Medicaid and SCHIP Provisions in H.R. 3162, S. 1893/H.R. 976, and Agreement
Order Code RL34129
Medicaid and SCHIP Provisions in
H.R. 3162, S. 1893/H.R. 976, and Agreement
Updated October 18, 2007
Evelyne P. Baumrucker, Coordinator,
Bernadette Fernandez, April Grady, Jean Hearne,
Elicia J. Herz, and Chris L. Peterson
Domestic Social Policy Division
Medicaid and SCHIP Provisions in
H.R. 3162, S. 1893/H.R. 976, and Agreement
Summary
Medicaid, authorized under Title XIX of the Social Security Act, is a federal-
state program providing medical assistance for low-income individuals who are aged,
blind, disabled, members of families with dependent children, or who have one of a
few specified medical conditions.
The Balanced Budget Act of 1997 (BBA 1997) established the State Children’s
Health Insurance Program (SCHIP) under a new Title XXI of the Social Security Act.
SCHIP builds on Medicaid by providing health insurance to uninsured children in
families with incomes above applicable Medicaid income standards. States provide
children with health insurance that meets specific standards for benefits and cost-
sharing through separate SCHIP programs, or through their Medicaid programs, or
through a combination of both. SCHIP has federal appropriations for the current
fiscal year, but none are slated for FY2008 and beyond.
The 110th Congress has considered legislation that would make important
changes to Medicaid and SCHIP. On August 1, 2007, the House passed H.R. 3162,
the Children’s Health and Medicare Protection (CHAMP) Act of 2007. The bill
would reauthorize and increase funding levels and state grant distributions for SCHIP
and make changes to the Medicare and Medicaid programs. The major SCHIP
provisions would enhance outreach and enrollment efforts to increase the number of
children covered by the program, modify the program’s citizenship verification
process, change minimum benefit requirements, among other changes.
On July 19, 2007, the Senate Finance Committee marked up the Children’s
Health Insurance Program Reauthorization Act of 2007 (S. 1893/H.R. 976). The
Senate struck the language in an unrelated House-passed tax measure (H.R. 976) and
replaced it with the language contained in S. 1893, as approved by the Senate Finance
Committee. A total of 92 amendments were offered, with 9 adopted. The bill passed
the Senate on August 2, 2007. The Senate bill provides authorized appropriations to
SCHIP through FY2012 and changes how federal SCHIP funds are allotted to states.
Other key provisions would enhance the program’s outreach and enrollment efforts,
extend coverage to pregnant women, and alter the citizenship verification process for
program eligibility.
A bicameral agreement on SCHIP reauthorization passed the House as an
amendment to H.R. 976 on September 25, and also passed the Senate on September
27. President Bush vetoed the legislation on October 3, 2007. The House sustained
the President’s veto with a vote on October 18, 2007.
The following side-by-side comparison provides a brief description of current
law and the changes that would be made to Medicaid and SCHIP under H.R. 3162,
S. 1893/H.R. 976, and the bicameral agreement. Medicare provisions in Titles II
through VII of H.R. 3162, provisions related to support to injured service members,
military family job protection, and Sense of the Senate regarding health care access
are not described here. This report will be updated as legislative activity warrants.
Key Policy Staff:
The Children's Health and Medicare Protection Act of 2007 and
The Children’s Health Insurance Program Reauthorization Act of 2007
Area of Expertise
Name
Phone
Coordinator
Evelyne P. Baumrucker
7-8913 ebaumrucker@crs.loc.gov
Funding/Financing
Chris L. Peterson
7-4681 cpeterson@crs.loc.gov
Funding for the Territories
Chris L. Peterson
7-4681 cpeterson@crs.loc.gov
Evelyne P. Baumrucker
7-8913 ebaumrucker@crs.loc.gov
Federal Matching Payments April Grady
7-9578 agrady@crs.loc.gov
Eligibility
Elicia J. Herz
7-1377 eherz@crs.loc.gov
Optional Coverage of Older
Children
Elicia J. Herz
7-1377 eherz@crs.loc.gov
Optional Coverage of
Pregnant Women
Elicia J. Herz
7-1377 eherz@crs.loc.gov
Coverage of Non-pregnant
Childless Adults and
Parents
Evelyne P. Baumrucker
7-8913 ebaumrucker@crs.loc.gov
Legal Immigrants
Evelyne P. Baumrucker
7-8913 ebaumrucker@crs.loc.gov
Medicaid Temporary
Medical Assistance (TMA)
April Grady
7-9578 agrady@crs.loc.gov
Spousal Impoverishment
and Asset Verification
Julie L. Stone
7-1386 jstone@crs.loc.gov
Enrollment/Access
Evelyne P. Baumrucker
7-8913 ebaumrucker@crs.loc.gov
Citizenship Documentation
April Grady
7-9578 agrady@crs.loc.gov
Crowd-Out
Elicia J. Herz
7-1377 eherz@crs.loc.gov
Chris Peterson
7-4681 cpeterson@crs.loc.gov
Premium Assistance/Employer
Buy-in
Evelyne P. Baumrucker
7-8913 ebaumrucker@crs.loc.gov
Benefits
Elicia J. Herz
7-1377 eherz@crs.loc.gov
Family Planning Services
Evelyne P. Baumrucker
7-8913 ebaumrucker@crs.loc.gov
Monitoring Quality
Elicia J. Herz
7-1377 eherz@crs.loc.gov
Payments
Elicia J. Herz
7-1377 eherz@crs.loc.gov
Medicaid Drug Rebate
Jean Hearne
7-7362 jhearne@crs.loc.gov
Disproportionate Share
Hospital Payments (DSH)
Jean Hearne
7-7362 jhearne@crs.loc.gov
Contents
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Recent Legislative Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Medicaid and SCHIP Provisions in H.R. 3162, S. 1893/H.R. 976, and
the Bicameral Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Funding/Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Enrollment/Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Premium Assistance/Employer Buy-In . . . . . . . . . . . . . . . . . . . . . . . . . 6
Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Monitoring Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
References to Title XXI; Elimination of Confusing Program References . . . . . . . 8
H§155. References to Title XXI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
S§606. Elimination of confusing program references. . . . . . . . . . . . . . 8
A§1. Short Title; Amendments to Social Security Act; References;
Table of Contents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
A§612. References to Title XXI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Funding/Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CHIP appropriations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
H§101. Establishment of new base CHIP allotments. . . . . . . . . . . . . . 9
S§101. Extension of CHIP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
A§101. Extension of CHIP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
S§103. One-time appropriation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
A§108. One-time appropriation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Allotment of federal CHIP funds to states . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
H§101. Establishment of new base CHIP allotments. . . . . . . . . . . . . . 9
S§102. Allotments for the 50 states and the District of Columbia. . . . 9
A§102. Allotments for states and territories. . . . . . . . . . . . . . . . . . . . . . 9
Allotment of federal CHIP funds to territories . . . . . . . . . . . . . . . . . . . . . . 16
H§101. Establishment of new base CHIP allotments. . . . . . . . . . . . . 16
S§104. Improving funding for the territories under CHIP and
Medicaid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
A§102. Allotments for states and territories. . . . . . . . . . . . . . . . . . . . . 16
Period of availability of CHIP allotments . . . . . . . . . . . . . . . . . . . . . . . . . . 17
H§102. 2-year initial availability of CHIP allotments. . . . . . . . . . . . . 17
S§109. Two-year availability of allotments; expenditures counted
against oldest allotments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
A§105. 2-year initial availability of CHIP allotments. . . . . . . . . . . . . 17
CHIP funds for shortfall states . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
H§102. 2-year initial availability of CHIP allotments. . . . . . . . . . . . . 17
H§103. Redistribution of unused allotments to address state
funding shortfalls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
S§105. Incentive bonuses for states. . . . . . . . . . . . . . . . . . . . . . . . . . . 17
A§106. Redistribution of unused allotments to address state
funding shortfalls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
H§101. Establishment of new base CHIP allotments. . . . . . . . . . . . . 19
S§108. CHIP contingency fund. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
A§103. Child enrollment contingency fund. . . . . . . . . . . . . . . . . . . . 19
Extension of option for qualifying states
. . . . . . . . . . . . . . . . . . . . . . . . . . 22
H§104. Extension of option for qualifying states. . . . . . . . . . . . . . . 22
S§111. Option for qualifying states to receive the enhanced portion
of the CHIP matching rate for Medicaid coverage of certain
children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
A§107. Option for qualifying states to receive the enhanced portion
of the CHIP matching rate for Medicaid coverage of certain
children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Bonuses for increasing enrollment of children . . . . . . . . . . . . . . . . . . . . . . 23
H§111. CHIP performance bonus payment to offset additional
enrollment costs resulting from enrollment and retention efforts. 23
S§105. Incentive bonuses for states. . . . . . . . . . . . . . . . . . . . . . . . . . . 23
A§104. CHIP performance bonus payment to offset additional
enrollment costs resulting from enrollment and retention efforts. 23
H§135. No federal funding for illegal aliens. . . . . . . . . . . . . . . . . . . . 29
A§605. No federal funding for illegal aliens. . . . . . . . . . . . . . . . . . . . 29
Medicaid funding for the territories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
H§811. Payments for Puerto Rico and territories. . . . . . . . . . . . . . . . 30
Enhanced matching funds for certain data systems in the territories . . . . . . 31
H§811. Payments for Puerto Rico and territories. . . . . . . . . . . . . . . . . 31
S§104. Improving funding for the territories under CHIP and
Medicaid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
A§109. Improving funding for the territories under CHIP and
Medicaid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Medicaid FMAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
H§813. Adjustment in computation of Medicaid FMAP to disregard
an extraordinary employer pension contribution. . . . . . . . . . . . . 32
A§615. Adjustment in computation of Medicaid FMAP to disregard
an extraordinary employer pension contribution. . . . . . . . . . . . . 32
CHIP E-FMAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
S§110. Limitation on matching rate for states that propose to
cover children with effective family income that exceeds 300
percent of the poverty line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
A§114. Limitation on matching rate for states that propose to
cover children with effective family income that exceeds 300
percent of the poverty line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Premium grace period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
H§123. Premium grace period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
A§504. Premium grace period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Optional coverage of older children under CHIP . . . . . . . . . . . . . . . . . . . . 37
H§131. Optional coverage of children up to age 21 under CHIP. . . . 37
Optional coverage of legal immigrants in Medicaid and CHIP . . . . . . . . . 37
H§132. Optional coverage of legal immigrants under the
Medicaid program and CHIP. . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Optional coverage of pregnant women under CHIP . . . . . . . . . . . . . . . . . . 38
H§133. State option to expand or add coverage of certain pregnant
women under CHIP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
S§107. State option to cover low-income pregnant women under
CHIP through a state plan amendment. . . . . . . . . . . . . . . . . . . . . 38
A§111. State option to cover low-income pregnant women under
CHIP through a state plan amendment. . . . . . . . . . . . . . . . . . . . . 38
A§113. Elimination of counting Medicaid child presumptive
eligibility costs against title XXI allotment. . . . . . . . . . . . . . . . . 39
Nonpregnant childless adult coverage under CHIP . . . . . . . . . . . . . . . . . . 40
H§134. Limitation on waiver authority to cover adults. . . . . . . . . . . . 40
S§106. Phase-out coverage for nonpregnant childless adults under
CHIP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
A§112. Phase-Out of coverage for nonpregnant childless adults
under CHIP; conditions for coverage of parents. . . . . . . . . . . . . . 40
Parent coverage under CHIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
S§106. Conditions for coverage of parents. . . . . . . . . . . . . . . . . . . . . . 43
A§109. Phase-Out of coverage for nonpregnant childless adults
under CHIP; conditions for coverage of parents. . . . . . . . . . . . . . 43
Medicaid TMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
H§801. Modernizing transitional Medicaid. . . . . . . . . . . . . . . . . . . . . 45
A§115. State Authority Under Medicaid. . . . . . . . . . . . . . . . . . . . . . . 46
Spousal impoverishment rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
H§804. State option to protect community spouses of individuals
with disabilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Medicaid asset verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
H§817. Extension of SSI web-based asset demonstration project to
the Medicaid program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
A§619. Extension of SSI web-based asset demonstration project to
the Medicaid program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Enrollment/Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
“Express lane” eligibility determinations . . . . . . . . . . . . . . . . . . . . . . . . . . 49
H§112. State option to rely on finding from an express lane agency
to conduct simplified eligibility determinations. . . . . . . . . . . . 49
S§203. Demonstration project to permit States to rely on findings by
an Express Lane agency to determine components of a
child’s eligibility for Medicaid or CHIP. . . . . . . . . . . . . . . . . . . 49
A§203. State option to rely on finding from an Express Lane
agency to conduct simplified eligibility determinations. . . . . . . . 49
Out-stationed eligibility determinations . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
H§113. Application of Medicaid outreach procedures to all children
and pregnant women. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Funding for outreach and enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
H§114. Encouraging culturally appropriate enrollment and
retention practices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
S§201. Grants for outreach and enrollment. . . . . . . . . . . . . . . . . . . . . 55
A§201. Grants and enhanced administrative funding for outreach
and enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Continuous eligibility under CHIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
H§115. Continuous eligibility under CHIP. . . . . . . . . . . . . . . . . . . . . . 56
Commission to monitor access and other matters . . . . . . . . . . . . . . . . . . . . 57
H§141. Children’s Access, Payment and Equality Commission. . . . . 57
Model enrollment practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
H§142. Model of interstate coordinated enrollment and coverage
process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
A§213. Model of interstate coordinated enrollment and coverage
process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Citizenship documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
H§143. Medicaid citizenship documentation requirements. . . . . . . . . 59
S§301. Verification of declaration of citizenship or nationality
for purposes of eligibility for Medicaid and CHIP. . . . . . . . . . . . 59
A§211. Verification of declaration of citizenship or nationality
for purposes of eligibility for Medicaid and CHIP. . . . . . . . . . . . 59
Elimination of Health Opportunity Accounts . . . . . . . . . . . . . . . . . . . . . . . 66
H§145. Prohibiting initiation of new health opportunity
account demonstration programs. . . . . . . . . . . . . . . . . . . . . . . . . 66
A§613. Prohibiting initiation of new health opportunity
account demonstration programs. . . . . . . . . . . . . . . . . . . . . . . . . 66
Outreach and enrollment of Indians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
S§202. Increased outreach and enrollment of Indians. . . . . . . . . . . . . 66
A§202. Increased outreach and enrollment of Indians. . . . . . . . . . . . . 66
Eligibility information disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
S§204. Authorization of certain information disclosures to simplify
health coverage determinations. . . . . . . . . . . . . . . . . . . . . . . . . . 67
A§203. State option to rely on finding from an Express Lane agency
to conduct simplified eligibility determinations. . . . . . . . . . . . . . 67
Reducing administrative barriers to enrollment . . . . . . . . . . . . . . . . . . . . . . 68
S§302. Reducing administrative barriers to enrollment. . . . . . . . . . . . 68
A§212. Reducing administrative barriers to enrollment. . . . . . . . . . . . 68
Preventing Crowd-Out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
A§116. Preventing substitution of CHIP coverage for private
coverage.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Medical Child Support Under SCHIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
A§116(f). Treatment of medical support order. . . . . . . . . . . . . . . . . . 72
Premium Assistance/Employer Buy-In Programs . . . . . . . . . . . . . . . . . . . . . . . . 73
Employer Buy-in to CHIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
H§821. Demonstration project for employer buy-in. . . . . . . . . . . . . . . 73
S§401. Additional State option for providing premium assistance. . 75
A§301. Additional State option for providing premium assistance. . . 75
Education and enrollment assistance in premium assistance programs . . . 79
S§402. Outreach, education, and enrollment assistance. . . . . . . . . . . . 79
A§302. Outreach, education, and enrollment assistance. . . . . . . . . . . 79
Special enrollment period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
S§411. Special enrollment period under group health plans in case of
termination of Medicaid or CHIP coverage or eligibility for
assistance in purchase of employment-based coverage;
coordination of coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
A§311. Special enrollment period under group health plans in case of
termination of Medicaid or CHIP coverage or eligibility for
assistance in purchase of employment-based coverage;
coordination of coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Dental services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
H§121. Ensuring child-centered coverage. . . . . . . . . . . . . . . . . . . . . . 81
H§144. Access to dental care for children. . . . . . . . . . . . . . . . . . . . . . 81
S§608. Dental health grants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
A§501. Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Federally qualified health centers (FQHCs) and rural health centers (RHCs)
services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
H§121. Ensuring child-centered coverage. . . . . . . . . . . . . . . . . . . . . . 83
Mental health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
H§121. Ensuring child-centered coverage. . . . . . . . . . . . . . . . . . . . . . 84
S§607. Mental health parity in CHIP plans. . . . . . . . . . . . . . . . . . . . . 84
A§502. Mental health parity in CHIP plans. . . . . . . . . . . . . . . . . . . . . 84
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
H§121. Ensuring child-centered coverage. . . . . . . . . . . . . . . . . . . . . . 85
S§605. Deficit Reduction Act technical corrections. . . . . . . . . . . . . . . 85
A§611(a). Deficit Reduction Act technical corrections - Clarification
of requirement to provide EPSDT services for all children in
benchmark benefit packages under Medicaid. . . . . . . . . . . . . . . . 85
School-based health centers services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
H§121. Ensuring child-centered coverage. . . . . . . . . . . . . . . . . . . . . . 85
A§506. Clarification of coverage of services provided through
school-based health centers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Benchmark coverage options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
H§121. Ensuring child-centered coverage. . . . . . . . . . . . . . . . . . . . . . 86
H§122. Improving benchmark coverage options. . . . . . . . . . . . . . . . . 86
Extension of family planning services and supplies . . . . . . . . . . . . . . . . . . 87
H§802. Family planning services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Adult day health services
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
H§803. Authority to continue providing adult day health services
approved under a State Medicaid plan. . . . . . . . . . . . . . . . . . . . . 88
Monitoring Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Quality measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
H§151. Pediatric health quality measurement program. . . . . . . . . . . . 89
S§501. Child health quality improvement activities for children
enrolled in Medicaid or CHIP. . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
A§401. Child health quality improvement activities for children
enrolled in Medicaid or CHIP. . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Information on access to coverage under CHIP . . . . . . . . . . . . . . . . . . . . . 92
S§502. Improved information regarding access to coverage under
CHIP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
A§402. Improved availability of public information regarding
enrollment of children in CHIP and Medicaid. . . . . . . . . . . . . . . 92
Federal evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
H§153. Updated federal evaluation of CHIP. . . . . . . . . . . . . . . . . . . . 93
A§603. Updated federal evaluation of CHIP. . . . . . . . . . . . . . . . . . . . 93
Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Medicaid Drug Rebate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
H§812. Medicaid Drug Rebate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Moratorium on certain payment restrictions . . . . . . . . . . . . . . . . . . . . . . . . 96
H§814. Moratorium on certain payment restrictions. . . . . . . . . . . . . . 96
A§616. Moratorium on certain payment restrictions. . . . . . . . . . . . . . 96
Tennessee and Hawaii DSH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
H§ 815. Tennessee DSH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
A§617. Medicaid DSH allotments for Tennessee and Hawaii. . . . . . . 97
Monitoring erroneous payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
S§602. Payment error rate measurement (“PERM”). . . . . . . . . . . . . . 98
A§601. Payment error rate measurement (“PERM”). . . . . . . . . . . . . . 98
Payments for FQHCs and RHCs under CHIP . . . . . . . . . . . . . . . . . . . . . . 100
H§121. Ensuring child-centered coverage. . . . . . . . . . . . . . . . . . . . . 100
S§609. Application of prospective payment system for services
provided by Federally-qualified health centers and rural health
clinics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
A§503. Application of prospective payment system for services
provided by federally-qualified health centers and rural health
clinics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Purpose of Title XXI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
H§100. Purpose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
A§2. Purpose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Citizenship auditing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
H§136. Auditing requirement to enforce citizenship restrictions on
eligibility for Medicaid and CHIP benefits. . . . . . . . . . . . . . . . . 101
Managed care safeguards
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
H§152. Application of certain managed care quality safeguards to
CHIP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
S§503. Application of certain managed care quality safeguards to
CHIP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
A§403. Application of certain managed care quality safeguards to
CHIP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Access to records for CHIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
H§154. Access to records for IG and GAO audits. . . . . . . . . . . . . . . 103
A§604. Access to records for IG and GAO audits. . . . . . . . . . . . . . . 103
Effective date
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
H§156. Reliance on law; exception for state legislation. . . . . . . . . . 104
S§801. Effective date. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
A§3. General effective date; exception for state legislation;
contingent effective date; reliance on law. . . . . . . . . . . . . . . . . . 104
County Medicaid health insuring organizations . . . . . . . . . . . . . . . . . . . . 106
H§805. County Medicaid health insuring organizations. . . . . . . . . . 106
A§614. County Medicaid health insuring organizations; GAO
report on Medicaid managed care payment rates. . . . . . . . . . . . 106
Clarification of treatment of regional medical center . . . . . . . . . . . . . . . . 107
H§816. Clarification treatment of regional medical center . . . . . . . . 107
A§618. Clarification treatment of regional medical center. . . . . . . . . 107
Diabetes grants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
H§822. Diabetes grants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
S§613. Demonstration projects relating to diabetes prevention. . . . . 109
A§505. Demonstration projects relating to diabetes prevention. . . . 109
S§501. Child health quality improvement activities for children
enrolled in Medicaid and CHIP. . . . . . . . . . . . . . . . . . . . . . . . . 110
Collection of data used in providing CHIP funds . . . . . . . . . . . . . . . . . . . 110
S§604. Improving data collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
A§602. Improving data collection. . . . . . . . . . . . . . . . . . . . . . . . . . . 110
S§105. Incentive bonuses for states. . . . . . . . . . . . . . . . . . . . . . . . . . 112
Technical correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
H§823. Technical correction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
S§605. Deficit Reduction Act technical corrections. . . . . . . . . . . . . . 112
A611(b). Deficit Reduction Act technical corrections — Correction
of reference to children in foster care receiving child welfare
services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
S§605. Deficit Reduction Act technical corrections. . . . . . . . . . . . . 113
A§611(c). Transparency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Technical corrections regarding current state authority under Medicaid
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
S§601. Technical corrections regarding current state authority under
Medicaid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Elimination of counting of Medicaid child presumptive eligibility costs
against CHIP allotments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
S§603. Elimination of counting Medicaid child presumptive
eligibility costs against title XXI allotment. . . . . . . . . . . . . . . . 115
A§113. Elimination of counting Medicaid child presumptive
eligibility costs against title XXI allotment. . . . . . . . . . . . . . . . 115
Outreach to small businesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
S§614. Outreach regarding health insurance options available to
children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
A§623. Outreach regarding health insurance options available to
children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
List of Tables
Table 1. Medicaid and SCHIP Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Medicaid and SCHIP Provisions in
H.R. 3162, S. 1893/H.R. 976,
and Agreement
Background
Medicaid, authorized under Title XIX of the Social Security Act, is a federal-
state program providing medical assistance for low-income individuals who are
aged, blind, disabled, members of families with dependent children, or who have
one of a few specified medical conditions.
The Balanced Budget Act of 1997 (BBA 1997) established SCHIP under a
new Title XXI of the Social Security Act. SCHIP builds on Medicaid by
providing health insurance to uninsured children in families with incomes above
applicable Medicaid income standards. States provide SCHIP children with
health insurance that meets specific standards for benefits and cost-sharing, or
through their Medicaid programs, or through a combination of both.
SCHIP has federal appropriations through FY2007, but none are slated for
FY2008 (which begins on October 1, 2007) and beyond.1
Recent Legislative Activity
The 110th Congress has considered legislation that would make important
changes to Medicaid and SCHIP. On August 1, 2007, the House passed H.R.
3162, the Children’s Health and Medicare Protection (CHAMP) Act of 2007. The
bill would reauthorize and increase funding levels and state grant distributions for
the State Children’s Health Insurance Program (SCHIP) and make changes to the
Medicare and Medicaid programs.
