II 109th CONGRESS 1st Session S. 740 IN THE SENATE OF THE UNITED STATES April 7, 2005 Mr. Bingaman (for himself, Mr. Lugar, Mrs. Lincoln, Mrs. Murray, Mr. Kerry, Ms. Cantwell, Mr. Kohl, Mr. Lautenberg, Mrs. Boxer, and Mr. Corzine) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend titles XIX and XXI of the Social Security Act to expand or add coverage of pregnant women under the medicaid and State children’s health insurance program, and for other purposes.

1.

Short title

This Act may be cited as the Start Healthy, Stay Healthy Act of 2005 .

2.

State option to expand or add coverage of certain pregnant women under medicaid and SCHIP

(a)

Medicaid

(1)

Authority to expand coverage

Section 1902(l)(2)(A)(i) of the Social Security Act (42 U.S.C. 1396a(l)(2)(A)(i)) is amended by inserting (or such higher percent as the State may elect for purposes of expenditures for medical assistance for pregnant women described in section 1905(u)(4)(A)) after 185 percent. (2)

Enhanced matching funds available if certain conditions met

Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended— (A) in the fourth sentence of subsection (b), by striking or subsection (u)(3) and inserting , (u)(3), or (u)(4); and (B) in subsection (u)— (i) by redesignating paragraph (4) as paragraph (5); and (ii) by inserting after paragraph (3) the following: (4) For purposes of the fourth sentence of subsection (b) and section 2105(a), the expenditures described in this paragraph are the following: (A)

Certain pregnant women

If the conditions described in subparagraph (B) are met, expenditures for medical assistance for pregnant women described in subsection (n) or under section 1902(l)(1)(A) in a family the income of which exceeds the effective income level (expressed as a percent of the poverty line and considering applicable income disregards) that has been specified under subsection (a)(10)(A)(i)(III) or (l)(2)(A) of section 1902, as of January 1, 2005, but does not exceed the income eligibility level established under title XXI for a targeted low-income child. (B)

Conditions

The conditions described in this subparagraph are the following: (i) The State plans under this title and title XXI do not provide coverage for pregnant women described in subparagraph (A) with higher family income without covering such pregnant women with a lower family income. (ii) The State does not apply an effective income level for pregnant women that is lower than the effective income level (expressed as a percent of the poverty line and considering applicable income disregards) that has been specified under the State plan under subsection (a)(10)(A)(i)(III) or (l)(2)(A) of section 1902, as of January 1, 2005, to be eligible for medical assistance as a pregnant woman. (C)

Definition of poverty line

In this subsection, the term poverty line has the meaning given such term in section 2110(c)(5). . (3)

Payment from title XXI allotment for medicaid expansion costs; elimination of counting medicaid child presumptive eligibility costs against title XXI allotment

Section 2105(a)(1) of the Social Security Act (42 U.S.C. 1397ee(a)(1)) is amended— (A) in the matter preceding subparagraph (A), by striking (or, in the case of expenditures described in subparagraph (B), the Federal medical assistance percentage (as defined in the first sentence of section 1905(b))); and (B) by striking subparagraph (B) and inserting the following: (B) for the provision of medical assistance that is attributable to expenditures described in section 1905(u)(4)(A); . (4)

Additional amendments to medicaid

(A)

Eligibility of a newborn

Section 1902(e)(4) of the Social Security Act (42 U.S.C. 1396a(e)(4)) is amended in the first sentence by striking so long as the child is a member of the woman’s household and the woman remains (or would remain if pregnant) eligible for such assistance. (B)

Application of qualified entities to presumptive eligibility for pregnant women under medicaid

Section 1920(b) of the Social Security Act (42 U.S.C. 1396r–1(b)) is amended by adding at the end after and below paragraph (2) the following flush sentence: The term qualified provider includes a qualified entity as defined in section 1920A(b)(3).. (b)

SCHIP

(1)

Coverage

Title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.) is amended by adding at the end the following:

2111.

