Short title

This Act may be cited as the

Family Opportunity Act of 2005

or the

Dylan Lee James Act

References; table of contents

(a)

Amendments to social security act

Except as otherwise specifically provided, whenever in this title an amendment is expressed in terms of an amendment to or repeal of a section or other provision, the reference shall be considered to be made to that section or other provision of the Social Security Act. (b)

Table of contents

The table of contents for this Act is as follows:

Sec. 1. Short title.

Sec. 2. References; table of contents.

Sec. 3. Opportunity for families of disabled children to purchase medicaid coverage for such children.

Sec. 4. Demonstration projects regarding home and community-based alternative to psychiatric residential treatment facilities for children.

Sec. 5. Development and support of family-to-family health information centers.

Sec. 6. Restoration of medicaid eligibility for certain SSI beneficiaries.

Opportunity for families of disabled children to purchase medicaid coverage for such children

(a)

State option To allow families of disabled children To purchase medicaid coverage for such children

(1)

In general

Section 1902 (42 U.S.C. 1396a) is amended— (A)in subsection (a)(10)(A)(ii)— (i)by striking or at the end of subclause (XVII); (ii)by adding or at the end of subclause (XVIII); and (iii)by adding at the end the following new subclause:

(XIX)who are disabled children described in subsection (cc)(1);

; and

(B)by adding at the end the following new subsection:

(cc) (1)Individuals described in this paragraph are individuals— (A)who are children who have not attained 19 years of age and are born— (i)on or after October 1, 1999 (or, at the option of a State, on or after an earlier date), in the case of fiscal year 2006; (ii)on or after October 1, 1994 (or, at the option of a State, on or after an earlier date), in the case of fiscal year 2007; and (iii)after October 1, 1988, in the case of fiscal year 2008 and any fiscal year thereafter; (B)who would be considered disabled under section 1614(a)(3)(C) but for having earnings or deemed income or resources (as determined under title XVI for children) that exceed the requirements for receipt of supplemental security income benefits; and (C)whose family income does not exceed such income level as the State establishes and does not exceed— (i)300 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved; or (ii)such higher percent of such poverty line as a State may establish, except that— (I)any medical assistance provided to an individual whose family income exceeds 300 percent of such poverty line may only be provided with State funds; and (II)no Federal financial participation shall be provided under section 1903(a) for any medical assistance provided to such an individual.

(2)

Interaction with employer-sponsored family coverage

Section 1902(cc) (42 U.S.C. 1396a(cc)), as added by paragraph (1)(B), is amended by adding at the end the following new paragraph:

(2) (A)If an employer of a parent of an individual described in paragraph (1) offers family coverage under a group health plan (as defined in section 2791(a) of the Public Health Service Act), the State shall— (i)require such parent to apply for, enroll in, and pay premiums for such coverage as a condition of such parent’s child being or remaining eligible for medical assistance under subsection (a)(10)(A)(ii)(XIX) if the parent is determined eligible for such coverage and the employer contributes at least 50 percent of the total cost of annual premiums for such coverage; and (ii)if such coverage is obtained— (I)subject to paragraph (2) of section 1916(h), reduce the premium imposed by the State under that section in an amount that reasonably reflects the premium contribution made by the parent for private coverage on behalf of a child with a disability; and (II)treat such coverage as a third party liability under subsection (a)(25). (B)In the case of a parent to which subparagraph (A) applies, a State, subject to paragraph (1)(A)(iii)(II), may provide for payment of any portion of the annual premium for such family coverage that the parent is required to pay. Any payments made by the State under this subparagraph shall be considered, for purposes of section 1903(a), to be payments for medical assistance.

(b)

State option To impose Income-Related premiums

Section 1916 (42 U.S.C. 1396o) is amended— (1)in subsection (a), by striking subsection (g) and inserting subsections (g) and (h); and (2)by adding at the end the following new subsection:

