II 110th CONGRESS 1st Session S. 1213 IN THE SENATE OF THE UNITED STATES April 25, 2007 Mr. Lugar (for himself, Mr. Bingaman, and Mrs. Lincoln) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To give States the flexibility to reduce bureaucracy by streamlining enrollment processes for the medicaid and State children’s health insurance programs through better linkages with programs providing nutrition and related assistance to low-income families.

1.

Short title

This Act may be cited as the Children’s Express Lane to Health Coverage Act of 2007.

2.

Findings; purpose

(a)

Findings

Congress finds the following: (1)Despite gains made in recent years, 9,000,000 children in the United States are uninsured. At least 70 percent of those children are eligible for public health insurance coverage. (2)Most low-income uninsured children are enrolled in nutrition and related programs that operate under income guidelines similar to those of the Medicaid program. In fact, 71 percent of low-income uninsured children are in families that receive benefits through the food stamps program, the National school lunch program, or the special supplemental nutrition program for women, infants and children (commonly referred to as WIC). (3)The public would be well served if Federal means-tested public programs were able to improve administrative efficiency and coordination as well as reduce unnecessary bureaucracy. (4)Uninsured children would be well served if their enrollment in a nutrition-based or other means-tested program could serve as a gateway to health coverage. (5)Existing law already allows children to be found income eligible for WIC based on their enrollment in the Medicaid program. Current law does not, however, give States adequate flexibility to make an income determination for eligibility for the Medicaid program or the State Children’s Health Insurance Program based on an uninsured child’s enrollment in WIC or another public program. (b)

Purpose

The purpose of this Act is to give States the flexibility to find children income eligible for the Medicaid program or State Children’s Health Insurance Program based on findings that have already been made by nutrition assistance or similar public programs with comparable income standards.

3.

State option to provide for simplified determinations of a child’s financial eligibility for medical assistance under Medicaid or child health assistance under SCHIP

(a)

