age
21;
* * * * * * *
(7)(A) In making estimates under paragraph (2)(D) in the
case of a waiver that applies only to individuals with a
particular illness or condition who are inpatients in, or who
would require the level of care provided in, hospitals, nursing
facilities, or intermediate care facilities for the mentally
retarded, ``or would require inpatient psychiatric hospital
services for individuals under age 21, the State may determine
the average per capita expenditure that would have been made in
a fiscal year for those individuals under the State plan
separately from the expenditures for other individuals who are
inpatients in, or who would require the level of care provided
in, those respective facilities or who would require inpatient
psychiatric hospital services for individuals under age 21.
* * * * * * *
USE OF ENROLLMENT FEES, PREMIUMS, DEDUCTIONS, COST SHARING, AND SIMILAR
CHARGES
Sec. 1916. (a) Subject to [subsection (g) subsections (g)
and (h)], the State plan shall provide that in the case of
individuals described in subparagraph (A) or (E)(i) of section
1902(a)(10) who are eligible under the plan--
* * * * * * *
* * * come for a year that exceeds 250 percent
of the income official poverty line (referred
to in subsection (c)(1)) applicable to a family
of the size involved, except that in the case
of such an individual who has income for a year
that does not exceed 450 percent of such
poverty line, such requirement may only apply
to the extent such premiums do not exceed 7.5
percent of such income; and
(2) such State shall require payment of 100 percent
of such premiums for a year by such an individual whose
adjusted gross income (as defined in section 62 of the
Internal Revenue Code of 1986) for such year exceeds
$75,000, except that a State may choose to subsidize
such premiums by using State funds which may not be
federally matched under this title.
In the case of any calendar year beginning after 2000, the
dollar amount specified in paragraph (2) shall be increased in
accordance with the provisions of section 215(i)(2)(A)(ii).
(h)(1) With respect to disabled children provided medical
assistance under section 1902(a)(10)(A)(ii)(XIX), subject to
paragraph (2) a State may (in a uniform manner for such
children) require the families of such children to pay monthly
premiums set on a sliding scale based on family income.
(2) A premium requirement imposed under paragraph (1) may
only apply to the extent that--
(A) the aggregate amount of such premium and any
premium that the parent is required to pay for family
coverage under section 1902(cc)(2)(A)(i) does not
exceed 5 percent of the family's income; and
(B) the requirement is imposed consistent with
section 1902(cc)(2)(A)(ii)(I).
(3) A State shall not require prepayment of a premium
imposed pursuant to paragraph (1) and shall not terminate
eligibility of a child under section 1902(a)(10)(A)(ii)(XIX)
for medical assistance under this title on the basis of failure
to pay any such premium until such failure continues for a
period of not less than 60 days from the date on which the
premium became past due. The State may waive payment of any
such premium in any case where the State determines that
requiring such payment would create an undue hardship.