1.
This Act may be cited as the
Family Opportunity Act of
2005
or the Dylan
Lee James Act
.
2.
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)
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.
3.
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)
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)
(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)
The amendments made by this
section shall apply to medical assistance for items and services furnished on
or after October 1, 2005.
4.
Demonstration projects regarding home and community-based
alternative to psychiatric residential treatment facilities for
children
(a)
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)
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)
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)
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)
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)
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)
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)
(1)
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)
(A)
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)
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.
5.
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.
.
6.
Restoration of medicaid eligibility for certain ssi
beneficiaries
(a)
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)
The amendments made by
subsection (a) shall apply to medical assistance for items and services
furnished on or after January 1, 2006.