An August 1 estimate from the Congressional Budget Office (CBO) indicates
that the SCHIP title of H.R. 3162 would increase outlays by $47.4 billion over 5
years and by $128.7 billion over 10 years, and that the Medicaid title of the bill
would increase outlays by $4.4 billion over 5 years and by $4.6 billion over 10
years. Including Medicare and miscellaneous provisions, the CBO estimates that
the entire bill would increase outlays by $25.6 billion over 5 years and by $58.0
billion over 10 years. These costs would be offset by an increase in the federal
1 Although no SCHIP appropriations are currently slated for FY2008 forward, both OMB
and CBO assume through the new calendar year that the program continues at the FY2007
appropriation level of $5.04 billion.
CRS-2
tobacco tax and other changes, which the CBO estimates would increase revenue
by $28.1 billion over 5 years and by $58.1 billion over 10 years.2
On July 19, 2007, the Senate Finance Committee marked up the Children’s
Health Insurance Program Reauthorization Act of 2007 (S. 1893/H.R. 976). The
Senate struck the language in an unrelated House-passed tax measure (H.R. 976)
and replaced it with the language contained in S. 1893, as approved by the Senate
Finance Committee. A total of 92 amendments were offered, with 9 adopted.
The bill passed the Senate on August 2, 2007.
The Senate bill contains eight titles, six dealing with SCHIP and Medicaid.
An August 24 estimate from CBO and JCT3 indicates that the Senate bill would
increase SCHIP outlays by $28.1 billion over the five-year period of FY2008-
FY2012. Additional outlay increases would occur as a result of effects on
Medicaid (e.g., changes in citizenship documentation). In sum, the CBO and JTC
estimate indicates that the Senate bill would increase net outlays by $35.2 billion
over 5 years and by $71.0 billion over 10 years.4 These costs would be offset by
an increase in the federal tobacco tax and other changes, which CBO and JCT
estimate would increase net revenue by $36.1 billion over 5 years and by $72.8
billion over 10 years.
A bicameral agreement on SCHIP reauthorization passed the House as an
amendment to H.R. 976 on September 25, and also passed the Senate on
September 27. President Bush vetoed the legislation on October 3, 2007. The
House sustained the President’s veto with a vote of 273 to 156 on October 18,
2007 — a vote that failed to achieve the two-thirds majority of voting members
required for an override. A continuing resolution that contains short-term funding
for SCHIP (H.J.Res. 52) was passed by the House on September 26, and the
Senate on September 27, and signed into law on September 29, 2007, as P.L. 110-
92.
2 CBO, Estimated Effect on Direct Spending and Revenues of H.R. 3162, the Children’s
Health and Medicare Protection Act, for the Rules Committee (August 1, 2007), available
at [http://www.cbo.gov/ftpdocs/85xx/doc8519/HR3162.pdf].
3 CBO, letter to the Honorable Max Baucus (August 24, 2007), available at
[http://www.cbo.gov/ftpdocs/85xx/doc8584/08-28-CHIP.pdf].
4 As described above, the Senate bill would specify national allotment funding for five years.
In FY2012, this funding would consist of two semi-annual allotments of $1.75 billion each
plus a one-time appropriation of $12.5 billion to accompany the first semi-annual allotment.
For years beyond FY2012, CBO is required to assume that national allotment funding
continues at the level prescribed by existing law, which appears to be $3.5 billion under the
Senate bill. In contrast, the SCHIP baseline under current law assumes an appropriation of
$5.04 billion for years beyond FY2007. As a result of this difference, CBO’s cost estimate
for national allotments in the Senate bill shows savings in years beyond FY2012. For more
information on budget baselines and scorekeeping, see CRS Report 98-560, Baselines and
Scorekeeping in the Federal Budget Process, by Bill Heniff Jr.
CRS-3
A September 24 estimate from CBO and JCT5 indicates that the SCHIP
agreement would increase net outlays by $34.9 billion over 5 years and by $71.5
billion over 10 years.6 These costs would be offset by an increase in the federal
tobacco tax and other changes, which CBO and JCT estimate would increase net
revenue by $36.3 billion over 5 years and by $72.8 billion over 10 years.
Medicaid and SCHIP Provisions in H.R. 3162,
S. 1893/H.R. 976, and the Bicameral Agreement
Table 1 provides a brief description of current law and a side-by-side
comparison of the changes that would be made to Medicaid and SCHIP under
H.R. 3162, S. 1893/H.R. 976, and the bicameral agreement.7 Medicare provisions
in Titles II through VII of H.R. 3162, provisions related to support to injured
service members, military family job protection, and the Sense of the Senate
regarding health care access are not described in this report. A comparison of
some of the key provisions across all three bills is described below.
Funding/Financing. Allotments. Under current law, the SCHIP
appropriation for FY2007 (the last year for which there is an appropriation) was
just over $5 billion, with states’ allotments available for three years. Under the
House bill, allotments from FY2008 onward would be available for only two
years. Appropriations for FY2008 onward would be provided without a national
amount specified. The annual appropriation would be determined automatically
as the sum total of the allotments calculated for all the states and territories. For
FY2009 onward, states’ allotments would be based on either prior-year allotments
or prior-year spending. States would not be limited in the amount of prior-year
balances they could carry forward.
Under the Senate legislation, allotments from FY2007 onward would be
available for only two years. The FY2008 appropriation would be $9.125 billion,
rising to $16.0 billion in FY2012, with no appropriations provided thereafter. As
long as those amounts were adequate, states would be allotted in FY2009-FY2011
what they project to spend for the year in federal SCHIP expenditures plus 10%,
with the funds not used for states’ allotments going into a bonus pool. States
would be limited in the amount of prior-year balances they could carry forward.
The agreement uses the national appropriations and the FY2008 allotment
formula specified in the Senate legislation. For FY2009 to FY2012, the allotment
formula would be structured according to the House bill, in which the FY2009
and FY2011 allotments are based on the prior year’s allotment, and the FY2010
and FY2012 allotments are based on the prior year’s federal SCHIP spending. As
in the House legislation, the agreement would reduce SCHIP allotments’ period of
5 CBO, letter to the Honorable Max Baucus (September 25, 2007), available at
[http://www.cbo.gov/ftpdocs/86xx/doc8655/hr976.pdf].
6 For an explanation of why CBO’s cost estimate for national allotments in the agreement
shows savings in years beyond FY2012, see earlier footnote on the Senate bill.
7 Medicare provisions in Titles II through VII of H.R. 3162 are not described here.
CRS-4
availability to two years, beginning with the FY2008 allotment. Also like the
House bill, there is no limit in the amount of prior-year balances states could carry
forward.
The House legislation calls for bonus payments to states that (1) increase
their enrollment of children in Medicaid or SCHIP above certain levels and (2)
implement certain activities to encourage enrollment and retention among
Medicaid- and SCHIP-eligible children. Qualifying states would receive cash
payments as a percentage of the state share of their Medicaid/SCHIP expenditures,
though setting a higher bar and paying a lower percentage in SCHIP as compared
to Medicaid. The Senate bill would also provide bonus payments, but the
payments would be for increasing child enrollment in Medicaid, not in SCHIP. In
addition, the Senate bill does not require the implementation of the specific
enrollment and retention efforts. The payments would be based on fixed-dollar
amounts specified in the legislation. The bonus payments in the agreement are
structured after the House bill, except altered to yield smaller payments than under
the House bill.8
Limitations on SCHIP Matching Rate. Under current law, states can
set their upper income eligibility level for SCHIP at the higher of 200% of the
federal poverty level (FPL) or 50 percentage points above their income eligibility
level for Medicaid children prior to SCHIP’s enactment. However, by using
existing flexibility to define what “counts” as income, any state can raise its
effective SCHIP income eligibility level above 200% FPL through the use of
income disregards. The House, Senate, and agreement bills would not affect
states’ ability to use income disregards. However, the Senate and agreement bills
would reduce the federal reimbursement rate for costs associated with SCHIP
enrollees whose income would exceed 300% FPL without the use of certain
disregards. An exception would be provided for states that, on the date of
enactment, have federal approval or have enacted a state law to cover SCHIP
enrollees above 300% FPL.
Eligibility. With respect to eligibility, the House bill would allow states to
cover individuals up to age 21 (rather than age 19) in their SCHIP programs. This
provision is not in the agreement. Although some differences apply, both the
House and Senate bills would allow broader coverage of pregnant women under
SCHIP, in terms of eligibility and benefits, when certain conditions are met. The
agreement follows the Senate bill with some modifications based on the House
bill. The House bill would allow states to cover certain legal immigrants who
meet applicable categorical and financial eligibility requirements (i.e., pregnant
women and/or children under age 21) before such persons have been in the United
States for a minimum of five years as required under current law. The Senate bill
and the agreement do not include a comparable provision.
8 Over the five-year period of FY2008 to FY2012, CBO estimated the cost of the bonus
payments at $2.7 billion in the Senate bill, $10.8 billion in the House bill, and $2.6 billion
in the agreement.
CRS-5
Section 1115 of the Social Security Act allows the Secretary of HHS to
waive certain statutory requirements to modify virtually all aspects of Medicaid
and SCHIP as long as such changes further the goals of Titles XIX (Medicaid)
and/or XXI (SCHIP). States and the federal government have used the Section
1115 waiver authority to cover non-Medicaid and SCHIP services, limit benefit
packages for certain groups, cap program enrollment, cover groups such as non-
pregnant childless adults that are not otherwise eligible, among other purposes.
With respect to SCHIP coverage of adult populations (e.g., nonpregnant
childless adults and parents of Medicaid and SCHIP-eligible children), the House
bill would allow for such coverage as long as states ensure that they have not
instituted a waiting list for their SCHIP program, and that they have an outreach
program to reach all targeted low-income children in families with annual
incomes less than 200% FPL. By contrast, the Senate and the agreement bills
phase out SCHIP coverage of non-pregnant childless adults after two years, and in
FY2009, federal reimbursement for such coverage would be reduced to the
Medicaid federal medical assistance percentage (FMAP) rate. Coverage of
parents would still be allowed, but beginning in FY2010, allowable spending
under the waivers would be subject to a set aside amount from a separate
allotment and would be matched at the state’s regular Medicaid FMAP rate unless
the state is able to prove that it met certain coverage benchmarks (related to
performance in providing coverage to children). Finally, in FY2011 and FY2012,
the federal matching rate for costs associated with such parent coverage would be
reduced to a rate between the Medicaid and SCHIP rates for states that meet
certain coverage benchmarks, and to the state’s regular Medicaid FMAP for all
other states.
Enrollment/Access. Each of the bills include provisions to facilitate
access and enrollment in Medicaid and SCHIP. Among the major provisions, the
House and the agreement bills would create a state option to rely on a finding
from specified agencies to determine whether a child under age 19 (or an age
specified by the state not to exceed 21 years of age) has met one or more of the
eligibility requirements (e.g., income, assets or resources, citizenship, or other
criteria) necessary to determine an individual’s initial eligibility, eligibility
redetermination, or renewal of eligibility for medical assistance under Medicaid or
SCHIP. The Senate bill, by contrast, would allow up to 10 states to use Express
Lane9 eligibility determinations for Medicaid and SCHIP enrollment and renewal
through a three-year demonstration program. Like the House and agreement bills,
the Senate bill does not relieve states of their obligation to determine eligibility
for Medicaid, and would require the state to inform families that they may qualify
for lower premium payments or more comprehensive health coverage under
Medicaid if the family’s income were directly evaluated by the state Medicaid
agency. All three bills would drop the requirement for signatures on a Medicaid
application form under penalty of perjury.
9 Express Lane eligibility refers to specified agencies that would be permitted to a streamline
the Medicaid and SCHIP eligibility determination and intake process to make it easier for
individuals to qualify for coverage.
CRS-6
Current law and regulations require that SCHIP plans include procedures to
ensure that SCHIP coverage does not substitute for coverage provided in group
health plans, also known as crowd-out. In mid-August, the Administration issued
a guidance letter explaining how CMS would apply existing requirements in
reviewing state requests to extend SCHIP eligibility to children with income
levels exceeding 250% FPL, including specified crowd-out strategies states would
be required to implement within one year. The agreement also includes a new
crowd-out provision. It would require states already covering children with
income exceeding 300% FPL (and beginning in 2010, new states that propose to
do so) to describe how they will address crowd-out and implement “best
practices” to avoid crowd-out (to be developed by the Secretary in consultation
with the states). Beginning in 2010, these higher income states cannot have a rate
of public and private coverage for low-income children that is less than the target
rate of coverage for low-income children (a measure to be calculated by the
Secretary representing the average rate of private and public coverage among the
10 states and DC with the highest percentage of such coverage.) States failing to
meet this requirement in a given fiscal year would not receive any federal SCHIP
payments for higher income children until they come into compliance with this
rule. States would develop corrective action plans and the Secretary would not be
permitted to deny payments if there is a reasonable likelihood that such plans
would bring affected states into compliance. Both the GAO and the IOM (with a
$2 million appropriation) would conduct related crowd-out analyses on best
practices and measurement accuracy, respectively. This provision supersedes the
August guidance letter.
Citizenship Documentation Rules. The House, Senate, and agreement
bills would make some similar modifications of existing Medicaid citizenship
documentation rules (e.g., by requiring additional documentation options for
federally recognized Indian tribes and specifying the reasonable opportunity
period for individuals who are required to present documentation). However, the
Senate and agreement bills would allow states to meet Medicaid citizenship
documentation requirements through name and Social Security number validation,
make citizenship documentation a requirement for SCHIP, provide an enhanced
match for certain administrative costs, and require separate identification numbers
for children born to women on emergency Medicaid. In contrast, the House bill
would make Medicaid citizenship documentation for children under age 21 a state
option, allow “Express Lane” agencies to determine eligibility without citizenship
documentation, and require eligibility audits to ensure that federal funds are not
spent on individuals who are not legal residents.
Premium Assistance/Employer Buy-In. The House bill would allow
the Secretary of Health and Human Services to establish a five-year demonstration
project under which up to 10 states would be permitted to provide SCHIP child
health assistance to children (and their families) to individuals who are
beneficiaries under a group health plan. The Senate and the agreement bills
would allow states to offer a premium assistance subsidy for qualified employer
sponsored coverage to all targeted low-income children who are eligible for child
health assistance and have access to such coverage, or to parents of targeted low-
income children. The agreement bill would also allow states to offer a premium
assistance subsidy for qualified employer sponsored coverage (ESI) to Medicaid-
CRS-7
eligible children and/or parents of Medicaid-eligible children where the family
has access to ESI coverage. In addition, the agreement specifies that family
participation in premium assistance programs would be optional.
Benefits. Both the House and Senate bills would make other changes to
covered benefits under SCHIP. With respect to dental care, the agreement
includes selected provisions from both the House and Senate bills, as well as new
provisions. States would have the option to provide “benchmark dental benefit
packages” meeting certain requirements and would be available through FEHBP,
state employee coverage, and commercial HMOs. The House bill would also
require the Secretary of HHS to implement a program to educate new parents
about the importance of oral health care for infants, and would require states to
report data on the receipt of dental services for SCHIP children, both of which are
included in the agreement. In the Senate bill, a new grant would be authorized to
improve the availability of dental services and strengthen dental coverage for
children under SCHIP. The agreement includes a provision in the Senate bill to
make available to the public information on dental providers and covered dental
benefits. GAO would be required to evaluate access to dental care under both the
House and Senate bills, and in the agreement. In addition, the Senate bill and the
agreement include a new mental health parity provision for SCHIP, while the
House bill would broaden the scope of coverage for mental health services under
certain SCHIP benefit plans. Provisions to reduce diabetes in children are
included in both the House and Senate bills. The House bill would extend
funding for existing diabetes programs authorized under the Public Health
Services Act, while the Senate bill would create a new demonstration project to
promote screening and improvements in diet and physical activity. The agreement
follows the Senate bill. Finally, for the benchmark package option under
Medicaid, established in the Deficit Reduction Act of 2005 (P.L. 109-171), both
the House and Senate bills, and the agreement, would require coverage of the
Early and Periodic Screening, Diagnostic and Treatment (EPSDT), benefit for
individuals under 21 (rather than under age 19).
Monitoring Quality. There are other new initiatives to improve access and
quality of care for children under Medicaid and SCHIP, including a new federal
commission (House bill only), child health care quality measurement programs
(both the House and Senate bills, and the agreement), and a second federal SCHIP
evaluation (House bill and the agreement).
Payments. With respect to payment policies, both the House and Senate
bills would require that payments for Federally Qualified Health Care Centers
(FQHCs) and Rural Health Centers (RHCs) under SCHIP follow the prospective
payment system for such services under Medicaid. The House bill would prohibit
the Secretary of HHS from taking actions to further restrict Medicaid coverage or
payments for rehabilitation services or for certain school-based services beyond
policies in effect as of July 1, 2007. This prohibition would continue for one year
after the date of enactment of this provision. However, in mid-August and early
September, the Administration issued proposed rules for such payments. The
agreement is the same as the House bill except that the Secretary would be
prohibited from taking any action prior to May 28, 2008. Finally, the federal and
state governments are required to monitor and take actions to reduce erroneous
CRS-8
payments under both Medicaid and SCHIP. The two systems for conducting these
evaluations are the Medicaid Eligibility Quality Control (MEQC) program and the
newer Payment Error Rate Measurement (PERM) program. In mid-August, the
Administration issued a final rule for PERM. The Senate bill and the agreement
stipulate several requirements for a final rule on PERM and require the Secretary
of HHS to coordinate these two systems and reduce redundancies.
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Table 1. Medicaid and SCHIP Provisions
A§1. Short title; amendments to Social Security Act; references; table of contents.
Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
References to Title XXI; Elimination of Confusing Program References
A provision in P.L. 106-113 directed the H§155. References to Title XXI. The S§606. Elimination of confusing A§1. Short Title; Amendments to
Secretary of HHS or any other federal provision would repeal this section of program references. Same as House Social Security Act; References;
officer or employee, with respect to P.L. 106-113. Thus, for official bill.
Table of Contents. The provision
references to the program under Title publication and communication
would apply the following short title to
XXI, in any publication or official purposes, the provision would reinstate
the bill, “Children’s Health Insurance
communication to use the term “CHIP” and “children’s health
Program Reauthorization Act of 2007;”
“SCHIP” instead of “CHIP” and to use insurance program,” as applicable, when
specify that amendments made by this
the term “State children’s health referencing Title XXI.
bill would be made to the Social
insurance program” instead of
Security Act; and, like the House bill,
“children’s health insurance program.”
would reinstate “CHIP” and “children’s
health insurance program,” as
applicable, when referencing Title XXI.
A§612. References to Title XXI.
Same as the House bill.
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
Funding/Financing
CHIP appropriations
Section 2104(a) of the Social Security H§101. Establishment of new base S§101. Extension of CHIP. The A§101. Extension of CHIP. Same as
Act specifies the following SCHIP CHIP allotments. Appropriations for following national appropriation Senate bill.
appropriation amounts (of which the FY2008 onward would be provided amounts would be specified for CHIP in
territories receive 0.25%): $4.3 billion without a national amount specified. §2104(a): $9.125 billion in FY2008;
annually from FY1998 to FY2001; The annual appropriation would be $10.675 billion in FY2009; $11.85
$3.15 billion annually from FY2002 to determined automatically as the sum billion in FY2010; $13.75 billion in
FY2004; $4.05 billion in FY2005 and total of the allotments calculated for all FY2011; and two semiannual
FY2006; and $5.0 billion in FY2007. the states and territories. No end year installments of $1.75 billion each in
No amounts are specified for FY2008 would be specified; the program could FY2012.
onward.
receive annual appropriations in S§103. One-time appropriation. A A§108. One-time appropriation.
perpetuity.
separate appropriation of $12.5 billion Same as Senate bill.
would be provided for CHIP allotments
in the first half of FY2012.
Allotment of federal CHIP funds to states
The national SCHIP amount available to H§101. Establishment of new base S§102. Allotments for the 50 states A§102. Allotments for states and
states is allotted primarily on the basis CHIP allotments. FY2008. Generally, and the District of Columbia. territories. FY2008. Same as Senate
of estimates of each state’s number of a state’s FY2008 allotment would be the FY2008. For FY2008, a state’s bill.
children who are low income (that is, greater of (1) its own projection of allotment would be calculated as 110%
with family income below 200% of the federal CHIP expenditures in FY2008, of the greatest of the following four
federal poverty threshold) and the based on the state’s May 2007 amounts: (1) the state’s FY2007 federal
number of such children who are submission to CMS, and (2) the state’s CHIP spending multiplied by the annual
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
uninsured. The source of data is the FY2007 CHIP allotment multiplied by adjustment (described below); (2) the
average of the number of such children the allotment increase factor (described state’s FY2007 federal CHIP allotment
based on the three most recent Annual below). If the state enacted legislation multiplied by the annual adjustment; (3)
Social and Economic (ASEC) during 2007 that would expand for states that receive federal CHIP
Supplements (formerly known as the eligibility or improve benefits, the state funds in FY2007 because of their
March supplements) to the Census may use its August 2007 submission of shortfalls, or states that were projected
Bureau’s Current Population Survey expenditure projections instead.
to be in shortfall based on their
(CPS) before the beginning of the
November 2006 submission of projected
calendar year in which the applicable
expenditures, the state’s FY2007
fiscal year begins. The estimates are
projected federal spending as of
adjusted to account for geographic
November 2006 (or as of May 2006, for
variations in health costs (calculated as
a state whose May 2006 projection was
85% of each state’s variation from the
$95 million to $96 million higher than
national average in its average wages in
its November 2006 projection, a
the health services industry). A ceiling
provision that affects only North
is in place to ensure that a state’s
Carolina) multiplied by the annual
portion of the total available
adjustment; and (4) the state’s FY 2008
appropriation does not exceed 145% of
federal CHIP projected spending as of
its share of funds in FY1999. In
August 2007 and certified by the state
addition, there are three floors to ensure
not later than September 30, 2007.
a state’s share does not fall below
certain levels.
Adjustment for cost and child Adjustment for cost and child Adjustment for cost and child
population growth. The allotment population growth. The annual population growth. Same as House bill.
increase factor would be the product of adjustment for health care cost growth
(1) the per capita health care growth and child population growth is the
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
factor, and (2) the child population product of (1) 1 plus the percentage
growth factor. The per capita health increase (if any) in the nominal
care growth factor would be 1 plus the projected per capita spending in
percentage increase in the projected per National Health Expenditures for the
capita amount of National Health year over the prior year, and (2) 1.01
Expenditures over the prior year’s. The plus the percentage change in the child
child population growth factor would be population (under age 19) in each state,
1.01 plus the percentage increase (if based on the most timely and accurate
any) in the population of children under published estimates from the Census
19 years of age in the state, based on the Bureau.
most recent published estimates from
the Census Bureau.
FY2009 onward. For FY2009 and every FY2009 to FY2012. For FY2009 to FY2009 to FY2012. Similar to House
future odd-numbered fiscal year, a FY2011, a state’s allotment would be bill. The FY2009 allotment and the
state’s federal CHIP allotment would be calculated as 110% of its projected FY2011 allotment would be the state’s
equal to the prior year’s allotment spending for that year.
prior-year allotment, plus amounts
(including “performance-based shortfall
received by the state in the prior year
adjustment” described below)
from the contingency fund (similar to
multiplied by the allotment increase
the House bill’s shortfall adjustment)
factor.
multiplied by the allotment increase
factor.