Medicaid

Section 1902(e) of the Social Security Act (42 U.S.C. 1396a(e)) is amended by adding at the end the following: (13)(A)At the option of the State, the plan may provide that financial or other eligibility requirements (including such requirements applicable to redeterminations or renewals of eligibility) for medical assistance are met for a child who is under 19 years of age (or, at State option, 20 or 21 years of age) by using a determination made within a reasonable period (as determined by the State) before its use for this purpose, of the child’s family or household income, or if applicable for purposes of determining eligibility under this title or title XXI, assets, resources, or other factual determinations (notwithstanding any other provision of law, including section 1903(x) and section 1137(d)), by a Federal or State agency, or a public or private entity making such determination on behalf of such agency, specified by the plan, including (but not limited to) an agency administering the State program funded under part A of title IV, the Food Stamp Act of 1977, the Richard B. Russell National School Lunch Act, or the Child Nutrition Act of 1966, notwithstanding any differences in budget unit, disregard, deeming, or other methodology, but only if— (i)the agency has fiscal liabilities or responsibilities affected or potentially affected by such determination; (ii)the agency or entity notifies the child's family— (I)of the information which shall be disclosed in accordance with this subparagraph; and (II)that the information disclosed will be used solely for purposes of determining eligibility for medical assistance under this title or for child health assistance under title XXI; (iii)interagency agreements limit the use of such information to that purpose; and (iv)the requirements of section 1939 are satisfied. (B)Nothing in this paragraph shall be construed— (i)to authorize the denial of medical assistance under this title or of child health assistance under title XXI to a child who, without the application of this paragraph, would qualify for such assistance; (ii)to relieve a State of the obligation under subsection (a)(8) to furnish medical assistance with reasonable promptness after the submission of an initial application that is evaluated or for which evaluation is requested pursuant to this paragraph, including an application that is submitted through failure to decline enrollment, as provided in subparagraph (E); (iii)to relieve a State of the obligation to determine, on another basis, eligibility for medical assistance under this title or for child health assistance under title XXI if a child is determined ineligible for such assistance on the basis of information furnished pursuant to this paragraph; or (iv)as rendering subparagraph (A) inapplicable to redeterminations or renewals of eligibility. (C)If a State applies the eligibility process described in subparagraph (A) to individuals eligible under this title and to individuals eligible under title XXI, the State may, at its option, implement its duties under subparagraphs (A) and (B) of section 2102(b)(3) using either or both of the following approaches: (i)The State may— (I)establish a threshold percentage of the Federal poverty level (that shall exceed the income eligibility level applicable for a population of individuals under this title by 30 percentage points (as a fraction of the Federal poverty level) or such other higher number of percentage points as the State determines reflects the typical application of income methodologies by the non-health program and the State plan under this title); (II)provide that, with respect to any individual within such population whom a non-health agency determines has income that does not exceed such threshold percentage for such population, such individual meets all income requirements for eligibility for medical assistance under this title (regardless of whether such individual would otherwise be determined to be eligible to receive such assistance); and (III)provide that, with respect to any individual within such population whom a non-health agency determines has income that exceeds such threshold percentage for such population, such individual has a family income that exceeds the Medicaid applicable income level under section 2110(b)(4), regardless of whether the individual would otherwise be determined to have such a family income. In exercising the approaches under this clause, a State shall inform families whose children are enrolled in a State child health plan under title XXI based on having family income above the threshold described in subclause (I) that they may qualify for medical assistance under this title and, at their option, can seek a regular eligibility determination for such assistance for their child.(ii)Regardless of whether a State otherwise provides for presumptive eligibility under section 1920A, a State may provide presumptive eligibility under this title, consistent with subsection (e) of section 1920A, to a child who, based on a determination by a non-health agency, would qualify for child health assistance under a State child health plan under title XXI. During such presumptive eligibility period, the State may determine the child’s eligibility for medical assistance under this title, pursuant to subparagraph (A) of section 2102(b)(3), based on telephone contact with family members, access to data available in electronic or paper form, and other means of gathering information that are less burdensome to the family than completing an application form on behalf of the child. The procedures described in the previous sentence may be used regardless of whether the State uses similar procedures under other circumstances for purposes of determining eligibility for medical assistance under this title. (D)At the option of a State, the eligibility process described in subparagraph (A) may apply to an individual who is not a child. (E)(i)At the option of a State, an individual determined to be eligible for medical assistance or child health assistance pursuant to subparagraph (A) or (C) or other procedures through which eligibility is determined based on data obtained from sources other than the individual may receive medical assistance under this title if such individual (or, in the case of an individual under age 19 (or if the State elects the option under subparagraph (A), age 20 or 21) who is not authorized to consent to medical care, the individual’s parent, guardian, or other caretaker relative) fails to decline enrollment after receiving notice of eligibility and a reasonable opportunity to decline enrollment, in which case the State (at its option) may waive any otherwise applicable requirements for signatures by or on behalf of the individual. (ii)(I)If the application of clause (i) results in the enrollment of individuals in managed care organizations that receive capitated payments to cover some or all of the cost of providing medical assistance or child health assistance, the State shall establish mechanisms (including full or partial withholding of capitated payments until the managed care organization documents the provision of services to that individual and awarding of default enrollment shares based in significant part on such organization’s documentation of prior services furnished to default enrollees) to ensure that individuals enrolled pursuant to this subparagraph do not receive fewer preventive services (including well-child and well-baby visits) than do individuals enrolled in such managed care organizations who are eligible for medical assistance on the basis of the same general eligibility category but who are not determined to be so eligible pursuant to subparagraph (A) or (C). (II)For purposes of subclause (I), the term general eligibility category shall be construed as including the following categories: low-income children who are eligible for medical assistance based on factors other than disability, adults eligible for such assistance because they are parents or other caretaker relatives of dependent children, and women eligible for such assistance because of pregnancy. (iii)In the case of an individual enrolled pursuant to clause (i), the State shall inform the individual (or, in the case of an individual under age 18, the individual’s parent, guardian, or other caretaker relative) about the significance of such enrollment, including appropriate methods to access covered services. (iv)In the case of an individual enrolled pursuant to clause (i) who is charged premiums and who does not use any health care services during the first 90 days following enrollment, enrollment shall be considered declined if such individual fails to pay premiums during that 90 day period, in which case no financial liability or penalty may apply to such individual. Such an individual shall be sent a notice explaining the disenrollment and offering an opportunity to reenroll. (F)For purposes of this paragraph— (i)the term non-health agency means an agency or entity described in subparagraph (A); and (ii)the term non-health benefits means the benefits or assistance provided by a non-health agency. . (b)

