SOCIAL SECURITY ACT
TITLE XXI OF THE SOCIAL SECURITY ACT
Chapter 531 of the 74th Congress, as amended
49 Stat. 620, as amended
SOCIAL SECURITY ACT
ch531
119–21
Statute Compilation
United States House of Representatives
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Social Security Act-TITLE XXI (State Children's Health Insurance Program)
Federal Employees Unemployment Compensation Act
Health Insurance for the Aged Act
Medicaid Act
Medicare Act
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Medicare Access and CHIP Reauthorization Act of 2015
8770
74
1935-08-14
SOCIAL SECURITY ACT
[Chapter 531 of the 74th Congress, approved August 14, 1935, 49 Stat. 620.]
[As Amended Through P.L. 119–21, Enacted July 4, 2025]
[Currency: This publication is a compilation of the text of title XXI of Chapter 531 of the 74th Congress. It was last amended by the public law listed in the As Amended Through note above and below at the bottom of each page of the pdf version and reflects current law through the date of the enactment of the public law listed at https://www.govinfo.gov/app/collection/comps/]
[Note: While this publication does not represent an official version of any Federal statute, substantial efforts have been made to ensure the accuracy of its contents. The official version of Federal law is found in the United States Statutes at Large and in the United States Code. The legal effect to be given to the Statutes at Large and the United States Code is established by statute (1 U.S.C. 112, 204).]
TITLE XXI—

STATE CHILDREN'S HEALTH INSURANCE PROGRAM

TABLE OF CONTENTS OF TITLE1
^1
This table of contents does not appear in the law.
Sec. 2101.
Purpose; State child health plans.
Sec. 2102.
General contents of State child health plan; eligibility; outreach.
Sec. 2103.
Coverage requirements for children's health insurance.
Sec. 2104.
Allotments.
Sec. 2105.
Payments to States.
Sec. 2106.
Process for submission, approval, and amendment of State child health plans.
Sec. 2107.
Strategic objectives and performance goals; plan administration.
Sec. 2108.
Annual reports; evaluations.
Sec. 2109.
Miscellaneous provisions.
Sec. 2110.
Definitions.
Sec. 2111.
Phase-out of coverage for nonpregnant childless adults; conditions for coverage of parents.
Sec. 2112.
Optional coverage of targeted low-income pregnant women through a state plan amendment.
Sec. 2113.
Grants to improve outreach and enrollment.
SEC. 2101.
[42 U.S.C. 1397aa]

PURPOSE; STATE CHILD HEALTH PLANS.
(a)

Purpose.—
Except with respect to the rural health transformation program established in section 2105(h), the purpose of this title is to provide funds to States to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner that is coordinated with other sources of health benefits coverage for children. Such assistance shall be provided primarily for obtaining health benefits coverage through—
(1)
obtaining coverage that meets the requirements of section 2103, or
(2)
providing benefits under the State's medicaid plan under title XIX,
or a combination of both.
(b)

State Child Health Plan Required.—
A State is not eligible for payment under subsection (a) or (g) of section 2105 unless the State has submitted to the Secretary under section 2106 a plan that—
(1)
sets forth how the State intends to use the funds provided under this title to provide child health assistance to needy children consistent with the provisions of this title, and
(2)
has been approved under section 2106.
(c)

State Entitlement.—
This title constitutes budget authority in advance of appropriations Acts and represents the obligation of the Federal Government to provide for the payment to States of amounts provided under section 2104.
(d)

Effective Date.—
No State is eligible for payments under section 2105 for child health assistance for coverage provided for periods beginning before October 1, 1997.
SEC. 2102.
[42 U.S.C. 1397bb]

GENERAL CONTENTS OF STATE CHILD HEALTH PLAN; ELIGIBILITY; OUTREACH.
(a)

General Background and Description.—
A State child health plan shall include a description, consistent with the requirements of this title, of—
(1)
the extent to which, and manner in which, children in the State, including targeted low-income children and other classes of children classified by income and other relevant factors, currently have creditable health coverage (as defined in section 2110(c)(2));
(2)
current State efforts to provide or obtain creditable health coverage for uncovered children, including the steps the State is taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs and health insurance programs that involve public-private partnerships;
(3)
how the plan is designed to be coordinated with such efforts to increase coverage of children under creditable health coverage;
(4)
the child health assistance provided under the plan for targeted low-income children, including the proposed methods of delivery, and utilization control systems;
(5)
eligibility standards consistent with subsection (b);
(6)
outreach activities consistent with subsection (c); and
(7)
methods (including monitoring) used—
(A)
to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan;
(B)
to assure access to covered services, including emergency services and services described in paragraphs (5) and (6) of section 2103(c); and
(C)
to ensure that the State agency involved is in compliance with subparagraphs (A), (B), and (C) of section 1128K(b)(2).
(b)

General Description of Eligibility Standards and Methodology.—
(1)

Eligibility standards.—
(A)

In general.—
The plan shall include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. Such standards may include (to the extent consistent with this title) those relating to the geographic areas to be served by the plan, age, income and resources (including any standards relating to spenddowns and disposition of resources), residency, disability status (so long as any standard relating to such status does not restrict eligibility), access to or coverage under other health coverage, and duration of eligibility. Such standards may not discriminate on the basis of diagnosis.
(B)

Limitations on eligibility standards.—
Such eligibility standards—
(i)
shall, within any defined group of covered targeted low-income children, not cover such children with higher family income without covering children with a lower family income;
(ii)
may not deny eligibility based on a child having a preexisting medical condition;
(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 provided pregnancy-related assistance under section 2112;
(iv)
at State option, may not apply a waiting period in the case of a child provided dental-only supplemental coverage under section 2110(b)(5);
(v)
shall, beginning January 1, 2014, use modified adjusted gross income and household income (as defined in section 36B(d)(2) of the Internal Revenue Code of 1986) to determine eligibility for child health assistance under the State child health plan or under any waiver of such plan and for any other purpose applicable under the plan or waiver for which a determination of income is required, including with respect to the imposition of premiums and cost-sharing, consistent with section 1902(e)(14); and
(vi)
shall, in the case that the State elects to provide child health or pregnancy-related assistance to an individual for any period prior to the month in which the individual made application for such assistance (or application was made on behalf of the individual), provide that such assistance is not made available to such individual for items and services included under the State child health plan (or waiver of such plan) that are furnished before the second month preceding the month in which such individual made application (or application was made on behalf of such individual) for assistance.
(2)

Methodology.—
The plan shall include a description of methods of establishing and continuing eligibility and enrollment.
(3)

Eligibility screening; coordination with other health coverage programs.—
The plan shall include a description of procedures to be used to ensure—
(A)
through both intake and followup screening, that only targeted low-income children are furnished child health assistance under the State child health plan;
(B)
that children found through the screening to be eligible for medical assistance under the State medicaid plan under title XIX are enrolled for such assistance under such plan;
(C)
that the insurance provided under the State child health plan does not substitute for coverage under group health plans;
(D)
the provision of child health assistance to targeted low-income children in the State who are Indians (as defined in section 4(c) of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c)); and
(E)
coordination with other public and private programs providing creditable coverage for low-income children.
(4)

Reduction of administrative barriers to enrollment.—
(A)

In general.—
Subject to subparagraph (B), the plan shall include a description of the procedures used to reduce administrative barriers to the enrollment of children and pregnant women who are eligible for medical assistance under title XIX or for child health assistance or health benefits coverage under this title. Such procedures shall be established and revised as often as the State determines appropriate to take into account the most recent information available to the State identifying such barriers.
(B)

Deemed compliance if joint application and renewal process that permits application other than in person.—
A State shall be deemed to comply with subparagraph (A) if the State's application and renewal forms and supplemental forms (if any) and information verification process is the same for purposes of establishing and renewing eligibility for children and pregnant women for medical assistance under title XIX and child health assistance under this title, and such process does not require an application to be made in person or a face-to-face interview.
(5)

Nonentitlement.—
Nothing in this title shall be construed as providing an individual with an entitlement to child health assistance under a State child health plan.
(c)

Outreach and Coordination.—
A State child health plan shall include a description of the procedures to be used by the State to accomplish the following:
(1)

Outreach.—
Outreach (through community health workers and others) to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs to inform these families of the availability of, and to assist them in enrolling their children in, such a program.
(2)

Coordination with other health insurance programs.—
Coordination of the administration of the State program under this title with other public and private health insurance programs.
(3)

Premium assistance subsidies.—
In the case of a State that provides for premium assistance subsidies under the State child health plan in accordance with paragraph (2)(B), (3), or (10) of section 2105(c), or a waiver approved under section 1115, outreach, education, and enrollment assistance for families of children likely to be eligible for such subsidies, to inform such families of the availability of, and to assist them in enrolling their children in, such subsidies, and for employers likely to provide coverage that is eligible for such subsidies, including the specific, significant resources the State intends to apply to educate employers about the availability of premium assistance subsidies under the State child health plan.
(d)

Treatment of Children who are Inmates of a Public Institution.—
(1)

In general.—
The State child health plan shall provide that—
(A)2
the State shall not terminate eligibility for child health or pregnancy-related assistance under the State child health plan for a targeted low-income child or targeted low-income pregnant woman because the child or pregnant woman is an inmate of a public institution, but may suspend coverage during the period the child or pregnant woman is such an inmate;
^2
Section 205(b)(1) of division G of Public Law 118–42 amends subparagraph (A) of section 2102(d)(1). Paragraph (2) of such section 205(b) provides: “The amendments made by paragraph (1) shall apply beginning January 1, 2026”.
The amendment by section 205(b)(1)(A) of to insert “or pregnancy-related” after “child health” was executed to the first occurrence of “child health” to effectuate the probable intent of Congress.
(B)
in the case of a targeted low-income child who was determined eligible for child health assistance under the State child health plan (or waiver of such plan) immediately before becoming an inmate of a public institution, the State shall, prior to the child’s release from such public institution, conduct a redetermination of eligibility for such child with respect to such child health assistance (without requiring a new application from the child) and, if the State determines pursuant to such redetermination that the child continues to meet the eligibility requirements for such child health assistance, the State shall restore coverage for such child health assistance to such child upon the child’s release from such public institution; and
(C)
in the case of a targeted low-income child who is determined eligible for child health assistance while an inmate of a public institution (subject to the exception to the exclusion of children who are inmates of a public institution described in section 2110(b)(7)), the State shall process any application for child health assistance submitted by, or on behalf of, the child such that the State makes a determination of eligibility for the child with respect to child health assistance upon release of the child from the public institution.
(2)

Required coverage of screenings, diagnostic services, referrals, and case management for certain inmates pre-release.—
A State child health plan shall provide that, in the case of a targeted low-income child who is within 30 days of the date on which such child is scheduled to be released from a public institution following adjudication, the State shall have in place a plan for providing, and shall provide in accordance with such plan, screenings, diagnostic services, referrals, and case management services otherwise covered under the State child health plan (or waiver of such plan) in the same manner as described in section 1902(a)(84)(D).
SEC. 2103.
[42 U.S.C. 1397cc]

COVERAGE REQUIREMENTS FOR CHILDREN'S HEALTH INSURANCE.
(a)

Required Scope of Health Insurance Coverage.—
The child health assistance provided to a targeted low-income child under the plan in the form described in paragraph (1) of section 2101(a) shall consist, consistent with paragraphs (5), (6), (7) and (8) of subsection (c), of any of the following:
(1)

Benchmark coverage.—
Health benefits coverage that is at least equivalent to the benefits coverage in a benchmark benefit package described in subsection (b).
(2)

Benchmark-equivalent coverage.—
Health benefits coverage that meets the following requirements:
(A)

Inclusion of basic services.—
The coverage includes benefits for items and services within each of the categories of basic services described in subsection (c)(1).
(B)

Aggregate actuarial value equivalent to benchmark package.—
The coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages.
(C)

Substantial actuarial value for additional services included in benchmark package.—
With respect to each of the categories of additional services described in subsection (c)(2) for which coverage is provided under the benchmark benefit package used under subparagraph (B), the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the coverage of that category of services in such package.
(3)

Existing comprehensive state-based coverage.—
Health benefits coverage under an existing comprehensive State-based program, described in subsection (d)(1).
(4)

Secretary-approved coverage.—
Any other health benefits coverage that the Secretary determines, upon application by a State, provides appropriate coverage for the population of targeted low-income children proposed to be provided such coverage.
(b)

Benchmark Benefit Packages.—
The benchmark benefit packages are as follows:
(1)

FEHBP-equivalent children's health insurance coverage.—
The standard Blue Cross/Blue Shield preferred provider option service benefit plan, described in and offered under section 8903(1) of title 5, United States Code.
(2)

State employee coverage.—
A health benefits coverage plan that is offered and generally available to State employees in the State involved.
(3)

Coverage offered through hmo.—
The health insurance coverage plan that—
(A)
is offered by a health maintenance organization (as defined in section 2791(b)(3) of the Public Health Service Act), and
(B)
has the largest insured commercial, non-medicaid enrollment of covered lives of such coverage plans offered by such a health maintenance organization in the State involved.
(c)

Categories of Services; Determination of Actuarial Value of Coverage.—
(1)

Categories of basic services.—
For purposes of this section, the categories of basic services described in this paragraph are as follows:
(A)
Inpatient and outpatient hospital services.
(B)
Physicians' surgical and medical services.
(C)
Laboratory and x-ray services.
(D)
Well-baby and well-child care, including age-appropriate immunizations.
(E)
Mental health and substance use disorder services (as defined in paragraph (5)).
(2)

Categories of additional services.—
For purposes of this section, the categories of additional services described in this paragraph are as follows:
(A)
Coverage of prescription drugs.
(B)
Vision services.
(C)
Hearing services.
(3)

Treatment of other categories.—
Nothing in this subsection shall be construed as preventing a State child health plan from providing coverage of benefits that are not within a category of services described in paragraph (1) or (2).
(4)

Determination of actuarial value.—
The actuarial value of coverage of benchmark benefit packages, coverage offered under the State child health plan, and coverage of any categories of additional services under benchmark benefit packages and under coverage offered by such a plan, shall be set forth in an actuarial opinion in an actuarial report that has been prepared—
(A)
by an individual who is a member of the American Academy of Actuaries;
(B)
using generally accepted actuarial principles and methodologies;
(C)
using a standardized set of utilization and price factors;
(D)
using a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan;
(E)
applying the same principles and factors in comparing the value of different coverage (or categories of services);
(F)
without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used; and
(G)
taking into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage.
The actuary preparing the opinion shall select and specify in the memorandum the standardized set and population to be used under subparagraphs (C) and (D).
(5)

Mental health and substance use disorder services.—
Regardless of the type of coverage elected by a State under subsection (a), child health assistance provided under such coverage for targeted low-income children and, in the case that the State elects to provide pregnancy-related assistance under such coverage pursuant to section 2112, such pregnancy-related assistance for targeted low-income pregnant women (as defined in section 2112(d)) shall—
(A)
include coverage of mental health services (including behavioral health treatment) necessary to prevent, diagnose, and treat a broad range of mental health symptoms and disorders, including substance use disorders; and
(B)
be delivered in a culturally and linguistically appropriate manner.
(6)

Dental benefits.—
(A)

In general.—
The child health assistance provided to a targeted low-income child shall include coverage of dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.
(B)

Permitting use of dental benchmark plans by certain states.—
A State may elect to meet the requirement of subparagraph (A) through dental coverage that is equivalent to a benchmark dental benefit package described in subparagraph (C).
(C)

Benchmark dental benefit packages.—
The benchmark dental benefit packages are as follows:
(i)

FEHBP children's dental coverage.—
A dental benefits plan under chapter 89A of title 5, United States Code, that has been selected most frequently by employees seeking dependent coverage, among such plans that provide such dependent coverage, in either of the previous 2 plan years.
(ii)

State employee dependent dental coverage.—
A dental benefits plan that is offered and generally available to State employees in the State involved and that has been selected most frequently by employees seeking dependent coverage, among such plans that provide such dependent coverage, in either of the previous 2 plan years.
(iii)

Coverage offered through commercial dental plan.—
A dental benefits plan that has the largest insured commercial, non-medicaid enrollment of dependent covered lives of such plans that is offered in the State involved.
(7)

Mental health services parity.—
(A)

In general.—
A State child health plan shall ensure that the financial requirements and treatment limitations applicable to mental health and substance use disorder services (as described in paragraph (5)) provided under such plan comply with the requirements of section 2726(a) of the Public Health Service Act in the same manner as such requirements or limitations apply to a group health plan under such section. In applying the previous sentence with respect to requirements under paragraph (8) of section 2726(a) of the Public Health Service Act, a State child health plan described in such sentence shall be treated as in compliance with such requirements if the State child health plan is in compliance with section 457.496 of title 42, Code of Federal Regulations, or any successor regulation.
(B)