For FY2010 and every future The regular CHIP appropriations For FY2010, similar to House bill: A
even-numbered fiscal year, a state’s available to states in FY2012 (that is, state’s federal CHIP allotment would be
federal CHIP allotment would be the $1.75 billion provided semi- “rebased.” The state’s allotment would
“rebased.” In these years, the state’s annually reduced by payments to the be the FY2009 federal CHIP
allotment would be the prior year’s territories) would be calculated using expenditures (from the state’s available
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
federal CHIP expenditures multiplied by states’ projected federal CHIP spending allotments, contingency funds, and
the allotment increase factor.
allocable to each semi-annual period. redistribution funds) multiplied by the
The one-time appropriation of $12.5 allotment increase factor.
billion in §103 of the legislation is to be For FY2012, although the national
treated in the same manner as the $1.75 appropriation is the same as the Senate
billion appropriation for the first semi- bill, the funds would be allotted to states
annual allotment. If the available based on the House bill’s rebasing to
national allotment for a semi-annual FY2011 federal CHIP expenditures
period in FY2012 exceeds the amount to (though accommodating the semi-
be allotted in that period based on annual nature of the national
states’ projected CHIP expenditures, the appropriation). Specifically, the full-
remaining amount would be allotted year allotment amount for FY2012
proportionally based on each state’s would be calculated as the state’s
share of the allotment calculated for that FY2011 federal CHIP expenditures
FY2012 period.
(from the state’s available allotments,
contingency funds, and redistribution
funds) multiplied by the allotment
increase factor. Approximately 89% of
this amount would be allotted on
October 1, 2011, and the remainder
would be allotted on April 1, 2012.
Increase in allotment to account for
approved program expansions. For
determining allotments in FY2009 to
FY2011, if a state has an approved State
Plan Amendment (SPA) or waiver to
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
expand CHIP eligibility or benefits and
if the state requests an expansion
allotment adjustment that specifies (i)
the additional expenditures attributable
to the expansion by not later than
August 31 before the beginning of the
fiscal year and (ii) the extent to which
the additional expenditures are projected
to exceed the allotment, the amount of
the state’s allotment would be increased
by the amount in (i).
If national appropriation is inadequate. If national appropriation is inadequate.
For FY2008, if the state allotments as For FY2008 to FY2012, if the state
calculated exceed the available national allotments as calculated exceed the
allotment, states’ allotments would be available national allotment, states’
reduced proportionally.
allotments would be reduced
For FY2009 to FY2012, if the state proportionally.
allotments as calculated exceed the
available national allotment, then the
available national allotment would be
distributed among states using a
different formula. It would calculate
each state’s share (percentage) of the
available national allotment primarily
based on states’ own projected CHIP
expenditures for that fiscal year.
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
Increases in states’ projected spending.
If a state’s projected CHIP expenditures
for FY2009 to FY2012 are at least 10%
more than the allotment calculated for
the preceding fiscal year (regardless of
the computation used if the national
appropriation was inadequate) and,
during the preceding fiscal year, the
state did not receive approval for a
CHIP state plan amendment or waiver
to expand CHIP coverage or did not
receive a CHIP Contingency Fund
payment, then the state would be
required to submit to the Secretary by
August 31 of the preceding fiscal year
information relating to the factors that
contributed to the increase as well as
any additional information requested by
the Secretary. The Secretary would be
required to review the information and
provide a response in writing within 60
days as to whether the states’
projections of CHIP expenditures are
approved or disapproved (and if
disapproved, reasons for disapproval),
or specified additional information. If
disapproved or requested to provide
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
additional information, the state would
be provided with reasonable opportunity
to submit additional information. If the
Secretary has not determined by
September 30 whether the state has
demonstrated the need for the increase
in the succeeding fiscal year’s
allotment, a provisional allotment would
be provided based on 110% of the
allotment calculated for the preceding
fiscal year (regardless of the
computation used if the national
appropriation was inadequate) and may
adjust the allotment by not later than
November 30.
Deadline and data for determining Deadline and data for determining
FY2008 allotments. For calculating the FY2008 allotments. Same as Senate
FY2008 allotments to states and bill.
territories, the Secretary would be
required to use the most recent data
available before the start of the fiscal
year but may adjust the allotments as
necessary on the basis of actual
expenditure data for FY2007 submitted
no later than November 30, 2007. The
Secretary could make no adjustments
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
for FY2008 after December 31, 2007.
Allotment of federal CHIP funds to territories
In addition to receiving 0.25% of the H§101. Establishment of new base S§104. Improving funding for the A§102. Allotments for states and
national SCHIP appropriation in Section CHIP allotments. There would be no territories under CHIP and Medicaid. territories. As in both the House and
2104(a) of the Social Security Act, the separate CHIP appropriation for the There would be no separate CHIP Senate bills, there would be no separate
following SCHIP appropriation amounts territories. Beginning with FY2008, the appropriation for the territories. CHIP appropriation for the territories;
were specified for the territories: The a l l o t me n t t o a t e r r i t o r y o r FY2008. Each territory’s allotment as with the states, the territories’
territories are also allotted the following commonwealth would be equal to its would be its highest annual federal allotments would come entirely from
a p p r o p r i a t i o n a m o u n t s i n prior year federal CHIP expenditures CHIP spending between FY1998 and the national appropriation. FY2008.
§2104(c)(4)(B): $32 million in FY1999; multiplied by the per capita health care FY2007, plus the annual adjustment for Same as Senate bill. FY2009 to
$34.2 million in FY2000 and FY2001; growth factor (described above) and by health care cost growth and national FY2012. Territories would be treated
$25.2 million in FY2002 to FY2004; 1.01 plus the percentage increase (if child population growth described like states (that is, allotments in FY2009
$32.4 million in FY2005 and FY2006; any) in the population of children under above. FY2009 to FY2012. Each and FY2011 based on prior-year
and $40 million in FY2007. The 19 years of age in the United States.
territory’s allotment would be the prior allotment, and allotments in FY2010
amounts set aside for the territories are
year’s allotment, plus the annual and FY2012 based on prior-year
distributed according to the percentages
adjustment for health care cost growth spending).
specified in statute: Puerto Rico,
and national child population growth. In
91.6%; Guam, 3.5%; the Virgin Islands,
FY2012, 89% of the amount to be
2.6%; American Samoa, 1.2%; and the
allotted to the territories would be
Northern Mariana Islands, 1.1%.
allotted in the first half of the fiscal
year, with the remaining 11% allotted in
the second half of the fiscal year.
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
Period of availability of CHIP allotments
SCHIP allotments are available for three H§102. 2-year initial availability of S§109. Two-year availability of A§105. 2-year initial availability of
years.
CHIP allotments. Beginning with the allotments; expenditures counted CHIP allotments. Same as House bill.
FY2008 allotment, CHIP allotments against oldest allotments. Beginning
would be available for two years.
with the FY2007 allotment, CHIP
allotments would be available for two
years. Notwithstanding the period of
availability, states would forgo from
their unspent FY2006 and FY2007
allotments the amount by which those
allotments not expended by September
30, 2007, exceeded 50% of the FY2008
allotment. On October 1 of fiscal years
2009 to 2012, states would also forgo
the amount by which the unspent funds
from the prior year’s allotment
exceeded a particular percentage of that
allotment (that is, 20% in FY2009, and
10% in FY2010, FY2011, and FY2012).
CHIP funds for shortfall states
Allotments unspent after three years are H§102. 2-year initial availability of S§105. Incentive bonuses for states. A§106. Redistribution of unused
available for redistribution to states that C H I P a l l o t m e n t s . H § 1 0 3 . Redistribution of unspent FY2005 allotments to address state funding
had exhausted that particular allotment Redistribution of unused allotments allotments. FY2005 allotments unspent shortfalls. Redistribution of unspent
by the end of the three-year period of to address state funding shortfalls. after their three-year period of FY2005 allotments. Same as Senate
availability. The HHS Secretary Redistribution of unspent FY2005 availability would be redistributed only bill, except that it would not apply if the
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
determines how the funds are allotments and subsequent allotments. to states that met the third criteria used redistribution of FY2005 funds had
redistributed to those states. In the past Only a shortfall state (that is, a state that in calculating the base allotment for already occurred by the bill’s date of
couple of years, redistributed funds have the Secretary estimates will have federal FY2008 (that is, states that received enactment. Redistribution of
gone exclusively to shortfall states (i.e., CHIP expenditures that exceed its federal CHIP funds in FY2007 because subsequent allotments. Same as House
states that were projected to exhaust all available prior-year allotment balances, of their shortfalls, states that were bill.
their available SCHIP allotments during its performance-based shortfall projected to be in shortfall in FY2007
the year) and sometimes the territories. adjustment, and its allotment for the based on their November 2006
fiscal year) would be eligible to receive submission of projected expenditures, or
redistributed funds. If the funds states whose May 2006 projection was
redistributed to a state based on its $95 million to $96 million higher than
projected shortfall are not spent by the its November 2006 projection). For
end of the fiscal year, they would be these states, the unspent FY2005 funds
available for redistribution to other would be redistributed in proportion to
states in the next fiscal year. If the total their FY2007 allotment. Redistribution
amount available for redistribution of subsequent allotments. None
exceeds the projected shortfalls, the provided. Unspent funds from
remaining amounts would be available subsequent allotments used for bonus
for redistribution in the next fiscal year. payments, discussed below.
If the total amount available for
redistribution is less than the projected
shortfalls, the amounts provided to
shortfall states would be reduced
proportionally. The Secretary could
adjust the amounts redistributed based
on actual expenditure data as submitted
not later than November 30 of the
succeeding fiscal year.
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
H§101. Establishment of new base S§108. CHIP contingency fund. A§103. Child enrollment contingency
CHIP allotments. Source of funds. Source of funds. A CHIP Contingency fund. Source of funds. Similar to the
Performance-based shortfall adjustment Fund would be established in the U.S. Senate bill, a Child Enrollment
would be calculated as part of a state’s Treasury. The Contingency Fund would Contingency Fund would be established
allotment, which is not subject to a cap. receive deposits through a separate in the U.S. Treasury. The Contingency
appropriation. For FY2009, its Fund would receive deposits through a
appropriation would be 12.5% of the separate appropriation. For FY2008, its
CHIP available national allotment. For appropriation would be 20% of the
FY2010 through FY2012, the CHIP available national allotment. For
appropriation would be such sums as are FY2010 through FY2012, the
necessary for making payments to appropriation would be such sums as are
eligible states for the fiscal year, as long necessary for making payments to
as the annual payments did not exceed eligible states for the fiscal year, as long
12.5% of that fiscal year’s CHIP as the annual payments did not exceed
available national allotment. Balances 20% of that fiscal year’s CHIP available
that are not immediately required for national allotment. Balances that are not
payments from the Fund would be immediately required for payments
invested in U.S. securities that provide from the Fund would be invested in U.S.
additional income to the Fund. Amounts securities that provide additional
in excess of the 12.5% limit shall be income to the Fund. Amounts in excess
deposited into the Incentive Pool. For of the 20% limit shall be deposited into
purposes of the CHIP Contingency the Incentive Pool.
Fund, amounts set aside for block grant
payments for transitional coverage of
childless adults shall not count as part of
the available national allotment.
Payments from the Fund are to be used
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Current Law
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Senate: H.R. 976
Agreement
only to eliminate any eligible state’s
shortfall (that is, the amount by which a
state’s available federal CHIP
allotments are not adequate to cover the
state’s federal CHIP expenditures).
Payments. A payment would be made Payments. The Secretary would Payments. Same as House bill except
to a state if (1) its federal CHIP separately compute the shortfalls for the following: If funds balances are
expenditures in a fiscal year (beginning attributable to children and pregnant not enough to make payments, then
with FY2008) exceeds the amount of women, to childless adults, and to p a yme nt s w o u l d b e r e d u c e d
federal CHIP allotments available to the parents of low-income children. No proportionally; the Comptroller General
state (not including any available CHIP payment from the Contingency Fund would not be required to audit the data
funds redistributed from other states), shall be made for nonpregnant childless used in determining contingency fund
and (2) its average monthly enrollment adults. Any payments for shortfalls payments; payments based on a fiscal
of children in CHIP exceeded the target attributable to parents shall be made year’s data would occur in that fiscal
enrollment number for the year. For from the Fund at the relevant matching year, with reconciliation committed
FY2008, the target number is the rate. Eligible states for any month in based on the submission of actual
average monthly CHIP enrollment in FY2009 to FY2012 are those that meet expenditures.
FY2007 increased by 1% and by the any of the following criteria: (1) The
state’s child population growth. For state’s available federal CHIP
subsequent fiscal years, the target allotments are at least 95% but less than
number is the prior year’s target number 100% of its projected federal CHIP
increased by 1% and by the state’s child expenditures for the fiscal year (i.e., less
population growth. The adjustment than 5% shortfall in federal funds),
would be calculated as the product of without regard to any payments
(1) the amount by which the actual provided from the Incentive Pool; or
average monthly caseload exceeded the (2) The state’s available federal CHIP
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Current Law
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Senate: H.R. 976
Agreement
target number of enrollees, and (2) the allotments are less than 95% of its
state’s projected per capita CHIP projected federal CHIP expenditures for
expenditures (state and federal) the fiscal year (i.e., more than 5%
multiplied by the enhanced FMAP for shortfall in federal funds) and that such
the state for the fiscal year involved. shortfall is attributable to one or more of
The adjustment would only be available the following: (a) One or more parishes
in the fiscal year in which it was or counties has been declared a major
provided and would not be available for disaster and the President has
redistribution if unspent. The determined individual and public
Comptroller General would be required assistance has been warranted from the
to periodically audit the accuracy of the federal government pursuant to the
data used for the allotment adjustment Stafford Act, or a public health
and make recommendations to Congress emergency was declared by the
and the Secretary as the Comptroller Secretary pursuant to the Public Health
General deems appropriate.
Service Act; (b) the state unemployment
rate is at least 5.5% during any
consecutive 13 week period during the
fiscal year and such rate is at least 120%
of the state unemployment rate for the
same period as averaged over the last
three fiscal years; (c) the state
experienced a recent event that resulted
in an increase in the percentage of
low-income children in the state without
health insurance that was outside the
control of the state and warrants
granting the state access to the Fund, as
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Current Law
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Senate: H.R. 976
Agreement
determined by the Secretary.
Application to territories. Territories Application to territories. Territories
would not be eligible for contingency would be eligible for contingency fund
fund payments.
payments once the Secretary determines
there are satisfactory methods for
collecting and reporting the necessary
enrollment information reliably.
The Secretary shall make monthly
payments from the Fund to all states
determined eligible for a month. If the
sum of the payments from the Fund
exceeds the amount available, the
Secretary shall reduce each payment
proportionally.
Extension of option for qualifying states
For qualifying states, federal SCHIP H§104. Extension of option for S§111. Option for qualifying states to A§107. Option for qualifying states to
funds may be used to pay the difference qualifying states. In addition to the receive the enhanced portion of the receive the enhanced portion of the
between SCHIP’s enhanced Federal current-law provisions, qualifying states CHIP matching rate for Medicaid CHIP matching rate for Medicaid
Medical Assistance Percentage (FMAP) would also be able to use the entirety of coverage of certain children.
coverage of certain children. Same as
and the Medicaid FMAP that the state is any allotment from FY2008 onward for Qualifying states under §2105(g) may Senate bill.
already receiving for children above CHIP spending under §2105(g).
also use available balances from their
150% of poverty who are enrolled in
CHIP allotments from FY2008 to
Medicaid.
Qualifying states
FY2012 to pay the difference between
are limited in the amount they can claim
the regular Medicaid FMAP and the
for this purpose to the lesser of(1) 20%
CHIP enhanced FMAP for Medicaid
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Senate: H.R. 976
Agreement
of the state’s original SCHIP allotment
enrollees under age 19 (or age 20 or 21,
a mo u n t s ( i f ava i l a b l e ) f r o m
if the state has so elected in its Medicaid
FY1998-FY2001 and FY2004-FY2007;
plan) whose family income exceeds
and (2) the state’s available balances of
133% of poverty.
those allotments. The statutory
definitions for qualifying states capture
most of those that had expanded their
upper-income eligibility levels for
children in their Medicaid programs to
185% of poverty prior to the enactment
of SCHIP. Based on statutory
definitions, 11 states were determined to
be qualifying states: Connecticut,
Hawaii, Maryland, Minnesota, New
Hampshire, New Mexico, Rhode Island,
Tennessee, Vermont, Washington and
Wisconsin.
Bonuses for increasing enrollment of children
No provision.
H§111. CHIP performance bonus S§105. Incentive bonuses for states. A§104. CHIP performance bonus
payment to offset additional A CHIP Incentive Bonuses Pool would payment to offset additional
enrollment costs resulting from be established in the U.S. Treasury, to enrollment costs resulting from
enrollment and retention efforts. be used for any purpose the state enrollment and retention efforts.
From FY2009 to FY2013, performance determines is likely to reduce the Like the House bill, from FY2009 to
bonus payments would be paid to states percentage of low-income children in FY2013, performance bonus payments
implementing specified enrollment and the state without health insurance.
would be paid to states implementing
retention efforts and enrolling eligible
specified enrollment and retention
CRS-25
Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
children above specified target levels.
efforts and enrolling eligible children
above specified target levels.
Source of funds. No source of Source of funds. The Incentive Pool Source of funds. Like the Senate bill,
appropriations specified.
would receive deposits from an initial the bonus pool would receive an initial
appropriation in FY2008 of $3 billion, deposit of $3 billion in FY2008, to be
along with transfers from six different available until expended, along with
potential sources, with currently transfers from four different potential
available but not immediately required sources. The four additional sources for
funds invested in interest-bearing U.S. deposits would be as follows: (1) from
securities that provide additional 2008 to 2012, any of the national CHIP
income into the Incentive Pool.
appropriation not allotted to the states;
The six additional sources for deposits (2) as of November 15 of fiscal years
would be as follows: (1) On December 2009 through 2012, the amount of
31, 2007, the amount by which states’ unspent allotments available for
FY2006 and FY2007 allotments not redistribution that were not used for
expended by September 30, 2007, redistribution to shortfall states or were
exceed 50% of the FY2008 allotment; not spent by those states; (3) on October
(2) from 2008 to 2012, any of the 1 of FY2009 through FY2012, any
national CHIP appropriation not allotted amounts in the CHIP Contingency Fund
to the states; (3) on October 1 of fiscal in excess of the fund’s aggregate cap;
years 2009 to 2012, the amount by and (4) on October 1, 2009, any
which the unspent funds from the prior amounts set aside for transition off of
year’s allotment exceeds a particular CHIP coverage for childless adults that
percentage of that allotment (that is, are not expended by September 30,
20% in FY2009, and 10% in FY2010, 2009.
FY2011, and FY2012); (4) any original
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Current Law
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Senate: H.R. 976
Agreement
allotment amounts not expended by the
end of their second year of availability
(beginning with the FY2007 allotment);
(5) on October 1, 2009, any amounts set
aside for transition off of CHIP
coverage for childless adults that are not
expended by September 30, 2009; and
(6) on October 1 of FY2009 through
FY2012, any amounts in the CHIP
Contingency Fund in excess of the
fund’s aggregate cap, as well as any
Contingency Fund payments provided
to a state that are unspent at the end of
the fiscal year following the one in
which the funds were provided.
Qualifying for bonus payments. States Qualifying for bonus payments. Funds
that implement at least 4 out of 7 from the Incentive Pool would be
specified enrollment and retention payable in FY2009 to FY2012 to states
efforts (that is, continuous eligibility, that have increased their average
liberalization of asset requirements, monthly Medicaid enrollment among
elimination of in-person interview low-income children (with children
requirement, use of joint application for defined as those under age 19 — or
Medicaid and CHIP, automatic renewal, under age 20 or 21 if a state has so
presumptive eligibility for children, and elected in its Medicaid program) during
express lane) would be eligible to a coverage period above a baseline
receive a bonus payment not later than monthly average for the state.Qualifying
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
the last day of the first calendar quarter for bonus payments. Same as House
of the following fiscal year. The bill.
amount would be the sum of payments
calculated for the number of child
enrollees in each of two “tiers” in
Medicaid as well as in CHIP (reflecting
certain levels of enrollment growth)
multiplied by a percentage of the state’s
share of projected Medicaid and CHIP
per capita expenditures.
Baseline enrollment. The baseline Baseline enrollment. The coverage Baseline enrollment. Same as House
number of child enrollees for FY2008 period for FY2009 would be the first bill.
would be equal to the monthly average two quarters of FY2009. The baseline
number of child enrollees during monthly average would be the average
FY2007 increased by child population monthly enrollment of low-income
growth for the year ending on June 30, children in Medicaid in the first two
2006 (as estimated by the Census quarters of FY2007 multiplied by the
Bureau) plus one percentage point. For sum of 1.02 and percentage population
a subsequent fiscal year, the baseline growth among low-income children in
number would be equal to the prior the state from FY2007 to FY2009.
year’s baseline number plus child
population growth in that state plus one For FY2010 to FY2012, the coverage
percentage point.
period would consist of the last two
quarters of the preceding fiscal year and
For such calculations, projected per the first two quarters of the fiscal year.
capita state expenditures would be For FY2010 to FY2012, the baseline
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Senate: H.R. 976
Agreement
defined as projected average per capita monthly average would be the baseline
federal and state Medicaid and CHIP monthly average for the preceding fiscal
expenditures for children for the most year multiplied by the sum of 1.01 and
recent fiscal year, increased by the percentage population growth among
annual percentage increase in per capita low-income children in the state over
a mo u n t s o f N a t i o n al Hea l t h the prior year.
Expenditures for the respective
subsequent fiscal year, and multiplied
by the state’s share of such expenditures
required for the fiscal year involved.
Qualifying children. Average monthly Qualifying children. Average monthly Qualifying children. Same as House
enrollment and the baseline averages enrollment and the baseline averages bill.
would consist only of Medicaid- and would exclude Medicaid-enrolled
CHIP-enrolled children who would children who would not meet the
meet the eligibility criteria (including income eligibility criteria in effect on
income, categorical eligibility, age and July 19, 2007.
immigration status criteria) in effect on
July 1, 2007.
Amount of bonus payments. The first Amount of bonus payments. A state Amount of bonus payments. Same as
tier of child enrollment would be the eligible for a bonus would receive in the House bill, except for the percentage of
amount by which the monthly average last quarter of FY2009 the following the state share of expenditures used to
of children enrolled during the fiscal amounts, depending on the “excess” of calculate bonus payments. For the first
year exceeded the baseline number, but the state’s enrollment of children in tier above baseline child Medicaid
by no more than 3% for Medicaid or Medicaid above the baseline monthly enrollment, the state would receive 15%
7.5% for CHIP. For the first tier above average during the coverage period: (i) of the state share of those projected
baseline child Medicaid enrollment, the If the excess does not exceed 2%, the expenditures. For the first tier above
CRS-29
Current Law
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Senate: H.R. 976
Agreement
state would receive 35% of the state product of $75 and the number of baseline child CHIP enrollment, the
share of those projected expenditures. individuals in such excess; (ii) if the state would receive 10% of the state
For the first tier above baseline child excess is more than 2% but less than share of those projected expenditures.
CHIP enrollment, the state would 5%, the product of $300 and the number
receive 5% of the state share of those of individuals in such excess, less the
projected expenditures.
amount in (i); and (iii) if the excess
exceeds 5%, the product of $625 and the
number of individuals in such excess,
less the sum of the amounts in (i) and
(ii).
The second tier of child enrollment For FY2010 onward, these dollar For the second tier above baseline child
would be the amount by which the amounts would be increased by the Medicaid enrollment, the state would
monthly average of children enrolled percentage increase (if any) in the receive 60% of the state share of those
during the fiscal year exceeded the projected per capita spending in the projected expenditures. For the second
baseline number by 3% for Medicaid or National Health Expenditures for the tier above baseline child CHIP
7.5% for CHIP. For the second tier calendar year beginning on January 1 of enrollment, the state would receive 40%
above baseline child Medicaid the coverage period over that of the of the state share of those projected
enrollment, the state would receive 90% preceding coverage period.
expenditures.
of the state share of those projected
expenditures. For the second tier above
baseline child CHIP enrollment, the
state would receive 75% of the state
share of those projected expenditures.