SCHIP

Section 2107(e)(1) of the Social Security Act (42 U.S.C. 1397gg(e)(1)) is amended by adding at the end the following: (E)Section 1902(e)(13) (relating to the State option to base a determination of a child's eligibility for assistance on determinations made by a non-health agency administering a program providing nutrition or other public assistance (except that the State option under subparagraph (D) of such section shall apply under this title only if an individual is pregnant)). . (c)

Presumptive eligibility

(1)

In general

Section 1920A of the Social Security Act (42 U.S.C. 1396r–1a) is amended— (A)in subsection (b)(3)(A)(i)(II) is amended— (i)by striking or before eligibility of a child for child health assistance; and (ii)by inserting or is an agency or entity described in section 1902(e)(13)(A), before (III); (B)by adding at the end the following: (e)In the case of a State with a child health plan under title XXI that provides for presumptive eligibility under such plan and under this title, the State shall place each presumptively eligible child in the program under this title or title XXI for which the child appears most likely to qualify. During the child's period of presumptive eligibility, the State shall receive Federal matching funds under section 1903 or section 2105, depending on the program in which the child has been placed. If at the conclusion of such period, the child is found to qualify for, and is enrolled in, the program established under this title or title XXI when the child was enrolled in the program under the other such title during such period, the State’s receipt of Federal matching funds shall be adjusted both retroactively and prospectively so that Federal matching funds are provided, both during and following such period of presumptive eligibility, based on the program in which the child is enrolled following the conclusion of the presumptive eligibility period. . (2)

Payment for presumptive eligibility for children from the Medicaid or SCHIP program in which the child is enrolled

(A)

In general

Section 2105(a)(1)of such Act (42 U.S.C. 1397ee(a)(1)) is amended— (i)by striking subparagraph (B) and inserting the following: (B)at State option, for the provision of medical assistance to a child described in section 1902(a)(10)(A)(ii)(XIV) during a period of presumptive eligibility under section 1920A; ; and (ii)in subparagraph (C), by inserting , including child health assistance provided during a period of presumptive eligibility in accordance with section 2107(e)(1)(D) after 2103. (B)

Rule of construction

Section 2105(a)(1)(B) of such Act (42 U.S.C. 1397ee(a)(1)(B)), as amended by subparagraph (A)(i), shall not be construed as affecting in any way the application of section 1920A(d) of such Act (42 U.S.C. 1396r–1a(d)) for purposes of making payments to States under section 1903 of such Act (42 U.S.C. 1396b) for medical assistance provided during a period of presumptive eligibility in accordance with section 1920A of such Act (42 U.S.C. 1396r–1a). (d)

Signature requirements

Section 1902(a) of such Act (42 U.S.C. 1396a(a)) is amended by adding at the end the following: “Notwithstanding any other provision of law, a signature under penalty of perjury shall not be required on an application form for medical assistance as to any element of eligibility for which eligibility is based on information received from a source other than applicant, rather than on representations from the applicant. Notwithstanding any other provision of law, any signature requirement for an application for medical assistance may be satisfied through an electronic signature, as defined in section 1710(1) of the Government Paperwork Elimination Act (44 U.S.C. 3504 note).”.

4.