Optional coverage of targeted low-income pregnant women

(a)

Optional coverage

Notwithstanding any other provision of this title, a State may provide for coverage, through an amendment to its State child health plan under section 2102, of pregnancy-related assistance for targeted low-income pregnant women in accordance with this section, but only if the State meets the conditions described in section 1905(u)(4)(B). (b)

Definitions

For purposes of this title: (1)

Pregnancy-related assistance

The term pregnancy-related assistance has the meaning given the term child health assistance in section 2110(a) as if any reference to targeted low-income children were a reference to targeted low-income pregnant women, except that the assistance shall be limited to services related to pregnancy (which include prenatal, delivery, and postpartum services and services described in section 1905(a)(4)(C)) and to other conditions that may complicate pregnancy. (2)

Targeted low-income pregnant woman

The term targeted low-income pregnant woman means a woman— (A) during pregnancy and through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends; (B) whose family income exceeds the effective income level (expressed as a percent of the poverty line and considering applicable income disregards) that has been specified under subsection (a)(10)(A)(i)(III) or (l)(2)(A) of section 1902, as of January 1, 2005, to be eligible for medical assistance as a pregnant woman under title XIX but does not exceed the income eligibility level established under the State child health plan under this title for a targeted low-income child; and (C) who satisfies the requirements of paragraphs (1)(A), (1)(C), (2), and (3) of section 2110(b). (c)

References to terms and special rules

In the case of, and with respect to, a State providing for coverage of pregnancy-related assistance to targeted low-income pregnant women under subsection (a), the following special rules apply: (1) Any reference in this title (other than in subsection (b)) to a targeted low-income child is deemed to include a reference to a targeted low-income pregnant woman. (2) Any such reference to child health assistance with respect to such women is deemed a reference to pregnancy-related assistance. (3) Any such reference to a child is deemed a reference to a woman during pregnancy and the period described in subsection (b)(2)(A). (4) In applying section 2102(b)(3)(B), any reference to children found through screening to be eligible for medical assistance under the State medicaid plan under title XIX is deemed a reference to pregnant women. (5) There shall be no exclusion of benefits for services described in subsection (b)(1) based on any preexisting condition and no waiting period (including any waiting period imposed to carry out section 2102(b)(3)(C)) shall apply. (6) Subsection (a) of section 2103 (relating to required scope of health insurance coverage) shall not apply insofar as a State limits coverage to services described in subsection (b)(1) and the reference to such section in section 2105(a)(1)(C) is deemed not to require, in such case, compliance with the requirements of section 2103(a). (7) In applying section 2103(e)(3)(B) in the case of a pregnant woman provided coverage under this section, the limitation on total annual aggregate cost-sharing shall be applied to the entire family of such pregnant woman. (d)

Automatic enrollment for children born to women receiving Pregnancy-Related assistance

If a child is born to a targeted low-income pregnant woman who was receiving pregnancy-related assistance under this section on the date of the child’s birth, the child shall be deemed to have applied for child health assistance under the State child health plan and to have been found eligible for such assistance under such plan or to have applied for medical assistance under title XIX and to have been found eligible for such assistance under such title, as appropriate, on the date of such birth and to remain eligible for such assistance until the child attains 1 year of age. During the period in which a child is deemed under the preceding sentence to be eligible for child health or medical assistance, the child health or medical assistance eligibility identification number of the mother shall also serve as the identification number of the child, and all claims shall be submitted and paid under such number (unless the State issues a separate identification number for the child before such period expires).

. (2)

Additional allotments for providing coverage of pregnant women

(A)

In general

Section 2104 of the Social Security Act (42 U.S.C. 1397dd) is amended by inserting after subsection (c) the following: (d)

Additional allotments for providing coverage of pregnant women

(1)

Appropriation; total allotment

For the purpose of providing additional allotments to States under this title, there is appropriated, out of any money in the Treasury not otherwise appropriated, for each of fiscal years 2006 and 2007, $200,000,000. (2)

State and territorial allotments

In addition to the allotments provided under subsections (b) and (c), subject to paragraphs (3) and (4), of the amount available for the additional allotments under paragraph (1) for a fiscal year, the Secretary shall allot to each State with a State child health plan approved under this title— (A) in the case of such a State other than a commonwealth or territory described in subparagraph (B), the same proportion as the proportion of the State’s allotment under subsection (b) (determined without regard to subsection (f)) to the total amount of the allotments under subsection (b) for such States eligible for an allotment under this paragraph for such fiscal year; and (B) in the case of a commonwealth or territory described in subsection (c)(3), the same proportion as the proportion of the commonwealth’s or territory’s allotment under subsection (c) (determined without regard to subsection (f)) to the total amount of the allotments under subsection (c) for commonwealths and territories eligible for an allotment under this paragraph for such fiscal year. (3)