If the funds in the Incentive Pool were Same as Senate bill.
inadequate to cover the amounts
calculated for all the eligible states, the
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Current Law
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Senate: H.R. 976
Agreement
a m o u n t w o u l d b e r e d u c e d
proportionally.
Application to territories. Territories
would be eligible for bonus payments
once the Secretary determines there are
satisfactory methods for collecting and
reporting the necessary enrollment
information reliably.
The Government Accountability Office
(GAO) would be required to submit a
report for Congress not later than
January 1, 2013, regarding the
effectiveness of the performance bonus
payment program in enrolling and
retaining uninsured children in
Medicaid and CHIP.
No federal funding for illegal aliens
Under the Medicaid program, H§135. No federal funding for illegal No provision.
A§605. No federal funding for illegal
unauthorized aliens who meet all other aliens. The House bill would specify
aliens. Same as the House bill.
program criteria are only eligible for that nothing in the bill allows federal
emergency coverage. Under SCHIP, payment for individuals who are not
states may opt to cover unauthorized legal residents.
aliens who are pregnant, but covered
services must be related to the
pregnancy or to conditions that could
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
complicate the pregnancy or threaten
the health of the unborn child (who will
be a U.S. citizen if he or she is born in
the United States).
Medicaid funding for the territories
Medicaid programs in the territories are H§811. Payments for Puerto Rico and No provision.
No provision.
subject to spending caps. For FY1999 territories. Would increase the territory
and subsequent fiscal years, these caps Medicaid caps by the following
are increased by the percentage change amounts:
in the medical care component of the
Consumer Price Index (CPI-U) for all
Urban Consumers (as published by the
Bureau of Labor Statistics). The Deficit
Reduction Act of 2005 increased the
federal Medicaid caps in each of
FY2006 and FY2007. For FY2007 the
Medicaid caps are equal to:
•
For Puerto Rico, $250,400,000.
•
For Puerto Rico, $250,000,000 for
FY2009; $350,000,000 for FY2010;
$500,000,000 for FY2011; and
$600,000,000 for FY2012.
•
For the Virgin Islands, $12,520,000. •
For the Virgin Islands, $5,000,000
for each of fiscal years 2009
through 2012.
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Senate: H.R. 976
Agreement
•
For Guam, $12,270,000.
•
For Guam, $5,000,000 for each of
fiscal years 2009 through 2012.
•
For the Northern Mariana Islands, •
For the Northern Mariana Islands,
$4,580,000.
$4,000,000 for each of fiscal years
2009 through 2012.
•
For American Samoa $8,290,000. •
For American Samoa, $4,000,000
for each of fiscal years 2009
through 2012.
For FY2008 and subsequent fiscal
years, the total annual cap on federal
funding for the Medicaid programs in
the insular areas is calculated by
increasing the FY2007 ceiling for
inflation.
Enhanced matching funds for certain data systems in the territories
The federal Medicaid matching rate, H§811. Payments for Puerto Rico and S§104. Improving funding for the A§109. Improving funding for the
which determines the federal share of territories. Beginning with FY2008, if territories under CHIP and Medicaid. territories under CHIP and Medicaid.
most Medicaid expenditures, is a territory qualifies for the enhanced Same as the House bill, but would also Same as Senate bill.
statutorily set at 50 percent in the federal match (90% or 75%) that is require a GAO study (due to Congress
territories (an enhanced match is also available under Medicaid for no later than September 30, 2009)
available for certain administrative improvements in data reporting systems, regarding federal funding under
costs). Therefore, the federal such reimbursement would not count Medicaid and CHIP in the territories.
government generally pays 50% of the towards its Medicaid spending cap.
cost of Medicaid items and services in
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
the territories up to the spending caps.
Medicaid FMAP
The federal medical assistance H§813. Adjustment in computation No provision.
A§615. Adjustment in computation
percentage (FMAP) is the rate at which of Medicaid FMAP to disregard an
of Medicaid FMAP to disregard an
states are reimbursed for most Medicaid extraordinary employer pension
extraordinary employer pension
service expenditures. It is based on a contribution. For purposes of
contribution. For purposes of
formula that provides higher computing Medicaid FMAPs beginning
computing Medicaid FMAPs beginning
reimbursement to states with lower per with FY2006, any significantly
with FY2006, any significantly
capita incomes relative to the national disproportionate employer pension
disproportionate employer pension or
average (and vice versa). When state contribution would be disregarded in
insurance fund contribution would be
FMAPs are calculated by HHS for the computing state per capita income, but
disregarded in computing state per
upcoming fiscal year, the state and U.S. not U.S. per capita income. A
capita income, but not U.S. per capita
per capita income amounts used in the significantly disproportionate employer
income.
formula are equal to the average of the pension contribution would be defined
three most recent calendar years of data as an employer contribution towards
A significantly disproportionate
on per capita personal income available pensions that is allocated to a state for a
employer pension and insurance fund
from the Department of Commerce’s period if the aggregate amount so
contribution would be defined as any
Bureau of Economic Analysis (BEA). allocated exceeds 25% of the total
identifiable employer contribution
BEA revises its most recent estimates of increase in personal income in that state
towards pension or other employee
state per capita personal income on an for the period involved.
insurance funds that is estimated to
annual basis to incorporate revised and
accrue to residents of such state for a
newly available source data on
calendar year (beginning with calendar
population and income. It also
year 2003) if the increase in the amount
undertakes a comprehensive data
so estimated exceeds 25% of the total
revision every few years that may result
increase in personal income in that State
in upward and downward revisions to
for the year involved.
CRS-34
Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
each of the component parts of personal
For estimating and adjusting an FMAP
income, one of which is employer
already calculated as of the date of
contributions for employee pension and
enactment for a state with a
insurance funds. In describing its 2003
significantly disproportionate employer
comprehensive revision, BEA reported
p e n s i o n a n d i n s u r a n c e f u n d
that upward revisions to employer
contribution, the Secretary shall use the
contributions for pensions beginning
personal income data set originally used
with 1989 were the result of
in calculating such FMAP.
methodological improvements and more
complete source data.
If in any calendar year the total personal
income growth in a state is negative, an
employer pension and insurance fund
contribution for the purposes of
calculating the state’s FMAP for a
calendar year shall not exceed 125% of
the amount of such contribution for the
previous calendar year for the State.
No state would have its FMAP for a
fiscal year reduced as a result of the
application of this section. Not later
than May 15, 2008, the Secretary shall
submit to the Congress a report on the
problems presented by the current
treatment of pension and insurance fund
contributions in the use of Bureau of
Economic Affairs calculations for the
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Current Law
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Senate: H.R. 976
Agreement
FMAP and for Medicaid and on
possible alternative methodologies to
mitigate such problems.
CHIP E-FMAP
The federal medical assistance No provision.
S§110. Limitation on matching rate A§114. Limitation on matching rate
percentage (FMAP) is the rate at which
for states that propose to cover for states that propose to cover
states are reimbursed for most Medicaid
children with effective family income children with effective family income
service expenditures. It is based on a
that exceeds 300 percent of the that exceeds 300 percent of the
formul a that provides higher
poverty line. For child health poverty line. Same as the Senate bill,
reimbursement to states with lower per
assistance or health benefits coverage with an additional statement that
capita incomes relative to the national
furnished in any fiscal year beginning nothing in the amendments made by the
average (and vice versa); it has a
with FY2008 to targeted low-income section shall be construed as: (1)
statutory minimum of 50% and
children whose effective family income changing any income eligibility level
maximum of 83%. The enhanced
would exceed 300% of the poverty line for children under CHIP or (2) changing
FMAP (E-FMAP) for SCHIP equals a
but for the application of a general the flexibility provided states under
state’s Medicaid FMAP increased by
exclusion of a block of income that is CHIP to establish the income eligibility
the number of percentage points that is
not determined by type of expense or level for targeted low-income children
equal to 30% of the difference between
type of income, states would be under a state child health plan and the
a state’s FMAP and 100%. For
reimbursed using the FMAP instead of methodologies used by the state to
example, in states with an FMAP of
the E-FMAP. An exception would be determine income or assets under such
60%, the E-FMAP equals the FMAP
provided for states that, on the date of plan.
increased by 12 percentage points (60%
enactment, have an approved state plan
+ [30% multiplied by 40 percentage
amendment or waiver, or have enacted
points] = 72%). E-FMAPs can range
a state law to submit a state plan
from 65% to 85%.
amendment to cover targeted low-
income children above 300% of the
CRS-36
Current Law
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Senate: H.R. 976
Agreement
There are two types of income
poverty line.
disregards used by states. The first type
excludes particular dollar amounts or
types of income (or certain expenses,
such as child care expenses). Nearly
every state uses such disregards in
SCHIP. These disregards often mirror
the disregards in states’ Medicaid
programs. Although an individual’s
gross family income may be above the
state’s income eligibility level for
SCHIP, the person may qualify because
his or her net family income (taking into
account the state’s disregards) falls
below the income threshold. The
SCHIP statute provides flexibility for
states to use such disregards. The
second type of income disregard
excludes an entire block of
percent-of-poverty income. For
example, New Jersey’s SCHIP program
covers children with gross family
income up to 350% FPL by excluding
all family income between 200% and
350% of poverty (thereby reducing net
family income to 200% of poverty).
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Current Law
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Senate: H.R. 976
Agreement
Eligibility
Premium grace period
No statutory provision specifies a grace H§123. Premium grace period. States No provision.
A§504. Premium grace period. Same
period for payment of SCHIP would have to provide CHIP enrollees
as House bill.
premiums. The congressionally with a grace period of at least 30 days
mandated evaluation of SCHIP in 10 from the beginning of a new coverage
states (required not later than December period to make premium payments
31, 2001) was to include an before the individual’s coverage may be
“[e]valuation of disenrollment or other terminated. Within seven days after the
retention issues, such as … failure to first day of the grace period, the state
pay premiums ….”
would have to provide the individual
Federal regulations require states’ with notice that failure to make a
SCHIP plans to describe the premium payment within the grace
consequences for an enrollee or period will result in termination of
applicant who does not pay required coverage and that the individual has the
premiums and the disenrollment right to challenge the proposed
protections adopted by the state. termination pursuant to the applicable
According to the federal regulations, the federal regulations. This provision
protections must include the following: would be effective for new coverage
(1) The state must give enrollees periods beginning on or after January 1,
reasonable notice of and an opportunity 2009.
to pay past due premiums prior to
disenrollment; (2) the disenrollment
process must give the individual the
opportunity to show a decline in family
income that may qualify the individual
CRS-38
Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
for lower or no cost-sharing; and (3) the
state must provide the enrollee with an
opportunity for an impartial review to
address disenrollment from the
program, during which time the
individual will continue being enrolled.
Optional coverage of older children under CHIP
Generally, eligibility for children under H§131. Optional coverage of children No provision.
No provision.
Medicaid is limited to persons under age up to age 21 under CHIP. Would
19 (or in some cases, under age 18, 19, expand the definition of child under
20 or 21). Under SCHIP, children are CHIP to include persons under age 20 or
defined as persons under age 19.
21, at state option. The effective date
would be January 1, 2008.
Optional coverage of legal immigrants in Medicaid and CHIP
States may provide full Medicaid H§132. Optional coverage of legal No provision.
No provision.
coverage to legal immigrants who meet immigrants under the Medicaid
applicable categorical and financial program and CHIP. Would allow
eligibility requirements after such states to cover legal immigrants who are
persons have been in the United States pregnant women and/or children under
for a minimum of five years. Sponsors age 21 (or such higher age as the state
can be held liable for the costs of public has elected) under Medicaid or CHIP
benefits (such as Medicaid and SCHIP) before the five-year bar is met effective
provided to legal immigrants.
upon the date of enactment. Sponsors
would not be held liable for the costs
associated with providing benefits to
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Current Law
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Senate: H.R. 976
Agreement
such legal immigrants, and the cost of
such assistance would not be considered
an unreimbursed cost.
Optional coverage of pregnant women under CHIP
Under SCHIP, states can cover pregnant H§133. State option to expand or add S§107. State option to cover low- A§111. State option to cover low-
women ages 19 and older through coverage of certain pregnant women income pregnant women under CHIP income pregnant women under CHIP
waiver authority or by providing under CHIP. The provision would through a state plan amendment. through a state plan amendment.
coverage to unborn children as allow states to cover pregnant women Would allow states to provide optional Same as the Senate bill with
permitted through regulation. In the under CHIP through a state plan coverage under CHIP to pregnant modifications based on the House bill.
latter case, coverage includes prenatal amendment only if: (1) the Medicaid women when specific conditions are With respect to minimum income
and delivery services only.
income eligibility threshold for pregnant met, including, for example (1) the eligibility levels, states may cover
women is at least 185% FPL (but cannot upper income eligibility level for certain pregnant women under CHIP through a
be lower than the percentage in effect pregnant women under traditional state plan amendment if the minimum
for certain groups of pregnant women as Medicaid must be at least 185% FPL, Medicaid income level for certain
of July 1, 2007), (2) the income (2) states must not apply any groups of pregnant women is at least
eligibility threshold is at least 200% pre-existing condition or waiting period 185% FPL (or such higher percentage as
FPL for children under CHIP or restrictions under CHIP, and (3) states the state has in effect), but in no case
Medicaid, and (3) certain enrollment must provide the same cost-sharing lower than the percent in effect for such
limitations for CHIP children are not protections applicable to CHIP children, groups as of July 1, 2007, as per the
imposed. For the new group of CHIP and all cost-sharing incurred by House bill. An additional condition
pregnant women, the lower income limit pregnant women must be capped at 5% would be added to coverage of pregnant
would exceed 185% FPL (or the of annual family income. No cost- women under CHIP as per the House
applicable Medicaid threshold, if sharing would apply to pregnancy- bill — for children under age 19 in
higher) and the upper income limit related services. States choosing this CHIP or Medicaid, the income
could be up to the level of coverage for new option would also be allowed to eligibility threshold must be at least
CHIP children in the state. Other temporarily enroll such women for up to 200% FPL. Also from the House bill,
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
limitations on eligibility for CHIP two months until a formal determination the agreement adds another condition to
children would also apply. No pre- of eligibility is made. The upper the option to cover pregnant women
existing condition exclusions or waiting income limit for this new coverage under CHIP — no waiting lists for
periods would be permitted. All cost- group would be the upper income enrollment of children under CHIP.
sharing would be capped at 5% of standard applicable to CHIP children in
annual income. States electing to cover the state. Other eligibility restrictions A§113. Elimination of counting
pregnant women would receive an for children under CHIP would also Medicaid child presumptive eligibility
adjustment to their annual CHIP apply to this new group of pregnant costs against title XXI allotment.
allotments to cover these additional women (i.e., must be uninsured, Includes amendments to Medicaid that
costs. Pregnancy-related assistance ineligible for state employee coverage, are the same as the House bill (Sec.
would include all services provided to etc.). Pregnancy-related assistance 133) with respect to (1) continuous
CHIP children in the state (excluding would include all services covered eligibility of newborns through age 1
EPSDT), and the period of coverage under CHIP for children in a state as regardless of their living arrangements
would be during pregnancy through the well as prenatal, delivery and and mothers’ eligibility, and (2)
end of the month in which the 60-day postpartum care, including care allowing entities that make presumptive
postpartum period ends. Additional provided to pregnant women under the eligibility determinations for children
provisions would: (1) deem infants born state’s Medicaid program. Also under Medicaid to make such
to CHIP pregnant women to be eligible children born to these pregnant women determinations for pregnant women
for Medicaid or CHIP (as applicable) up would be deemed eligible for Medicaid under Medicaid.
to age one year (regardless of whether or CHIP, as appropriate, and would be
the infant lives with the mother or the covered up to age one year. States may
mother remains eligible), (2) allow continue to provide coverage to
presumptive eligibility for pregnant pregnant women through waivers and
women and children under CHIP, and the unborn child regulation. States
(3) allow entities that make presumptive covering pregnant women through the
eligibility determinations for children unborn child regulation would be
under Medicaid to make such allowed to provide postpartum services
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Current Law
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Senate: H.R. 976
Agreement
determinations for pregnant women to those women at state option.
under CHIP. The provision also
amendments Medicaid to (1) no longer
require that a newborn deemed eligible
for Medicaid at birth through age 1
remain in the mother’s household and
that the mother remain eligible for
Medicaid during this period in order for
such a newborn to remain eligible for
Medicaid, and (2) allow entities
qualified to make presumptive
eligibility determinations for children
under Medicaid to also be allowed to
make such determinations for pregnant
women under Medicaid.
Nonpregnant childless adult coverage under CHIP
Under current law, Section 1115 of the H§134. Limitation on waiver S§106. Phase-out coverage for A§112. Phase-Out of coverage for
Social Security Act gives the Secretary authority to cover adults. The nonpregnant childless adults under nonpregnant childless adults under
of Health and Human Services (HHS) provision would prohibit the Secretary CHIP. Would prohibit the approval or CHIP; conditions for coverage of
broad authority to modify virtually all from allowing federal CHIP allotments renewal of Section 1115 demonstration parents. Same as Senate bill.
aspects of the Medicaid and SCHIP to be used to provide health care waivers that allow federal CHIP funds
programs including expanding services (under the Section 1115 waiver to be used to provide coverage to
eligibility to populations who are not authority) to individuals who are not nonpregnant childless adults. The six
otherwise eligible for Medicaid or targeted low-income children or states with CMS approval for such
SCHIP (e.g., childless adults). pregnant women (e.g., non-pregnant waivers would be permitted to use
Approved SCHIP Section 1115 waivers childless adults or parents of Medicaid federal CHIP funds to continue such
CRS-42
Current Law
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Senate: H.R. 976
Agreement
are deemed to be part of a state’s SCHIP or CHIP-eligible children) unless the coverage through FY2008, but in
state plan for purposes of federal Secretary determines that no CHIP- FY2009, such states would receive an
reimbursement. Costs associated with eligible child in the state would be amount (as part of a separate allotment)
waiver programs are subject to each denied CHIP coverage because of such equal to the federal share of the State’s
state’s enhanced-FMAP. Under SCHIP eligibility. To meet this requirement, projected FY2008 waiver expenditures
Section 1115 waivers, states must meet states would have to assure that they increased by the annual adjustment for
an “allotment neutrality test” where have not instituted a waiting list for per capita health care growth, and such
combined federal expenditures for the their CHIP program, and that they have waiver expenditures would be matched
state’s regular SCHIP program and for an outreach program to reach all at the regular Medicaid FMAP rate.
the state’s SCHIP demonstration targeted low-income children in
program are capped at the state’s families with annual income less than
individual SCHIP allotment. The 200% FPL
Deficit Reduction Act of 2005
prohibited the approval of new
demonstration projects that allow
federal SCHIP funds to be used to
provide coverage to nonpregnant
childless adults, but allowed for the
continuation of such existing Medicaid
or SCHIP waiver projects affecting
federal SCHIP funds that were approved
before February 8, 2006.
States with nonpregnant childless adult Same as Senate bill.
CHIP waivers in effect during FY2007
would be permitted to seek approval for
a Medicaid nonpregnant childless adult
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Current Law
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Senate: H.R. 976
Agreement
waiver, but allowable spending under
the Medicaid waiver would be limited to
waiver spending in the preceding fiscal
year, increased by the percentage
increase (if any) in the projected per
capita spending in the National Health
Expenditures for the calendar year that
begins during the fiscal year involved
over the prior calendar year.
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Current Law
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Senate: H.R. 976
Agreement
Parent coverage under CHIP
Same as above.
Same as above.
S§106. Conditions for coverage of A§109. Phase-Out of coverage for
parents. Would prohibit the approval nonpregnant childless adults under
or renewal of Section 1115 CHIP; conditions for coverage of
demonstration waivers that allow parents. Same as Senate bill.
federal CHIP funds to be used to
provide coverage to parent(s) of
targeted low-income child(ren). The 11
states with CMS approval for such
waivers would be permitted to use
federal CHIP funds to continue such
coverage during FY2008 and FY2009 as
long as such funds are not used to cover
individuals with annual income that
exceeds the income eligibility in place
as of the date of enactment. Beginning
in FY2010, allowable spending under
the waivers would be subject to a set
aside amount from a separate allotment.
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Current Law
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Senate: H.R. 976
Agreement
In FY2010 only, costs associated with Same as Senate bill.
such parent coverage would be subject
to each such state’s CHIP enhanced
FMAP for States that meet certain
coverage benchmarks (related to
performance in providing coverage to
children) in FY2009, or each such
state’s Medicaid FMAP rate for all other
states.
For FY2011 or 2012, costs associated Same as Senate bill.
with such parent coverage would be
subject to: (1) a state’s REMAP
percentage (i.e., a percentage which
would be equal to the sum of (a) the
state’s FMAP percentage and (b) the
number of percentage points equal to
one-half of the difference between the
state’s FMAP rate and the state’s E-
FMAP rate) if the state meets certain
coverage benchmarks (related to
performance in providing coverage to
children) for the preceding fiscal year,
or (2) the state’s regular Medicaid
FMAP rate if the state failed to meet the
specified coverage benchmarks for the
preceding fiscal year.
CRS-46
Current Law
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Senate: H.R. 976
Agreement
Would require a Government Same as Senate bill.
Accountability Office study regarding
effects of adult coverage on the increase
in child enrollment or quality of care.
Medicaid TMA
States are required to continue Medicaid H§801. Modernizing transitional No provision.
No provision.
benefits for certain low-income families Medicaid. The House bill would
who would otherwise lose coverage extend work-related TMA under section
because of changes in their income. 1925 through September 30, 2011.
This continuation is called transitional States could opt to treat any reference to
medical assistance (TMA). Federal law a 6-month period (or 6 months) as a
permanently requires four months of reference to a 12-month period (or 12
TMA for families who lose Medicaid months) for purposes of the initial
eligibility due to increased child or eligibility period for work-related TMA,
spousal support collections, as well as in which case the additional 6-month
those who lose eligibility due to an extension would not apply. States could
increase in earned income or hours of opt to waive the requirement that a
employment. Congress expanded family have received Medicaid in at
work-related TMA under section 1925 least three of the last six months in
of the Social Security Act in 1988, order to qualify. They would be
requiring states to provide TMA to required to collect and submit to the
families who lose Medicaid for Secretary of HHS (and make publicly
work-related reasons for at least six, and available) information on average
up to 12, months. Since 2001, monthly enrollment and participation
work-related TMA requirements under rates for adults and children under
section 1925 have been funded by a work-related TMA, and on the number
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Current Law
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Senate: H.R. 976
Agreement
series of short-term extensions, most and percentage of children who become
recently through September 30, 2007.
ineligible for work-related TMA and
whose eligibility is continued under
another Medicaid eligibility category or
who are enrolled in CHIP. The
Secretary would submit annual reports
to Congress concerning these rates.
Except for the four-year extension of
work-related TMA, which would be
effective October 1, 2007, the provision
would be effective upon enactment.
State authority to expand income or resource eligibility for children
States have the ability under current law No provision.
No provision.
A§115. State
Authori t y
Under
to extend Medicaid coverage to children
Medicaid. The provision clarifies that
in families with income below 133% of
nothing in the bill should be construed
FPL for children under age 6, or 7, or 8
as limiting the flexibility of states to
and below 100% of FPL for children
increase the income or resource
under age 19. States also are able to
eligibility levels for children under
define income and resource counting
Medicaid state plans or under Medicaid
methodologies. Part of this flexibility
waivers. In addition, the provision
includes the ability to disregard certain
would protect the ability of states to
amounts form income or resources for
extend Medicaid coverage beyond the
the purpose of determining Medicaid
Medicaid applicable income level
eligibility. A targeted low-income child
effectively allowing a shift of children
qualifying for enhanced federal
from a targeted low-income eligibility
matching payments is one who is under
pathway to a traditional Medicaid
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Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
the age of 19 years without health
eligibility pathway.
insurance, and who would not have been
eligible for Medicaid under the rules in
effect in the state on March 31, 1997.
States can set the upper income level for
targeted low-income children up to
200% of the federal poverty level
(FPL), or 50 percentage points above
the applicable pre-SCHIP Medicaid
income level.