Deemed compliance.—
To the extent that a State child health plan includes coverage with respect to an individual described in section 1905(a)(4)(B) and covered under the State plan under section 1902(a)(10)(A) of the services described in section 1905(a)(4)(B) (relating to early and periodic screening, diagnostic, and treatment services defined in section 1905(r)) and provided in accordance with section 1902(a)(43), such plan shall be deemed to satisfy the requirements of subparagraph (A).
(8)

Construction on prohibited coverage.—
Nothing in this section shall be construed as requiring any health benefits coverage offered under the plan to provide coverage for items or services for which payment is prohibited under this title, notwithstanding that any benchmark benefit package includes coverage for such an item or service.
(9)

Availability of coverage for items and services furnished through school-based health centers.—
Nothing in this title shall be construed as limiting a State's ability to provide child health assistance for covered items and services that are furnished through school-based health centers (as defined in section 2110(c)(9)).
(10)

Certain in vitro diagnostic products for covid–19 testing.—
The child health assistance provided to a targeted low-income child shall include coverage of any in vitro diagnostic product described in section 1905(a)(3)(B) that is administered during any portion of the emergency period described in such section beginning on or after the date of the enactment of this subparagraph (and the administration of such product).
(11)

Required coverage of covid–19 vaccines and treatment.—
Regardless of the type of coverage elected by a State under subsection (a), the child health assistance provided for a targeted low-income child, and, in the case of a State that elects to provide pregnancy-related assistance pursuant to section 2112, the pregnancy-related assistance provided for a targeted low-income pregnant woman (as such terms are defined for purposes of such section), shall include coverage, during the period beginning on the date of the enactment of this paragraph and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in section 1135(g)(1)(B), of—
(A)
a COVID–19 vaccine (and the administration of the vaccine); and
(B)
testing and treatments for COVID–19, including specialized equipment and therapies (including preventive therapies), and, in the case of an individual who is diagnosed with or presumed to have COVID–19, during the period during which such individual has (or is presumed to have) COVID–19, the treatment of a condition that may seriously complicate the treatment of COVID–19, if otherwise covered under the State child health plan (or waiver of such plan).
(12)

Required coverage of approved, recommended adult vaccines and their administration.—
Regardless of the type of coverage elected by a State under subsection (a), if the State child health plan or a waiver of such plan provides child health assistance or pregnancy-related assistance (as defined in section 2112) to an individual who is 19 years of age or older, such assistance shall include coverage of vaccines described in section 1905(a)(13)(B) and their administration.
(d)

Description of Existing Comprehensive State-Based Coverage.—
(1)

In general.—
A program described in this paragraph is a child health coverage program that—
(A)
includes coverage of a range of benefits;
(B)
is administered or overseen by the State and receives funds from the State;
(C)
is offered in New York, Florida, or Pennsylvania; and
(D)
was offered as of the date of the enactment of this title.
(2)

Modifications.—
A State may modify a program described in paragraph (1) from time to time so long as it continues to meet the requirement of subparagraph (A) and does not reduce the actuarial value of the coverage under the program below the lower of—
(A)
the actuarial value of the coverage under the program as of the date of the enactment of this title, or
(B)
the actuarial value described in subsection (a)(2)(B),
evaluated as of the time of the modification.
(e)

Cost-Sharing.—
(1)

Description; general conditions.—
(A)

Description.—
A State child health plan shall include a description, consistent with this subsection, of the amount (if any) of premiums, deductibles, coinsurance, and other cost sharing imposed. Any such charges shall be imposed pursuant to a public schedule.
(B)

Protection for lower income children.—
The State child health plan may only vary premiums, deductibles, coinsurance, and other cost sharing based on the family income of targeted low-income children in a manner that does not favor children from families with higher income over children from families with lower income.
(2)

No cost sharing on benefits for preventive services, covid–19 testing, a covid– 19 vaccine, covid–19 treatment, or pregnancy-related assistance.—
The State child health plan may not impose deductibles, coinsurance, or other cost sharing with respect to benefits for services within the categories of services described in subsection (c)(1)(D), in vitro diagnostic products described in subsection (c)(10) (and administration of such products), vaccines described in subsection (c)(12) (and the administration of such vaccines), services described in section 1916(a)(2)(G), vaccines described in section 1916(a)(2)(H) administered during the period described in such section (and the administration of such vaccines), testing or treatments described in section 1916(a)(2)(I) furnished during the period described in such section, or for pregnancy-related assistance.
(3)

Limitations on premiums and cost-sharing.—
(A)

Children in families with income below 150 percent of poverty line.—
In the case of a targeted low-income child whose family income is at or below 150 percent of the poverty line, the State child health plan may not impose—
(i)
an enrollment fee, premium, or similar charge that exceeds the maximum monthly charge permitted consistent with standards established to carry out section 1916(b)(1) (with respect to individuals described in such section); and
(ii)
a deductible, cost sharing, or similar charge that exceeds an amount that is nominal (as determined consistent with regulations referred to in section 1916(a)(3), with such appropriate adjustment for inflation or other reasons as the Secretary determines to be reasonable).
(B)

Other children.—
For children not described in subparagraph (A), subject to paragraphs (1)(B) and (2), any premiums, deductibles, cost sharing or similar charges imposed under the State child health plan may be imposed on a sliding scale related to income, except that the total annual aggregate cost-sharing with respect to all targeted low-income children in a family under this title may not exceed 5 percent of such family's income for the year involved.
(C)

Premium grace period.—
The State child health plan—
(i)
shall afford individuals enrolled under the plan a grace period of at least 30 days from the beginning of a new coverage period to make premium payments before the individual's coverage under the plan may be terminated; and
(ii)
shall provide to such an individual, not later than 7 days after the first day of such grace period, notice—
(I)
that failure to make a premium payment within the grace period will result in termination of coverage under the State child health plan; and
(II)
of the individual's right to challenge the proposed termination pursuant to the applicable Federal regulations.
For purposes of clause (i), the term “new coverage period” means the month immediately following the last month for which the premium has been paid.
(4)

Relation to medicaid requirements.—
Nothing in this subsection shall be construed as affecting the rules relating to the use of enrollment fees, premiums, deductions, cost sharing, and similar charges in the case of targeted low-income children who are provided child health assistance in the form of coverage under a medicaid program under section 2101(a)(2).
(f)

Application of Certain Requirements.—
(1)

Restriction on application of preexisting condition exclusions.—
(A)

In general.—
Subject to subparagraph (B), the State child health plan shall not permit the imposition of any preexisting condition exclusion for covered benefits under the plan.
(B)

Group health plans and group health insurance coverage.—
If the State child health plan provides for benefits through payment for, or a contract with, a group health plan or group health insurance coverage, the plan may permit the imposition of a preexisting condition exclusion but only insofar as it is permitted under the applicable provisions of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 and title XXVII of the Public Health Service Act.
(2)

Compliance with other requirements.—
Coverage offered under this section shall comply with the requirements of subpart 2 of part A of title XXVII of the Public Health Service Act insofar as such requirements apply with respect to a health insurance issuer that offers group health insurance coverage.
(3)

Compliance with managed care requirements.—
The State child health plan shall provide for the application of subsections (a)(4), (a)(5), (b), (c), (d), (e), and (j) of section 1932 (relating to requirements for managed care) to coverage, State agencies, enrollment brokers, managed care entities, and managed care organizations under this title in the same manner as such subsections apply to coverage and such entities and organizations under title XIX.
SEC. 2104.
[42 U.S.C. 1397dd]

ALLOTMENTS.
(a)

Appropriation; Total Allotment.—
For the purpose of providing allotments to States under this section, subject to subsection (d), there is appropriated, out of any money in the Treasury not otherwise appropriated—
(1)
for fiscal year 1998, $4,295,000,000;
(2)
for fiscal year 1999, $4,275,000,000;
(3)
for fiscal year 2000, $4,275,000,000;
(4)
for fiscal year 2001, $4,275,000,000;
(5)
for fiscal year 2002, $3,150,000,000;
(6)
for fiscal year 2003, $3,150,000,000;
(7)
for fiscal year 2004, $3,150,000,000;
(8)
for fiscal year 2005, $4,050,000,000;
(9)
for fiscal year 2006, $4,050,000,000;
(10)
for fiscal year 2007, $5,000,000,000;
(11)
for fiscal year 2008, $5,000,000,000.
(12)
for fiscal year 2009, $10,562,000,000;
(13)
for fiscal year 2010, $12,520,000,000;
(14)
for fiscal year 2011, $13,459,000,000;
(15)
for fiscal year 2012, $14,982,000,000;
(16)
for fiscal year 2013, $17,406,000,000;
(17)
for fiscal year 2014, $19,147,000,000;
(18)
for fiscal year 2015, for purposes of making 2 semi-annual allotments—
(A)
$2,850,000,000 for the period beginning on October 1, 2014, and ending on March 31, 2015, and
(B)
$2,850,000,000 for the period beginning on April 1, 2015, and ending on September 30, 2015;
(19)
for fiscal year 2016, $19,300,000,000;
(20)
for fiscal year 2017, for purposes of making 2 semi-annual allotments—
(A)
$2,850,000,000 for the period beginning on October 1, 2016, and ending on March 31, 2017; and
(B)
$2,850,000,000 for the period beginning on April 1, 2017, and ending on September 30, 2017;
(21)
for fiscal year 2018, $21,500,000,000;
(22)
for fiscal year 2019, $22,600,000,000;
(23)
for fiscal year 2020, $23,700,000,000;
(24)
for fiscal year 2021, $24,800,000,000;
(25)
for fiscal year 2022, $25,900,000,000;
(26)
for fiscal year 2023, for purposes of making two semi-annual allotments—
(A)
$2,850,000,000 for the period beginning on October 1, 2022, and ending on March 31, 2023; and
(B)
$2,850,000,000 for the period beginning on April 1, 2023, and ending on September 30, 2023;
(27)
for each of fiscal years 2024 through 2028, such sums as are necessary to fund allotments to States under subsections (c) and (m); and
(28)
for fiscal year 2029, for purposes of making two semi-annual allotments—
(A)
$7,650,000,000 for the period beginning on October 1, 2028, and ending on March 31, 2029; and
(B)
$7,650,000,000 for the period beginning on April 1, 2029, and ending on September 30, 2029.
(b)

Allotments to 50 States and District of Columbia.—
(1)

In general.—
Subject to paragraph (4) and subsections (d) and (m), of the amount available for allotment under subsection (a) for a fiscal year, reduced by the amount of allotments made under subsection (c) (determined without regard to paragraph (4) thereof) for the fiscal year, the Secretary shall allot to each State (other than a State described in such subsection) with a State child health plan approved under this title the same proportion as the ratio of—
(A)
the product of (i) the number of children described in paragraph (2) for the State for the fiscal year and (ii) the State cost factor for that State (established under paragraph (3)); to
(B)
the sum of the products computed under subparagraph (A).
(2)

Number of children.—
(A)

In general.—
The number of children described in this paragraph for a State for—
(i)
each of fiscal years 1998 and 1999 is equal to the number of low-income children in the State with no health insurance coverage for the fiscal year;
(ii)
fiscal year 2000 is equal to—
(I)
75 percent of the number of low-income children in the State for the fiscal year with no health insurance coverage, plus
(II)
25 percent of the number of low-income children in the State for the fiscal year; and
(iii)
each succeeding fiscal year is equal to—
(I)
50 percent of the number of low-income children in the State for the fiscal year with no health insurance coverage, plus
(II)
50 percent of the number of low-income children in the State for the fiscal year.
(B)

Determination of number of children.—
For purposes of subparagraph (A), a determination of the number of low-income children (and of such children who have no health insurance coverage) for a State for a fiscal year shall be made on the basis of the arithmetic average of the number of such children, as reported and defined in the 3 most recent March supplements to the Current Population Survey of the Bureau of the Census before the beginning of the calendar year in which such fiscal year begins.
(3)

Adjustment for geographic variations in health costs.—
(A)

In general.—
For purposes of paragraph (1)(A)(ii), the “State cost factor” for a State for a fiscal year equal to the sum of—
(i)
0.15, and
(ii)
0.85 multiplied by the ratio of—
(I)
the annual average wages per employee for the State for such year (as determined under subparagraph (B)), to
(II)
the annual average wages per employee for the 50 States and the District of Columbia.
(B)

Annual average wages per employee.—
For purposes of subparagraph (A), the “annual average wages per employee” for a State, or for all the States, for a fiscal year is equal to the average of the annual wages per employee for the State or for the 50 States and the District of Columbia for employees in the health services industry (SIC code 8000), as reported by the Bureau of Labor Statistics of the Department of Labor for each of the most recent 3 years before the beginning of the calendar year in which such fiscal year begins.
(4)

Floors and ceilings in state allotments.—
(A)

In general.—
The proportion of the allotment under this subsection for a subsection (b) State (as defined in subparagraph (D)) for fiscal year 2000 and each fiscal year thereafter shall be subject to the following floors and ceilings:
(i)

Floor of $2,000,000.—
A floor equal to $2,000,000 divided by the total of the amount available under this subsection for all such allotments for the fiscal year.
(ii)

Annual floor of 10 percent below preceding fiscal year's proportion.—
A floor of 90 percent of the proportion for the State for the preceding fiscal year.
(iii)

Cumulative floor of 30 percent below the fy 1999 proportion.—
A floor of 70 percent of the proportion for the State for fiscal year 1999.
(iv)

Cumulative ceiling of 45 percent above fy 1999 proportion.—
A ceiling of 145 percent of the proportion for the State for fiscal year 1999.
(B)

Reconciliation.—
(i)

Elimination of any deficit by establishing a percentage increase ceiling for states with highest annual percentage increases.—
To the extent that the application of subparagraph (A) would result in the sum of the proportions of the allotments for all subsection (b) States exceeding 1.0, the Secretary shall establish a maximum percentage increase in such proportions for all subsection (b) States for the fiscal year in a manner so that such sum equals 1.0.
(ii)

Allocation of surplus through pro rata increase.—
To the extent that the application of subparagraph (A) would result in the sum of the proportions of the allotments for all subsection (b) States being less than 1.0, the proportions of such allotments (as computed before the application of floors under clauses (i), (ii), and (iii) of subparagraph (A)) for all subsection (b) States shall be increased in a pro rata manner (but not to exceed the ceiling established under subparagraph (A)(iv)) so that (after the application of such floors and ceiling) such sum equals 1.0.
(C)

Construction.—
This paragraph shall not be construed as applying to (or taking into account) amounts of allotments redistributed under subsection (f).
(D)

Definitions.—
In this paragraph:
(i)

Proportion of allotment.—
The term “proportion” means, with respect to the allotment of a subsection (b) State for a fiscal year, the amount of the allotment of such State under this subsection for the fiscal year divided by the total of the amount available under this subsection for all such allotments for the fiscal year.
(ii)

Subsection (b) state.—
The term “subsection (b) State” means one of the 50 States or the District of Columbia.
(c)

Allotments to Territories.—
(1)

In general.—
Of the amount available for allotment under subsection (a) for a fiscal year, subject to subsections (d) and (m)(5), the Secretary shall allot 0.25 percent among each of the commonwealths and territories described in paragraph (3) in the same proportion as the percentage specified in paragraph (2) for such commonwealth or territory bears to the sum of such percentages for all such commonwealths or territories so described.
(2)

Percentage.—
The percentage specified in this paragraph for—
(A)
Puerto Rico is 91.6 percent,
(B)
Guam is 3.5 percent,
(C)
the Virgin Islands is 2.6 percent,
(D)
American Samoa is 1.2 percent, and
(E)
the Northern Mariana Islands is 1.1 percent.
(3)

Commonwealths and territories.—
A commonwealth or territory described in this paragraph is any of the following if it has a State child health plan approved under this title:
(A)
Puerto Rico.
(B)
Guam.
(C)
The Virgin Islands.
(D)
American Samoa.
(E)
The Northern Mariana Islands.
(4)

Additional allotment.—
(A)

In general.—
In addition to the allotment under paragraph (1), the Secretary shall allot each commonwealth and territory described in paragraph (3) the applicable percentage specified in paragraph (2) of the amount appropriated under subparagraph (B).
(B)

