I 111th CONGRESS 1st Session H. R. 3823 IN THE HOUSE OF REPRESENTATIVES October 15, 2009 Mr. Deal of Georgia (for himself, Mr. Pitts, Mr. Blunt, Mr. Barton of Texas, and Mr. Buyer) introduced the following bill; which was referred to the Committee on Energy and Commerce A BILL To amend titles XIX and XXI of the Social Security Act to make certain changes to the State Children’s Health Insurance Program and the Medicaid Program.
1.
Short title
This Act may be cited as the Medicaid and SCHIP Beneficiary Choice Improvement Act of 2009.
2.
Easing administrative barriers to State cooperation with employer-sponsored insurance coverage
(a)
Requiring some coverage for employer-Sponsored insurance
(1)
In general
Section 2102(a) of the Social Security Act (42 U.S.C. 1397b(a)) is amended— (A)in paragraph (6), by striking and at the end; (B)in paragraph (7), by striking the period at the end and inserting ; and; and (C)by adding at the end the following new paragraph: (8)effective for plan years beginning on or after October 1, 2010, how the plan will provide for child health assistance with respect to targeted low-income children who have access to coverage under a group health plan. . (2)
Effective date
The amendments made by paragraph (1) shall apply beginning on October 1, 2010. (b)
Federal financial participation for employer-Sponsored insurance
Section 2105 of such Act (42 U.S.C. 1397d) is amended— (1)in subsection (a)(1)(C), by inserting before the semicolon at the end the following: and, subject to paragraph (3)(C) of subsection (c), in the form of payment of the premiums for coverage under a group health plan that includes coverage of targeted low-income children and benefits supplemental to such coverage; and (2)by amending paragraph (3) of subsection (c) to read as follows: (3)
Purchase of employer-sponsored insurance
(A)
In general
Payment may be made to a State under subsection (a)(1)(C), subject to the provisions of this paragraph, for the purchase of family coverage under a group health plan that includes coverage of targeted low-income children unless such coverage would otherwise substitute for coverage that would be provided to such children but for the purchase of family coverage. (B)
Waiver of certain provisions
With respect to coverage described in subparagraph (A)— (i)notwithstanding section 2102, no minimum benefits requirement (other than those otherwise applicable with respect to services within the categories of basic services described in section 2103(c)(1) and emergency services) under this title shall apply; and (ii)no limitation on beneficiary cost-sharing otherwise applicable under this title or title XIX shall apply. (C)
Required provision of supplemental benefits
If the coverage described in subparagraph (A) does not provide coverage for the services in each of the categories of basic services described in section 2103(c)(1) and for emergency services, the State child health plan shall provide coverage of such services as supplemental benefits. (D)
Limitation on FFP
The amount of the payment under subsection (a)(1)(C) for coverage described in subparagraph (A) (and supplemental benefits under subparagraph (C) for individuals so covered) during a fiscal year may not exceed the product of— (i)the national per capita expenditure under this title (taking into account both Federal and State expenditures) for the previous fiscal year (as determined by the Secretary using the best available data); (ii)the enhanced FMAP for the State and fiscal year involved; and (iii)the number of targeted low-income children for whom such coverage is provided. (E)
Voluntary enrollment
A State child health plan— (i)may not require a targeted low-income child to enroll in family coverage described in subparagraph (A) in order to obtain child health assistance under this title; (ii)before providing such child health assistance for such coverage of a child, shall make available (which may be through an Internet website or other means) to the parent or guardian of the child information on the coverage available under this title, including benefits and cost-sharing; and (iii)shall provide at least one opportunity per fiscal year for beneficiaries to switch coverage under this title from coverage described in subparagraph (A) to the coverage that is otherwise made available under this title. (F)
Information on coverage options
A State child health plan shall— (i)describe how the State will notify potential beneficiaries of coverage described in subparagraph (A); (ii)provide such notification in writing at least during the initial application for enrollment under this title and during redeterminations of eligibility if the individual was enrolled before October 1, 2010; and (iii)post a description of these coverage options on any official Internet website that may be established by the State in connection with the plan. (G)
Semiannual verification of coverage
If coverage described in subparagraph (A) is provided under a group health plan with respect to a targeted low-income child, the State child health plan shall provide for the collection, at least once every six months, of proof from the plan that the child is enrolled in such coverage. (H)
Rule of construction
Nothing in this section is to be construed to prohibit a State from— (i)offering wrap around benefits in order for a group health plan to meet any State-established minimum benefit requirements; (ii)establishing a cost-effectiveness test to qualify for coverage under such a plan; (iii)establishing limits on beneficiary cost-sharing under such a plan; (iv)paying all or part of a beneficiary’s cost-sharing requirements under such a plan; (v)paying less than the full cost of the employee’s share of the premium under such a plan, including prorating the cost of the premium to pay for only what the State determines is the portion of the premium that covers targeted low-income children; (vi)using State funds to pay for benefits above the Federal upper limit established under subparagraph (D); (vii)allowing beneficiaries enrolled in group health plans from changing plans to another coverage option available under this title at any time; or (viii)providing any guidance or information it deems appropriate in order to help beneficiaries make an informed decision regarding the option to enroll in coverage described in subparagraph (A). (I)
Group health plan defined
In this paragraph, the term group health plan has the meaning given such term in section 2791(a)(1) of the Public Health Service Act (42 U.S.C. 300gg–91(a)(1)). .
3.