Spousal impoverishment rules
Medicaid law grants states the option to H§804. State option to protect No provision.
No provision.
apply spousal impoverishment rules to community spouses of individuals
the counting of income and assets for a with disabilities. The provision would
married person who applies to Medicaid amend Medicaid law to allow states to
as a medically needy individual under apply spousal impoverishment rules to
section 1915(c) and (d) home and medically needy applicants and their
community-based (HCBS) waivers. spouses during the eligibility and
States may not, however, apply spousal post-eligibility determination of income
impoverishment rules when determining process for applicants of HCBS waivers
eligibility for medically needy authorized under sections 1915(c), (d),
individuals under 1915(e) waivers. In or (e) as well as section 1115 of the
addition, states may not apply spousal Social Security Act. It would also apply
impoverishment rules t o the to medically needy individuals who are
post-eligibility treatment of income for receiving benefits under sections
medically needy persons enrolled in 1915(I) and (j).
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Current Law
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Agreement
1915(c), (d), and (e) waivers. Neither
eligibility nor post-eligibility spousal
impoverishment rules are applied to
persons receiving section 1915(I) or
1915(j) benefits unless these persons
qualify for Medicaid through an
eligibility group for which spousal
impoverishment rules apply. Medicaid
law allows states to apply spousal
impoverishment eligibility and post-
eligibility rules to medically needy
individuals, subject to the Secretary’s
approval.
Medicaid asset verification
The Social Security Administration H§817. Extension of SSI web-based No provision.
A§619. Extension of SSI web-based
(SSA) is piloting a financial account asset demonstration project to the
asset demonstration project to the
verification system (in field offices Medicaid program. Under the House
Medicaid program. Same as the
located in New York and New Jersey) bill, the Secretary of HHS would be
House bill, except that the provision
that uses an electronic asset verification required to provide for application of
would apply beginning on October 1,
system to help confirm that individuals the current law SSI pilot to asset
FY2012.
who apply for Supplemental Security eligibility determinations under the
Income (SSI) benefits are eligible. The Medicaid program. This application
process permits automated paperless would only extend to states in which the
transmission of asset verification SSI pilot is operating and only for the
requests between SSA field offices and period in which the pilot is otherwise
financial institutions. Part of this pilot provided. For purposes of applying the
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Current Law
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Senate: H.R. 976
Agreement
involved a comprehensive study to SSI pilot to Medicaid, information
measure the value of such a system for obtained from a financial institution that
SSI applicants as well as recipients is used for purposes of SSI eligibility
already on the payment rolls. This determinations could also be shared and
study identified a small percentage used by states for purposes of Medicaid
(about 5 percent) of applicants and eligibility determinations.
recipients who were overpaid based on
this financial account verification
system. A bill (H.R. 3668) that would
apply the pilot to Medicaid beginning
on October 1, 2007, and ending on
September 30, 2012, was passed by the
House on September 26.
Enrollment/Access
“Express lane” eligibility determinations
Medicaid law and regulations contain H§112. State option to rely on finding S§203. Demonstration project to A§203. State option to rely on finding
requirements regarding determinations from an express lane agency to permit States to rely on findings by an from an Express Lane agency to
of eligibility and applications for conduct simplif ied eligibility Express Lane agency to determine conduct simplif ied eligibility
assistance. In limited circumstances determinations. Beginning in January components of a child’s eligibility for determinations. Like the House bill,
outside agencies are permitted to 2008, the bill would allow States to rely Medicaid or CHIP. Would create a beginning in January 2008, the
determine eligibility for Medicaid. For on an eligibility determination finding three-year demonstration program that agreement would allow states to rely on
example, when a joint TANF-Medicaid made within a State-defined period from would allow up to ten states to use an eligibility determination finding
application is used the state TANF an Express Lane Agency to determine Express Lane eligibility determinations made within a State-defined period from
agency may make the Medicaid whether a child under age 19 (or up to at Medicaid and CHIP enrollment and an Express Lane Agency to determine
eligibility determination.
age 21 at state option) has met one or renewal. The demonstration would whether a child under age 19 (or up to
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Current Law
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Senate: H.R. 976
Agreement
more of the eligibility requirements authorize and appropriate $44 million age 21 at state option) has met one or
(e.g., income, assets or resources, for the period of FY2008 through more of the eligibility requirements
citizenship, or other criteria) necessary FY2012 for systems upgrades and (e.g., income, assets or resources,
to determine an individual’s initial implementation. Of this amount, $5 citizenship, or other criteria) necessary
eligibility, eligibility redetermination, or million would be dedicated to an to determine an individual’s initial
renewal of eligibility for medical independent evaluation of the eligibility, eligibility redetermination, or
assistance under Medicaid or CHIP.
demonstration for the Congress. Under renewal of eligibility for medical
the demonstration, states would be assistance under Medicaid or CHIP.
permitted to rely on a finding made by Under the agreement, however, states
an Express Lane Agency within the would be required to verify citizenship
preceding 12 months to determine or nationality status, and such eligibility
whether a child has met one or more of determinations would not be permitted
the eligibility requirements (e.g., after September 30, 2012.
income, assets, citizenship or other
criteria) necessary to determine an
individual’s eligibility for Medicaid or
CHIP.
SCHIP defines a targeted low-income States would be permitted to meet the Like the House provision the Senate’s Same as House bill.
CHIP screen and enroll requirements by provision would establish criteria for
child as one who is under the age of 19
years with no health insurance, and who using either or both of the following how a state would meet screen and
requirements: (1) establishing a enroll requirements, would not relieve
would not have been eligible for
Medicaid under the rules in effect in the threshold percentage of the Federal states of their obligation to determine
poverty level that exceeds the highest eligibility for Medicaid, and would
State on March 31, 1997. Federal law
requires that eligibility for Medicaid and income eligibility threshold applicable require the state to inform families that
under Medicaid for the child by a they may qualify for lower premium
SCHIP be coordinated when States
implement separate SCHIP programs. In minimum of 30 percentage points (or payments or more comprehensive health
CRS-52
Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
these circumstances, applications for such other higher number of percentage coverage under Medicaid if the family’s
SCHIP coverage must first be screened points) as the state determines reflects income were directly evaluated by the
for Medicaid eligibility.
the income methodologies of the state Medicaid agency.
program administered by the Express
Lane Agency, or (2) with respect to any
individual within such population for
whom an Express Lane Agency finds
has income that does not exceed such
threshold percentage, such individual
would be eligible for Medicaid. If a
finding from an Express Lane Agency
results in a child not being found
eligible for Medicaid or CHIP, the
States would be required to determine
Medicaid or CHIP eligibility using its
regular procedures and to inform the
family that they may qualify for lower
premium payments if the family’s
income were directly evaluated for an
eligibility determination by the State
using its regular policies.
Subsequent to initial application, States No provision.
Error rates associated with incorrect Same as Senate bill.
must request information from other
eligibility determinations would be
federal and State agencies, to verify
monitored.
applicants’ income, resources,
citizenship status, and validity of Social
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Current Law
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Senate: H.R. 976
Agreement
Security number (e.g., income from the
Social Security Administration (SSA),
unearned income from the Internal
Revenue Service (IRS), unemployment
information from the appropriate State
agency, qualified aliens must present
documentation of their immigration
status, which States must then verify
with the Immigration and Naturalization
Service, and the State must verify the
SSN with the Social Security
Administration). States must also
establish a Medicaid eligibility quality
control (MEQC) program designed to
reduce erroneous expenditures by
monitoring eligibility determinations.
Express Lane agencies would include Express Lane agencies would include Same as Senate bill.
public agencies determined by the State public agencies determined by the State
as capable of making eligibility as capable of making eligibility
determinations including public determinations and goes beyond list of
agencies that determine eligibility under agencies included in the House
the Food Stamp Act, the School Lunch provisions to include additional public
Act, the Child Nutrition Act, or the agencies such as those that determine
Child Care Development Block Grant eligibility under TANF, CHIP,
Act.
Medicaid, Head Start, etc. Also included
are state specified governmental
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Current Law
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Senate: H.R. 976
Agreement
agencies that have fiscal liability or
legal responsibility for the accuracy of
eligibility determination findings, and
public agencies that are subject to an
interagency agreement limiting the
disclosure and use of such information
for eligibility determination purposes.
The provision would explicitly exclude
programs run through title XX (Social
Services Block Grants) of the Social
Security Act, and private for-profit
organizations as agencies that would
qualify as an Express Lane agency.
Medicaid applicants must attest to the Signatures under penalty of perjury Like the House provision, the Senate Same as House bill, however, like the
accuracy of the information submitted would not be required on a Medicaid bill would drop the requirement for Senate bill the agreement would
on their applications, and sign application form attesting to any signatures under penalty of perjury. authorize entities in possession of
application forms under penalty of element of the application for which The provision would permit signature potentially pertinent data relevant for
perjury.
eligibility is based on information requirements for a Medicaid application the determination of eligibility under
received from an Express Lane Agency to be satisfied through an electronic CHIP or Medicaid (e.g., the National
or from another public agency. The signature and would monitor error rates Directory of New Hires database) to
provision would authorize federal or associated with incorrect eligibility share such information with the CHIP
State agencies or private entities in determinations. Like the House bill, the or Medicaid agency.
possession of potentially pertinent data provision would authorize entities in
relevant for the determination of possession of potentially pertinent data
eligibility under Medicaid to share such relevant for the determination of
information with the Medicaid agency eligibility under CHIP or Medicaid
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Current Law
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Senate: H.R. 976
Agreement
for the purposes of child enrollment in (e.g., the National Directory of New
Medicaid, and would impose criminal Hires database) to share such
penalties for entities who engage in information with the CHIP or Medicaid
unauthorized activities with such data.
agency.
No provision.
The Senate bill would authorize and Like the Senate bill, the agreement
appropriate $5 million in new federal would authorize and appropriate $5
funds for fiscal years 2008 through million in new federal funds for fiscal
FY2011 for the purpose of conducting years 2008 through FY2011 for the
an evaluation of the effectiveness of purpose of conducting an evaluation of
these demonstration programs. The the effectiveness of this state plan
Secretary would be required to submit a option, and the Secretary would be
report to Congress with regard to the required to submit a report to Congress
evaluation findings no later than with regard to the evaluation findings no
September 30, 2011.
later than September 30, 2011.
Out-stationed eligibility determinations
Under current law, a Medicaid state H§113. Application of Medicaid No provision.
No provision.
plan must provide for the receipt and outreach procedures to all children
initial processing of applications for and pregnant women. Effective
medical assistance for low-income January 1, 2008, the House bill would
pregnant women, infants, and children provide for the receipt and initial
under age 19 at outstation locations processing of applications for medical
other than Temporary Funding for assistance for children and pregnant
Needy Assistance (TANF) offices such women under any provision of this title,
as, disproportionate share hospitals, and and would allow for such application
Federally-qualified health centers. State forms to vary across outstation
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Current Law
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Senate: H.R. 976
Agreement
eligibility workers assigned to locations.
outstation locations perform initial
processing of Medicaid applications
including taking applications, assisting
applicants in completing the application,
providing information and referrals,
obtaining required documentation to
complete processing of the application,
assuring that the information contained
on the application form is complete, and
conducting any necessary interviews.
Funding for outreach and enrollment
Under current law, title XXI specifies H§114. Encouraging culturally S§201. Grants for outreach and A§201. Grants and enhanced
that federal SCHIP funds can be used appropriate enrollment and retention enrollment. The provision would set administrative funding for outreach
for SCHIP health insurance coverage practices. The provision would permit aside $100 million (during the period of and enrollment. Same as Senate bill
which meets certain requirements. Apart states to receive Medicaid federal fiscal years 2008 through 2012) for a with the following changes: (1) the
from these benefit payments, SCHIP matching payments for translation or grant program under CHIP to finance agreement is silent as to whether grant
payments for four other specific health interpretation services in connection outreach and enrollment efforts that funds would be subject to current law
care activities can be made, including with the enrollment and use of services increase participation of Medicaid and restrictions on expenditures for outreach
(1) other child health assistance for by individuals for whom English is not CHIP-eligible children. Such amounts activities, (2) in addition to the
targeted low-income children; (2) their primary language. Payments for would not be subject to current law enhanced matching rate available for
health services initiatives to improve the this activity would be matched at 75% restrictions on expenditures for outreach translation and interpretation services
health of SCHIP children and other low- FMAP rate.
activities. For such period, 10% of the under CHIP, the agreement would also
income children; (3) outreach activities;
funding would be dedicated to a provide a 75% FMAP rate for
and (4) other reasonable administrative
national enrollment campaign, and 10% translation and interpretation services
costs. For a given fiscal year, payments
would be set-side for grants for outreach under Medicaid, and (3) the agreement
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Current Law
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Agreement
for other specific health care activities
to, and enrollment of, children who are would allow for the use of Community
cannot exceed 10% of the total amount
Indians. Remaining funds would be Health Workers for outreach activities.
of expenditures for SCHIP benefits and
distributed to specified entities to
other specific health care activities
conduct outreach campaigns that target
combined. The federal and state
geographic areas with high rates of
governments share in the costs of both
eligible but not enrolled children who
Medicaid and SCHIP, based on
reside in rural areas, or racial and ethnic
formulas defining the federal
minorities and health disparity
contribution in federal law. The federal
populations. Grant funds would also be
match for administrative expenditures
targeted at proposals that address
does not vary by state and is generally
cultural and linguistic barriers to
50%, but certain administrative
enrollment. Finally, the bill would
functions have a higher federal
provide the greater of 75%, or the sum
matching rate.
of the enhanced FMAP for the state plus
five percentage points for translation
and interpretation services under CHIP
by individuals for whom English is not
their primary language.
Continuous eligibility under CHIP
States are required to redetermine H§115. Continuous eligibility under No provision.
No provision.
Medicaid and SCHIP eligibility at least CHIP. The House bill would require
every 12 months with respect to separate CHIP programs (or CHIP
circumstances that may change and programs operating under the Section
affect eligibility. Continuous eligibility 1115 waiver authority) to implement 12
allows a child to remain enrolled for a months of continuous eligibility for
set period of time regardless of whether targeted low-income children whose
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Current Law
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Agreement
the child’s circumstances change (e.g., annual family income is less than 200%
the family’s income rises above the FPL.
eligibility threshold), thus making it
easier for a child to stay enrolled. Not
all states offer it, but among those that
do the period of continuous eligibility
ranges from 6 months to 12 months.
Commission to monitor access and other matters
In accordance with P.L. 92-263, in May H§141. Children’s Access, Payment No provision.
No provision.
of 2005, the Secretary of HHS and Equality Commission. Would
established a Medicaid Commission, to establish a new federal commission.
provide advice on ways to modernize Among many tasks, this new
Medicaid so that it could provide high Commission would review (1) factors
quality health care to its beneficiaries in affecting expenditures for services in
a financially sustainable way. The d i f f e r e n t s e c t o r s , p a y m e n t
charter for this Commission included methodologies, and their relationship to
rules regarding voting and non-voting access and quality of care for Medicaid
members, meetings, compensation, and CHIP beneficiaries, (2) the impact
estimated costs, and two reports. The of Medicaid and CHIP policies on the
Commission terminated 30 days after overall financial stability of safety net
submission of its final report to the providers (e.g., FQHCs, school-based
Secretary of HHS (dated December 29, clinics, disproportionate share
2006). No ongoing Commission has hospitals), and (3) the extent to which
ever existed for the program.
the operation of Medicaid and CHIP
ensures access comparable to access
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Agreement
under employer-sponsored or other
private health insurance. Commission
recommendations would be required to
consider budget consequences, be voted
on by all members, and the voting
results would be included in
Commission reports. Certain MEDPAC
provisions would apply to this new
commi ssion (i.e., relati ng t o
membership with the addition of
Medicaid and CHIP beneficiary
representatives, staff and consultants,
and powers). The provision would
authorize to be appropriated such sums
as necessary to carry out the duties of
the new Commission.
Model enrollment practices
No provision.
H § 1 4 2 . M o d e l o f
i n t e r s t a t e No provision.
A § 2 1 3 . M o d e l o f
i n t e r s t a t e
coordinated enrollment and coverage
coordinated enrollment and coverage
process. The House bill would require
process. Like the House bill, except the
the Comptroller General, in consultation
agreement would require the Secretary
with State Medicaid, CHIP directors,
of HHS, in consultation with State
and organizations representing program
Medicaid, CHIP directors, and
beneficiaries to develop a model process
organizations representing program
(and report for Congress) for the
beneficiaries to develop a model process
coordination of enrollment, retention,
(and report for Congress) for the
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Current Law
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Agreement
and coverage of children who frequently
coordination of enrollment, retention,
change their residency due to migration
and coverage of children who frequently
of families, emergency evacuations,
change their residency due to migration
educational needs, etc.
of families, emergency evacuations,
educational needs, etc.
Citizenship documentation
Under current law, noncitizens who H§143. Medicaid citizenship S§301. Verification of declaration of A§211. Verification of declaration of
apply for full Medicaid benefits have documentation requirements. The citizenship or nationality for purposes citizenship or nationality for purposes
been required since 1986 to present House bill would make Medicaid of eligibility for Medicaid and CHIP. of eligibility for Medicaid and CHIP.
documentation that indicates a citizenship documentation for children The Senate bill would provide a new Same as the Senate bill regarding a new
“satisfactory immigration status.” Due under age 21 a state option, using option for meeting citizenship option for meeting citizenship
to recent changes, citizens and nationals criteria that are no more stringent than documentation requirements. As part of documentation requirements, except that
also must present documentation that the existing documentation specified in its Medicaid state plan and with respect in the case of an individual whose name
proves citizenship and documents section 1903(x)(3) of the Social to individuals declaring to be U.S. or SSN is invalid, the state would have
personal identity in order for states to Security Act. See H§136 (under citizens or nationals for purposes of to make a reasonable effort to identify
receive federal Medicaid reimbursement M i s c e l l a n e o u s ) f o r a u d i t i n g establishing Medicaid eligibility, a state and address the causes of such invalid
for services provided to them. This requirements. See H§112(a) for ability would be required to provide that it match (including through typographical
citizenship documentation requirement of “Express Lane” agencies to satisfies existing Medicaid citizenship or other clerical errors) by contacting
was included in the Deficit Reduction determine eligibility without citizenship documentation rules under section the individual to confirm the accuracy
Act of 2005 (DRA, P.L. 109-171) and documentation.
1903(x) of the Social Security Act or of the name or SSN submitted and
modified by the Tax Relief and Health
new rules under section 1902(dd). taking such additional actions as the
Care Act of 2006 (P.L. 109-432).
Under section 1902(dd), a state could Secretary or the state may identify, and
Before the DRA, states could accept
meet its Medicaid state plan continue to provide the individual with
self-declaration of citizenship for
r e q u i r e m e n t f o r c i t i z e n s h i p medical assistance while making such
Medicaid, although some chose to
documentation by: (1) submitting the effort. If the name or SSN remains
require additional supporting evidence.
name and Social Security number (SSN) invalid after such effort, the state would
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Agreement
The citizenship documentation
of an individual to the Commissioner of be required to notify the individual,
requirement is outlined under section
Social Security as part of a plan provide him or her with a period of 90
1903(x) of the Social Security Act and
established under specified rules and (2) days to either present evidence of
applies to Medicaid eligibility
in the case of an individual whose name citizenship as defined in section 1903(x)
determinations and redeterminations
or SSN is invalid, notifying the or cure the invalid determination with
made on or after July 1, 2006. The law
individual, providing him or her with a the Commissioner of Social Security
specifies documents that are acceptable
period of 90 days to either present (and continue to provide the individual
for this purpose and exempts certain
evidence of citizenship as defined in with medical assistance during such 90-
groups from the requirement. It does
section 1903(x) or cure the invalid day period), and disenroll the individual
not apply to SCHIP. However, since
determination with the Commissioner of within 30 days after the end of the
some states use the same enrollment
Social Security, and disenrolling the 90-day period if evidence is not
procedures for all Medicaid and SCHIP
individual within 30 days after the end provided or the invalid determination is
applicants, it is possible that some
of the 90-day period if evidence is not not cured.
SCHIP enrollees would be asked to
provided.
present evidence of citizenship.
States electing the name and SSN Same as the Senate bill, except that
validation option would be required to states would only submit the name and
establish a program under which the SSN of newly enrolled individuals who
state submits each month to the are not exempt from the citizenship
Commissioner of Social Security for documentation requirement.
verification the name and SSN of each
individual enrolled in the State plan
under this title that month who has
attained the age of 1 before the date of
the enrollment.
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In establishing the program, the state In establishing the program, the state
would be allowed to enter into an would be allowed to enter into an
agreement with the Commissioner to agreement with the Commissioner: (1)
provide for the electronic submission to provide for the electronic submission
and verification of the name and SSN of and verification, through an on-line
an individual before the individual is system or otherwise, of the name and
enrolled.
SSN of an individual enrolled in the
State plan under this title; (2) to submit
to the Commissioner the names and
SSNs of such individuals on a batch
basis, provided that such batches are
submitted at least on a monthly basis; or
(3) to provide for the verification of the
names and SSNs of such individuals
through such other method as agreed to
by the state and the Commissioner and
approved by the Secretary, provided that
such method is no more burdensome for
individuals to comply with than any
burdens that may apply under a method
described in (1) or (2).
The program would be required to
provide that, in the case of any
individual who is required to submit an
SSN to the state and who is unable to
provide the state with such number,
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shall be provided with at least the same
reasonable opportunity to present
evidence that is provided under section
1137(d)(4)(A) of the Social Security
Act to noncitizens who are required to
present evidence of satisfactory
immigration status.
States would be required to provide States would be required to provide
information to the Secretary on the information to the Secretary on the
percentage of invalid names and SSNs percentage of invalid names and SSNs
submitted each month, and could be submitted each month, and could be
subject to a penalty if the average subject to a penalty if the average
monthly percentage for any fiscal year monthly percentage for any fiscal year
is greater than 7%.
is greater than 3%. A name or SSN
would be treated as invalid and included
If a state entered into an agreement with in the determination of such percentage
the Commissioner of Social Security as only if: (1) the name or SSN does not
described above, the invalid name and match Social Security Administration
SSN percentages and penalties records; (2) the inconsistency between
described here would not apply.
the name or SSN could not be resolved
by the State; (3) the individual was
provided with a reasonable period of
time to resolve the inconsistency with
the Social Security Administration or
provide satisfactory documentation of
citizenship and did not successfully
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resolve such inconsistency; and (4)
payment has been made for an item or
service furnished to the individual under
this title.
If a state entered into an agreement with
the Commissioner of Social Security as
described above, the invalid name and
SSN percentages and penalties
described here would not apply.
S t a t e s w o u l d r e c e i v e 9 0 % Same as the Senate bill.
reimbursement for costs attributable to
the design, development, or installation
of such mechanized verification and
information retrieval systems as the
Secretary determines are necessary to
implement name and SSN validation,
and 75% for the operation of such
systems.
Groups that are exempt from the The Senate provision would also clarify Same as the Senate bill, except that
citizenship documentation requirement requirements under the existing section A§113(b)(1) would remove the
would remain the same as under current 1903(x). It is similar to the House requirement that a newborn remain in
law, except for the inclusion of an provision regarding the inclusion of an his or her Medicaid-eligible mother’s
additional permanent exemption for additional permanent exemption for household in order to qualify for
children who are deemed eligible for children who are deemed eligible for deemed eligibility.