Appropriations.—
For purposes of providing allotments pursuant to subparagraph (A), there is appropriated, out of any money in the Treasury not otherwise appropriated $32,000,000 for fiscal year 1999, $34,200,000 for each of fiscal years 2000 and 2001, $25,200,000 for each of fiscal years 2002 through 2004, $32,400,000 for each of fiscal years 2005 and 2006, and $40,000,000 for each of fiscal years 2007 through 2009.
(d)

Additional Allotments To Eliminate Funding Shortfalls.—
(1)

Appropriation; allotment authority.—
For the purpose of providing additional allotments to shortfall States described in paragraph (2), there is appropriated, out of any money in the Treasury not otherwise appropriated, $283,000,000 for fiscal year 2006.
(2)

Shortfall states described.—
For purposes of paragraph (1), a shortfall State described in this paragraph is a State with a State child health plan approved under this title for which the Secretary estimates, on the basis of the most recent data available to the Secretary as of December 16, 2005, that the projected expenditures under such plan for such State for fiscal year 2006 will exceed the sum of—
(A)
the amount of the State's allotments for each of fiscal years 2004 and 2005 that will not be expended by the end of fiscal year 2005;
(B)
the amount, if any, that is to be redistributed to the State during fiscal year 2006 in accordance with subsection (f); and
(C)
the amount of the State's allotment for fiscal year 2006.
(3)

Allotments.—
In addition to the allotments provided under subsections (b) and (c), subject to paragraph (4), of the amount available for the additional allotments under paragraph (1) for fiscal year 2006, the Secretary shall allot—
(A)
to each shortfall State described in paragraph (2) such amount as the Secretary determines will eliminate the estimated shortfall described in such paragraph for the State; and
(B)
to each 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 1.05 percent of the amount appropriated under paragraph (1).
(4)

Use of additional allotment.—
Additional allotments provided under this subsection are only available for amounts expended under a State plan approved under this title for child health assistance for targeted low-income children.
(5)

1-year availability; no redistribution of unexpended additional allotments.—
Notwithstanding subsections (e) and (f), amounts allotted to a State pursuant to this subsection for fiscal year 2006 shall only remain available for expenditure by the State through September 30, 2006. Any amounts of such allotments that remain unexpended as of such date shall not be subject to redistribution under subsection (f) and shall revert to the Treasury on October 1, 2006.
(e)

Availability of Amounts Allotted.—
(1)

In general.—
Except as provided in paragraph (2), amounts allotted to a State pursuant to this section—
(A)
for each of fiscal years 1998 through 2008, shall remain available for expenditure by the State through the end of the second succeeding fiscal year; and
(B)
for fiscal year 2009 and each fiscal year thereafter, shall remain available for expenditure by the State through the end of the succeeding fiscal year.
(2)

Availability of amounts redistributed.—
Amounts redistributed to a State under subsection (f) shall be available for expenditure by the State through the end of the fiscal year in which they are redistributed.
(f)

Procedure for Redistribution of Unused Allotments.—
(1)

In general.—
The Secretary shall determine an appropriate procedure for redistribution of allotments from States that were provided allotments under this section for a fiscal year but that do not expend all of the amount of such allotments during the period in which such allotments are available for expenditure under subsection (e), to States that the Secretary determines with respect to the fiscal year for which unused allotments are available for redistribution under this subsection, are shortfall States described in paragraph (2) for such fiscal year, but not to exceed the amount of the shortfall described in paragraph (2)(A) for each such State (as may be adjusted under paragraph (2)(C)).
(2)

Shortfall states described.—
(A)

In general.—
For purposes of paragraph (1), with respect to a fiscal year, a shortfall State described in this subparagraph is a State with a State child health plan approved under this title for which the Secretary estimates on the basis of the most recent data available to the Secretary, that the projected expenditures under such plan for the State for the fiscal year will exceed the sum of—
(i)
the amount of the State's allotments for any preceding fiscal years that remains available for expenditure and that will not be expended by the end of the immediately preceding fiscal year;
(ii)
the amount (if any) of the child enrollment contingency fund payment under subsection (n); and
(iii)
the amount of the State's allotment for the fiscal year.
(B)

Determination of redistributed amounts if insufficient amounts available.—
(i)

Proration rule.—
Subject to clause (ii), if the amounts available for redistribution under paragraph (1) for a fiscal year are less than the total amounts of the estimated shortfalls determined for the year under subparagraph (A), the amount to be redistributed under such paragraph for each shortfall State shall be reduced proportionally.
(ii)

Special rule for first half of fiscal year 2018.—
(I)

In general.—
For each month beginning during the period beginning on October 1, 2017, and ending March 31, 2018, subject to the succeeding subclauses of this clause, the Secretary shall redistribute any amounts available for redistribution under paragraph (1) for fiscal year 2018, to each State that is an emergency shortfall State (as defined in subclause (II)) for the month such amount as the Secretary determines will eliminate the estimated shortfall described in subclause (II) for such State for the month (as may be adjusted under subparagraph (C)) before the Secretary may redistribute such amounts to any shortfall State that is not an emergency shortfall State. In the case of any amounts redistributed under this subclause to a State that is not an emergency shortfall State, such amounts shall be determined in accordance with clause (i).
(II)

Emergency shortfall state defined.—
For purposes of this clause, the term “emergency shortfall State” means, with respect to a month beginning during the period beginning October 1, 2017, and ending March 31, 2018, a shortfall State for which the Secretary estimates, in accordance with subparagraph (A) (unless otherwise specified in this subclause) and on a monthly basis using the most recent data available to the Secretary as of such month, that the projected expenditures under the State child health plan and under section 2105(g) (calculated as if the reference under section 2105(g)(4)(A), as in effect on the day before the date of the enactment of the HEALTHY KIDS Act, to “2017” were a reference to “2018” and insofar as the allotments are available to the State under this subsection or subsection (e) or (m)) for such month will exceed the sum of the amounts described in clauses (i) through (iii) of subparagraph (A) for such month, including after application of any amount redistributed under paragraph (1) for a previous month for fiscal year 2018 in accordance with this clause, to such State. A shortfall State may be an emergency shortfall State under the previous sentence without regard to whether any amounts were redistributed to such State under paragraph (1) for a previous month in fiscal year 2018.
(III)

Funds redistributed in the order in which states realize funding shortfalls.—
The Secretary shall redistribute the amounts available for redistribution under paragraph (1) to emergency shortfall States described in subclause (II) in the order in which such States realize monthly funding shortfalls under this title for fiscal year 2018. The Secretary shall only make redistributions under this clause to the extent that such amounts are available for such redistributions.
(IV)

Proration rule.—
If the amounts available for redistribution under paragraph (1) for a month during the period described in subclause (I) are less than the total amounts of the estimated shortfalls determined for the month for emergency shortfall States described in subclause (II), the amount computed under subclause (I) for each emergency shortfall State shall be reduced proportionally.
(V)

Unobligated redistributed funds.—
The Secretary shall withhold any funds redistributed under paragraph (1) for fiscal year 2018 before January 1, 2018, but which have not been obligated for amounts expended by a State as of that date, and shall redistribute such funds in accordance with the preceding subclauses of this clause.
(VI)

Application of qualifying state option.—
During the period described in subclause (I), section 2105(g)(4), as in effect on the day before the date of the enactment of the HEALTHY KIDS Act shall apply to a qualifying State (as defined in section 2105(g)(2)) as if under section 2105(g)(4), as so in effect—
- (aa)
the reference to “2017” were a reference to “2018”; and
- (bb)
the reference to “under subsections (e) and (m) of such section” were a reference to “under subsections (e), (f), and (m) of such section”.
(C)

Retrospective adjustment.—
The Secretary may adjust the estimates and determinations made under paragraph (1) and this paragraph with respect to a fiscal year as necessary on the basis of the amounts reported by States not later than November 30 of the succeeding fiscal year, as approved by the Secretary.
(D)

Rule of construction.—
Nothing in this paragraph may be construed as preventing a commonwealth or territory described in subsection (c)(3) from being treated as a shortfall State or an emergency shortfall State.
(g)

Rule for Redistribution and Extended Availability of Fiscal Years 1998, 1999, 2000, and 2001 Allotments.—
(1)

Amount redistributed.—
(A)

In general.—
In the case of a State that expends all of its allotment under subsection (b) or (c) for fiscal year 1998 by the end of fiscal year 2000, or for fiscal year 1999 by the end of fiscal year 2001, or for fiscal year 2000 by the end of fiscal year 2002, or for fiscal year 2001 by the end of fiscal year 2003, the Secretary shall redistribute to the State under subsection (f) (from the fiscal year 1998, 1999, 2000, or 2001 allotments of other States, respectively, as determined by the application of paragraphs (2) and (3) with respect to the respective fiscal year) the following amount:
(i)

State.—
In the case of one of the 50 States or the District of Columbia, with respect to—
(I)
the fiscal year 1998 allotment, the amount by which the State's expenditures under this title in fiscal years 1998, 1999, and 2000 exceed the State's allotment for fiscal year 1998 under subsection (b);
(II)
the fiscal year 1999 allotment, the amount by which the State's expenditures under this title in fiscal years 1999, 2000, and 2001 exceed the State's allotment for fiscal year 1999 under subsection (b);
(III)
the fiscal year 2000 allotment, the amount specified in subparagraph (C)(i) (less the total of the amounts under clause (ii) for such fiscal year), multiplied by the ratio of the amount specified in subparagraph (C)(ii) for the State to the amount specified in subparagraph (C)(iii); or
(IV)
the fiscal year 2001 allotment, the amount specified in subparagraph (D)(i) (less the total of the amounts under clause (ii) for such fiscal year), multiplied by the ratio of the amount specified in subparagraph (D)(ii) for the State to the amount specified in subparagraph (D)(iii).
(ii)

Territory.—
In the case of a commonwealth or territory described in subsection (c)(3), an amount that bears the same ratio to 1.05 percent of the total amount described in paragraph (2)(B)(i)(I) as the ratio of the commonwealth's or territory's fiscal year 1998, 1999, 2000, or 2001 allotment under subsection (c) (as the case may be) bears to the total of all such allotments for such fiscal year under such subsection.
(B)

Expenditure rules.—
An amount redistributed to a State under this paragraph—
(i)
shall not be included in the determination of the State's allotment for any fiscal year under this section;
(ii)
notwithstanding subsection (e), with respect to fiscal year 1998, 1999, or 2000, shall remain available for expenditure by the State through the end of fiscal year 2004;
(iii)
notwithstanding subsection (e), with respect to fiscal year 2001, shall remain available for expenditure by the State through the end of fiscal year 2005; and
(iv)
shall be counted as being expended with respect to a fiscal year allotment in accordance with applicable regulations of the Secretary.
(C)

Amounts used in computing redistributions for fiscal year 2000.—
For purposes of subparagraph (A)(i)(III)—
(i)
the amount specified in this clause is the amount specified in paragraph (2)(B)(i)(I) for fiscal year 2000, less the total amount remaining available pursuant to paragraph (2)(A)(iii);
(ii)
the amount specified in this clause for a State is the amount by which the State's expenditures under this title in fiscal years 2000, 2001, and 2002 exceed the State's allotment for fiscal year 2000 under subsection (b); and
(iii)
the amount specified in this clause is the sum, for all States entitled to a redistribution under subparagraph (A) from the allotments for fiscal year 2000, of the amounts specified in clause (ii).
(D)

Amounts used in computing redistributions for fiscal year 2001.—
For purposes of subparagraph (A)(i)(IV)—
(i)
the amount specified in this clause is the amount specified in paragraph (2)(B)(i)(I) for fiscal year 2001, less the total amount remaining available pursuant to paragraph (2)(A)(iv);
(ii)
the amount specified in this clause for a State is the amount by which the State's expenditures under this title in fiscal years 2001, 2002, and 2003 exceed the State's allotment for fiscal year 2001 under subsection (b); and
(iii)
the amount specified in this clause is the sum, for all States entitled to a redistribution under subparagraph (A) from the allotments for fiscal year 2001, of the amounts specified in clause (ii).
(2)

Extension of availability of portion of unexpended fiscal years 1998 through 2001 allotments.—
(A)

In general.—
Notwithstanding subsection (e):
(i)

Fiscal year 1998 allotment.—
Of the amounts allotted to a State pursuant to this section for fiscal year 1998 that were not expended by the State by the end of fiscal year 2000, the amount specified in subparagraph (B) for fiscal year 1998 for such State shall remain available for expenditure by the State through the end of fiscal year 2004.
(ii)

Fiscal year 1999 allotment.—
Of the amounts allotted to a State pursuant to this subsection for fiscal year 1999 that were not expended by the State by the end of fiscal year 2001, the amount specified in subparagraph (B) for fiscal year 1999 for such State shall remain available for expenditure by the State through the end of fiscal year 2004.
(iii)

Fiscal year 2000 allotment.—
Of the amounts allotted to a State pursuant to this section for fiscal year 2000 that were not expended by the State by the end of fiscal year 2002, 50 percent of that amount shall remain available for expenditure by the State through the end of fiscal year 2004.
(iv)

Fiscal year 2001 allotment.—
Of the amounts allotted to a State pursuant to this section for fiscal year 2001 that were not expended by the State by the end of fiscal year 2003, 50 percent of that amount shall remain available for expenditure by the State through the end of fiscal year 2005.
(B)

Amount remaining available for expenditure.—
The amount specified in this subparagraph for a State for a fiscal year is equal to—
(i)
the amount by which (I) the total amount available for redistribution under subsection (f) from the allotments for that fiscal year, exceeds (II) the total amounts redistributed under paragraph (1) for that fiscal year; multiplied by
(ii)
the ratio of the amount of such State's unexpended allotment for that fiscal year to the total amount described in clause (i)(I) for that fiscal year.
(C)

Use of up to 10 percent of retained 1998 allotments for outreach activities.—
Notwithstanding section 2105(c)(2)(A), with respect to any State described in subparagraph (A)(i), the State may use up to 10 percent of the amount specified in subparagraph (B) for fiscal year 1998 for expenditures for outreach activities approved by the Secretary.
(3)

Determination of amounts.—
For purposes of calculating the amounts described in paragraphs (1) and (2) relating to the allotment for fiscal year 1998, fiscal year 1999, fiscal year 2000, or fiscal year 2001, the Secretary shall use the amounts reported by the States not later than December 15, 2000, November 30, 2001, November 30, 2002, or November 30, 2003, respectively, on HCFA Form 64 or HCFA Form 21 or CMS Form 64 or CMS Form 21, as the case may be,,3 as approved by the Secretary.
^3
Two commas so in law.
(h)

Special Rules to Address Fiscal Year 2007 Shortfalls.—
(1)

Redistribution of unused fiscal year 2004 allotments.—
(A)

In general.—
Notwithstanding subsection (f) and subject to subparagraphs (C) and (D), with respect to months beginning during fiscal year 2007, the Secretary shall provide for a redistribution under such subsection from the allotments for fiscal year 2004 under subsection (b) that are not expended by the end of fiscal year 2006, to a shortfall State described in subparagraph (B), such amount as the Secretary determines will eliminate the estimated shortfall described in such subparagraph for such State for the month.
(B)

Shortfall state described.—
For purposes of this paragraph, a shortfall State described in this subparagraph is a State with a State child health plan approved under this title for which the Secretary estimates, on a monthly basis using the most recent data available to the Secretary as of such month, that the projected expenditures under such plan for such State for fiscal year 2007 will exceed the sum of—
(i)
the amount of the State's allotments for each of fiscal years 2005 and 2006 that was not expended by the end of fiscal year 2006; and
(ii)
the amount of the State's allotment for fiscal year 2007.
(C)

Funds redistributed in the order in which states realize funding shortfalls.—
The Secretary shall redistribute the amounts available for redistribution under subparagraph (A) to shortfall States described in subparagraph (B) in the order in which such States realize monthly funding shortfalls under this title for fiscal year 2007. The Secretary shall only make redistributions under this paragraph to the extent that there are unexpended fiscal year 2004 allotments under subsection (b) available for such redistributions.
(D)

Proration rule.—
If the amounts available for redistribution under subparagraph (A) for a month are less than the total amounts of the estimated shortfalls determined for the month under that subparagraph, the amount computed under such subparagraph for each shortfall State shall be reduced proportionally.
(2)

Funding part of shortfall for fiscal year 2007 through redistribution of certain unused fiscal year 2005 allotments.—
(A)

In general.—
Subject to subparagraphs (C) and (D) and paragraph (5)(B), with respect to months beginning during fiscal year 2007 after March 31, 2007, the Secretary shall provide for a redistribution under subsection (f) from amounts made available for redistribution under paragraph (3) to each shortfall State described in subparagraph (B), such amount as the Secretary determines will eliminate the estimated shortfall described in such subparagraph for such State for the month.
(B)