Improving beneficiary choice in SCHIP
(a)
Requiring offering of alternative coverage options
Section 2102 of the Social Security Act (42 U.S.C. 1397b), as amended by section 1, is amended— (1)in subsection (a)— (A)in paragraph (7), by striking and at the end; (B)in paragraph (8), by striking the period at the end and inserting ; and; and (C)by adding at the end the following new paragraph: (9)effective for plan years beginning on or after October 1, 2010, how the plan will provide for child health assistance with respect to targeted low-income children through alternative coverage options in accordance with subsection (d). ; and (2)by adding at the end the following new subsection: (d)
Alternative coverage options
(1)
In general
Effective October 1, 2010, a State child health plan shall provide for the offering of any qualified alternative coverage that a qualified entity seeks to offer to targeted low-income children through the plan in the State. (2)
Application of uniform financial limitation for all alternative coverage options
With respect to all qualified alternative coverage offered in a State, the State child health plan shall establish a uniform dollar limitation on the per capita monthly amount that will be paid by the State to the qualified entity with respect to such coverage provided to a targeted low-income child. Such limitation may not be less than 90 percent of the per capita monthly payment made for coverage offered under the State child health plan that is not in the form of an alternative coverage option. Nothing in this paragraph shall be construed— (A)as requiring a State to provide for the full payment of premiums for qualified alternative coverage; (B)as preventing a State from charging additional premiums to cover the difference between the cost of qualified alternative coverage and the amount of such payment limitation; (C)as preventing a State from using its own funds to provide a dollar limitation that exceeds the Federal financial participation as limited under section 2105(c)(8). (3)
Qualified alternative coverage defined
In this section, the term qualified alternative coverage means health insurance coverage that— (A)meets the coverage requirements of section 2103; and (B)is offered by a qualified insurer, and not directly by the State. (4)
Qualified insurer defined
In this section, the term qualified insurer means, with respect to a State, an entity that is licensed to offer health insurance coverage in the State. . (b)
Federal financial participation for qualified alternative coverage
Section 2105 of such Act (42 U.S.C. 1397d), as amended by sections 301(a) and 601(a) of the Children’s Health Insurance Program Reauthorization Act of 2009 (Public Law 111–5), is amended— (1)in subsection (a)(1)(C), by inserting before the semicolon at the end the following: and, subject to subsection (c)(12)(C), in the form of payment of the premiums for coverage for qualified alternative coverage; and (2)by adding at the end of subsection (c) the following new paragraph: (12)
Purchase of qualified alternative coverage
(A)
In general
Payment may be made to a State under subsection (a)(1)(C), subject to the provisions of this paragraph, for the purchase of qualified alternative coverage. (B)
Waiver of certain provisions
With respect to coverage described in subparagraph (A), no limitation on beneficiary cost-sharing otherwise applicable under this title or title XIX shall apply. (C)
Limitation on FFP
The amount of the payment under paragraph (1)(C) for coverage described in subparagraph (A) during a fiscal year in the aggregate for all such coverage in the State may not exceed the product of— (i)the national per capita expenditure under this title (taking into account both Federal and State expenditures) for the previous fiscal year (as determined by the Secretary using the best available data); (ii)the enhanced FMAP for the State and fiscal year involved; and (iii)the number of targeted low-income children for whom such coverage is provided. (D)
Voluntary enrollment
A State child health plan— (i)may not require a targeted low-income child to enroll in coverage described in subparagraph (A) in order to obtain child health assistance under this title; (ii)before providing such child health assistance for such coverage of a child, shall make available (which may be through an Internet website or other means) to the parent or guardian of the child information on the coverage available under this title, including benefits and cost-sharing; and (iii)shall provide at least one opportunity per fiscal year for beneficiaries to switch coverage under this title from coverage described in subparagraph (A) to the coverage that is otherwise made available under this title. (E)
Information on coverage options
A State child health plan shall— (i)describe how the State will notify potential beneficiaries of coverage described in subparagraph (A); (ii)provide such notification in writing at least during the initial application for enrollment under this title and during redeterminations of eligibility if the individual was enrolled before October 1, 2010; and (iii)post a description of these coverage options on any official website that may be established by the State in connection with the plan. (F)
Rule of construction
Nothing in this section is to be construed to prohibit a State from— (i)establishing limits on beneficiary cost-sharing under such alternative coverage; (ii)paying all or part of a beneficiary’s cost-sharing requirements under such coverage; (iii)paying less than the full cost of a child’s share of the premium under such coverage, insofar as the premium for such coverage exceeds the limitation established by the State under subparagraph (C); (iv)using State funds to pay for benefits above the Federal upper limit established under subparagraph (C); or (v)providing any guidance or information it deems appropriate in order to help beneficiaries make an informed decision regarding the option to enroll in coverage described in subparagraph (A). .
4.
Application to Medicaid
In accordance with rules established by the Secretary of Health and Human Services, the requirements imposed under a State child health plan under title XXI of the Social Security Act under the amendments made by the preceding sections of this subtitle shall apply in the same manner to a State plan under title XIX of such Act, except that— (1)such requirements shall not apply to individuals whose eligibility for medical assistance under such title is based on being aged, blind, or disabled or to individuals with a category of individuals described in section 1937(a)(2)(B) of such Act; (2)the national per capita expenditures shall be determined based on a benchmark coverage described in section 1937(b)(1) of such Act but without regard to expenditures for individuals described in paragraph (1) or for nursing facility services and other long-term care services (as determined by the Secretary).
5.
Expansion of health opportunity account program
(a)
In general
Section 613 of the Children’s Health Insurance Program Reauthorization Act of 2009 (Public Law 111–3) is repealed. (b)
Expansion
Section 1938(a)(2) of the Social Security Act (42 U.S.C. 1396u–8(a)(2)) is amended— (1)in subparagraph (A) by striking everything following the first sentence; and (2)by striking subparagraph (B).