Medicaid coverage by virtue of being Medicaid coverage by virtue of being
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born to a woman on Medicaid (note that born to a woman on Medicaid,
H§131(b)(1) is also relevant because it additional documentation options for
would explicitly allow one year of federally recognized Indian tribes, and
deemed eligibility for all children born the reasonable opportunity to present
to women on Medicaid, including evidence. However, the Senate
emergency Medicaid, by removing the provision would not include additional
requirement that a newborn remain in language to reiterate that states must not
his or her Medicaid-eligible mother’s deny medical assistance on the basis of
household in order to qualify for failure to provide documentation until
deemed eligibility under 1902(e)(4) of an individual has had a reasonable
the Social Security Act). The provision opportunity. In addition, although the
would require additional documentation Senate provision would clarify that
options for federally recognized Indian deemed eligibility applies to children
tribes. It would also specify that states born to noncitizen women on
must provide citizens with the same emergency Medicaid and would require
reasonable opportunity to present separate identification numbers for
evidence that is provided under section children born to these women, the bill
1137(d)(4)(A) of the Social Security would not remove the requirement that
Act to noncitizens who are required to a newborn remain in his or her
present evidence of satisfactory Medicaid-eligible mother’s household
immigration status and must not deny in order to qualify for deemed eligibility
medical assistance on the basis of under 1902(e)(4).
failure to provide such documentation
until the individual has had such an
opportunity.
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The Senate provision would make Same as the Senate bill.
c i t i z e n s h i p d o c u m e n t a t i o n a
requirement for CHIP. In order to
receive reimbursement for an individual
who has, or is, declared to be a U.S.
citizen or national for purposes of
establishing CHIP eligibility, a state
would be required to meet the Medicaid
state plan requirement for citizenship
documentation described above. The
90% and 75% reimbursement for name
and SSN validation would be available
under CHIP, and would not count
towards a state’s CHIP administrative
expenditures cap.
These changes would be effective as if Except for clarifications made to the Same as the Senate bill.
included in the Deficit Reduction Act of existing citizenship documentation
2005. States would be allowed to requirement, which would be
provide retroactive eligibility for certain retroactive, the provision would be
individuals who had been determined effective on October 1, 2008. States
ineligible under previous citizenship would be allowed to provide retroactive
documentation rules.
eligibility for certain individuals who
had been determined ineligible under
previous citizenship documentation
rules.
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Elimination of Health Opportunity Accounts
The Deficit Reduction Act of 2005 H§145. Prohibiting initiation of new No provision.
A§613. Prohibiting initiation of new
allowed the Secretary of HHS to h e a l t h o p p o r t u n i t y a c c o u n t
h e a l t h o p p o r t u n i t y a c c o u n t
establish no more then 10 demonstration demonstration programs. The House
demonstration programs. Same as
programs within Medicaid for health bill would prohibit the Secretary of
House bill.
opportunity accounts (HOAs). HOAs HHS from approving any new Health
are used to pay (via electronic funds Opportunity Account demonstrations as
transfers) health care expenses specified of the date of enactment of this Act.
by the state. As of July 2007, South
Carolina was the only state to receive
CMS approval for a Health Opportunity
Account Demonstration.
Outreach and enrollment of Indians
State SCHIP plans must include a No provision.
S§202. Increased outreach
and A§202. Increased outreach and
description of procedures used to ensure
enrollment of Indians. Would enrollment of Indians. Same as the
the provision of child health assistance
encourage states to take steps to enroll Senate bill.
to American Indian and Alaskan Native
Indians residing in or near reservations
children. Certain non-benefit payments
in Medicaid and CHIP. These steps
under SCHIP (e.g., for other child health
may include outstationing of eligibility
assistance, health service initiatives,
workers [at certain hospitals and
outreach, and program administration)
Federally Qualified Health Centers];
cannot exceed 10% of the total amount
entering into agreements with Indian
of expenditures for benefits and these
entities (i.e., the IHS, tribes, tribal
non-benefit payments combined.
organizations) to provide outreach;
education regarding eligibility, benefits,
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and enrollment; and translation services.
The Secretary would be required to
facilitate cooperation between states and
Indian entities in providing benefits to
Indians under Medicaid and CHIP. This
provision would also exclude costs for
outreach to potentially eligible Indian
children and families from the 10% cap
on non-benefit expenditures under
CHIP.
Eligibility information disclosure
Under current law, each State must have No provision.
S§204. Authorization of certain A§203. State option to rely on finding
an income and eligibility verification
information disclosures to simplify from an Express Lane agency to
system under which (1) applicants for
health coverage determinations. The conduct simplif ied eligibility
Medicaid and several other specified
Senate bill would authorize federal or determinations. Same as Senate bill,
government programs must furnish their
State agencies or private entities with but included in the “Express Lane”
Social Security numbers to the state as
data sources that are directly relevant eligibility provision.
a condition for eligibility, and (2) wage
for the determination of eligibility under
information from various specified
Medicaid to share such information with
government agencies is used to verify
the Medicaid agency if: (1) there is no
eligibility and to determine the amount
family objection to such disclosure, (2)
of the available benefits. Subsequent to
the data would be used solely for the
initial application, States must request
purpose of determining Medicaid
information from other federal and state
eligibility, and (3) there is an
agencies, to verify applicants’ income,
interagency agreement in place to
resources, citizenship status, and
prevent the unauthorized use or
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validity of Social Security number,
disclosure of such information.
unearned income, unemployment
Individuals involved in such
information, etc.
unauthorized use would be subject to
criminal penalty. In addition, for the
purposes of the Express Lane
Demonstration states only, the provision
would allow the Medicaid and CHIP
programs to receive such data from (1)
the National New Hires Database, (2)
the National Income Data collected by
the Commissioner of Social Security, or
(3) data about enrollment in insurance
that may help to facilitate outreach and
enrollment under Medicaid, CHIP, and
certain other
programs.
Reducing administrative barriers to enrollment
During the implementation of SCHIP No provision.
S§302. Reducing administrative A§212. Reducing administrative
states instituted a variety of enrollment
barriers to enrollment. The Senate barriers to enrollment. Same as
facilitation and outreach strategies to
bill would require the State plan to Senate bill.
bring eligible children into Medicaid
describe the procedures used to reduce
and SCHIP. As a result, substantial
the administrative barriers to the
progress was made at the state level to
enrollment of children and pregnant
simplify the application and enrollment
women in Medicaid and CHIP, and to
processes to find, enroll, and maintain
ensure that such procedures are revised
eligibility among those eligible for the
as often as the State determines is
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program.
appropriate to reduce newly identified
barriers to enrollment.
Preventing Crowd-Out
Current law and regulations require that No provision.
No provision.
A§116. Preventing substitution of
state SCHIP plans include procedures to
CHIP coverage for private coverage.
ensure that SCHIP coverage does not
The agreement defines “CHIP crowd-
substitute for coverage provided in
out” as the substitution of CHIP
group health plans (also know as
coverage for health benefits coverage
“crowd out”). State SCHIP plans must
other than Medicaid or CHIP. The
also include procedures for outreach and
agreement would require that states
coordination with other public and
already covering children with income
private health insurance programs. On
exceeding 300% FPL (and beginning in
August 17, 2007, the Bush
2010, new states that propose to do so)
Administration released a letter to state
to describe how they will address
health officials to explain how CMS
crowd-out and implement “best
would apply these existing requirements
practices” to avoid crowd-out (to be
in reviewing state requests to extend
developed by the Secretary in
SCHIP eligibility to children in families
consultation with state). Beginning in
with income exceeding 250% FPL.
2010, these “higher income eligibility
Such states will now be required to
states” cannot have a rate of public and
implement specific crowd-out
private coverage for low-income
prevention strategies, including some
children that is statistically significantly
already adopted by many states (e.g.,
less than the “target rate of coverage of
imposing waiting periods, requiring
low-income children” (i.e., the average
cost-sharing similar to policies for
rate of both private and public health
private coverage, verifying family
benefits coverage as of 1/1/10, among
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insurance status). Such states must also
the 10 states and DC with the highest
provide certain assurances regarding
percentage of such coverage, to be
policies targeting the “core” low-income
calculated by the Secretary). States that
child population (e.g., enrollment of at
fail to meet this requirement in a given
least 95% of children below 200% FPL
fiscal year would not receive any federal
in either Medicaid or SCHIP ) and
CHIP payments for higher income
policies expected to minimize crowd-
children until they are able to establish
out (e.g., monitoring changes in private
that they are in compliance with this
insurance coverage for the target
rule. States would have an opportunity
population). While all states will be
to submit and implement a corrective
monitored for adherence to these
action plan prior to the start of the
policies, states covering children above
affected fiscal year. The Secretary
250% FPL are expected to amend their
would not be permitted to deny
state SCHIP plans (and/or waivers as
payments before the beginning of such
applicable) in accordance with this
a fiscal year and must not deny
review strategy within 12 months, or
payments if there is a reasonable
CMS may pursue corrective action.
likelihood that the corrective action plan
would bring the state into compliance
with the target rate of coverage for low-
income children. Not later than 18
months after the date of enactment of
this Act, GAO would be required to
submit to the Congressional committees
with jurisdiction over CHIP and the
Secretary of HHS, a report describing
the best practices of states in addressing
CHIP crowd-out. Analyses must
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address several issues, including (1) the
impact of different geographic areas
(urban versus rural) and different labor
markets on CHIP crowd-out, (2) the
impact of different strategies for
addressing CHIP crowd-out, (3) the
incidence of crowd-out at different
income levels, and (4) the relationship
between changes in the availability and
affordability of dependent coverage
under employer-sponsored health
insurance and CHIP crowd-out. In
addition, not later than 18 months after
the date of enactment of this Act, the
IOM would be required to submit to the
Congressional committees with
jurisdiction over CHIP and the
Secretary, a report on the most accurate,
reliable and timely way to measure (1)
state-specific rates of public and private
health benefits coverage among children
with income below 200% FPL, (2)
CHIP crowd-out, including for children
with income exceeding 200% FPL, and
(3) the least burdensome way to obtain
the necessary data to conduct these
measurements. The agreement
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appropriates $2 million for this IOM
study for the period ending September
30, 2009.
Medical Child Support Under SCHIP
The Child Support Enforcement No provision.
No provision.
A§116(f). Treatment
of
medical
Program, within the Administration for
support order. The agreement would
Children and Families, provides
specify that nothing in title XXI of the
assistance in obtaining support (both
Social Security Act (CHIP) shall be
financial and medical) to children
construed to allow the Secretary to
through locating parents, establishing
require that a state deny CHIP eligibility
paternity and support obligations, and
for a targeted low-income child on the
enforcing those obligations. The federal
basis of the existence of a valid medical
government has a major role in
support order being in effect. A state
determining the main components of
could elect to limit eligibility on the
state programs, funding, monitoring,
basis of the existence of a valid medical
and providing technical assistance, but
support order, but only if the state does
the basic responsibility of administering
not deny eligibility in cases where the
the Child Support Enforcement Program
child asserts that the order is not being
is left to the states. Provisions for
complied with for specified reasons
health insurance coverage, called
(failure of the noncustodial parent to
medical support, are required to be
comply with the order; failure of an
included in support orders and may
employer, group health plan or health
affect a child’s eligibility for SCHIP.
insurance issuer to comply with such an
order; or the child resides in a
geographic area in which benefits under
the health benefits coverage are
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generally unavailable), unless the state
demonstrates that none of the reasons
apply.
Effective Date for Amendment Affecting Crowd-Out and Medical Child Support
No provision
No provision
No provision
The amendments made by this section
shall take effect as if enacted August 16,
2007. The Secretary may not impose
(or continue in effect) any requirement
on the basis of any policy or
interpretation relating to CHIP crowd-
out or medical support order other than
amendments made by this section.
Premium Assistance/Employer Buy-In Programs
Employer Buy-in to CHIP
An enrollee buy-in program is a H§821. Demonstration project for No provision.
No provision.
program under which the family of a employer buy-in. The House bill would
child that does not qualify for the allow the Secretary of Health and
SCHIP program (usually due to excess Human Services to establish a five-year
income) can enroll their children into demonstration project under which up to
the SCHIP program by paying for most 10 states would be permitted to provide
or all of the cost of coverage. Under CHIP child health assistance to children
current law, states may not receive (and their families) who would be
federal matching funds for the services targeted low-income children except for
provided to these children, or for the the fact that they have group health
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costs of administering the buy-in coverage as allowed under this
program.
provision. To qualify, states must have
a CHIP income eligibility that is at least
200% FPL. Under the demonstrations,
CHIP federal financial participation
would be permitted only for such costs
attributable to eligible children.
The House bill would require coverage
and benefits under a demonstration
project to be the same as the coverage
and benefits provided under the state’s
CHIP plan for targeted low-income
children with the highest family income
level provided.
Families would be responsible for
payments towards the premium for such
assistance in an amount specified by the
state as long as no cost sharing is
imposed on benefits for preventive
services, and CHIP rules related to
income-related limitations on cost
sharing are applied.
Qualifying providers would be
responsible for providing payment in an
amount that is equal to at least 50% of
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the portion of the cost of the family
coverage that exceeds the amount of the
family’s cost sharing contribution.
Qualifying employers would be defined
as an employer with a majority of its
workforce that is composed of full time
workers (where two, part-time workers
are treated as a single full-time worker)
with family incomes reasonably
estimated by the employer (based on
wage information) at or below 200%
FPL.
Premium assistance programs
Under Medicaid, states may pay a No provision.
S§401. Additional State option for A§301. Additional State option for
Medicaid beneficiary’s share of costs
providing premium assistance. The providing premium assistance. Same
for group (employer-based) health
Senate bill would allow states to offer a as Senate bill, however, the agreement
coverage for any Medicaid enrollee for
premium assistance subsidy for would also allow states to offer a
whom coverage is available,
qualified employer sponsored coverage premium assistance subsidy for
comprehensive, and cost-effective for
(ESI) to all targeted low-income qualified employer sponsored coverage
the state. An individual’s enrollment in
children who are eligible for CHIP, or (ESI) to Medicaid-eligible children
an employer plan is considered cost
parents of CHIP-eligible children where and/or parents of Medicaid-eligible
effective if paying the premiums,
the family has access to ESI coverage. children where the family has access to
deductibles, coinsurance and other cost-
Qualified employer sponsored coverage ESI coverage. In addition, the
sharing obligations of the employer plan
would be defined as a group health plan agreement specifies that family
is less expensive than the state’s
or health insurance coverage offered participation in the premium assistance
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expected cost of directly providing
through an employer that (1) qualifies as program would be optional.
Medicaid-covered services. States were
credible health coverage as a group
also to provide coverage for those
health plan under the Public Health
Medicaid covered services that are not
Service Act, (2) for which the employer
included in the private plans.
contributes at least 40% toward the cost
of the premium, and (3) is
nondiscriminatory in a manner similar
to section 105(h)of the Internal Revenue
Code but would not allow employers to
exclude workers who had less than three
years of service. The Bill explicitly
excludes (1) benefits provided under a
health flexible spending arrangement,
(2) a high deductible health plan
purchased in conjunction with a health
savings account as defined in the
Internal Revenue Code of 1986 as
qualified coverage.
Under SCHIP, the Secretary has the
The Senate bill would establish a new The agreement would make the
authority to approve funding for the
cost effectiveness test for employer following modifications to the cost
purchase of “family coverage”under an
sponsored insurance (ESI) programs effectiveness tests included in the
employer-sponsored health insurance
that are approved after the date of Senate bill: (1) with regard to the
plan if it is cost effective relative to the
enactment of this Act. The state would “individual test,” administrative costs
amount paid to cover only the targeted
be required to establish that (1) the cost would be taken into account when
low-income children and does not
of such coverage is less than state determining the cost-effectiveness of
substitute for coverage under group
expenditures to enroll the child or the extending ESI coverage to the child or
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health plans otherwise being provided to
family (as applicable) in CHIP family (as applicable); and (2) with
the children. In addition, states using
(individual test), or (2) the aggregate regard to the “aggregate test,” the
SCHIP funds for employer-based plan
amount of State expenditures for the agreement specifies that federal
premiums must ensure that SCHIP
purchase of all such coverage for spending would not be permitted to
minimum benefits are provided and
targeted low-income children under exceed the aggregate amount of
SCHIP cost-sharing ceilings are met.
CHIP (including administrative expenditures that the State would have
Because of these requirements,
expenses) does not exceed the aggregate made for providing CHIP coverage to
implementation of premium assistance
amount of expenditures that the State all such children or families (as
programs under Medicaid and SCHIP
would have made for providing applicable).
are not widespread.
coverage under the CHIP state plan for
all such children (aggregate test).
Under the Bush Administration’s Health
States would be required to provide Same as Senate bill.
Insurance Flexibility and Accountability
supplemental coverage for a targeted
(HIFA) Initiative, states were
low-income child enrolled in the ESI
encouraged to seek approval for Section
plan consisting of items or services that
1115 waiver programs to direct unspent
are not covered, or are only partially
SCHIP funds to extend coverage to
covered, and cost-sharing protections
uninsured populations with annual
consistent with the requirements of
income less than 200% FPL and to use
CHIP. Plans that meet the CHIP benefit
Medicaid and SCHIP funds to pay
coverage requirements (i.e., as
premium costs for waiver enrollees who
determined to be actuarially equivalent
have access to Employer Sponsored
to CHIP benchmark or benchmark-
Insurance (ESI). ESI programs approved
equivalent coverage) would not be
under the Section 1115 waiver authority
required to provide supplemental
are not subject to the same current law
coverage for benefits and cost-sharing
constraints required under Medicaid’s
protections as required under CHIP.
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Health Insurance Premium Payment
(HIPP) program or SCHIP’s family
coverage variance option (i.e., the
c o mp r e h e n s i ve n e s s a n d c o s t -
effectiveness tests).
States would be permitted to directly Same as Senate bill.
pay out-of-pocket expenditures for cost-
sharing imposed under the qualified ESI
coverage and collect all (or any) portion
for cost-sharing imposed on the family.
Parents would be permitted to disenroll
their child(ren) from ESI coverage and
enroll them in CHIP coverage effective
on the first day of any month for which
the child is eligible for such coverage.
States would be permitted to establish Same as Senate bill, except the
an employer-family premium assistance agreement specifies that administrative
purchasing pool for employers with less costs associated with the start up or
than 250 employees who have at least operation of such purchasing pools
one employee who is a CHIP-eligible would only be permitted in so far as
pregnant woman or at least one member they meet the definition of allowable
of the family is a CHIP-eligible child. administrative expenditures under
Eligible families would have access to CHIP.
not less than 2 private health plans
where the health benefits coverage is
equivalent to the benefits coverage
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available through a CHIP benchmark
benefit package or CHIP benchmark
equivalent coverage benefits package.
Finally the Senate bill would require the Same as Senate bill.
Government Accountability Office to
submit a report to Congress not later
than January 1, 2009 regarding cost and
coverage issues under State premium
assistance programs.
Education and enrollment assistance in premium assistance programs
SCHIP state plans are required to No provision.
S§402. Outreach, education, and A§302. Outreach, education, and
include a description of the procedures
enrollment assistance. The Senate bill enrollment assistance. Same as the
in place to provide outreach to children
would require states to include a Senate bill, but would limit expenditures
eligible for SCHIP child health
description of the procedures in place to for such outreach activities to 1.25% of
assistance, or other public or private
provide outreach, education, and the state’s limit on spending for
health programs to (1) inform these
enrollment assistance for families of administrative costs associated with
families of the availability of public and
children likely to be eligible for their CHIP program (i.e. 10% of the
private health coverage and (2) to assist
premium assistance subsidies under state’s spending on benefit coverage in
them in enrolling such children in
CHIP or a waiver approved under a given fiscal year).
SCHIP. There is a limit on federal
§1115. For employers likely to provide
spending for SCHIP administrative
qualified employer-sponsored coverage,
expenses (i.e., 10% of a state’s spending
the state is required to include the
on benefit coverage in a given fiscal
specific resources the State intends to
year). Administrative expenses include
use to educate employers about the
activities such as data collection and
availability of premium assistance
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reporting, as well as outreach and
subsidies under the CHIP state plan.
education. In addition, states are
Expenditures for such outreach
required to provide a description of the
activities would not be subject to the
state’s efforts to ensure coordination
10% l i mi t o n s p e n d i ng f or
between SCHIP and other health
administrative costs associated with the
insurance coverage applies to State
CHIP program.
administrative expenses.
Special enrollment period
Under the Internal Revenue Code, the No provision.
S§411. Special enrollment
period A§311. Special enrollment period
Employee Retirement Income Security
under group health plans in case of under group health plans in case of
Act, and the Public Health Service Act,
termination of Medicaid or CHIP termination of Medicaid or CHIP
a group health plan is required to
coverage or eligibility for assistance coverage or eligibility for assistance
provide special enrollment opportunities
in purchase of employment-based in purchase of employment-based
to qualified individuals. Such
coverage; coordination of coverage. coverage; coordination of coverage.
individuals must have lost eligibility for
The bill would amend applicable federal Same as Senate bill.
other group coverage, or lost employer
laws to streamline coordination between
contributions towards health coverage,
public and private coverage, including
or added a dependent due to marriage,
making the loss of Medicaid/CHIP
birth, adoption, or placement for
eligibility a “qualifying event” for the
adoption, in order to enroll in a group
purpose of purchasing employer-
health plan without having to wait until
sponsored coverage. Individuals may
a late enrollment opportunity or open
request for such coverage up to 60 days
season. The individual still must meet
after the qualifying event. The bill
the plan’s substantive eligibility
would require health plan administrators
requirements, such as being a full-time
to disclose to the state, upon request,
worker or satisfying a waiting period.
information about their benefit packages
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Health plans must give qualified
so states can evaluate the need to
individuals at least 30 days after the
provide wraparound coverage. The bill
qualifying event (e.g., loss of eligibility)
also would require employers to notify
to make a request for special
families of their potential eligibility for
enrollment.
premium assistance.