Shortfall state described.—
For purposes of this paragraph, a shortfall State described in this subparagraph is a State with a State child health plan approved under this title for which the Secretary estimates, on a monthly basis using the most recent data available to the Secretary as of March 31, 2007, that the projected expenditures under such plan for such State for fiscal year 2007 will exceed the sum of—
(i)
the amount of the State's allotments for each of fiscal years 2005 and 2006 that was not expended by the end of fiscal year 2006;
(ii)
the amount, if any, that is to be redistributed to the State in accordance with paragraph (1); and
(iii)
the amount of the State's allotment for fiscal year 2007.
(C)

Funds redistributed in the order in which states realize funding shortfalls.—
The Secretary shall redistribute the amounts available for redistribution under subparagraph (A) to shortfall States described in subparagraph (B) in the order in which such States realize monthly funding shortfalls under this title for fiscal year 2007. The Secretary shall only make redistributions under this paragraph to the extent that such amounts are available for such redistributions.
(D)

Proration rule.—
If the amounts available for redistribution under paragraph (3) for a month are less than the total amounts of the estimated shortfalls determined for the month under subparagraph (A), the amount computed under such subparagraph for each shortfall State shall be reduced proportionally.
(3)

Treatment of certain states with fiscal year 2005 allotments unexpended at the end of the first half of fiscal year 2007.—
(A)

Identification of states.—
The Secretary, on the basis of the most recent data available to the Secretary as of March 31, 2007—
(i)
shall identify those States that received an allotment for fiscal year 2005 under subsection (b) which have not expended all of such allotment by March 31, 2007; and
(ii)
for each such State shall estimate—
(I)
the portion of such allotment that was not so expended by such date; and
(II)
whether the State is described in subparagraph (B).
(B)

States with funds in excess of 200 percent of need.—
A State described in this subparagraph is a State for which the Secretary determines, on the basis of the most recent data available to the Secretary as of March 31, 2007, that the total of all available allotments under this title to the State as of such date, is at least equal to 200 percent of the total projected expenditures under this title for the State for fiscal year 2007.
(C)

Redistribution and limitation on availability of portion of unused allotments for certain states.—
(i)

In general.—
In the case of a State identified under subparagraph (A)(i) that is also described in subparagraph (B), notwithstanding subsection (e), the applicable amount described in clause (ii) shall not be available for expenditure by the State on or after April 1, 2007, and shall be redistributed in accordance with paragraph (2).
(ii)

Applicable amount.—
For purposes of clause (i), the applicable amount described in this clause is the lesser of—
(I)
50 percent of the amount described in subparagraph (A)(ii)(I); or
(II)
$20,000,000.
(4)

Additional amounts to eliminate remainder of fiscal year 2007 funding shortfalls.—
(A)

In general.—
From the amounts provided in advance in appropriations Acts, the Secretary shall allot to each remaining shortfall State described in subparagraph (B) such amount as the Secretary determines will eliminate the estimated shortfall described in such subparagraph for the State for fiscal year 2007.
(B)

Remaining shortfall state described.—
For purposes of subparagraph (A), a remaining shortfall State is a State with a State child health plan approved under this title for which the Secretary estimates, on the basis of the most recent data available to the Secretary as of the date of the enactment of this paragraph, that the projected Federal expenditures under such plan for the State for fiscal year 2007 will exceed the sum of—
(i)
the amount of the State's allotments for each of fiscal years 2005 and 2006 that will not be expended by the end of fiscal year 2006;
(ii)
the amount of the State's allotment for fiscal year 2007; and
(iii)
the amounts, if any, that are to be redistributed to the State during fiscal year 2007 in accordance with paragraphs (1) and (2).
(5)

Retrospective adjustment.—
(A)

In general.—
The Secretary may adjust the estimates and determinations made under paragraphs (1), (2), (3), and (4) as necessary on the basis of the amounts reported by States not later than November 30, 2007, on CMS Form 64 or CMS Form 21, as the case may be and as approved by the Secretary, but in no case may the applicable amount described in paragraph (3)(C)(ii) exceed the amount determined by the Secretary on the basis of the most recent data available to the Secretary as of March 31, 2007.
(B)

Funding of any retrospective adjustments only from unexpended 2005 allotments.—
Notwithstanding subsections (e) and (f), to the extent the Secretary determines it necessary to adjust the estimates and determinations made for purposes of paragraphs (1), (2), and (3), the Secretary may use only the allotments for fiscal year 2005 under subsection (b) that remain unexpended through the end of fiscal year 2007 for providing any additional amounts to States described in paragraph (2)(B) (without regard to whether such unexpended allotments are from States described in paragraph (3)(B)).
(C)

Rules of construction.—
Nothing in this subsection shall be construed as—
(i)
authorizing the Secretary to use the allotments for fiscal year 2006 or 2007 under subsection (b) of States described in paragraph (3)(B) to provide additional amounts to States described in paragraph (2)(B) for purposes of eliminating the funding shortfall for such States for fiscal year 2007; or
(ii)
limiting the authority of the Secretary to redistribute the allotments for fiscal year 2005 under subsection (b) that remain unexpended through the end of fiscal year 2007 and are available for redistribution under subsection (f) after the application of subparagraph (B).
(6)

1-year availability; no further redistribution.—
Notwithstanding subsections (e) and (f), amounts redistributed or allotted to a State pursuant to this subsection for fiscal year 2007 shall only remain available for expenditure by the State through September 30, 2007, and any amounts of such redistributions or allotments that remain unexpended as of such date, shall not be subject to redistribution under subsection (f). Nothing in the preceding sentence shall be construed as limiting the ability of the Secretary to adjust the determinations made under paragraphs (1), (2), (3), and (4) in accordance with paragraph (5).
(7)

Definition of state.—
For purposes of this subsection, the term “State” means a State that receives an allotment for fiscal year 2007 under subsection (b).
(i)

Redistribution of Unused Fiscal Year 2005 Allotments to States With Estimated Funding Shortfalls for Fiscal Year 2008.—
(1)

In general.—
Notwithstanding subsection (f) and subject to paragraphs (3) and (4), with respect to months beginning during fiscal year 2008, the Secretary shall provide for a redistribution under such subsection from the allotments for fiscal year 2005 under subsection (b) that are not expended by the end of fiscal year 2007, to a fiscal year 2008 shortfall State described in paragraph (2), such amount as the Secretary determines will eliminate the estimated shortfall described in such paragraph for such State for the month.
(2)

Fiscal year 2008 shortfall state described.—
A fiscal year 2008 shortfall State described in this paragraph is a State with a State child health plan approved under this title for which the Secretary estimates, on a monthly basis using the most recent data available to the Secretary as of such month, that the projected expenditures under such plan for such State for fiscal year 2008 will exceed the sum of—
(A)
the amount of the State's allotments for each of fiscal years 2006 and 2007 that was not expended by the end of fiscal year 2007; and
(B)
the amount of the State's allotment for fiscal year 2008.
(3)

Funds redistributed in the order in which states realize funding shortfalls.—
The Secretary shall redistribute the amounts available for redistribution under paragraph (1) to fiscal year 2008 shortfall States described in paragraph (2) in the order in which such States realize monthly funding shortfalls under this title for fiscal year 2008. The Secretary shall only make redistributions under this subsection to the extent that there are unexpended fiscal year 2005 allotments under subsection (b) available for such redistributions.
(4)

Proration rule.—
If the amounts available for redistribution under paragraph (1) are less than the total amounts of the estimated shortfalls determined for the month under that paragraph, the amount computed under such paragraph for each fiscal year 2008 shortfall State for the month shall be reduced proportionally.
(5)

Retrospective adjustment.—
The Secretary may adjust the estimates and determinations made to carry out this subsection as necessary on the basis of the amounts reported by States not later than November 30, 2007, on CMS Form 64 or CMS Form 21, as the case may be, and as approved by the Secretary.
(6)

1–Year availability; no further redistribution.—
Notwithstanding subsections (e) and (f), amounts redistributed to a State pursuant to this subsection for fiscal year 2008 shall only remain available for expenditure by the State through September 30, 2008, and any amounts of such redistributions that remain unexpended as of such date, shall not be subject to redistribution under subsection (f).
(j)

Additional Allotments To Eliminate Funding Shortfalls for Fiscal Year 2008.—
(1)

Appropriation; allotment authority.—
For the purpose of providing additional allotments described in subparagraphs (A) and (B) of paragraph (3), there is appropriated, out of any money in the Treasury not otherwise appropriated, such sums as may be necessary, not to exceed $1,600,000,000 for fiscal year 2008.
(2)

Shortfall states described.—
For purposes of paragraph (3), a shortfall State described in this paragraph is a State with a State child health plan approved under this title for which the Secretary estimates, on the basis of the most recent data available to the Secretary as of November 30, 2007, that the Federal share amount of the projected expenditures under such plan for such State for fiscal year 2008 will exceed the sum of—
(A)
the amount of the State's allotments for each of fiscal years 2006 and 2007 that will not be expended by the end of fiscal year 2007;
(B)
the amount, if any, that is to be redistributed to the State during fiscal year 2008 in accordance with subsection (i); and
(C)
the amount of the State's allotment for fiscal year 2008.
(3)

Allotments.—
In addition to the allotments provided under subsections (b) and (c), subject to paragraph (4), of the amount available for the additional allotments under paragraph (1) for fiscal year 2008, the Secretary shall allot—
(A)
to each shortfall State described in paragraph (2) not described in subparagraph (B), such amount as the Secretary determines will eliminate the estimated shortfall described in such paragraph for the State; and
(B)
to each commonwealth or territory described in subsection (c)(3), an amount equal to the percentage specified in subsection (c)(2) for the commonwealth or territory multiplied by 1.05 percent of the sum of the amounts determined for each shortfall State under subparagraph (A).
(4)

Proration rule.—
If the amounts available for additional allotments under paragraph (1) are less than the total of the amounts determined under subparagraphs (A) and (B) of paragraph (3), the amounts computed under such subparagraphs shall be reduced proportionally.
(5)

Retrospective adjustment.—
The Secretary may adjust the estimates and determinations made to carry out this subsection as necessary on the basis of the amounts reported by States not later than November 30, 2008, on CMS Form 64 or CMS Form 21, as the case may be, and as approved by the Secretary.
(6)

One-year availability; no redistribution of unexpended additional allotments.—
Notwithstanding subsections (e) and (f), amounts allotted to a State pursuant to this subsection for fiscal year 2008, subject to paragraph (5), shall only remain available for expenditure by the State through September 30, 2008. Any amounts of such allotments that remain unexpended as of such date shall not be subject to redistribution under subsection (f).
(k)

Redistribution of Unused Fiscal Year 2006 Allotments to States With Estimated Funding Shortfalls During Fiscal Year 2009.—
(1)

In general.—
Notwithstanding subsection (f) and subject to paragraphs (3) and (4), with respect to months beginning during fiscal year 2009, the Secretary shall provide for a redistribution under such subsection from the allotments for fiscal year 2006 under subsection (b) that are not expended by the end of fiscal year 2008, to a fiscal year 2009 shortfall State described in paragraph (2), such amount as the Secretary determines will eliminate the estimated shortfall described in such paragraph for such State for the month.
(2)

Fiscal year 2009 shortfall state described.—
A fiscal year 2009 shortfall State described in this paragraph is a State with a State child health plan approved under this title for which the Secretary estimates, on a monthly basis using the most recent data available to the Secretary as of such month, that the Federal share amount of the projected expenditures under such plan for such State for the first 2 quarters of fiscal year 2009 will exceed the sum of—
(A)
the amount of the State's allotments for each of fiscal years 2007 and 2008 that was not expended by the end of fiscal year 2008; and
(B)
the amount of the State's allotment for fiscal year 2009.
(3)

Funds redistributed in the order in which states realize funding shortfalls.—
The Secretary shall redistribute the amounts available for redistribution under paragraph (1) to fiscal year 2009 shortfall States described in paragraph (2) in the order in which such States realize monthly funding shortfalls under this title for fiscal year 2009. The Secretary shall only make redistributions under this subsection to the extent that there are unexpended fiscal year 2006 allotments under subsection (b) available for such redistributions.
(4)

Proration rule.—
If the amounts available for redistribution under paragraph (1) are less than the total amounts of the estimated shortfalls determined for the month under that paragraph, the amount computed under such paragraph for each fiscal year 2009 shortfall State for the month shall be reduced proportionally.
(5)

Retrospective adjustment.—
The Secretary may adjust the estimates and determinations made to carry out this subsection as necessary on the basis of the amounts reported by States not later than May 31, 2009, on CMS Form 64 or CMS Form 21, as the case may be, and as approved by the Secretary.
(6)

Availability; no further redistribution.—
Notwithstanding subsections (e) and (f), amounts redistributed to a State pursuant to this subsection for fiscal year 2009 shall only remain available for expenditure by the State through September 30, 2009, and any amounts of such redistributions that remain unexpended as of such date, shall not be subject to redistribution under subsection (f).
(l)

Additional Allotments To Eliminate Funding Shortfalls for the First 2 Quarters of Fiscal Year 2009.—
(1)

Appropriation; allotment authority.—
For the purpose of providing additional allotments described in subparagraphs (A) and (B) of paragraph (3), there is appropriated, out of any money in the Treasury not otherwise appropriated, such sums as may be necessary, not to exceed $275,000,000 for the first 2 quarters of fiscal year 2009.
(2)

Shortfall states described.—
For purposes of paragraph (3), a shortfall State described in this paragraph is a State with a State child health plan approved under this title for which the Secretary estimates, on the basis of the most recent data available to the Secretary, that the Federal share amount of the projected expenditures under such plan for such State for the first 2 quarters of fiscal year 2009 will exceed the sum of—
(A)
the amount of the State's allotments for each of fiscal years 2007 and 2008 that will not be expended by the end of fiscal year 2008;
(B)
the amount, if any, that is to be redistributed to the State during fiscal year 2009 in accordance with subsection (k); and
(C)
the amount of the State's allotment for fiscal year 2009.
(3)

Allotments.—
In addition to the allotments provided under subsections (b) and (c), subject to paragraph (4), of the amount available for the additional allotments under paragraph (1) for the first 2 quarters of fiscal year 2009, the Secretary shall allot—
(A)
to each shortfall State described in paragraph (2) not described in subparagraph (B) such amount as the Secretary determines will eliminate the estimated shortfall described in such paragraph for the State; and
(B)
to each commonwealth or territory described in subsection (c)(3), an amount equal to the percentage specified in subsection (c)(2) for the commonwealth or territory multiplied by 1.05 percent of the sum of the amounts determined for each shortfall State under subparagraph (A).
(4)

Proration rule.—
If the amounts available for additional allotments under paragraph (1) are less than the total of the amounts determined under subparagraphs (A) and (B) of paragraph (3), the amounts computed under such subparagraphs shall be reduced proportionally.
(5)

Retrospective adjustment.—
The Secretary may adjust the estimates and determinations made to carry out this subsection as necessary on the basis of the amounts reported by States not later than May 31, 2009, on CMS Form 64 or CMS Form 21, as the case may be, and as approved by the Secretary.
(6)

Availability; no redistribution of unexpended additional allotments.—
Notwithstanding subsections (e) and (f), amounts allotted to a State pursuant to this subsection for fiscal year 2009, subject to paragraph (5), shall only remain available for expenditure by the State through March 31, 2009. Any amounts of such allotments that remain unexpended as of such date shall not be subject to redistribution under subsection (f).
(m)

Allotments for Fiscal Years 2009 and Thereafter.—
(1)

For fiscal year 2009.—
(A)

For the 50 states and the district of columbia.—
Subject to the succeeding provisions of this paragraph and paragraph (5), the Secretary shall allot for fiscal year 2009 from the amount made available under subsection (a)(12), to each of the 50 States and the District of Columbia 110 percent of the highest of the following amounts for such State or District:
(i)
The total Federal payments to the State under this title for fiscal year 2008, multiplied by the allotment increase factor determined under paragraph (6) for fiscal year 2009.
(ii)
The amount allotted to the State for fiscal year 2008 under subsection (b), multiplied by the allotment increase factor determined under paragraph (6) for fiscal year 2009.
(iii)
The projected total Federal payments to the State under this title for fiscal year 2009, as determined on the basis of the February 2009 projections certified by the State to the Secretary by not later than March 31, 2009.
(B)