Investments to promote administrative efficiency

(a)

Management information systems

(1)

In general

Section 1903(a)(3)(A)(i) of the Social Security Act (42 U.S.C. 1396b(a)(3)(A)(i)) is amended by inserting (including technology that enables inter-program connections, as defined in section 1905(y), and other technology that reduces the number of individuals who are inaccurately granted eligibility, that increases the number of individuals who are accurately granted eligibility, or that improves the efficiency of eligibility determinations, under this title or title XXI) after mechanized claims processing and information retrieval systems. (2)

Inter-program connections defined

Section 1905 of such Act (42 U.S.C. 1396d) is amended by adding at the end the following: (y)(1)For purposes of section 1903(a)(3)(A)(i), the term technology that enables inter-program connections means information technology (including software and hardware) that connects systems for determining eligibility or storing eligibility-related data pursuant to this title or title XXI to other sources of data potentially pertinent to eligibility determinations under this title or title XXI, including— (A)eligibility files maintained by programs described in section 1902(e)(13)(A); (B)information described in paragraph (2) or (3) of section 1137(a); (C)vital records information about births in any State; and (D)information described in sections 453(i) and 1902(a)(25)(I)(i). (2)The technology described in paragraph (1) includes systems and activities involved in preparing, transmitting, processing, matching, analyzing, inputting, and storing information from the other sources of data described in that paragraph. . (b)

Authorization of information disclosure

(1)

In general

Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) is amended— (A)by redesignating section 1939 as section 1940; and (B)by inserting after section 1938 the following:

1939.

Authorization to receive pertinent information

(a)

In general

Notwithstanding any other provision of law, a Federal, State, or local agency or private entity in possession of the other sources of data described in section 1905(y) or the information described in section 453(i) or 1902(a)(25)(I)(i) is authorized to convey such data or information to a person directly connected with the administration or enforcement of a State plan under this title or title XXI, consistent with the succeeding provisions of this section. (b)

Requirements for conveyance

Data or information may be conveyed pursuant to this section only if the following requirements are met: (1)The individual whose circumstances are described in the data or information (or such individual’s parent, guardian, caretaker relative, or authorized representative) has either provided advance consent to disclosure or has not objected to disclosure after receiving advance notice of disclosure and a reasonable opportunity to object. (2)Such data or information are used solely for the purposes of— (A)identifying individuals who are eligible or potentially eligible for assistance under this title or title XXI and enrolling such individuals in the State plans established under such titles; and (B)verifying the eligibility of individuals for assistance under the State plans established under this title or title XXI. (3)An interagency or other agreement, consistent with standards developed by the Secretary— (A)prevents the unauthorized use, disclosure, or modification of such data and otherwise meets applicable Federal requirements safeguarding privacy and data security; and (B)requires the State agencies administering the State plans established under this title and title XXI to use the data and information obtained under this section to seek to enroll individuals in such plans. (c)

Criminal penalty

A person described in the subsection (a) who publishes, divulges, discloses, or makes known in any manner, or to any extent not authorized by Federal law, any information obtained under this section shall be fined not more than $1,000 or imprisoned not more than 1 year, or both. (d)

Rule of construction

The limitations and requirements that apply to disclosure pursuant to this section shall not be construed to prohibit the conveyance or disclosure of data or information otherwise permitted under Federal law (without regard to this section).

. (2)

Conforming amendment to assure access to national new hires database

Section 453(i)(1) of such Act (42 U.S.C. 653(i)(1)) is amended— (A)by striking and programs and inserting , programs; and (B)by inserting and State plans approved under title XIX or XXI after part A,. (3)

Conforming amendment to provide schip programs with access to national income data

Section 6103(l)(7)(D)(ii) of the Internal Revenue Code of 1986 is amended by inserting or title XXI after title XIX. (4)

Conforming amendment to provide access to data about enrollment in private insurance

Section 1902(a)(25)(I)(i) of the Social Security Act (42 U.S.C. 1396a(a)(25)(I)(i)) is amended— (A)by inserting (and, at State option, individuals who are potentially eligible or who apply) after with respect to individuals who are eligible; and (B)by inserting under this title (and, at State option, child health assistance under title XXI) after the State plan.

5.

Effective date

The amendments made by this Act take effect on October 1, 2007.