Benefits
Dental services
Under SCHIP, states may provide H§121. Ensuring child-centered S§608. Dental health grants. As A§501. Dental benefits. The provision
coverage under their Medicaid coverage. The provision would make amended, would provide authority for regarding dental benefits under CHIP in
programs, create a new separate SCHIP dental services a required benefit under new dental health grants to improve the the agreement includes selected
program, or both. Under separate CHIP. States would also be required to availability of dental services and provisions in both the Senate and House
SCHIP programs, states may elect any assure access to these services. The strengthen dental coverage for children bills, as well as new provisions. Under
of three benefit options: (1) a effective date would be October 1, under CHIP. To be awarded such a the agreement, dental services would be
benchmark plan, (2) a benchmark- 2008.
grant, states would describe quality and a required benefit under CHIP and
equivalent plan, or (3) any other plan
outcomes performance measures to be would include services necessary to
that the Secretary of HHS deems would H§144. Access to dental care for used to evaluate the effectiveness of prevent disease and promote oral health,
provide appropriate coverage for the children. The provision would require grant activities, and must assure that restore oral structures to health and
target population (called Secretary- the Secretary of HHS to develop and they will cooperate with the collection function, and treat emergency
approved coverage). Benchmark plans implement a program to deliver oral and reporting of data to the Secretary of conditions. States would have the
include (1) the standard Blue health education materials that inform HHS, among several requirements. option to provide dental services
Cross/Blue Shield preferred provider new parents about risks for, and Grantees would be required to maintain equivalent to “benchmark dental benefit
option under FEHBP, (2) the coverage prevention of, early childhood caries state funding of dental services under packages.” These include (1) a dental
generally available to state employees, and the need for a dental visit within a CHIP at the level of expenditures in the benefits plan under FEHBP that has
and (3) the coverage offered by the newborn’s first year of life. States fiscal year preceding the first fiscal year been selected most frequently by
largest commercial HMO in the state. could not prevent an FQHC from for which the new grant is awarded. employees seeking dependent coverage,
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Benchmark-equivalent plans must cover entering into contractual relationships Such states would not be required to among such plans that offer such
basic benefits (i.e., inpatient and with private practice dental providers provide any state matching funds for the coverage, in either of the previous 2
outpatient hospital services, physician under both Medicaid and CHIP new dental grant program. The plan years, (2) a dental benefits plan
services, lab/x-ray, and well-child care (effective January 1, 2008). The data Secretary would be required to submit offered and generally available to state
including immunizations), and must that states submit to the federal to Congress an annual report on state employees that has been selected most
include at least 75% of the actuarial government documenting receipt of activities and performances assessments frequently by employees seeking
value of coverage under the selected EPSDT services each fiscal year would under the new dental grant program. dependent coverage, among such plans
benchmark plan for specific additional be required to include parallel For the period FY2008 through FY2012, that offer such coverage, in either of the
benefits (i.e., prescription drugs, mental information on receipt of dental services $200 million would be appropriated for previous 2 plan years, or (3) a dental
health services, vision care and hearing among CHIP children. This reporting this grant program, to remain available benefits plan that has the largest
services). Among other items, a state requirement would also apply to annual until expended. The provision would commercial, non-Medicaid enrollment
SCHIP plan must include a description state CHIP reports. Such reporting also require the Secretary of HHS to of dependent covered lives among such
of the methods (including monitoring) would be required to include include on the Insure Kids Now website plans offered in the state. As in the
used to (1) assure the quality and information on children enrolled in and hotline a current and accurate list of House bill (Sec. 121), states would be
appropriateness of care, particularly managed care plans, other private health all dentists and other dental providers in required to assure access to dental
with respect to well-baby care, well- plans, and contracts with such plans each state that provide such services to services under CHIP. The effective date
child care, and immunizations provided under CHIP (effective for annual state Medicaid and CHIP children, and must of these provisions would be October 1,
under the plan, and (2) assure access to CHIP reports submitted for years update this listing at least on a quarterly 2008. The agreement also includes
covered services, including emergency beginning after the date of enactment of basis. The Secretary would also be provisions from the House bill (Sec.
services. Under the Early and Periodic this Act). In addition, GAO would be required to work with states to include a 144) for (1) dental education for parents
Screening, Diagnostic and Treatment required to conduct a study examining description of covered dental services of newborns, (2) dental services through
(EPSDT) benefit under Medicaid, most access to dental services by children in for children under both programs Federally Qualified Health Care Centers
children under age 21 receive under-served areas, and the feasibility (including under applicable waivers) for (FQHCs), and (3) reporting information
comprehensive basic screening services and appropriateness of using qualified each state, and must post this on dental services for children. The
(i.e., well-child visits including age- mid-level dental providers to improve information on the Insure Kids Now agreement includes the provision in the
appropriate immunizations) as well as access. A report on this GAO study website. The provision would require Senate bill (with some modifications)
dental, vision and hearing services. In would be due not later than one year GAO to conduct a study on children’s regarding information on dental
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addition, EPSDT guarantees access to after the date of enactment of this Act. access to oral health care, including providers and descriptions of covered
all federally coverable services
preventive and restorative services dental services under Medicaid and
necessary to treat a problem or
under Medicaid and CHIP. The report CHIP, to be made available to the public
condition among eligible individuals.
on this study mu s t include via the Insure Kids Now website and
The EPSDT provision in Medicaid law
recommendations for such federal and hotline. The agreement would expand
also includes annual reporting
state legislative and administrative measurement of the availability of
requirements for states. The tool used
changes necessary to address barriers to dental care to include dental treatment
to capture these EPSDT data is called
access to dental care under Medicaid and services to maintain dental health
the CMS-416 form. Three separate
and CHIP (and would be due not later under the child health quality
measures capture the unduplicated
than two years after the date of improvement activities (Sec. 501 of the
number of EPSDT eligibles receiving
enactment of this Act). Also the Senate bill). Finally, the GAO study of
any dental services, preventive dental
provision would add an assessment of dental services for children in the
services and dental treatment services.
the quality of dental care provided to agreement follows the Senate bill with
Medicaid and CHIP children to the some additional provisions taken from
Secretary’s annual reports to Congress the House bill (e.g., regarding the
under the new child health quality availability of mid-level dental
improvement activities authorized in the providers). In addition, this GAO study
Senate-passed bill.
would be due within 18 months of the
date of enactment of this Act, rather
than within 2 years as under the Senate
bill.
Federally qualified health centers (FQHCs) and rural health centers (RHCs) services
In SCHIP statute, a number of coverable H§121. Ensuring child-centered No provision.
No provision.
benefits are listed such as “clinic coverage. The provision would make
services (including health center the services provided by FQHCs and
services) and other ambulatory health RHCs required benefits under CHIP.
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care services.” Services provided by States would also be required to assure
FQHCs and RHCs are a mandatory access to these services. The effective
benefit for most beneficiaries under date would be October 1, 2008.
Medicaid.
Mental health services
For an explanation of the benchmark H§121. Ensuring child-centered S§607. Mental health parity in CHIP A§502. Mental health parity in CHIP
coverage options under SCHIP, see the coverage. The provision would plans. The provision would ensure that plans. Same as Senate bill.
current law description in the “dental increase the minimum actuarial value the financial requirements (e.g., such as
services” row above.
for mental health services from 75% to annual and lifetime dollar limits) and
100% for benchmark-equivalent treatment limitations applicable to
Under the Mental Health Parity Act coverage under CHIP. The effective mental health or substance abuse
(MHPA), Medicaid and SCHIP plans date would be October 1, 2008.
benefits (when such benefits are
may define what constitutes mental
covered) are no more restrictive than the
health benefits (if any). The MHPA
financial requirements and treatment
prohibits group plans from imposing
limitations applicable to substantially all
annual and lifetime dollar limits on
medical and surgical benefits covered
mental health coverage that are more
under the state CHIP plan. State CHIP
restrictive than those applicable to
plans that include coverage of EPSDT
medical and surgical coverage. Full
services (as defined in Medicaid statute)
parity is not required, that is, group
would be deemed to satisfy this mental
plans may still impose more restrictive
health parity requirement.
treatment limits (e.g., with respect to
total number of outpatient visits or
inpatient days) or cost-sharing
requirements on mental health coverage
compared to their medical and surgical
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services.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services
The Deficit Reduction Act of 2005 H§121. Ensuring child-centered S§605. Deficit Reduction Act A§611(a). Deficit Reduction Act
(DRA; P.L. 109-171) gave states the coverage. The provision would require technical corrections. The provision technical corrections - Clarification of
option to provide Medicaid to coverage of the EPSDT benefit for would require that EPSDT be covered requirement to provide EPSDT
state-specified groups through individuals under age 21, whether such for any individual under age 21 who is services for all children in benchmark
enrollment in benchmark and persons are enrolled in benchmark eligible for Medicaid through the state benefit packages under Medicaid.
benchmark-equivalent coverage that is plans, benchmark-equivalent plans or Medicaid plan under one of the major Same as the Senate bill with some
nearly identical to plans available under otherwise under Medicaid. The mandatory and optional coverage modifications. The agreement identifies
SCHIP (described above in the “dental effective date would be the same as the groups and is enrolled in benchmark or specific sections of current Medicaid
services” row). For any child under age original DRA provision (i.e., March 31, benchmark-equivalent plans authorized law (instead of all of Title XIX as
19 in one of the major mandatory and 2006).
under DRA. The provision would also specified in DRA) that would be
optional eligibility groups in Medicaid,
give states flexibility in providing disregarded in order to provide
wrap-around benefits to the DRA
coverage of EPSDT services through the benchmark benefit coverage. It also
benchmark and benchmark-equivalent
i s s u e r o f b e n c h m a r k o r includes language from the House bill
coverage includes EPSDT. In
benchmark-equivalent coverage or that specifies that an individual’s
traditional Medicaid, EPSDT is
otherwise.
entitlement to EPSDT services remains
available to most individuals under age
intact under the benchmark benefit
21.
package option under Medicaid.
School-based health centers services
A number of coverable benefits are H§121. Ensuring child-centered No provision.
A§506. Clarification of coverage of
listed in the SCHIP statute, such as coverage. The provision would add to
services provided through school-
“clinic services (including health center the “clinic services” benefit category in
based health centers. The agreement
services) and other ambulatory health CHIP statute “school-based health
provides that nothing in Title XXI shall
care services.”
center services” for which coverage is
be construed as limiting a state’s ability
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otherwise provided under this title.
to provide CHIP for covered items and
Such providers must be authorized to
services furnished through school-based
cover such CHIP services under state
health centers.
law. The effective date would be on or
after the date of enactment of this Act.
Benchmark coverage options
Under SCHIP, states may provide H§121. Ensuring child-centered No provision.
coverage under their Medicaid coverage. The provision would require
programs, create a new separate SCHIP that benchmark coverage under CHIP be
program, or both. Under separate at least equivalent to the benchmark
SCHIP programs, states may elect any benefit packages specified in statute.
of three benefit options: (1) a The effective date would be October 1,
benchmark plan, (2) a benchmark- 2008.
equivalent plan, or (3) any other plan
that the Secretary of HHS deems would H§122. Improving benchmark
provide appropriate coverage for the coverage options. The provision would
target population (called Secretary- continue to allow Secretary-approved
approved coverage). Benchmark plans coverage under both CHIP and the DRA
include (1) the standard Blue option under Medicaid, but only if such
Cross/Blue Shield preferred provider coverage is at least equivalent to a
option under FEHBP, (2) the coverage benchmark benefit package. The
generally available to state employees, provision would also more explicitly
and (3) the coverage offered by the define state employees benchmark
largest commercial HMO in the state. coverage for both CHIP and the DRA
Benchmark-equivalent plans must cover option for Medicaid to include the state
basic benefits (i.e., inpatient and employee plan that has been selected the
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outpatient hospital services, physician most frequently, by employees seeking
services, lab/x-ray, and well-child care dependent coverage, among such plans
including immunizations), and must that provide dependent coverage, in
include at least 75% of the actuarial either of the previous two years. The
value of coverage under the selected effective date would be October 1,
benchmark plan for specific additional 2008.
benefits (i.e., prescription drugs, mental
health services, vision care and hearing
services). The DRA also allowed
similar benchmark coverage options
under Medicaid.
Extension of family planning services and supplies
State Medicaid programs must offer H§802. Family planning services. The No provision.
No provision.
family planning services and supplies to House bill would create a state option to
categorically needy individuals of extend family planning services and
childbearing age, including minors supplies (at the 90% federal Medicaid
considered to be sexually active. Family match rate) to women who are not
planning services must be available to pregnant and whose annual income does
eligible pregnant women through the not exceed the highest income eligibility
60th day following the end of the level established under the Medicaid
pregnancy. Coverage of the medically State plan (or under title XXI) for
needy other than pregnant women may pregnant women. States would be
include family planning. States receive permitted to include individuals eligible
a 90% federal matching rate for for Medicaid §1115 family planning
expenditures attributable to the offering, waivers that were approved as of
arranging, and furnishing of family January 1, 2007.
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planning services and supplies.
Federal financial participation for
medical assistance made available to
such individuals would be limited to
family planning services and supplies
including medical diagnosis or
treatment services, and only for the
duration of the woman’s eligibility
under this state option or during a
period of presumptive eligibility.
Finally, the House bill would prohibit
the enrollment of such individuals in a
Medicaid benchmark and benchmark-
equivalent state plan option, unless such
coverage includes medical assistance for
family planning services and supplies.
Adult day health services
Adult day care programs provide health H§803. Authority to continue No provision.
No provision.
and social services in a group setting on providing adult day health services
a part-time basis to certain frail older approved under a State Medicaid
persons and other persons with physical, plan. The provision would require the
emotional, or mental impairments. Secretary to provide for federal
Generally, states that cover adult day financial participation for adult day
care under Medicaid do so under home health care services, as defined under a
and community-based waivers, the state Medicaid plan, approved during or
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Program for All-Inclusive Care for the before 1994. The provision would be
Elderly (PACE) or section 1115 waiver effective beginning November 3, 2005
authority. Some states cover adult day and ending on March 1, 2009.
care under their Medicaid state plans
even though Medicaid law does not list
adult day care as a mandatory or
optional benefit. There have been
concerns that CMS may not continue to
allow adult day care to be offered under
a state’s Medicaid plan without the use
of a waiver.
Monitoring Quality
Quality measurement
The Centers for Medicare and Medicaid H§151. Pediatric health quality S§501. Child health quality A§401. Child health quality
Services (CMS) and the Agency for measurement program. The provision improvement activities for children improvement activities for children
Healthcare Research and Quality would require the Secretary to establish enrolled in Medicaid or CHIP. The enrolled in Medicaid or CHIP. Same
(AHRQ) are both actively involved in a child health care quality measurement provision would direct the Secretary of as the Senate bill. Adds a construction
funding and implementing an array of program. The purpose would be to HHS to develop (1) child health quality specifying that nothing in this provision
quality improvement initiatives, though develop and implement pediatric quality measures for children enrolled in supports restricting coverage under
only AHRQ has engaged in activities measures, a system for reporting such Medicaid and CHIP, and (2) a Medicaid and CHIP to only those
specific to children.
measures, and measures of overall standardized format for reporting services that are evidence-based.
program performance that may be used information, and procedures that
The federal share of states’ Medicaid by public and private health care encourage states to voluntarily report on
costs varies by type of expenditure. For purchasers. By September 30, 2009, the the quality of pediatric care in these
benefits, the federal medical assistance Secretary would be required to publish programs. The Secretary would be
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percentage (FMAP) is based on a the recommended measures for years required to disseminate information to
for mula that provides higher beginning with 2010. In developing and states regarding best practices in
reimbursement to states with lower per implementing this program, the measuring and reporting such data. A
capita incomes (and vise versa); it has a Secretary would be required to consult total of $45 million would be
statutory minimum of 50% and a with a number of entities. The appropriated for these provisions, of
maximum of 83%. All states receive a Secretary could award grants and which specific amounts would be
90% match for family planning services. contracts to develop, validate and earmarked for certain activities
The federal matching rates for disseminate these measures, and would (identified below). (The childhood
administrative expenses does not vary be required to provide technical obesity demonstration described below
by state and is generally 50%, but assistance to states to establish such would have its own separate
certain administrative functions have a reporting under Medicaid and CHIP. appropriation.) The Secretary would be
higher federal match. For example, a By January 1, 2009, and annually required to award grants and contracts
75% match rate applies to the operation thereafter, the Secretary would be to develop, test and update (as needed)
of an approved Medicaid management required to make available in an on-line evidence-based measures, and to
information system (MMIS) for claims format a complete list of all measures in disseminate such measures. Each state
and information processing. Start-up use by states to measure the quality of would be required to report annually to
expenses for MMISs are matched at medical and dental services provided to the Secretary on a variety of measures.
90%.
Medicaid and CHIP children. By In addition, the Secretary would be
January 1, 2010, and every two years required to award up to 10 grants to
thereafter, the Secretary would be states and child health providers to
required to report to Congress on the conduct demonstrations to evaluate
quality of care for children enrolled in promising ideas for improving the
CHIP and Medicaid, and patterns of quality of children’s health care under
utilization by pediatric characteristics.
Medicaid and CHIP, for which $20
million would be appropriated. The
Secretary would also be required to
conduct a demonstration to develop a
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comprehensive and systematic model
for reducing childhood obesity through
grants to eligible entities (e.g., local
government agencies, Indian tribes,
community based organizations). This
demonstration would be authorized at
$25 million over five years ($5 per
year). The Secretary would be required
to submit a report to Congress on this
demonstration. The Secretary would
also be required to establish a program
to encourage the creation and
dissemination of a model electronic
health record format for children
enrolled in Medicaid and CHIP. A total
of $5 million would be appropriated for
this purpose. The Institute of Medicine
would be required to study and report to
Congress on the extent and quality of
efforts to measure child health status
and quality of care for children. Up to
$1 million would be appropriated for
this activity. Finally, the federal share
of costs incurred by states for the
development or modification of existing
claims processing and retrieval systems
as is necessary for the efficient
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collection and reporting on child health
measures would be based on the FMAP
rate for benefits used under Medicaid.
Information on access to coverage under CHIP
Annually, states submit reports to the No provision.
S§502. Improved
inf orm a t i o n A§402. Improved availability of
Secretary of HHS assessing the
regarding access to coverage under public information regarding
operation of their SCHIP programs,
CHIP. The provision would add enrollment of children in CHIP and
including for example, progress made in
several reporting requirements to states’ Medicaid. Same as Senate bill. The
reducing the number of uninsured low-
annual CHIP reports that are submitted agreement adds a requirement that the
income children, progress made in
to the Secretary of HHS. Examples of Secretary specify a standardized format
meeting other strategic objectives and
these new reporting requirements for states to use to report the new data
performance goals identified in the state
include (1) data on eligibility criteria, required by the bill within one year of
plan, effectiveness of discouraging
enrollment and continuity of coverage, the date of enactment of this Act.
substitution of public coverage for
(2) use of self-declaration of income for Applicable states would be given up to
private coverage, identification of
applications and renewals, and 3 reporting periods to transition to the
expenditures by type of beneficiary
presumptive eligibility, (3) data on reporting of these new data in
(e.g., children versus adults), and
d e n i a l s o f e l i g i b i l i t y a n d accordance with this standardized
current income standards and
redeterminations of eligibility, (4) data format. In addition, the agreement
methodologies.
regarding access to primary and requires the Secretary to improve the
specialty care, networks of care and care timeliness of the data reported and
coordination, and (5) if the state analyzed from the Medicaid Statistical
provides premium assistance for Information System (MSIS) with
employer-based insurance, data respect to enrollment and eligibility for
regarding the extent to which such children under Medicaid and CHIP, and
coverage is available to CHIP children, to provide guidance to states regarding
the range of monthly premium amounts, any new reporting requirements related
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the number of children/families to such improvements. For this
receiving such assistance on a monthly purpose, the agreement appropriates $5
basis, the income level of the million to the Secretary in FY2008, to
children/families involved, the benefits remain available until expended.
and cost-sharing protections for such Beginning no later than October 1,
children/families, the strategies used to 2008, MSIS data on enrollment of low-
reduce administrative barriers to such income children in Medicaid or CHIP
coverage, and the effects of such with respect to a fiscal year must be
premium assistance on preventing collected and analyzed by the Secretary
substitution of CHIP coverage for within 6 months of submission.
employer-based coverage. The
provision would also require GAO to
conduct a study on access to primary
and speciality care under Medicaid and
CHIP, and report to Congress its
findings and recommendations for
addressing existing barriers to
children’s access to care under these
programs.
Federal evaluation
The Secretary was required to conduct H§153. Updated federal evaluation of No provision.
A§603. Updated federal evaluation of
an independent evaluation of 10 states CHIP. The provision would require the
CHIP. Same as House bill.
with approved SCHIP plans, and to Secretary to conduct an independent
submit a report on that study to evaluation of 10 states with approved
Congress by December 31, 2001. Ten CHIP plans, directly or through
million dollars was appropriated for this contracts or interagency agreements, as
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purpose in FY2000 and was available before. The new evaluation would be
for expenditure through FY2002. The submitted to Congress by December 31,
10 states chosen for the evaluation were 2010. Ten million dollars would be
to be ones that utilized diverse appropriated for this purpose in FY2009
approaches to providing SCHIP and made available for expenditure
coverage, represented various through FY2011. The current-law
geographic areas (including a mix of language for the types of states to be
rural and urban areas), and contained a chosen and the matters included in the
significant portion of uninsured evaluation would also apply to this new
children. A number of matters were evaluation.
included in this evaluation, including (1)
surveys of the target populations, (2) an
evaluation of effective and ineffective
outreach and enrollment strategies, and
identification of enrollment barriers, (3)
the extent to which coordination
between Medicaid and SCHIP affected
enrollment, (4) an assessment of the
effects of cost-sharing on utilization,
enrollment and retention, and (5) an
evaluation of disenrollment or other
retention issues.
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Payments
Medicaid Drug Rebate
Pharmaceutical manufacturers that wish H§812. Medicaid Drug Rebate. The No provision.
No provision.
to have their products available to provision would increase the rebate
Medicaid beneficiaries must enter into percentage for the basic rebate for single
“rebate agreements” under which they source and innovator multiple source
agree to provide state Medicaid drugs to 22.1% of the AMP or the
programs with rebates for drugs difference between the AMP and the
provided to Medicaid beneficiaries. best price. The higher rebate percentage
Basic rebates for single source drugs would become effective after December
(generally, those still under patent) and 31, 2007.
“innovator” multiple source drugs
(drugs originally marketed under a
patent or original new drug application
(NDA) but for which generic
competition now exists) are calculated
to be equal to the greater of 15.1% of
the average manufacturer’s price (AMP)
or the difference between the AMP and
the best price. Additional rebates are
required if the weighted average prices
for all of a given manufacturer’s single
source and innovator multiple source
drugs rise faster than inflation. For
non-innovator multiple source drugs,
rebates are equal to 11% of the AMP.
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Moratorium on certain payment restrictions
In the President’s FY2008 Budget, some H§814. Moratorium on certain No provision.
A§616. Moratorium on
certain
proposals affecting Medicaid and payment restrictions. The provision
payment restrictions. Same as the
SCHIP would be implemented would prohibit the Secretary of HHS
House bill, except that the Secretary
administratively (e.g., via regulatory from taking any action through
would be prohibited from taking any
change, issuance of program guidance, regulation, official guidance, use of
action with respect to rehabilitation and
or other possible methods) rather than federal payment audit procedures, or
school-based services prior to May 28,
through legislation. Two such other administrative action, policy or
2008 (rather than delaying such action
administrative proposals were to phase practice to restrict Medicaid coverage or
for one year after the date of enactment
out Medicaid reimbursement for certain payments for rehabilitation services, or
of this Act).
school-based transportation and s c h o o l - b a s e d a d m i n i s t r a t i o n ,
administrative claiming, and to clarify transportation, or medical services if
through regulation the types of service such actions are more restrictive in any
that may be claimed as Medicaid aspect than those applied to such
rehabilitation services. On August 13 coverage or payment as of July 1, 2007.
and September 7, 2007, the This prohibition would be in effect for
Administration issued proposed rules one year after the date of enactment of
for rehabilitation services and school- this Act.
based administration and transportation
services, respectively, limiting the
circumstances in which federal
reimbursements will be made for these
services under Medicaid.
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Agreement
Tennessee and Hawaii DSH
When establishing hospital payment H§ 815. Tennessee DSH. The provision No provision.
A§617. Medicaid DSH allotments for
rates, state Medicaid programs are would set a DSH allotment for the state
Tennessee and Hawaii. The provision
required to recognize the situation of of Tennessee for fiscal years beginning
includes the House bill language. In
hospitals that provide a disproportionate with 2008 to be equal to $30 million for
addition, it would set a DSH allotment
share of care to low-income patients each year. In addition, the provision
for the state of Hawaii for FY2008 of
w i t h s p e c i a l n e e d s . S u c h would allow the Secretary of HHS to
$10 million. For FY2009 and
“disproportionate share (DSH) limit the total amount of payments made
thereafter, DSH allotments for Hawaii
payments” are subject to statewide to hospitals under Tennessee’s research
would be increased in the same manner
allotment caps. Allotments for and demonstration waiver authorized
as for all low DSH states. The provision
Tennessee and Hawaii have, in the past, under Section 1115 of the Social
also prohibits the Secretary from
been equal to zero. This is because those Security Act only to the extent that such
imposing a limit on payments made to
states have operated their Medicaid limitation is necessary to ensure that a
hospitals under Hawaii’s QUEST
programs under the provisions of hospital does not receive a payment in
Section 1115 demonstration project
research and demonstration waivers. excess of Tennessee’s annual state DSH
except to the extent necessary to ensure
Both states have had special DSH allotment or is necessary to ensure that
that a hospital does not receive
provisions established for them in the the spending under the waiver remains
payments in excess of its hospital
past. For example, allowing for a DSH budget neutral.
specific cap, or that payments do not
allotment for Tennessee in the event that
exceed the amount that the Secretary
their waiver is discontinued, and an
determines is equal to the federal share
allotment for Hawaii for FY2007.
of DSH within the budget neutrality
provision of the QUEST demonstration
project.
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Monitoring erroneous payments
Federal agencies are required to No provision.