For the commonwealths and territories.—
Subject to the succeeding provisions of this paragraph and paragraph (5), the Secretary shall allot for fiscal year 2009 from the amount made available under subsection (a)(12) to each of the commonwealths and territories described in subsection (c)(3) an amount equal to the highest amount of Federal payments to the commonwealth or territory under this title for any fiscal year occurring during the period of fiscal years 1999 through 2008, multiplied by the allotment increase factor determined under paragraph (6) for fiscal year 2009, except that subparagraph (B) thereof shall be applied by substituting “the United States” for “the State”.
(C)

Adjustment for qualifying states.—
In the case of a qualifying State described in paragraph (2) of section 2105(g), the Secretary shall permit the State to submit a revised projection described in subparagraph (A)(iii) in order to take into account changes in such projections attributable to the application of paragraph (4) of such section.
(2)

For fiscal years beginning with fiscal year 2010.—
(A)

In general.—
Subject to paragraphs (4) and (6), from the amount made available under paragraphs (13) through (15) of subsection (a) for each of fiscal years 2010 through 2012, respectively, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for each such fiscal year as follows:
(i)

Growth factor update for fiscal year 2010.—
For fiscal year 2010, the allotment of the State is equal to the sum of—
(I)
the amount of the State allotment under paragraph (1) for fiscal year 2009; and
(II)
the amount of any payments made to the State under subsection (k), (l), or (n) for fiscal year 2009,
multiplied by the allotment increase factor under paragraph (6) for fiscal year 2010.
(ii)

Rebasing in fiscal year 2011.—
For fiscal year 2011, the allotment of the State is equal to the Federal payments to the State that are attributable to (and countable towards) the total amount of allotments available under this section to the State in fiscal year 2010 (including payments made to the State under subsection (n) for fiscal year 2010 as well as amounts redistributed to the State in fiscal year 2010), multiplied by the allotment increase factor under paragraph (6) for fiscal year 2011.
(iii)

Growth factor update for fiscal year 2012.—
For fiscal year 2012, the allotment of the State is equal to the sum of—
(I)
the amount of the State allotment under clause (ii) for fiscal year 2011; and
(II)
the amount of any payments made to the State under subsection (n) for fiscal year 2011,
multiplied by the allotment increase factor under paragraph (6) for fiscal year 2012.
(B)

Fiscal year 2013 and each succeeding fiscal year.—
Subject to paragraphs (5), (7), and (12), from the amount made available under paragraphs (16) through (27) of subsection (a) for fiscal year 2013 and each succeeding fiscal year, respectively, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for each such fiscal year as follows:
(i)

Rebasing in fiscal year 2013 and each succeeding odd-numbered fiscal year.—
For fiscal year 2013 and each succeeding odd-numbered fiscal year (other than fiscal years 2015, 2017, 2023, and 2029), the allotment of the State is equal to the Federal payments to the State that are attributable to (and countable toward) the total amount of allotments available under this section to the State in the preceding fiscal year (including payments made to the State under subsection (n) for such preceding fiscal year as well as amounts redistributed to the State in such preceding fiscal year), multiplied by the allotment increase factor under paragraph (6) for such odd-numbered fiscal year.
(ii)

Growth factor update for fiscal year 2014 and each succeeding even-numbered fiscal year.—
Except as provided in clauses (iii) and (iv) , for fiscal year 2014 and each succeeding even-numbered fiscal year, the allotment of the State is equal to the sum of—
(I)
the amount of the State allotment under clause (i) (or, in the case of fiscal year 2018 or 2024, under paragraph (4) or (10), respectively) for the preceding fiscal year; and
(II)
the amount of any payments made to the State under subsection (n) for such preceding fiscal year,
multiplied by the allotment increase factor under paragraph (6) for such even-numbered fiscal year.
(iii)

Special rule for 2016.—
For fiscal year 2016, the allotment of the State is equal to the Federal payments to the State that are attributable to (and countable toward) the total amount of allotments available under this section to the State in the preceding fiscal year (including payments made to the State under subsection (n) for such preceding fiscal year as well as amounts redistributed to the State in such preceding fiscal year), but determined as if the last two sentences of section 2105(b) were in effect in such preceding fiscal year and then multiplying the result by the allotment increase factor under paragraph (6) for fiscal year 2016.
(iv)

Reduction in 2018.—
For fiscal year 2018, with respect to the allotment of the State for fiscal year 2017, any amounts of such allotment that remain available for expenditure by the State in fiscal year 2018 shall be reduced by one-third.
(3)

For fiscal year 2015.—
(A)

First half.—
Subject to paragraphs (5) and (7), from the amount made available under subparagraph (A) of paragraph (18) of subsection (a) for the semi-annual period described in such paragraph, increased by the amount of the appropriation for such period under section 108 of the Children's Health Insurance Program Reauthorization Act of 2009, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for such semi-annual period in an amount equal to the first half ratio (described in subparagraph (D)) of the amount described in subparagraph (C).
(B)

Second half.—
Subject to paragraphs (5) and (7), from the amount made available under subparagraph (B) of paragraph (18) of subsection (a) for the semi-annual period described in such paragraph, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for such semi-annual period in an amount equal to the amount made available under such subparagraph, multiplied by the ratio of—
(i)
the amount of the allotment to such State under subparagraph (A); to
(ii)
the total of the amount of all of the allotments made available under such subparagraph.
(C)

Full year amount based on rebased amount.—
The amount described in this subparagraph for a State is equal to the Federal payments to the State that are attributable to (and countable towards) the total amount of allotments available under this section to the State in fiscal year 2014 (including payments made to the State under subsection (n) for fiscal year 2014 as well as amounts redistributed to the State in fiscal year 2014), multiplied by the allotment increase factor under paragraph (6) for fiscal year 2015.
(D)

First half ratio.—
The first half ratio described in this subparagraph is the ratio of—
(i)
the sum of—
(I)
the amount made available under subsection (a)(18)(A); and
(II)
the amount of the appropriation for such period under section 108 of the Children's Health Insurance Program Reauthorization Act of 2009; to
(ii)
the sum of the—
(I)
amount described in clause (i); and
(II)
the amount made available under subsection (a)(18)(B).
(4)

For fiscal year 2017.—
(A)

First half.—
Subject to paragraphs (5) and (7), from the amount made available under subparagraph (A) of paragraph (20) of subsection (a) for the semi-annual period described in such paragraph, increased by the amount of the appropriation for such period under section 301(b)(3) of the Medicare Access and CHIP Reauthorization Act of 2015, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for such semi-annual period in an amount equal to the first half ratio (described in subparagraph (D)) of the amount described in subparagraph (C).
(B)

Second half.—
Subject to paragraphs (5) and (7), from the amount made available under subparagraph (B) of paragraph (20) of subsection (a) for the semi-annual period described in such paragraph, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for such semi-annual period in an amount equal to the amount made available under such subparagraph, multiplied by the ratio of—
(i)
the amount of the allotment to such State under subparagraph (A); to
(ii)
the total of the amount of all of the allotments made available under such subparagraph.
(C)

Full year amount based on rebased amount.—
The amount described in this subparagraph for a State is equal to the Federal payments to the State that are attributable to (and countable towards) the total amount of allotments available under this section to the State in fiscal year 2016 (including payments made to the State under subsection (n) for fiscal year 2016 as well as amounts redistributed to the State in fiscal year 2016), multiplied by the allotment increase factor under paragraph (6) for fiscal year 2017.
(D)

First half ratio.—
The first half ratio described in this subparagraph is the ratio of—
(i)
the sum of—
(I)
the amount made available under subsection (a)(20)(A); and
(II)
the amount of the appropriation for such period under section 301(b)(3) of the Medicare Access and CHIP Reauthorization Act of 2015; to
(ii)
the sum of the—
(I)
amount described in clause (i); and
(II)
the amount made available under subsection (a)(20)(B).
(5)

Proration rule.—
If, after the application of this subsection without regard to this paragraph, the sum of the allotments determined under paragraph (1), (2), (3), (4), (10), or (11) for a fiscal year (or, in the case of fiscal year 2015 , 2017, 2023, or 2029, for a semi-annual period in such fiscal year) exceeds the amount available under subsection (a) for such fiscal year or period, the Secretary shall reduce each allotment for any State under such paragraph for such fiscal year or period on a proportional basis.
(6)

Allotment increase factor.—
The allotment increase factor under this paragraph for a fiscal year is equal to the product of the following:
(A)

Per capita health care growth factor.—
1 plus the percentage increase in the projected per capita amount of National Health Expenditures from the calendar year in which the previous fiscal year ends to the calendar year in which the fiscal year involved ends, as most recently published by the Secretary before the beginning of the fiscal year.
(B)

Child population growth factor.—
1 plus the percentage increase (if any) in the population of children in the State from July 1 in the previous fiscal year to July 1 in the fiscal year involved, as determined by the Secretary based on the most recent published estimates of the Bureau of the Census before the beginning of the fiscal year involved, plus 1 percentage point.
(7)

Increase in allotment to account for approved program expansions.—
In the case of one of the 50 States or the District of Columbia that—
(A)
has submitted to the Secretary, and has approved by the Secretary, a State plan amendment or waiver request relating to an expansion of eligibility for children or benefits under this title that becomes effective for a fiscal year (beginning with fiscal year 2010 and ending with fiscal year 2029); and
(B)
has submitted to the Secretary, before the August 31 preceding the beginning of the fiscal year (or, in the case of fiscal year 2018, by not later than the date that is 60 days after the date of the enactment of the HEALTHY KIDS Act), a request for an expansion allotment adjustment under this paragraph for such fiscal year that specifies—
(i)
the additional expenditures that are attributable to the eligibility or benefit expansion provided under the amendment or waiver described in subparagraph (A), as certified by the State and submitted to the Secretary by not later than August 31 preceding the beginning of the fiscal year; and
(ii)
the extent to which such additional expenditures are projected to exceed the allotment of the State or District for the year,
subject to paragraph (5), the amount of the allotment of the State or District under this subsection for such fiscal year shall be increased by the excess amount described in subparagraph (B)(i). A State or District may only obtain an increase under this paragraph for an allotment for fiscal year 2010, fiscal year 2012, fiscal year 2014, fiscal year 2016, fiscal year 2018, fiscal year 2020, fiscal year 2022, fiscal year 2024, fiscal year 2026, or fiscal year 2028.
(8)

Adjustment of fiscal year 2010 allotments to account for changes in projected spending for certain previously approved expansion programs.—
For purposes of recalculating the fiscal year 2010 allotment, in the case of one of the 50 States or the District of Columbia that has an approved State plan amendment effective January 1, 2006, to provide child health assistance through the provision of benefits under the State plan under title XIX for children from birth through age 5 whose family income does not exceed 200 percent of the poverty line, the Secretary shall increase the allotment by an amount that would be equal to the Federal share of expenditures that would have been claimed at the enhanced FMAP rate rather than the Federal medical assistance percentage matching rate for such population.
(9)

Availability of amounts for semi-annual periods in certain fiscal years.—
Each semi-annual allotment made under paragraph (3) , (4), (10), or (11) for a period in fiscal year 2015 , 2017, 2023, or 2029,4 shall remain available for expenditure under this title for periods after the end of such fiscal year in the same manner as if the allotment had been made available for the entire fiscal year.
^4
Section 50101(b)(1)(D)(ii) of division E of Public Law 115–123 provides for an amendment to strike “or 2023,” and insert “2023, or 2027,”. Such amendment was carried out by striking “or 2023” and inserting “2023, or 2027,” to reflect the probable intent of Congress. Paragraph (9) was subsequently amended by section 5111(b)(1)(D) of division FF of Public Law 117–283.
(10)

For fiscal year 2023.—
(A)

First half.—
Subject to paragraphs (5) and (7), from the amount made available under subparagraph (A) of paragraph (26) of subsection (a) for the semi-annual period described in such subparagraph, increased by the amount of the appropriation for such period under section 3002(b)(2) of the HEALTHY KIDS Act, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for such semi-annual period in an amount equal to the first half ratio (described in subparagraph (D)) of the amount described in subparagraph (C).
(B)

Second half.—
Subject to paragraphs (5) and (7), from the amount made available under subparagraph (B) of paragraph (26) of subsection (a) for the semi-annual period described in such subparagraph, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for such semi-annual period in an amount equal to the amount made available under such subparagraph, multiplied by the ratio of—
(i)
the amount of the allotment to such State under subparagraph (A); to
(ii)
the total of the amount of all of the allotments made available under such subparagraph.
(C)

Full year amount based on rebased amount.—
The amount described in this subparagraph for a State is equal to the Federal payments to the State that are attributable to (and countable towards) the total amount of allotments available under this section to the State in fiscal year 2022 (including payments made to the State under subsection (n) for fiscal year 2022 as well as amounts redistributed to the State in fiscal year 2022), multiplied by the allotment increase factor under paragraph (6) for fiscal year 2023.
(D)

First half ratio.—
The first half ratio described in this subparagraph is the ratio of—
(i)
the sum of—
(I)
the amount made available under subsection (a)(26)(A); and
(II)
the amount of the appropriation for such period under section 3002(b)(2) of the HEALTHY KIDS Act; to
(ii)
the sum of—
(I)
the amount described in clause (i); and
(II)
the amount made available under subsection (a)(26)(B).
(11)

For fiscal year 2029.—
(A)

First half.—
Subject to paragraphs (5) and (7), from the amount made available under subparagraph (A) of paragraph (28) of subsection (a) for the semi-annual period described in such subparagraph, increased by the amount of the appropriation for such period under section 50101(b)(2) of the Advancing Chronic Care, Extenders, and Social Services Act, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for such semi-annual period in an amount equal to the first half ratio (described in subparagraph (D)) of the amount described in subparagraph (C).
(B)

Second half.—
Subject to paragraphs (5) and (7), from the amount made available under subparagraph (B) of paragraph (28) of subsection (a) for the semi-annual period described in such subparagraph, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for such semi-annual period in an amount equal to the amount made available under such subparagraph, multiplied by the ratio of—
(i)
the amount of the allotment to such State under subparagraph (A); to
(ii)
the total of the amount of all of the allotments made available under such subparagraph.
(C)

Full year amount based on rebased amount.—
The amount described in this subparagraph for a State is equal to the Federal payments to the State that are attributable to (and countable towards) the total amount of allotments available under this section to the State in fiscal year 2028 (including payments made to the State under subsection (n) for fiscal year 2028 as well as amounts redistributed to the State in fiscal year 2028), multiplied by the allotment increase factor under paragraph (6) for fiscal year 2029.
(D)

First half ratio.—
The first half ratio described in this subparagraph is the ratio of—
(i)
the sum of—
(I)
the amount made available under subsection (a)(28)(A); and
(II)
the amount of the appropriation for such period under section 50101(b)(2) of the Advancing Chronic Care, Extenders, and Social Services Act; to
(ii)
the sum of—
(I)
the amount described in clause (i); and
(II)
the amount made available under subsection (a)(28)(B).
(12)

Adjusting allotments to account for increased federal payments for coverage and administration of covid–19 vaccines.—
If a State, commonwealth, or territory receives payment for a fiscal year (beginning with fiscal year 2021) under subsection (a) of section 2105 for expenditures that are subject to the enhanced FMAP specified under subsection (c)(12) of such section, the amount of the allotment determined for the State, commonwealth, or territory under this subsection—
(A)
for such fiscal year shall be increased by the projected expenditures for such year by the State, commonwealth, or territory under the State child health plan (or a waiver of such plan) for vaccines described in section 1905(a)(4)(E) (and the administration of such vaccines); and
(B)
once actual expenditures are available in the subsequent fiscal year, the fiscal year allotment that was adjusted by the amount described in subparagraph (A) shall be adjusted on the basis of the difference between—
(i)
such projected amount of expenditures described in subparagraph (A) for such fiscal year described in such subparagraph by the State, commonwealth, or territory; and
(ii)
the actual amount of expenditures for such fiscal year described in subparagraph (A) by the State, commonwealth, or territory under the State child health plan (or waiver of such plan) for vaccines described in section 1905(a)(4)(E) (and the administration of such vaccines).
(n)

Child Enrollment Contingency Fund.—
(1)

Establishment.—
There is hereby established in the Treasury of the United States a fund which shall be known as the “Child Enrollment Contingency Fund” (in this subsection referred to as the “Fund”). Amounts in the Fund shall be available without further appropriations for payments under this subsection.
(2)

Deposits into fund.—
(A)

Initial and subsequent appropriations.—
Subject to subparagraphs (B) and (D), out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated to the Fund—
(i)
for fiscal year 2009, an amount equal to 20 percent of the amount made available under paragraph (12) of subsection (a) for the fiscal year; and
(ii)
for each of fiscal years 2010 through 2014, 2016, 2018 through 2022, and 2024 through 2028 (and for each of the semi-annual allotment periods for fiscal years 2015, 2017, 2023, and 2029), such sums as are necessary for making payments to eligible States for such fiscal year or period, but not in excess of the aggregate cap described in subparagraph (B).
(B)

