For other versions of this document, see http://wikileaks.org/wiki/CRS-RL34129 ------------------------------------------------------------------------------ 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 E-mail 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. CRS-9 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. CRS-10 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 CRS-11 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 CRS-12 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 CRS-13 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 CRS-14 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. CRS-15 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 CRS-16 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 CRS-17 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 appropriation amounts in 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. CRS-18 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 CHIP allotments. H§103. 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 CRS-19 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. CRS-20 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 CRS-21 Current Law House: H.R. 3162 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 payments would be reduced 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 CRS-22 Current Law House: H.R. 3162 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 CRS-23 Current Law House: H.R. 3162 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 CRS-24 Current Law House: H.R. 3162 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 CRS-26 Current Law House: H.R. 3162 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 CRS-27 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 For FY2010 to FY2012, the coverage population growth in that state plus one 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 CRS-28 Current Law House: H.R. 3162 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 amounts of National Health 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 House: H.R. 3162 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 CRS-30 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement amount would be reduced 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 CRS-31 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. CRS-32 Current Law House: H.R. 3162 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 CRS-33 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 pension a n d insurance fund 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 CRS-35 Current Law House: H.R. 3162 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 formula 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 House: H.R. 3162 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). CRS-37 Current Law House: H.R. 3162 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 CRS-39 Current Law House: H.R. 3162 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, CRS-40 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 CRS-41 Current Law House: H.R. 3162 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 House: H.R. 3162 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 CRS-43 Current Law House: H.R. 3162 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. CRS-44 Current Law House: H.R. 3162 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. CRS-45 Current Law House: H.R. 3162 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 House: H.R. 3162 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 CRS-47 Current Law House: H.R. 3162 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 Authority 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 CRS-48 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). CRS-49 Current Law House: H.R. 3162 Senate: H.R. 976 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 CRS-50 Current Law House: H.R. 3162 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 simplified eligibility Express Lane agency to determine conduct simplified 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 CRS-51 Current Law House: H.R. 3162 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. child as one who is under the age of 19 CHIP screen and enroll requirements by provision would establish criteria for years with no health insurance, and who using either or both of the following how a state would meet screen and would not have been eligible for requirements: (1) establishing a enroll requirements, would not relieve Medicaid under the rules in effect in the threshold percentage of the Federal states of their obligation to determine State on March 31, 1997. Federal law poverty level that exceeds the highest eligibility for Medicaid, and would requires that eligibility for Medicaid and income eligibility threshold applicable require the state to inform families that SCHIP be coordinated when States under Medicaid for the child by a they may qualify for lower premium 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 CRS-53 Current Law House: H.R. 3162 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 CRS-54 Current Law House: H.R. 3162 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 CRS-55 Current Law House: H.R. 3162 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 CRS-56 Current Law House: H.R. 3162 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 CRS-57 Current Law House: H.R. 3162 Senate: H.R. 976 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 CRS-58 Current Law House: H.R. 3162 Senate: H.R. 976 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 different sectors, payment 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 CRS-59 Current Law House: H.R. 3162 Senate: H.R. 976 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 commission (i.e., relating to 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§213. Model of interstate 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 CRS-60 Current Law House: H.R. 3162 Senate: H.R. 976 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 Miscellaneous) for auditing 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 requirement for citizenship 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 CRS-61 Current Law House: H.R. 3162 Senate: H.R. 976 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. CRS-62 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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, CRS-63 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-64 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-65 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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. CRS-66 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement The Senate provision would make Same as the Senate bill. citizenship documentation 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. CRS-67 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 ni t y accoun t heal t h op p o r t u n i t y a c c o unt 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, CRS-68 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 simplified 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 CRS-69 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-70 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-71 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-72 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-73 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-74 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-75 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-76 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-77 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-78 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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. CRS-79 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement Health Insurance Premium Payment (HIPP) program or SCHIP's family coverage variance option (i.e., the compreh e n s iveness and cost- 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 CRS-80 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-81 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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% limit on spending for 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 CRS-82 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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, CRS-83 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-84 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 mus 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. CRS-85 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-86 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 issuer of benchmark or 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 CRS-87 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-88 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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. CRS-89 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-90 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-91 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement percentage (FMAP) is based on a the recommended measures for years required to disseminate information to formula 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 CRS-92 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-93 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 at i on 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 denials of eligibility and 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 CRS-94 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 CRS-95 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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. CRS-96 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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. CRS-97 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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 school-based administration, 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. CRS-98 Current Law House: H.R. 3162 Senate: H.R. 976 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 with special needs. Such 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. CRS-99 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement Monitoring erroneous payments Federal agencies are required to No provision. S§602. Payment error rate A§601. Payment 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 CRS-100 Current Law House: H.R. 3162 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 ocess for ap 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 , whi l e r educi ng 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 CRS-101 Current Law House: H.R. 3162 Senate: H.R. 976 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 CRS-102 Current Law House: H.R. 3162 Senate: H.R. 976 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. CRS-103 Current Law House: H.R. 3162 Senate: H.R. 976 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. CRS-104 Current Law House: H.R. 3162 Senate: H.R. 976 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 CRS-105 Current Law House: H.R. 3162 Senate: H.R. 976 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 CRS-106 Current Law House: H.R. 3162 Senate: H.R. 976 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. CRS-107 Current Law House: H.R. 3162 Senate: H.R. 976 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 "health insuring submit a report to the Committee on CRS-108 Current Law House: H.R. 3162 Senate: H.R. 976 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 99-272) grandfathered the f o r M edi cai d ma n a ge 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 CRS-109 Current Law House: H.R. 3162 Senate: H.R. 976 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 cannot pay 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. CRS-110 Current Law House: H.R. 3162 Senate: H.R. 976 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 reach 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 CRS-111 Current Law House: H.R. 3162 Senate: H.R. 976 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 CRS-112 Current Law House: H.R. 3162 Senate: H.R. 976 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 CRS-113 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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, CRS-114 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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) CRS-115 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 2006). Technical corrections regarding current state authority under Medicaid The federal medical assistance No provision. S§601. Tech n i c a l corrections 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. CRS-116 Current Law House: H.R. 3162 Senate: H.R. 976 Agreement 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. ------------------------------------------------------------------------------ For other versions of this document, see http://wikileaks.org/wiki/CRS-RL34129