Use of additional allotment

Additional allotments provided under this subsection are not available for amounts expended before October 1, 2005. Such amounts are available for amounts expended on or after such date for child health assistance for targeted low-income children, as well as for pregnancy-related assistance for targeted low-income pregnant women. (4)

No payments unless election to expand coverage of pregnant women

No payments may be made to a State under this title from an allotment provided under this subsection unless the State provides pregnancy-related assistance for targeted low-income pregnant women under this title, or provides medical assistance for pregnant women under title XIX, whose family income exceeds the effective income level applicable under subsection (a)(10)(A)(i)(III) or (l)(2)(A) of section 1902 to a family of the size involved as of January 1, 2005. . (B)

Conforming amendments

Section 2104 of the Social Security Act (42 U.S.C. 1397dd) is amended— (i) in subsection (a), in the matter preceding paragraph (1), by inserting subject to subsection (d), after under this section,; (ii) in subsection (b)(1), by inserting and subsection (d) after Subject to paragraph (4); and (iii) in subsection (c)(1), by inserting subject to subsection (d), after for a fiscal year,. (3)

Presumptive eligibility under title XXI

(A)

Application to pregnant women

Section 2107(e)(1)(D) of the Social Security Act (42 U.S.C. 1397gg(e)(1)) is amended to read as follows: (D) Sections 1920 and 1920A (relating to presumptive eligibility). . (B)

Exception from limitation on administrative expenses

Section 2105(c)(2) of the Social Security Act (42 U.S.C. 1397ee(c)(2)) is amended by adding at the end the following new subparagraph: (C)

Exception for presumptive eligibility expenditures

The limitation under subparagraph (A) on expenditures shall not apply to expenditures attributable to the application of section 1920 or 1920A (pursuant to section 2107(e)(1)(D)), regardless of whether the child or pregnant woman is determined to be ineligible for the program under this title or title XIX. . (4)

Additional amendments to title XXI

(A)

No cost-sharing for pregnancy-related services

Section 2103(e)(2) of the Social Security Act (42 U.S.C. 1397cc(e)(2)) is amended— (i) in the heading, by inserting or pregnancy-related services after Preventive services ; and (ii) by inserting before the period at the end the following: or for pregnancy-related services. (B)

No waiting period

Section 2102(b)(1)(B) of the Social Security Act (42 U.S.C. 1397bb(b)(1)(B)) is amended— (i) by striking , and at the end of clause (i) and inserting a semicolon; (ii) by striking the period at the end of clause (ii) and inserting ; and; and (iii) by adding at the end the following: (iii) may not apply a waiting period (including a waiting period to carry out paragraph (3)(C)) in the case of a targeted low-income pregnant woman. . (c)

Effective date

The amendments made by this section apply to items and services furnished on or after October 1, 2005, without regard to whether regulations implementing such amendments have been promulgated.

3.

Coordination with the maternal and child health program

(a)

In general

Section 2102(b)(3) of the Social Security Act (42 U.S.C. 1397bb(b)(3)) is amended— (1) in subparagraph (D), by striking and at the end; (2) in subparagraph (E), by striking the period and inserting ; and; and (3) by adding at the end the following new subparagraph: (F) that operations and activities under this title are developed and implemented in consultation and coordination with the program operated by the State under title V in areas including outreach and enrollment, benefits and services, service delivery standards, public health and social service agency relationships, and quality assurance and data reporting. . (b)

Conforming medicaid amendment

Section 1902(a)(11) of such Act (42 U.S.C. 1396a(a)(11)) is amended— (1) by striking and before (C); and (2) by inserting before the semicolon at the end the following: , and (D) provide that operations and activities under this title are developed and implemented in consultation and coordination with the program operated by the State under title V in areas including outreach and enrollment, benefits and services, service delivery standards, public health and social service agency relationships, and quality assurance and data reporting. (c)

Effective date

The amendments made by this section take effect on January 1, 2006.

4.

Increase in SCHIP income eligibility

(a)

Definition of Low-Income child

Section 2110(c)(4) of the Social Security Act (42 U.S.C. 42 U.S.C. 1397jj(c)(4)) is amended by striking 200 and inserting 250. (b)

Effective date

The amendment made by subsection (a) applies to child health assistance provided, and allotments determined under section 2104 of the Social Security Act (42 U.S.C. 1397dd) for fiscal years beginning with fiscal year 2006.