Aggregate cap.—
The total amount available for payment from the Fund for each of fiscal years 2010 through 2014, 2016, 2018 through 2022, and 2024 through 2028 (and for each of the semi-annual allotment periods for fiscal years 2015, 2017, 2023, and 2029), taking into account deposits made under subparagraph (C), shall not exceed 20 percent of the amount made available under subsection (a) for the fiscal year or period.
(C)

Investment of fund.—
The Secretary of the Treasury shall invest, in interest bearing securities of the United States, such currently available portions of the Fund as are not immediately required for payments from the Fund. The income derived from these investments constitutes a part of the Fund.
(D)

Availability of excess funds for performance bonuses.—
Any amounts in excess of the aggregate cap described in subparagraph (B) for a fiscal year or period shall be made available for purposes of carrying out section 2105(a)(3) for any succeeding fiscal year and the Secretary of the Treasury shall reduce the amount in the Fund by the amount so made available.
(3)

Child enrollment contingency fund payments.—
(A)

In general.—
If a State's expenditures under this title in any of fiscal years 2009 through 2014, fiscal year 2016, fiscal years 2018 through 2022, or fiscal years 2024 through 2028 (or a semi-annual allotment period for fiscal year 2015, 2017, 2023, or 2027), exceed the total amount of allotments available under this section to the State in the fiscal year or period (determined without regard to any redistribution it receives under subsection (f) that is available for expenditure during such fiscal year or period, but including any carryover from a previous fiscal year) and if the average monthly unduplicated number of children enrolled under the State plan under this title (including children receiving health care coverage through funds under this title pursuant to a waiver under section 1115) during such fiscal year or period exceeds its target average number of such enrollees (as determined under subparagraph (B)) for that fiscal year or period, subject to subparagraph (D), the Secretary shall pay to the State from the Fund an amount equal to the product of—
(i)
the amount by which such average monthly caseload exceeds such target number of enrollees; and
(ii)
the projected per capita expenditures under the State child health plan (as determined under subparagraph (C) for the fiscal year), multiplied by the enhanced FMAP (as defined in section 2105(b)) for the State and fiscal year involved (or in which the period occurs).
(B)

Target average number of child enrollees.—
In this paragraph, the target average number of child enrollees for a State—
(i)
for fiscal year 2009 is equal to the monthly average unduplicated number of children enrolled in the State child health plan under this title (including such children receiving health care coverage through funds under this title pursuant to a waiver under section 1115) during fiscal year 2008 increased by the population growth for children in that State for the year ending on June 30, 2007 (as estimated by the Bureau of the Census) plus 1 percentage point; or
(ii)
for a subsequent fiscal year (or semi-annual period occurring in a fiscal year) is equal to the target average number of child enrollees for the State for the previous fiscal year increased by the child population growth factor described in subsection (m)(6)(B) for the State for the prior fiscal year.
(C)

Projected per capita expenditures.—
For purposes of subparagraph (A)(ii), the projected per capita expenditures under a State child health plan—
(i)
for fiscal year 2009 is equal to the average per capita expenditures (including both State and Federal financial participation) under such plan for the targeted low-income children counted in the average monthly caseload for purposes of this paragraph during fiscal year 2008, increased by the annual percentage increase in the projected per capita amount of National Health Expenditures (as estimated by the Secretary) for 2009; or
(ii)
for a subsequent fiscal year (or semi-annual period occurring in a fiscal year) is equal to the projected per capita expenditures under such plan for the previous fiscal year (as determined under clause (i) or this clause) increased by the annual percentage increase in the projected per capita amount of National Health Expenditures (as estimated by the Secretary) for the year in which such subsequent fiscal year ends.
(D)

Proration rule.—
If the amounts available for payment from the Fund for a fiscal year or period are less than the total amount of payments determined under subparagraph (A) for the fiscal year or period, the amount to be paid under such subparagraph to each eligible State shall be reduced proportionally.
(E)

Timely payment; reconciliation.—
Payment under this paragraph for a fiscal year or period shall be made before the end of the fiscal year or period based upon the most recent data for expenditures and enrollment and the provisions of subsection (e) of section 2105 shall apply to payments under this subsection in the same manner as they apply to payments under such section.
(F)

Continued reporting.—
For purposes of this paragraph and subsection (f), the State shall submit to the Secretary the State's projected Federal expenditures, even if the amount of such expenditures exceeds the total amount of allotments available to the State in such fiscal year or period.
(G)

Application to commonwealths and territories.—
No payment shall be made under this paragraph to a commonwealth or territory described in subsection (c)(3) until such time as the Secretary determines that there are in effect methods, satisfactory to the Secretary, for the collection and reporting of reliable data regarding the enrollment of children described in subparagraphs (A) and (B) in order to accurately determine the commonwealth's or territory's eligibility for, and amount of payment, under this paragraph.
SEC. 2105.
[42 U.S.C. 1397ee]

PAYMENTS TO STATES.
(a)

Payments.—
(1)

In general.—
Subject to the succeeding provisions of this section, the Secretary shall pay to each State with a plan approved under this title, from its allotment under section 2104, an amount for each quarter equal to the enhanced FMAP (or, in the case of expenditures described in subparagraph (D)(iv), the higher of 75 percent or the sum of the enhanced FMAP plus 5 percentage points) of expenditures in the quarter—
(A)
for child health assistance under the plan for targeted low-income children in the form of providing medical assistance for which payment is made on the basis of an enhanced FMAP under the fourth sentence of section 1905(b);
(B)
[reserved]
(C)
for child health assistance under the plan for targeted low-income children in the form of providing health benefits coverage that meets the requirements of section 2103; and
(D)
only to the extent permitted consistent with subsection (c)—
(i)
for payment for other child health assistance for targeted low-income children;
(ii)
for expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children);
(iii)
for expenditures for outreach activities as provided in section 2102(c)(1) under the plan;
(iv)
for translation or interpretation services in connection with the enrollment of, retention of, and use of services under this title by, individuals for whom English is not their primary language (as found necessary by the Secretary for the proper and efficient administration of the State plan); and
(v)
for other reasonable costs incurred by the State to administer the plan.
(2)

Order of payments.—
Payments under paragraph (1) from a State's allotment shall be made in the following order:
(A)
First, for expenditures for items described in paragraph (1)(A).
(B)
Second, for expenditures for items described in paragraph (1)(B).
(C)
Third, for expenditures for items described in paragraph (1)(C).
(D)
Fourth, for expenditures for items described in paragraph (1)(D).
(3)

Performance bonus payment to offset additional medicaid and chip child enrollment costs resulting from enrollment and retention efforts.—
(A)

In general.—
In addition to the payments made under paragraph (1), for each fiscal year (beginning with fiscal year 2009 and ending with fiscal year 2013), the Secretary shall pay from amounts made available under subparagraph (E), to each State that meets the condition under paragraph (4) for the fiscal year, an amount equal to the amount described in subparagraph (B) for the State and fiscal year. The payment under this paragraph shall be made, to a State for a fiscal year, as a single payment not later than the last day of the first calendar quarter of the following fiscal year.
(B)

Amount for above baseline medicaid child enrollment costs.—
Subject to subparagraph (E), the amount described in this subparagraph for a State for a fiscal year is equal to the sum of the following amounts:
(i)

First tier above baseline medicaid enrollees.—
An amount equal to the number of first tier above baseline child enrollees (as determined under subparagraph (C)(i)) under title XIX for the State and fiscal year, multiplied by 15 percent of the projected per capita State Medicaid expenditures (as determined under subparagraph (D)) for the State and fiscal year under title XIX.
(ii)

Second tier above baseline medicaid enrollees.—
An amount equal to the number of second tier above baseline child enrollees (as determined under subparagraph (C)(ii)) under title XIX for the State and fiscal year, multiplied by 62.5 percent of the projected per capita State Medicaid expenditures (as determined under subparagraph (D)) for the State and fiscal year under title XIX.
(C)

Number of first and second tier above baseline child enrollees; baseline number of child enrollees.—
For purposes of this paragraph:
(i)

First tier above baseline child enrollees.—
The number of first tier above baseline child enrollees for a State for a fiscal year under title XIX is equal to the number (if any, as determined by the Secretary) by which—
(I)
the monthly average unduplicated number of qualifying children (as defined in subparagraph (F)) enrolled during the fiscal year under the State plan under title XIX; exceeds
(II)
the baseline number of enrollees described in clause (iii) for the State and fiscal year under title XIX;
but not to exceed 10 percent of the baseline number of enrollees described in subclause (II).
(ii)

Second tier above baseline child enrollees.—
The number of second tier above baseline child enrollees for a State for a fiscal year under title XIX is equal to the number (if any, as determined by the Secretary) by which—
(I)
the monthly average unduplicated number of qualifying children (as defined in subparagraph (F)) enrolled during the fiscal year under title XIX as described in clause (i)(I); exceeds
(II)
the sum of the baseline number of child enrollees described in clause (iii) for the State and fiscal year under title XIX, as described in clause (i)(II), and the maximum number of first tier above baseline child enrollees for the State and fiscal year under title XIX, as determined under clause (i).
(iii)

Baseline number of child enrollees.—
Subject to subparagraph (H), the baseline number of child enrollees for a State under title XIX—
(I)
for fiscal year 2009 is equal to the monthly average unduplicated number of qualifying children enrolled in the State plan under title XIX during fiscal year 2007 increased by the population growth for children in that State from 2007 to 2008 (as estimated by the Bureau of the Census) plus 4 percentage points, and further increased by the population growth for children in that State from 2008 to 2009 (as estimated by the Bureau of the Census) plus 4 percentage points;
(II)
for each of fiscal years 2010, 2011, and 2012, is equal to the baseline number of child enrollees for the State for the previous fiscal year under title XIX, increased by the population growth for children in that State from the calendar year in which the respective fiscal year begins to the succeeding calendar year (as estimated by the Bureau of the Census) plus 3.5 percentage points;
(III)
for each of fiscal years 2013, 2014, and 2015, is equal to the baseline number of child enrollees for the State for the previous fiscal year under title XIX, increased by the population growth for children in that State from the calendar year in which the respective fiscal year begins to the succeeding calendar year (as estimated by the Bureau of the Census) plus 3 percentage points; and
(IV)
for a subsequent fiscal year is equal to the baseline number of child enrollees for the State for the previous fiscal year under title XIX, increased by the population growth for children in that State from the calendar year in which the fiscal year involved begins to the succeeding calendar year (as estimated by the Bureau of the Census) plus 2 percentage points.
(D)

Projected per capita state medicaid expenditures.—
For purposes of subparagraph (B), the projected per capita State Medicaid expenditures for a State and fiscal year under title XIX is equal to the average per capita expenditures (including both State and Federal financial participation) for children under the State plan under such title, including under waivers but not including such children eligible for assistance by virtue of the receipt of benefits under title XVI, for the most recent fiscal year for which actual data are available (as determined by the Secretary), increased (for each subsequent fiscal year up to and including the fiscal year involved) by the annual percentage increase in per capita amount of National Health Expenditures (as estimated by the Secretary) for the calendar year in which the respective subsequent fiscal year ends and multiplied by a State matching percentage equal to 100 percent minus the Federal medical assistance percentage (as defined in section 1905(b)) for the fiscal year involved.
(E)

Amounts available for payments.—
(i)

Initial appropriation.—
Out of any money in the Treasury not otherwise appropriated, there are appropriated $3,225,000,000 for fiscal year 2009 for making payments under this paragraph, to be available until expended.
(ii)

Transfers.—
Notwithstanding any other provision of this title, the following amounts shall also be available, without fiscal year limitation, for making payments under this paragraph:
(I)

Unobligated national allotment.—
- (aa)

Fiscal years 2009 through 2012.—
As of December 31 of fiscal year 2009, and as of December 31 of each succeeding fiscal year through fiscal year 2012, the portion, if any, of the amount appropriated under subsection (a) for such fiscal year that is unobligated for allotment to a State under subsection (m) for such fiscal year or set aside under subsection (a)(3) or (b)(2) of section 2111 for such fiscal year.
- (bb)

First half of fiscal year 2013.—
As of December 31 of fiscal year 2013, the portion, if any, of the sum of the amounts appropriated under subsection (a)(16)(A) and under section 108 of the Children's Health Insurance Reauthorization Act of 2009 for the period beginning on October 1, 2012, and ending on March 31, 2013, that is unobligated for allotment to a State under subsection (m) for such fiscal year or set aside under subsection (b)(2) of section 2111 for such fiscal year.
- (cc)

Second half of fiscal year 2013.—
As of June 30 of fiscal year 2013, the portion, if any, of the amount appropriated under subsection (a)(16)(B) for the period beginning on April 1, 2013, and ending on September 30, 2013, that is unobligated for allotment to a State under subsection (m) for such fiscal year or set aside under subsection (b)(2) of section 2111 for such fiscal year.
(II)

Unexpended allotments not used for redistribution.—
As of November 15 of each of fiscal years 2010 through 2013, the total amount of allotments made to States under section 2104 for the second preceding fiscal year (third preceding fiscal year in the case of the fiscal year 2006, 2007, and 2008 allotments) that is not expended or redistributed under section 2104(f) during the period in which such allotments are available for obligation.
(III)

Excess child enrollment contingency funds.—
As of October 1 of each of fiscal years 2010 through 2013, any amount in excess of the aggregate cap applicable to the Child Enrollment Contingency Fund for the fiscal year under section 2104(n).
(iii)

Proportional reduction.—
If the sum of the amounts otherwise payable under this paragraph for a fiscal year exceeds the amount available for the fiscal year under this subparagraph, the amount to be paid under this paragraph to each State shall be reduced proportionally.
(F)

Qualifying children defined.—
(i)

In general.—
For purposes of this subsection, subject to clauses (ii) and (iii), the term “qualifying children” means children who meet the eligibility criteria (including income, categorical eligibility, age, and immigration status criteria) in effect as of July 1, 2008, for enrollment under title XIX, taking into account criteria applied as of such date under title XIX pursuant to a waiver under section 1115.
(ii)

Limitation.—
A child described in clause (i) who is provided medical assistance during a presumptive eligibility period under section 1920A shall be considered to be a “qualifying child” only if the child is determined to be eligible for medical assistance under title XIX.
(iii)

Exclusion.—
Such term does not include any children for whom the State has made an election to provide medical assistance under paragraph (4) of section 1903(v) or any children enrolled on or after October 1, 2013.
(G)

Application to commonwealths and territories.—
The provisions of subparagraph (G) of section 2104(n)(3) shall apply with respect to payment under this paragraph in the same manner as such provisions apply to payment under such section.
(H)

Application to states that implement a Medicaid expansion for children after fiscal year 2008.—
In the case of a State that provides coverage under section 115 of the Children's Health Insurance Program Reauthorization Act of 2009 for any fiscal year after fiscal year 2008—
(i)
any child enrolled in the State plan under title XIX through the application of such an election shall be disregarded from the determination for the State of the monthly average unduplicated number of qualifying children enrolled in such plan during the first 3 fiscal years in which such an election is in effect; and
(ii)
in determining the baseline number of child enrollees for the State for any fiscal year subsequent to such first 3 fiscal years, the baseline number of child enrollees for the State under title XIX for the third of such fiscal years shall be the monthly average unduplicated number of qualifying children enrolled in the State plan under title XIX for such third fiscal year.
(4)

Enrollment and retention provisions for children.—
For purposes of paragraph (3)(A), a State meets the condition of this paragraph for a fiscal year if it is implementing at least 5 of the following enrollment and retention provisions (treating each subparagraph as a separate enrollment and retention provision) throughout the entire fiscal year:
(A)

Continuous eligibility.—
The State has elected the option of continuous eligibility for a full 12 months for all children described in section 1902(e)(12) under title XIX under 19 years of age, as well as applying such policy under its State child health plan under this title.
(B)

Liberalization of asset requirements.—
The State meets the requirement specified in either of the following clauses:
(i)

Elimination of asset test.—
The State does not apply any asset or resource test for eligibility for children under title XIX or this title.
(ii)

Administrative verification of assets.—
The State—
(I)
permits a parent or caretaker relative who is applying on behalf of a child for medical assistance under title XIX or child health assistance under this title to declare and certify by signature under penalty of perjury information relating to family assets for purposes of determining and redetermining financial eligibility; and
(II)
takes steps to verify assets through means other than by requiring documentation from parents and applicants except in individual cases of discrepancies or where otherwise justified.
(C)