(h) (1)With respect to disabled children provided medical assistance under section 1902(a)(10)(A)(ii)(XIX), subject to paragraph (2), a State may (in a uniform manner for such children) require the families of such children to pay monthly premiums set on a sliding scale based on family income. (2)A premium requirement imposed under paragraph (1) may only apply to the extent that— (A)in the case of a disabled child described in that paragraph whose family income— (i)does not exceed 200 percent of the poverty line, the aggregate amount of such premium and any premium that the parent is required to pay for family coverage under section 1902(cc)(2)(A)(i) and other cost sharing charges do not exceed 5 percent of the family’s income; and (ii)exceeds 200, but does not exceed 300, percent of the poverty line, the aggregate amount of such premium and any premium that the parent is required to pay for family coverage under section 1902(cc)(2)(A)(i) and other cost sharing charges do not exceed 7.5 percent of the family’s income; and (B)the requirement is imposed consistent with section 1902(cc)(2)(A)(ii)(I). (3)A State shall not require prepayment of a premium imposed pursuant to paragraph (1) and shall not terminate eligibility of a child under section 1902(a)(10)(A)(ii)(XIX) for medical assistance under this title on the basis of failure to pay any such premium until such failure continues for a period of at least 60 days from the date on which the premium became past due. The State may waive payment of any such premium in any case where the State determines that requiring such payment would create an undue hardship.

(c)

Conforming amendments

(1)Section 1903(f)(4) (42 U.S.C. 1396b(f)(4)) is amended in the matter preceding subparagraph (A), by inserting 1902(a)(10)(A)(ii)(XIX), after 1902(a)(10)(A)(ii)(XVIII),. (2)Section 1905(u)(2)(B) (42 U.S.C. 1396d(u)(2)(B)) is amended by adding at the end the following sentence: Such term excludes any child eligible for medical assistance only by reason of section 1902(a)(10)(A)(ii)(XIX).. (d)

Effective date

The amendments made by this section shall apply to medical assistance for items and services furnished on or after October 1, 2005.

Demonstration projects regarding home and community-based alternative to psychiatric residential treatment facilities for children

(a)

In general

The Secretary of Health and Human Services (in this section referred to as the Secretary) is authorized to conduct, during each of fiscal years 2006 through 2010, demonstration projects (each in the section referred to as a demonstration project) in accordance with this section under which up to 10 States (as defined for purposes of title XIX of the Social Security Act) are awarded grants, on a competitive basis, to test the effectiveness in improving or maintaining a child’s functional level and cost-effectiveness of providing coverage of home and community-based alternatives to psychiatric residential treatment for children enrolled in the medicaid program under title XIX of such Act. (b)

Application of terms and conditions

(1)

In general

Subject to the provisions of this section, for the purposes of the demonstration projects, and only with respect to children enrolled under such demonstration projects, a psychiatric residential treatment facility (as defined in section 483.352 of title 42 of the Code of Federal Regulations) shall be deemed to be a facility specified in section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c)), and to be included in each reference in such section 1915(c) to hospitals, nursing facilities, and intermediate care facilities for the mentally retarded. (2)

State option to assure continuity of medicaid coverage

Upon the termination of a demonstration project under this section, the State that conducted the project may elect, only with respect to a child who is enrolled in such project on the termination date, to continue to provide medical assistance for coverage of home and community-based alternatives to psychiatric residential treatment for the child in accordance with section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c)), as modified through the application of paragraph (1). Expenditures incurred for providing such medical assistance shall be treated as a home and community-based waiver program under section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c)) for purposes of payment under section 1903 of such Act (42 U.S.C. 1396b). (c)

Terms of demonstration projects

(1)

In general

Except as otherwise provided in this section, a demonstration project shall be subject to the same terms and conditions as apply to a waiver under section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c)), including the waiver of certain requirements under the first sentence of paragraph (3) of such section but not applying the second sentence of such paragraph. (2)

Budget neutrality

In conducting the demonstration projects under this section, the Secretary shall ensure that the aggregate payments made by the Secretary under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) do not exceed the amount by which the Secretary estimates would have been paid under that title if the demonstration projects under this section had not been implemented. (3)

Evaluation

The application for a demonstration project shall include an undertaking to provide for such interim and final evaluations of the demonstration project by independent third parties, and for such interim and final reports to the Secretary, as the Secretary may require. (d)

Payments to States; limitations to scope and funding

(1)

In general

Subject to paragraph (2), a demonstration project approved by the Secretary under this section shall be treated as a home and community-based waiver program under section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c)) for purposes of payment under section 1903 of such Act (42 U.S.C. 1396b). (2)

Limitation

In no case may the amount of payments made by the Secretary under this section for State demonstration projects for a fiscal year exceed the amount available under subsection (f)(2)(A) for such fiscal year. (e)