S § 6 0 2 . P a y m e n t e r r o r
r a t e A§601. P ayment error rate
annually review programs that are
measurement (“PERM”). The measurement (“PERM”). Follows the
susceptible to significant erroneous
provision would apply a federal Senate bill with some modifications.
payments, and to estimate the amount of
matching rate of 90% to expenditures The agreement specifies that the
improper payments, to report those
related to administration of PERM payment error rate for a state must not
estimates to Congress, and to submit a
requirements applicable to CHIP. The take into account payment errors
report on actions the agency is taking to
provision also would exclude from the resulting from the state’s verification of
reduce erroneous payments. On August
10% cap on CHIP administrative costs an applicant’s self-declaration or self-
21, 2007, CMS issued a final rule for
all expenditures related to the certification of eligibility for, and the
PERM for Medicaid and SCHIP
administration of PERM requirements correct amount of, Medicaid or CHIP
(effective October 1, 2007) which
applicable to CHIP. The Secretary must assistance, if the state process for
responded to comments received on a
not calculate or publish national or verifying such information satisfies the
2006 interim final rule, and included
state-specific error rates based on requirements for such a process
some changes to that interim final rule.
PERM for CHIP until six months after applicable under regulations issued by
Assessments of payment error rates
the date on which a final PERM rule is or otherwise approved by the Secretary.
related to claims for both fee-for-service
in effect for all states. Calculations of In addition, the agreement deletes
and managed care services, as well as
national- or state-specific error rates language that would have been
eligibility determinations are made. A
after such a final rule is in effect for all applicable to states for which PERM
predecessor to PERM, called the
states could only be inclusive of errors, requirements were in effect under
Medicaid Eligibility Quality Control
as defined in this rule or in guidance interim rules (now obsolete) for
(MEQC) system, is operated by state
issued after the effective date that FY2008. The agreement also gives
Medicaid agencies for similar purposes.
includes detailed instructions for the states the option to substitute MEQC
specific methodology for error data for Medicaid eligibility reviews for
determinations. The final PERM rule data required for PERM purposes, but
would be required to include (1) clearly only if the state MEQC reviews are
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Senate: H.R. 976
Agreement
defined criteria for errors for both states based on a broad, representative sample
and providers, (2) a clearly defined of Medicaid applicants or enrollees.
p r o c e s s f o r a p p e a l i n g e r r o r
determinations by review contractors,
and (3) clearly defined responsibilities
and deadlines for states in implementing
any corrective action plans. Special
provisions would apply to states for
which the PERM requirements were
first in effect under interim final rules
for FY2007 or FY2008 and their
application would depend on when the
final PERM rule is in effect for all
states. The Senate bill would also
require the Secretary to review the
Medicaid Eligibility Quality Control
(MEQC) requirements with the PERM
requirements and coordinate consistent
implementation of both sets of
r equirements , w h i l e r e d u c i n g
redundancies. For purposes of
determining the erroneous excess
payments ratio applicable to the state
under MEQC, a state may elect to
substitute data resulting from the
application of PERM after the final
PERM rule is in effect for all states, for
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Agreement
the data used for the MEQC
requirements. The Secretary would also
be required to establish state-specific
sample sizes for application of the
PERM requirements to CHIP for
FY2009 forward. In establishing such
sample sizes, the Secretary must
minimize the administrative cost burden
on states under Medicaid and CHIP, and
must maintain state flexibility to
manage these programs.
Payments for FQHCs and RHCs under CHIP
Under current Medicaid law, payments H§121. Ensuring child-centered S§609. Application of prospective A§503. Application of prospective
to FQHCs and RHCs are based on a coverage. The provision would require payment system for services provided payment system for services provided
prospective payment system. Beginning that payments for FQHC and RHC by Federally-qualified health centers by federally-qualified health centers
in FY2001, per visit payments were services provided under CHIP follow and rural health clinics. The provision and rural health clinics. Same as
based on 100% of average costs during the prospective payment system for would require states that operate Senate bill.
1999 and 2000 adjusted for changes in such services under Medicaid. The separate and/or combination CHIP
the scope of services furnished. effective date would be October 1, programs to reimburse FQHCs and
(Special rules applied to entities first 2008.
RHCs based on the Medicaid
established after 2000). For subsequent
prospective payment system. This
years, the per visit payment for all
provision would apply to services
FQHCs and RHCs equals the amounts
provided on or after October 1, 2008.
for the preceding fiscal year increased
For FY2008, $5 million would be
by the percentage increase in the
appropriated (to remain available until
Medicare Economic Index applicable to
expended) to states with separate CHIP
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Agreement
primary care services, and adjusted for
programs for expenditures related to
any changes in the scope of services
transitioning to a prospective payment
furnished during that fiscal year. In
system for FQHCs/RHCs under CHIP.
managed care contracts, states are
Finally, the Secretary would be required
required to make supplemental
to report to Congress on the effects (if
payments to the facility equal to the
any) of the new prospective payment
difference between the contracted
system on access to benefits, provider
amount and the cost-based amounts.
payment rates or scope of benefits.
Miscellaneous
Purpose of Title XXI
No provision.
H§100. Purpose. The provision states No provision.
A§2. Purpose. Same as the House bill,
that the purpose of the CHIP title of the
except that the purpose would refer to
House bill is to provide dependable and
the entire agreement.
stable funding for children’s health
insurance under Titles XXI (CHIP) and
XIX (Medicaid) of the Social Security
Act in order to enroll all six million
children who are eligible, but not
enrolled, for coverage today.
Citizenship auditing
Under current law, the Medicaid statute H§136. Auditing requirement to See S§301 (under Enrollment/Access) See A§201 (under Enrollment/Access)
and associated Medicaid Eligibility enforce citizenship restrictions on for information on monitoring of invalid for information on monitoring of invalid
Quality Control (MEQC) regulations eligibility for Medicaid and CHIP names and SSNs submitted for names and SSNs submitted for
specify an allowable error rate (3%) for benefits. Under the House bill, each citizenship documentation purposes.
citizenship documentation purposes.
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Agreement
erroneous excess payments that are due state would be required to audit a
to eligibility errors, as well as a statistically based sample of individuals
methodology for determining a state’s whose Medicaid or CHIP eligibility is
error rate. Because state error rates determined under: (1) optional
discovered through MEQC programs citizenship documentation rules for
were consistently below 3% as of the children (specified in H§143 of the bill)
mid-1990s, CMS offered states the or (2) optional coverage rules for legal
option to develop alternative ways to immigrant pregnant women and
identify and reduce erroneous payments. children (specified in H§132 of the bill)
Under the Improper Payments to demonstrate to the satisfaction of the
Information Act of 2002 (P.L. 107-300), Secretary that federal Medicaid and
federal agencies are also required to CHIP funds are not unlawfully spent on
identify programs that are susceptible to individuals who are not legal residents.
significant improper payments, estimate In conducting such audits, a state may
the amount of overpayments, and report rely on MEQC or PERM eligibility
annually to Congress on those figures reviews. States would be required to
and on the steps being taken to reduce remit the federal share of any unlawful
such payments. A new regulation expenditures which are identified under
regarding Payment Error Rate the required audit.
Measurement (PERM) for Medicaid and
SCHIP was effective on October 1,
2006. With respect to these two
programs, the subset of states selected
for review in a given year are reviewed
using a statistically valid random
sample of claims and eligibility
determinations to determine error rates.
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Agreement
States must submit a corrective action
plan based on the error rate analysis,
and must return overpayments of federal
funds.
Managed care safeguards
A number of sections of the Social H§152. Application of certain S§503. Application of certain A§403. Application of certain
Security Act apply to states under Title managed care quality safeguards to managed care quality safeguards to managed care quality safeguards to
XXI (SCHIP) in the same manner as CHIP. The House bill would add CHIP. Same as the House bill, but CHIP. Same as the House bill.
they apply to a state under Title XIX subsections (a)(4), (a)(5), (b), (c), (d), with no effective date specified.
(Medicaid). These include section and (e) of section 1932, which relate to
1902(a)(4)(C) (relating to conflict of requirements for managed care, to the
interest standards); paragraphs (2), (16), list of Title XIX provisions that apply
and (17) of section 1903(i) (relating to under Title XXI. It would apply to
limitations on payment); section contract years for health plans
1903(w) (relating to limitations on beginning on or after July 1, 2008.
provider taxes and donations); and
section 1920A (relating to presumptive
eligibility for children).
Access to records for CHIP
Every third fiscal year (beginning with H§154. Access to records for IG and No provision.
A§604. Access to records for IG and
FY2000), the Secretary (through the GAO audits. Under the House bill, for
GAO audits. Same as the House bill,
Inspector General of the Department of the purpose of evaluating and auditing
except that it would also apply for the
Health and Human Services) must audit the CHIP program, the Secretary, the
purpose of evaluating and auditing the
a sample from among the states with an Office of Inspector General, and the
Medicaid program.
approved SCHIP state plan that does Comptroller General would have access
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Agreement
not, as part of such plan, provide health to any books, accounts, records,
benefits coverage under Medicaid. The correspondence, and other documents
Comptroller General of the United that are related to the expenditure of
States must monitor these audits and, federal CHIP funds and that are in the
not later than March 1 of each fiscal possession, custody, or control of states,
year after a fiscal year in which an audit political subdivisions of states, or their
is conducted, submit a report to grantees or contractors.
Congress on the results of the audit
conducted during the prior fiscal year.
Effective date
No provision.
H§156. Reliance on law; exception S§801. Effective date. The effective A§3. General effective date;
for state legislation. The House bill date of the Senate bill (unless otherwise exception for state legislation;
does not specify an effective date for the provided) would be October 1, 2007, contingent effective date; reliance on
bill in its entirety, however it states that whether or not final regulations to carry law. Same as the Senate bill with
with respect to amendments made by out provisions in the bill have been respect to the general effective date.
Title I (CHIP) or Title VIII (Medicaid) promulgated by that date.
Same as the House bill with respect to
of the bill that become effective as of a
amendments made by all but Title VII
date: (1) such amendments would be
(revenue provisions) of the bill that
effective as of such date whether or not
become effective as of a date: (1) such
regulations implementing such
amendments would be effective as of
amendments have been issued, and (2)
such date whether or not regulations
federal financial participation for
implementing such amendments have
medical or child health assistance
been issued, and (2) federal financial
furnished under Medicaid or CHIP on or
participation for medical or child health
after such date by a state in good faith
assistance furnished under Medicaid or
reliance on such amendments before the
CHIP on or after such date by a state in
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Agreement
date of promulgation of final regulations
good faith reliance on such amendments
(if any) to carry out such amendments,
before the date of promulgation of final
or the date of guidance (if any)
regulations (if any) to carry out such
regarding the implementation of such
amendments, or the date of guidance (if
amendments shall not be denied on the
any) regarding the implementation of
basis of the state’s failure to comply
such amendments shall not be denied on
with such regulations or guidance.
the basis of the state’s failure to comply
with such regulations or guidance..
In the case of CHIP and Medicaid state Same as the House bill in the case of a Same as the Senate and House bills in
plans, if the Secretary of HHS state that requires legislation.
the case of a state that requires
determines that a state must pass new
legislation.
state legislation to implement the
requirements of the CHIP and Medicaid
titles of the bill, the state plan, if
applicable, would not be regarded as
failing to comply solely on the basis of
its failure to meet such requirements
before the first day of the first calendar
quarter beginning after the close of the
first regular session of the state
legislature that begins after the date of
enactment of the House bill. In the case
of a state that has a two-year legislative
session, each year of such session would
be considered a separate regular session
of the state legislature.
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Agreement
The agreement would specify a
contingent effective date for CHIP
funding for FY2008. If funds are
appropriated under any law (other than
the agreement) to provide allotments to
states under CHIP for all (or any
portion) of FY2008: (1) any amounts
that are so appropriated that are not so
allotted and obligated before the date of
enactment of the agreement would be
rescinded and (2) any amount provided
for CHIP allotments to a state under the
agreement for such fiscal year would be
reduced by the amount of such
appropriations so allotted and obligated
before such date.
County Medicaid health insuring organizations
In general, Medicaid managed care H§805. County Medicaid health No provision.
A§614. County Medicaid
health
organizations are subject to contracting insuring organizations. The House bill
insuring organizations; GAO report
requirements described in section would add an exemption for HIOs
on Medicaid managed care payment
1903(m)(2)(A) of the Social Security operated by Ventura County and
rates. Same as the House bill, except
Act. However, certain county-operated Merced County, and would raise the
for the addition of a GAO report. Not
managed care plans in California that allowable percentage of beneficiaries to
later than 18 months after the date of the
serve Medicaid beneficiaries, which are 16%. The provision would be effective
enactment, the Comptroller General of
referred to as “county organized health upon enactment.
the United States would be required to
systems” or “healt h i nsuring
submit a report to the Committee on
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Agreement
organizations” (HIOs), are exempt from
Finance of the Senate and the
these contracting requirements. The
Committee on Energy and Commerce of
Consolidated Omnibus Budget
the House of Representatives analyzing
Reconciliation Act of 1985 (P.L.
the extent to which state payment rates
9 9 - 2 7 2 ) g r a n d f a t h e r e d t h e
f o r M e d i c a i d m a n a g e d c a r e
1903(m)(2)(A) exemption for HIOs
organizations are actuarially sound.
operating before January 1, 1986. In
addition, the Omnibus Budget
Reconciliation Act of 1990 (P.L.
101-508) provided an exemption for up
to three county-operated HIOs in
California that became operational on or
after January 1, 1986, provided that
certain requirements were met. For
example, the three entities could enroll
no more than 10% of all Medicaid
beneficiaries in California, later raised
to 14% by the Medicare, Medicaid, and
SCHIP Benefits Improvement and
Protection Act of 2000 (incorporated by
reference in P.L. 106-554).
Clarification of treatment of regional medical center
The states and federal government share H§816. Clarification treatment of No provision.
A§618. Clarification treatment
of
in the cost of the Medicaid program. regional medical center. The provision
regional medical center. Same as
Sometimes hospitals fund the state share would prohibit the Secretary from
House provision.
of some of its own Medicaid payments, denying federal matching payments
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Agreement
thereby ensuring that federal matching when the state share has been
funds will be available even if the state transferred from certain publicly-owned
cann o t p a y i t s share. Such regional medical centers in other states
“inter-governmental transfers” of if the Secretary determines that the use
certified public expenditures made by of such funds is proper and in the
those types of health care providers to interest of the Medicaid program..
fund the non-federal share of states’
Medicaid expenditures are allowable but
only under
certain circumstances. Some of those
circumstances are described in detailed
federal regulations. Other limitations are
based on recent CMS administrative
actions. For example, CMS has recently
denied federal matching payments when
the state share was comprised of
payments transferred from out-of-state
hospitals.
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Agreement
Diabetes grants
Section 330B of the Public Health H§822. Diabetes grants. The provision S§613. Demonstration projects A§505. Demonstration projects
Service Act specifies that the Secretary, would provide $150 million for FY2009 relating to diabetes prevention. The relating to diabetes prevention. Same
directly or through grants, must provide for each of these two diabetes grant Senate bill, as amended, would create a as Senate bill.
for research into the prevention and cure programs under the Public Health new demonstration project to fund up to
of Type I diabetes. Appropriations are Service Act, as part of the appropriation 10 states over three years to promote
set at $150 million per year during the for CHIP under this bill.
children’s receipt of screenings and
period FY2004 through FY2008.
improvements in healthy eating and
Section 330C of the Public Health
physical activity to reduce the incidence
Service Act specifies the Secretary must
of type 2 diabetes. Activities could
make grants for providing services for
include reductions in cost-sharing or
the prevention and treatment of diabetes
premiums when children receive regular
among American Indian and Alaska
screenings and r each certain
Natives. Appropriations are set at $150
benchmarks in healthy eating and
million per year during the period
physical activity. States would be
FY2004 through FY2008.
permitted to provide (1) financial
bonuses for partnerships with entities
(e.g., schools) that increase education
and other activities to reduce the
incidence of type 2 diabetes, and (2)
incentives to providers serving
Medicaid and CHIP children to perform
screening and counseling regarding
healthy eating and exercise. The
Secretary of HHS would be required to
provide a report to Congress on the
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Agreement
degree to which funded activities
improve health outcomes related to type
2 diabetes among children in
participating states. The provision
would authorize to be appropriated a
total of $15 million during FY2008
through FY2012 to fund this
demonstration.
S§501. Child health quality
improvement activities for children
enrolled in Medicaid and CHIP.
Would include a childhood obesity
demonstration project that would also
include activities designed to improve
health eating and physical activity
among children.
Collection of data used in providing CHIP funds
The Secretary of Commerce was No provision.
S§604. Improving data collection. A§602. Improving data collection.
required to make appropriate
Besides the $10 million provided Same as Senate bill.
adjustments to the Current Population
annually for the CPS since FY2000, an
Survey (CPS), which is the primary
additional $10 million (for a total of
current-law data source for determining
$20 million additionally) would be
states’ SCHIP allotments, (1) to produce
appropriated from FY2008 onward. In
statistically reliable annual state data on
addition to the current-law requirements
the number of low-income children who
of the appropriation, for data collection
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Agreement
do not have health insurance coverage,
beginning in FY2008, in appropriate
so that real changes in the uninsurance
consultation with the HHS Secretary,
rates of children can reasonably be
the Secretary of Commerce would be
detected; (2) to produce data that
required to make adjustments to the
categorizes such children by family
CPS to develop more accurate
income, age, and race or ethnicity; and
state-specific estimates of the number of
(3) where appropriate, to expand the
children enrolled in CHIP or Medicaid,
sample size used in the state sampling
or who are without coverage and to
units, to expand the number of sampling
assess whether estimates from the
units in a state, and to include an
American Community Survey (ACS)
appropriate verification element. For
produce more reliable estimates than the
this purpose, $10 million was
CPS for CHIP allotments and payments.
appropriated annually, beginning in
On the basis of that assessment, the
FY2000.
Commerce Secretary would recommend
to the HHS Secretary whether ACS
estimates should be used in lieu of, or in
some combination with, CPS estimates
for CHIP purposes.
If the Commerce Secretary recommends
to the HHS Secretary that ACS
estimates should be used instead of, or
in combination with, CPS estimates for
CHIP purposes, the HHS Secretary may
provide a transition period for using
ACS estimates, provided that the
transition is implemented in a way that
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avoids adverse impacts on states.
S§105. Incentive bonuses for states.
An appropriation of $5 million would be
provided to the Secretary for FY2008
for improving the timeliness of data
reported from the Medicaid Statistical
Information System (MSIS) and to
provide guidance to states with respect
to any new reporting requirements
related to such improvements. Amounts
appropriated are available until
expended. The resulting improvements
are to be designed and implemented so
that, no later than October 1, 2008,
Medicaid and CHIP enrollment data
could be collected and analyzed by the
Secretary within six months of
submission.
Technical correction
P.L. 109-171 gave states the option to H§823. Technical correction. The S§605. Deficit Reduction Act A611(b). Deficit Reduction Act
provide Medicaid to state-specified provision would make a correction to technical corrections. Same as House technical corrections — Correction of
groups through enrollment in the reference to children in foster care bill.
reference to children in foster care
benchmark and benchmark-equivalent receiving child welfare services in P.L.
receiving child welfare services. Same
coverage which is nearly identical to 109-171; this change would be effective
as House and Senate bill.
plans available under CHIP. This law as if included in this law (i.e., March 31,
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identifies a number of groups as exempt 2006).
from mandatory enrollment in
benchmark or benchmark equivalent
plans. These exempted groups may be
enrolled in such plans on a voluntary
basis. One such exempted group is
children in foster care receiving child
welfare services under Part B of title IV
of the Social Security Act and children
receiving foster care or adoption
assistance under Part E of such title.
The Deficit Reduction Act of 2005 No provision.
S§605. Deficit Reduction
Act A§611(c). Transparency. The
(DRA; P.L. 109-171) gave states the
technical corrections. The Secretary agreement would require the Secretary
option to provide Medicaid to state-
would be required to publish in the to publish on the CMS internet website
specific groups through enrollment in
Federal Register and on the internet only the list of provisions in Title XIX
benchmark and benchmark-equivalent
website of CMS, a list of the provisions that do not apply in order to enable a
coverage that is nearly identical to plans
in Title XIX that the Secretary has state to provide benchmark coverage
available under SCHIP (described above
determined do not apply in order to under Medicaid on the date that such
in the “dental services” row).
enable a state to carry out a state plan approval is given (rather than within 30
amendment to provide benchmark or days of such approval). It would also
benchmark-equivalent coverage under require the Secretary to publish these
Medicaid. In such publications, the same findings in the Federal Register
Secretary must also provide the reason within 30 days of the date of approval.
for each such determination. The The effective date would be the same as
effective date would be the same as the the original DRA provision (i.e., March
original DRA provision (i.e., March 31, 31, 2006)
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2006).
Technical corrections regarding current state authority under Medicaid
The federal medical assistance No provision.
S § 6 0 1 . T e c h n i c a l
c o r r e c t i o n s
percentage (FMAP) is the rate at which
regarding current state authority
states are reimbursed for most Medicaid
under Medicaid. With respect to
service expenditures. It is based on a
Medicaid expenditures for FY2007 and
formula that provides higher
FY2008 only, the provision would allow
reimbursement to states with lower per
states to elect (1) to cover optional,
capita incomes relative to the national
poverty-related children and, may apply
average (and visa versa); it has a
less restrictive income methodologies to
statutory minimum of 50% and
such individuals, for which the regular
maximum of 83%. The enhanced
Medicaid matching rate, rather than the
FMAP (E-FMAP) under SCHIP builds
enhanced matching rate under CHIP,
on top of the regular FMAP for
would apply to determine the federal
Medicaid. The E-FMAP can range from
share of such expenditures, or (2) to
65% to 85%.
receive the regular Medicaid matching
rate, rather than the enhanced CHIP
matching rate, for CHIP children under
an expansion of the state’s Medicaid
program. This provision would be
repealed as of October 1, 2008 (i.e., the
beginning of FY2009). States electing
these options would be “held harmless”
for related expenditures in FY2007 and
FY2008, once this repeal takes effect.
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Elimination of counting of Medicaid child presumptive eligibility costs against CHIP allotments
CHIP statute sets the federal share of No provision.
S§603. Elimination of
counting A§113. Elimination of counting
costs incurred during periods of
Medicaid child presumptive eligibility Medicaid child presumptive eligibility
presumptive eligibility for Medicaid
costs against title XXI allotment. The costs against title XXI allotment.
children (i.e, up to two months of
provision would strike these current law Same as Senate bill.
coverage while a final determination of
provisions.
eligibility is made) at the Medicaid
matching rate. The law also allows
payment out of CHIP allotments for
Medicaid benefits received by Medicaid
children during periods of presumptive
eligibility.
CRS-117
Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
Outreach to small businesses
No provision.
No provision.
S§614. Outreach regarding health A§623. Outreach regarding health
insurance options available to insurance options available to
children. The Senate bill would children. Same as the Senate bill.
establish a task force, consisting of the
Administrator of the Small Business
Administration (SBA) and the
Secretaries of HHS, Labor, and the
Treasury, to conduct a nationwide
campaign of education and outreach for
small businesses regarding the
availability of coverage for children
through private insurance, Medicaid,
and CHIP. The campaign would
include information regarding options to
make insurance more affordable,
including federal and state tax
deductions and credits and the federal
tax exclusion available under
employer-sponsored cafeteria plans; it
would also include efforts to educate
small businesses about the value of
health insurance coverage for children,
assistance available through public
programs, and the availability of the
hotline operated as part of the Insure
CRS-118
Current Law
House: H.R. 3162
Senate: H.R. 976
Agreement
Kids Now program at HHS. The task
force would be allowed to use any
business partner of the SBA, enter into
a memorandum of understanding with a
chamber of commerce and a partnership
with any appropriate small business or
health advocacy group, and designate
outreach programs at HHS regional
offices to work with SBA district
offices. It would require the SBA
website to prominently display links to
state eligibility and enrollment
requirements for Medicaid and CHIP,
and would require a report to Congress
every two years.