Elimination of in-person interview requirement.—
The State does not require an application of a child for medical assistance under title XIX (or for child health assistance under this title), including an application for renewal of such assistance, to be made in person nor does the State require a face-to-face interview, unless there are discrepancies or individual circumstances justifying an in-person application or face-to-face interview.
(D)

Use of joint application for medicaid and chip.—
The application form and supplemental forms (if any) and information verification process is the same for purposes of establishing and renewing eligibility for children for medical assistance under title XIX and child health assistance under this title.
(E)

Automatic renewal (use of administrative renewal).—
(i)

In general.—
The State provides, in the case of renewal of a child's eligibility for medical assistance under title XIX or child health assistance under this title, a pre-printed form completed by the State based on the information available to the State and notice to the parent or caretaker relative of the child that eligibility of the child will be renewed and continued based on such information unless the State is provided other information. Nothing in this clause shall be construed as preventing a State from verifying, through electronic and other means, the information so provided.
(ii)

Satisfaction through demonstrated use of ex parte process.—
A State shall be treated as satisfying the requirement of clause (i) if renewal of eligibility of children under title XIX or this title is determined without any requirement for an in-person interview, unless sufficient information is not in the State's possession and cannot be acquired from other sources (including other State agencies) without the participation of the applicant or the applicant's parent or caretaker relative.
(F)

Presumptive eligibility for children.—
The State is implementing section 1920A under title XIX as well as, pursuant to section 2107(e)(1), under this title.
(G)

Express lane.—
The State is implementing the option described in section 1902(e)(13) under title XIX as well as, pursuant to section 2107(e)(1), under this title.
(H)

Premium assistance subsidies.—
The State is implementing the option of providing premium assistance subsidies under section 2105(c)(10) or section 1906A.
(b)

Enhanced FMAP.—
For purposes of subsection (a), the “enhanced FMAP”, for a State for a fiscal year, is equal to the Federal medical assistance percentage (as defined in the first sentence of section 1905(b)) for the State increased by a number of percentage points equal to 30 percent of the number of percentage points by which (1) such Federal medical assistance percentage for the State, is less than (2) 100 percent; but in no case shall the enhanced FMAP for a State exceed 85 percent. Notwithstanding the preceding sentence, during the period that begins on October 1, 2015, and ends on September 30, 2019, the enhanced FMAP determined for a State for a fiscal year (or for any portion of a fiscal year occurring during such period) shall be increased by 23 percentage points, and during the period that begins on October 1, 2019, and ends on September 30, 2020, the enhanced FMAP determined for a State for a fiscal year (or for any portion of a fiscal year occurring during such period) shall be increased by 11.5 percentage points but in no case shall exceed 100 percent. The increase in the enhanced FMAP under the preceding sentence shall not apply with respect to determining the payment to a State under subsection (a)(1) for expenditures described in subparagraph (D)(iv), paragraphs (8), (9), (11) of subsection (c), or clause (4) of the first sentence of section 1905(b).
(c)

Limitation on Certain Payments for Certain Expenditures.—
(1)

General limitations.—
Funds provided to a State under this title shall only be used to carry out the purposes of this title (as described in section 2101) or to carry out the rural health transformation program established in subsection (h) and, except in the case of amounts made available under subsection (h), may not include coverage of a nonpregnant childless adult, and any health insurance coverage provided with such funds may include coverage of abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. For purposes of the preceding sentence, a caretaker relative (as such term is defined for purposes of carrying out section 1931) shall not be considered a childless adult.
(2)

Limitation on expenditures not used for medicaid or health insurance assistance.—
(A)

In general.—
Except as provided in this paragraph, the amount of payment that may be made under subsection (a) for a fiscal year for expenditures for items described in paragraph (1)(D) of such subsection shall not exceed 10 percent of the total amount of expenditures for which payment is made under subparagraphs (A), (C), and (D) of paragraph (1) of such subsection.
(B)

Waiver authorized for cost-effective alternative.—
The limitation under subparagraph (A) on expenditures for items described in subsection (a)(1)(D) shall not apply to the extent that a State establishes to the satisfaction of the Secretary that—
(i)
coverage provided to targeted low-income children through such expenditures meets the requirements of section 2103;
(ii)
the cost of such coverage is not greater, on an average per child basis, than the cost of coverage that would otherwise be provided under section 2103; and
(iii)
such coverage is provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(d)(5)(F) or 1923.
(C)

Nonapplication to certain expenditures.—
The limitation under subparagraph (A) shall not apply with respect to the following expenditures:
(i)

Expenditures to increase outreach to, and the enrollment of, indian children under this title and title xix.—
Expenditures for outreach activities to families of Indian children likely to be eligible for child health assistance under the plan or medical assistance under the State plan under title XIX (or under a waiver of such plan), to inform such families of the availability of, and to assist them in enrolling their children in, such plans, including such activities conducted under grants, contracts, or agreements entered into under section 1139(a).
(ii)

Expenditures to comply with citizenship or nationality verification requirements .—
Expenditures necessary for the State to comply with paragraph (9)(A).
(iii)

Expenditures for outreach to increase the enrollment of children under this title and title xix through premium assistance subsidies.—
Expenditures for outreach activities to families of children likely to be eligible for premium assistance subsidies in accordance with paragraph (2)(B), (3), or (10), or a waiver approved under section 1115, to inform such families of the availability of, and to assist them in enrolling their children in, such subsidies, and to employers likely to provide qualified employer-sponsored coverage (as defined in subparagraph (B) of such paragraph), but not to exceed an amount equal to 1.25 percent of the maximum amount permitted to be expended under subparagraph (A) for items described in subsection (a)(1)(D).
(iv)

Payment error rate measurement (perm) expenditures.—
Expenditures related to the administration of the payment error rate measurement (PERM) requirements applicable to the State child health plan in accordance with the subchapter IV of chapter 33 of title 31, United States Code and parts 431 and 457 of title 42, Code of Federal Regulations (or any related or successor guidance or regulations).
(3)

Waiver for purchase of family coverage.—
Payment may be made to a State under subsection (a)(1) for the purchase of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children only if the State establishes to the satisfaction of the Secretary that—
(A)
purchase of such coverage is cost-effective relative to—
(i)
the amount of expenditures under the State child health plan, including administrative expenditures, that the State would have made to provide comparable coverage of the targeted low-income child involved or the family involved (as applicable); or
(ii)
the aggregate amount of expenditures that the State would have made under the State child health plan, including administrative expenditures, for providing coverage under such plan for all such children or families; and
(B)
such coverage shall not be provided if it would otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage.
(4)

Use of non-federal funds for state matching requirement.—
Amounts provided by the Federal Government, or services assisted or subsidized to any significant extent by the Federal Government, may not be included in determining the amount of non-Federal contributions required under subsection (a).
(5)

Offset of receipts attributable to premiums and other cost-sharing.—
For purposes of subsection (a), the amount of the expenditures under the plan shall be reduced by the amount of any premiums and other cost-sharing received by the State.
(6)

Prevention of duplicative payments.—
(A)

Other health plans.—
No payment shall be made to a State under this section for expenditures for child health assistance provided for a targeted low-income child under its plan to the extent that a private insurer (as defined by the Secretary by regulation and including a group health plan (as defined in section 607(1) of the Employee Retirement Income Security Act of 1974), a service benefit plan, and a health maintenance organization) would have been obligated to provide such assistance but for a provision of its insurance contract which has the effect of limiting or excluding such obligation because the individual is eligible for or is provided child health assistance under the plan.
(B)

Other federal governmental programs.—
Except as provided in subparagraph (A) or (B) of subsection (a)(1) or any other provision of law, no payment shall be made to a State under this section for expenditures for child health assistance provided for a targeted low-income child under its plan to the extent that payment has been made or can reasonably be expected to be made promptly (as determined in accordance with regulations) under any other federally operated or financed health care insurance program, other than an insurance program operated or financed by the Indian Health Service, as identified by the Secretary. For purposes of this paragraph, rules similar to the rules for overpayments under section 1903(d)(2) shall apply.
(7)

Limitation on payment for abortions.—
(A)

In general.—
Payment shall not be made to a State under this section for any amount expended under the State plan to pay for any abortion or to assist in the purchase, in whole or in part, of health benefit coverage that includes coverage of abortion.
(B)

Exception.—
Subparagraph (A) shall not apply to an abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest.
(C)

Rule of construction.—
Nothing in this section shall be construed as affecting the expenditure by a State, locality, or private person or entity of State, local, or private funds (other than funds expended under the State plan) for any abortion or for health benefits coverage that includes coverage of abortion.
(8)

Limitation on matching rate for expenditures for child health assistance provided to children whose effective family income exceeds 300 percent of the poverty line.—
(A)

FMAP applied to expenditures.—
Except as provided in subparagraph (B), for fiscal years beginning with fiscal year 2009, the Federal medical assistance percentage (as determined under section 1905(b) without regard to clause (4) of such section) shall be substituted for the enhanced FMAP under subsection (a)(1) with respect to any expenditures for providing child health assistance or health benefits coverage for a targeted low-income child whose effective family income would exceed 300 percent of the poverty line but for the application of a general exclusion of a block of income that is not determined by type of expense or type of income.
(B)

Exception.—
Subparagraph (A) shall not apply to any State that, on the date of enactment of the Children's Health Insurance Program Reauthorization Act of 2009, has an approved State plan amendment or waiver to provide, or has enacted a State law to submit a State plan amendment to provide, expenditures described in such subparagraph under the State child health plan.
(9)

Citizenship documentation requirements.—
(A)

In general.—
No payment may be made under this section with respect to an individual who has, or is, declared to be a citizen or national of the United States for purposes of establishing eligibility under this title unless the State meets the requirements of section 1902(a)(46)(B) with respect to the individual.
(B)

Enhanced payments.—
Notwithstanding subsection (b), the enhanced FMAP with respect to payments under subsection (a) for expenditures described in clause (i) or (ii) of section 1903(a)(3)(G) necessary to comply with subparagraph (A) shall in no event be less than 90 percent and 75 percent, respectively.
(10)

State option to offer premium assistance.—
(A)

In general.—
A State may elect to offer a premium assistance subsidy (as defined in subparagraph (C)) for qualified employer-sponsored coverage (as defined in subparagraph (B)) to all targeted low-income children who are eligible for child health assistance under the plan and have access to such coverage in accordance with the requirements of this paragraph if the offering of such a subsidy is cost-effective, as defined for purposes of paragraph (3)(A). No subsidy shall be provided to a targeted low-income child under this paragraph unless the child (or the child's parent) voluntarily elects to receive such a subsidy. A State may not require such an election as a condition of receipt of child health assistance.
(B)

Qualified employer-sponsored coverage.—
(i)

In general.—
Subject to clause (ii), in this paragraph, the term “qualified employer-sponsored coverage” means a group health plan or health insurance coverage offered through an employer—
(I)
that qualifies as creditable coverage as a group health plan under section 2701(c)(1) of the Public Health Service Act;
(II)
for which the employer contribution toward any premium for such coverage is at least 40 percent; and
(III)
that is offered to all individuals in a manner that would be considered a nondiscriminatory eligibility classification for purposes of paragraph (3)(A)(ii) of section 105(h) of the Internal Revenue Code of 1986 (but determined without regard to clause (i) of subparagraph (B) of such paragraph).
(ii)

Exception.—
Such term does not include coverage consisting of—
(I)
benefits provided under a health flexible spending arrangement (as defined in section 106(c)(2) of the Internal Revenue Code of 1986); or
(II)
a high deductible health plan (as defined in section 223(c)(2) of such Code), without regard to whether the plan is purchased in conjunction with a health savings account (as defined under section 223(d) of such Code).
(C)

Premium assistance subsidy.—
(i)

In general.—
In this paragraph, the term “premium assistance subsidy” means, with respect to a targeted low-income child, the amount equal to the difference between the employee contribution required for enrollment only of the employee under qualified employer-sponsored coverage and the employee contribution required for enrollment of the employee and the child in such coverage, less any applicable premium cost-sharing applied under the State child health plan (subject to the limitations imposed under section 2103(e), including the requirement to count the total amount of the employee contribution required for enrollment of the employee and the child in such coverage toward the annual aggregate cost-sharing limit applied under paragraph (3)(B) of such section).
(ii)

State payment option.—
A State may provide a premium assistance subsidy either as reimbursement to an employee for out-of-pocket expenditures or, subject to clause (iii), directly to the employee's employer.
(iii)

Employer opt-out.—
An employer may notify a State that it elects to opt-out of being directly paid a premium assistance subsidy on behalf of an employee. In the event of such a notification, an employer shall withhold the total amount of the employee contribution required for enrollment of the employee and the child in the qualified employer-sponsored coverage and the State shall pay the premium assistance subsidy directly to the employee.
(iv)

Treatment as child health assistance.—
Expenditures for the provision of premium assistance subsidies shall be considered child health assistance described in paragraph (1)(C) of subsection (a) for purposes of making payments under that subsection.
(D)

Application of secondary payor rules.—
The State shall be a secondary payor for any items or services provided under the qualified employer-sponsored coverage for which the State provides child health assistance under the State child health plan.
(E)

Requirement to provide supplemental coverage for benefits and cost-sharing protection provided under the state child health plan.—
(i)

In general.—
Notwithstanding section 2110(b)(1)(C), the State shall provide for each targeted low-income child enrolled in qualified employer-sponsored coverage, supplemental coverage consisting of—
(I)
items or services that are not covered, or are only partially covered, under the qualified employer-sponsored coverage; and
(II)
cost-sharing protection consistent with section 2103(e).
(ii)

Record keeping requirements.—
For purposes of carrying out clause (i), a State may elect to directly pay out-of-pocket expenditures for cost-sharing imposed under the qualified employer-sponsored coverage and collect or not collect all or any portion of such expenditures from the parent of the child.
(F)

Application of waiting period imposed under the state.—
Any waiting period imposed under the State child health plan prior to the provision of child health assistance to a targeted low-income child under the State plan shall apply to the same extent to the provision of a premium assistance subsidy for the child under this paragraph.
(G)

Opt-out permitted for any month.—
A State shall establish a process for permitting the parent of a targeted low-income child receiving a premium assistance subsidy to disenroll the child from the qualified employer-sponsored coverage and enroll the child in, and receive child health assistance under, the State child health plan, effective on the first day of any month for which the child is eligible for such assistance and in a manner that ensures continuity of coverage for the child.
(H)

Application to parents.—
If a State provides child health assistance or health benefits coverage to parents of a targeted low-income child in accordance with section 2111(b), the State may elect to offer a premium assistance subsidy to a parent of a targeted low-income child who is eligible for such a subsidy under this paragraph in the same manner as the State offers such a subsidy for the enrollment of the child in qualified employer-sponsored coverage, except that—
(i)
the amount of the premium assistance subsidy shall be increased to take into account the cost of the enrollment of the parent in the qualified employer-sponsored coverage or, at the option of the State if the State determines it cost-effective, the cost of the enrollment of the child's family in such coverage; and
(ii)
any reference in this paragraph to a child is deemed to include a reference to the parent or, if applicable under clause (i), the family of the child.
(I)

Additional state option for providing premium assistance.—
(i)

In general.—
A State may establish an employer-family premium assistance purchasing pool for employers with less than 250 employees who have at least 1 employee who is a pregnant woman eligible for assistance under the State child health plan (including through the application of an option described in section 2112(f)) or a member of a family with at least 1 targeted low-income child and to provide a premium assistance subsidy under this paragraph for enrollment in coverage made available through such pool.
(ii)

Access to choice of coverage.—
A State that elects the option under clause (i) shall identify and offer access to not less than 2 private health plans that are health benefits coverage that is equivalent to the benefits coverage in a benchmark benefit package described in section 2103(b) or benchmark-equivalent coverage that meets the requirements of section 2103(a)(2) for employees described in clause (i).
(iii)

Clarification of payment for administrative expenditures.—
Nothing in this subparagraph shall be construed as permitting payment under this section for administrative expenditures attributable to the establishment or operation of such pool, except to the extent that such payment would otherwise be permitted under this title.
(J)

No effect on premium assistance waiver programs.—
Nothing in this paragraph shall be construed as limiting the authority of a State to offer premium assistance under section 1906 or 1906A, a waiver described in paragraph (2)(B) or (3), a waiver approved under section 1115, or other authority in effect prior to the date of enactment of the Children's Health Insurance Program Reauthorization Act of 2009.
(K)