Secretary’s evaluation and report

The Secretary shall conduct an interim and final evaluation of State demonstration projects under this section and shall report to the President and Congress the conclusions of such evaluations within 12 months of completing such evaluations. (f)

Funding

(1)

In general

For the purpose of carrying out this section, there are appropriated, from amounts in the Treasury not otherwise appropriated, for fiscal years 2006 through 2010 a total of $218,000,000, of which— (A)the amount specified in paragraph (2) shall be available for each of fiscal years 2006 through 2010; and (B)a total of $1,000,000 shall be available to the Secretary for the evaluations and report under subsection (f). (2)

Fiscal year limit

(A)

In general

For purposes of paragraph (1), the amount specified in this paragraph for a fiscal year is the amount specified in subparagraph (B) for the fiscal year plus the difference, if any, between the total amount available under this paragraph for prior fiscal years and the total amount previously expended under paragraph (1)(A) for such prior fiscal years. (B)

Fiscal year amounts

The amount specified in this subparagraph for— (i)fiscal year 2006 is $21,000,000; (ii)fiscal year 2007 is $37,000,000; (iii)fiscal year 2008 is $49,000,000; (iv)fiscal year 2009 is $53,000,000; and (v)fiscal year 2010 is $57,000,000.

Development and support of family-to-family health information centers

Section 501 (42 U.S.C. 701) is amended by adding at the end the following new subsection:

(c) (1) (A)For the purpose of enabling the Secretary (through grants, contracts, or otherwise) to provide for special projects of regional and national significance for the development and support of family-to-family health information centers described in paragraph (2)— (i)there is appropriated to the Secretary, out of any money in the Treasury not otherwise appropriated— (I)$3,000,000 for fiscal year 2006; (II)$4,000,000 for fiscal year 2007; and (III)$5,000,000 for fiscal year 2008; and (ii)there is authorized to be appropriated to the Secretary, $5,000,000 for each of fiscal years 2009 and 2010. (B)Funds appropriated or authorized to be appropriated under subparagraph (A) shall— (i)be in addition to amounts appropriated under subsection (a) and retained under section 502(a)(1) for the purpose of carrying out activities described in subsection (a)(2); and (ii)remain available until expended. (2)The family-to-family health information centers described in this paragraph are centers that— (A)assist families of children with disabilities or special health care needs to make informed choices about health care in order to promote good treatment decisions, cost-effectiveness, and improved health outcomes for such children; (B)provide information regarding the health care needs of, and resources available for, such children; (C)identify successful health delivery models for such children; (D)develop with representatives of health care providers, managed care organizations, health care purchasers, and appropriate State agencies a model for collaboration between families of such children and health professionals; (E)provide training and guidance regarding caring for such children; (F)conduct outreach activities to the families of such children, health professionals, schools, and other appropriate entities and individuals; and (G)are staffed— (i)by such families who have expertise in Federal and State public and private health care systems; and (ii)by health professionals. (3)The Secretary shall develop family-to-family health information centers described in paragraph (2) in accordance with the following: (A)With respect to fiscal year 2006, such centers shall be developed in not less than 25 States. (B)With respect to fiscal year 2007, such centers shall be developed in not less than 40 States. (C)With respect to fiscal year 2008, such centers shall be developed in all States. (4)The provisions of this title that are applicable to the funds made available to the Secretary under section 502(a)(1) apply in the same manner to funds made available to the Secretary under paragraph (1)(A). (5)For purposes of this subsection, the term State means each of the 50 States and the District of Columbia.

Restoration of medicaid eligibility for certain ssi beneficiaries

(a)

In general

Section 1902(a)(10)(A)(i)(II) (42 U.S.C. 1396a(a)(10)(A)(i)(II)) is amended— (1)by inserting (aa) after (II); (2)by striking ) and and inserting and; (3)by striking section or who are and inserting section), (bb) who are; and (4)by inserting before the comma at the end the following: , or (cc) who are under 21 years of age and with respect to whom supplemental security income benefits would be paid under title XVI if subparagraphs (A) and (B) of section 1611(c)(7) were applied without regard to the phrase the first day of the month following. (b)

Effective date

The amendments made by subsection (a) shall apply to medical assistance for items and services furnished on or after January 1, 2006.