Notice of availability.—
If a State elects to provide premium assistance subsidies in accordance with this paragraph, the State shall—
(i)
include on any application or enrollment form for child health assistance a notice of the availability of premium assistance subsidies for the enrollment of targeted low-income children in qualified employer-sponsored coverage;
(ii)
provide, as part of the application and enrollment process under the State child health plan, information describing the availability of such subsidies and how to elect to obtain such a subsidy; and
(iii)
establish such other procedures as the State determines necessary to ensure that parents are fully informed of the choices for receiving child health assistance under the State child health plan or through the receipt of premium assistance subsidies.
(L)

Application to qualified employer-sponsored benchmark coverage.—
If a group health plan or health insurance coverage offered through an employer is certified by an actuary as health benefits coverage that is equivalent to the benefits coverage in a benchmark benefit package described in section 2103(b) or benchmark-equivalent coverage that meets the requirements of section 2103(a)(2), the State may provide premium assistance subsidies for enrollment of targeted low-income children in such group health plan or health insurance coverage in the same manner as such subsidies are provided under this paragraph for enrollment in qualified employer-sponsored coverage, but without regard to the requirement to provide supplemental coverage for benefits and cost-sharing protection provided under the State child health plan under subparagraph (E).
(M)

Coordination with medicaid.—
In the case of a targeted low-income child who receives child health assistance through a State plan under title XIX and who voluntarily elects to receive a premium assistance subsidy under this section, the provisions of section 1906A shall apply and shall supersede any other provisions of this paragraph that are inconsistent with such section.
(11)

Enhanced payments.—
Notwithstanding subsection (b), the enhanced FMAP with respect to payments under subsection (a) for expenditures related to the administration of the payment error rate measurement (PERM) requirements applicable to the State child health plan in accordance with the subchapter IV of chapter 33 of title 31, United States Code and parts 431 and 457 of title 42, Code of Federal Regulations (or any related or successor guidance or regulations) shall in no event be less than 90 percent.
(12)

Temporary enhanced payment for coverage and administration of covid–19 vaccines.—
During the period described in section 1905(hh)(2), notwithstanding subsection (b), the enhanced FMAP for a State, with respect to payments under subsection (a) for expenditures under the State child health plan (or a waiver of such plan) for a vaccine described in section 1905(a)(4)(E) (and the administration of such a vaccine), shall be equal to 100 percent.
(d)

Maintenance of Effort.—
(1)

In medicaid eligibility standards.—
No payment may be made under subsection (a) with respect to child health assistance provided under a State child health plan if the State adopts income and resource standards and methodologies for purposes of determining a child's eligibility for medical assistance under the State plan under title XIX that are more restrictive than those applied as of June 1, 1997, except as required under section 1902(e)(14).
(2)

In amounts of payment expended for certain state-funded health insurance programs for children.—
(A)

In general.—
The amount of the allotment for a State in a fiscal year (beginning with fiscal year 1999) shall be reduced by the amount by which—
(i)
the total of the State children's health insurance expenditures in the preceding fiscal year, is less than
(ii)
the total of such expenditures in fiscal year 1996.
(B)

State children's health insurance expenditures.—
The term “State children's health insurance expenditures” means the following:
(i)
The State share of expenditures under this title.
(ii)
The State share of expenditures under title XIX that are attributable to an enhanced FMAP under the fourth sentence of section 1905(b).
(iii)
State expenditures under health benefits coverage under an existing comprehensive State-based program, described in section 2103(d).
(3)

Continuation of eligibility standards for children through september 30, 2029.—
(A)

In general.—
During the period that begins on the date of enactment of the Patient Protection and Affordable Care Act and ends on September 30, 2029, as a condition of receiving payments under section 1903(a), a State shall not have in effect eligibility standards, methodologies, or procedures under its State child health plan (including any waiver under such plan) for children (including children provided medical assistance for which payment is made under section 2105(a)(1)(A)) that are more restrictive than the eligibility standards, methodologies, or procedures, respectively, under such plan (or waiver) as in effect on the date of enactment of that Act. During the period that begins on October 1, 2019, and ends on September 30, 2029, the preceding sentence shall only apply with respect to children in families whose income does not exceed 300 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved. The preceding sentences shall not be construed as preventing a State during any such periods from—
(i)
applying eligibility standards, methodologies, or procedures for children under the State child health plan or under any waiver of the plan that are less restrictive than the eligibility standards, methodologies, or procedures, respectively, for children under the plan or waiver that are in effect on the date of enactment of such Act;
(ii)
after September 30, 2015, enrolling children eligible to be targeted low-income children under the State child health plan in a qualified health plan that has been certified by the Secretary under subparagraph (C); or
(iii)
imposing a limitation described in section 2112(b)(7) for a fiscal year in order to limit expenditures under the State child health plan to those for which Federal financial participation is available under this section for the fiscal year.
(B)

Assurance of exchange coverage for targeted low-income children unable to be provided child health assistance as a result of funding shortfalls.—
In the event that allotments provided under section 2104 are insufficient to provide coverage to all children who are eligible to be targeted low-income children under the State child health plan under this title, a State shall establish procedures to ensure that such children are screened for eligibility for medical assistance under the State plan under title XIX or a waiver of that plan and, if found eligible, enrolled in such plan or a waiver. In the case of such children who, as a result of such screening, are determined to not be eligible for medical assistance under the State plan or a waiver under title XIX, the State shall establish procedures to ensure that the children are enrolled in a qualified health plan that has been certified by the Secretary under subparagraph (C) and is offered through an Exchange established by the State under section 1311 of the Patient Protection and Affordable Care Act. For purposes of eligibility for premium assistance for the purchase of a qualified health plan under section 36B of the Internal Revenue Code of 1986 and reduced cost-sharing under section 1402 of the Patient Protection and Affordable Care Act, children described in the preceding sentence shall be deemed to be ineligible for coverage under the State child health plan.
(C)

Certification of comparability of pediatric coverage offered by qualified health plans.—
With respect to each State, the Secretary, not later than April 1, 2015, shall review the benefits offered for children and the cost-sharing imposed with respect to such benefits by qualified health plans offered through an Exchange established by the State under section 1311 of the Patient Protection and Affordable Care Act and shall certify those plans that offer benefits for children and impose cost-sharing with respect to such benefits that the Secretary determines are at least comparable to the benefits offered and cost-sharing protections provided under the State child health plan.
(e)

Advance Payment; Retrospective Adjustment.—
The Secretary may make payments under this section for each quarter on the basis of advance estimates of expenditures submitted by the State and such other investigation as the Secretary may find necessary, and may reduce or increase the payments as necessary to adjust for any overpayment or underpayment for prior quarters.
(f)

Flexibility in Submittal of Claims.—
Nothing in this section or subsections (e) and (f) of section 2104 shall be construed as preventing a State from claiming as expenditures in the quarter expenditures that were incurred in a previous quarter.
(g)

Authority for Qualifying States To Use Certain Funds for Medicaid Expenditures.—
(1)

State option.—
(A)

In general.—
Notwithstanding any other provision of law, subject to paragraph (4), a qualifying State (as defined in paragraph (2)) may elect to use not more than 20 percent of any allotment under section 2104 for fiscal year 1998, 1999, 2000, 2001, 2004, 2005, 2006, 2007, or 2008 (insofar as it is available under subsections (e) and (g) of such section) for payments under title XIX in accordance with subparagraph (B), instead of for expenditures under this title.
(B)

Payments to states.—
(i)

In general.—
In the case of a qualifying State that has elected the option described in subparagraph (A), subject to the availability of funds under such subparagraph with respect to the State, the Secretary shall pay the State an amount each quarter equal to the additional amount that would have been paid to the State under title XIX with respect to expenditures described in clause (ii) if the enhanced FMAP (as determined under subsection (b)) had been substituted for the Federal medical assistance percentage (as defined in section 1905(b)).
(ii)

Expenditures described.—
For purposes of this subparagraph, the expenditures described in this clause are expenditures, made after the date of the enactment of this subsection and during the period in which funds are available to the qualifying State for use under subparagraph (A), for medical assistance under title XIX to individuals who have not attained age 19 and whose family income exceeds 150 percent of the poverty line.
(iii)

No impact on determination of budget neutrality for waivers.—
In the case of a qualifying State that uses amounts paid under this subsection for expenditures described in clause (ii) that are incurred under a waiver approved for the State, any budget neutrality determinations with respect to such waiver shall be determined without regard to such amounts paid.
(2)

Qualifying state.—
In this subsection, the term “qualifying State” means a State that, on and after April 15, 1997, has an income eligibility standard that is at least 184 percent of the poverty line with respect to any 1 or more categories of children (other than infants) who are eligible for medical assistance under section 1902(a)(10)(A) or, in the case of a State that has a statewide waiver in effect under section 1115 with respect to title XIX that was first implemented on August 1, 1994, or July 1, 1995, has an income eligibility standard under such waiver for children that is at least 185 percent of the poverty line, or, in the case of a State that has a statewide waiver in effect under section 1115 with respect to title XIX that was first implemented on January 1, 1994, has an income eligibility standard under such waiver for children who lack health insurance that is at least 185 percent of the poverty line, or, in the case of a State that had a statewide waiver in effect under section 1115 with respect to title XIX that was first implemented on October 1, 1993, had an income eligibility standard under such waiver for children that was at least 185 percent of the poverty line and on and after July 1, 1998, has an income eligibility standard for children under section 1902(a)(10)(A) or a statewide waiver in effect under section 1115 with respect to title XIX that is at least 185 percent of the poverty line.
(3)

Construction.—
Nothing in paragraphs (1) and (2) shall be construed as modifying the requirements applicable to States implementing State child health plans under this title.
(4)

Option for allotments for fiscal years 2009 through 2029.—
(A)

Payment of enhanced portion of matching rate for certain expenditures.—
In the case of expenditures described in subparagraph (B), a qualifying State (as defined in paragraph (2)) may elect to be paid from the State's allotment made under section 2104 for any of fiscal years 2009 through 2029 (insofar as the allotment is available to the State under subsections (e) and (m) of such section) an amount each quarter equal to the additional amount that would have been paid to the State under title XIX with respect to such expenditures if the enhanced FMAP (as determined under subsection (b)) had been substituted for the Federal medical assistance percentage (as defined in section 1905(b)).
(B)

Expenditures described.—
For purposes of subparagraph (A), the expenditures described in this subparagraph are expenditures made after the date of the enactment of this paragraph and during the period in which funds are available to the qualifying State for use under subparagraph (A), for the provision of medical assistance to individuals residing in the State who are eligible for medical assistance under the State plan under title XIX or under a waiver of such plan and who have not attained age 19 (or, if a State has so elected under the State plan under title XIX, age 20 or 21), and whose family income equals or exceeds 133 percent of the poverty line but does not exceed the Medicaid applicable income level.
(h)

Rural Health Transformation Program.—
(1)

Appropriation.—
(A)

In general.—
There are appropriated, out of any money in the Treasury not otherwise appropriated, to the Administrator of the Centers for Medicare & Medicaid Services (in this subsection referred to as the “Administrator”), to provide allotments to States for purposes of carrying out the activities described in paragraph (6)—
(i)
$10,000,000,000 for fiscal year 2026;
(ii)
$10,000,000,000 for fiscal year 2027;
(iii)
$10,000,000,000 for fiscal year 2028;
(iv)
$10,000,000,000 for fiscal year 2029; and
(v)
$10,000,000,000 for fiscal year 2030.
(B)

Unexpended or unobligated funds.—
(i)

In general.—
Any amounts appropriated under subparagraph (A) that are unexpended or unobligated as of October 1, 2032, shall be returned to the Treasury of the United States.
(ii)

Redistribution of unexpended or unobligated funds.—
In carrying out subparagraph (A), the Administrator shall, not later than March 31, 2028, and annually thereafter through March 31, 2032, determine the amount of funds, if any, that are available under such subparagraph for a previous fiscal year, are unexpended or unobligated with respect to such fiscal year, and will not be available to a State in the current fiscal year, pursuant to clause (iii).
(iii)

Availability of funds.—
(I)

In general.—
Amounts allotted to a State under this subsection for a year shall be available for expenditure by the State through the end of the fiscal year following the fiscal year in which such amounts are allotted.
(II)

Availability of amounts redistributed.—
Amounts redistributed to a State under clause (ii) with respect to a fiscal year shall be available for expenditure by the State through the end of the fiscal year following the fiscal year in which such amounts are redistributed (except in the case of amounts redistributed in fiscal year 2032 which shall only be available for expenditure through September 30, 2032).
(iv)

Misuse of funds.—
If the Administrator determines that a State is not using amounts allotted or redistributed to the State under this subsection in a manner consistent with the description provided by the State in its application approved under paragraph (2), the Administrator may withhold payments to, or reduce payments to, or recover previous payments from, the State under this subsection as the Administrator deems appropriate, and any amounts so withheld, or that remain after any such reduction, or so recovered, shall be returned to the Treasury of the United States.
(2)

Application.—
(A)

In general.—
To be eligible for an allotment under this subsection, a State shall submit to the Administrator during an application submission period to be specified by the Administrator (but that ends not later than December 31, 2025) an application in such form and manner as the Administrator may specify, that includes—
(i)
a detailed rural health transformation plan—
(I)
to improve access to hospitals, other health care providers, and health care items and services furnished to rural residents of the State;
(II)
to improve health care outcomes of rural residents of the State;
(III)
to prioritize the use of new and emerging technologies that emphasize prevention and chronic disease management;
(IV)
to initiate, foster, and strengthen local and regional strategic partnerships between rural hospitals and other health care providers in order to promote measurable quality improvement, increase financial stability, maximize economies of scale, and share best practices in care delivery;
(V)
to enhance economic opportunity for, and the supply of, health care clinicians through enhanced recruitment and training;
(VI)
to prioritize data and technology driven solutions that help rural hospitals and other rural health care providers furnish high-quality health care services as close to a patient's home as is possible;
(VII)
that outlines strategies to manage long-term financial solvency and operating models of rural hospitals in the State; and
(VIII)
that identifies specific causes driving the accelerating rate of stand-alone rural hospitals becoming at risk of closure, conversion, or service reduction;
(ii)
a certification that none of the amounts provided under this subsection shall be used by the State for an expenditure that is attributable to an intergovernmental transfer, certified public expenditure, or any other expenditure to finance the non-Federal share of expenditures required under any provision of law, including under the State plan established under this title, the State plan established under title XIX, or under a waiver of such plans; and
(iii)
such other information as the Administrator may require.
(B)

Deadline for approval.—
Not later than December 31, 2025, the Administrator shall approve or deny all applications submitted for an allotment under this subsection.
(C)

One-time application.—
If an application of a State for an allotment under this subsection is approved by the Administrator, the State shall be eligible for an allotment under this subsection for each of fiscal years 2026 through 2030, except as provided in paragraph (1)(B)(iv).
(D)

Eligibility.—
Only the 50 States shall be eligible for an allotment under this subsection and all references in this subsection to a State shall be treated as only referring to the 50 States.
(3)

Allotments.—
(A)

In general.—
For each of fiscal years 2026 through 2030, the Administrator shall determine under subparagraph (B) the amount of the allotment for such fiscal year for each State with an approved application under this subsection.
(B)

Amount determined.—
Subject to subparagraph (C), from the amounts appropriated under paragraph (1)(A) for each of fiscal years 2026 through 2030, the Administrator shall allot—
(i)
50 percent of the amounts appropriated for each such fiscal year equally among all States with an approved application under this subsection; and
(ii)
50 percent of the amounts appropriated for each such fiscal year among all such States in an amount to be determined by the Administrator in accordance with subparagraph (C).
(C)

Requirements.—
In determining the amount to be allotted to a State under clause (ii) of subparagraph (B) for a fiscal year, the Administrator shall—
(i)
ensure that not less than ¼ of the States with an approved application under this subsection for a fiscal year are allotted funds from amounts that are to be allotted under clause (ii) of such subparagraph; and
(ii)
consider—
(I)
the percentage of the State population that is located in a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 Fed. Reg. 6725));
(II)
the proportion of rural health facilities (as defined in subparagraph (D)) in the State relative to the number of rural health facilities nationwide;
(III)
the situation of hospitals in the State, as described in section 1902(a)(13)(A)(iv); and
(IV)
any other factors that the Administrator determines appropriate.
(D)

Rural health facility defined.—
For the purposes of subparagraph (C)(ii), the term “rural health facility” means the following:
(i)
A subsection (d) hospital (as defined in paragraph (1)(B) of section 1886(d)) that—
(I)
is located in a rural area (as defined in paragraph (2)(D) of such section);
(II)
is treated as being located in a rural area pursuant to paragraph (8)(E) of such section; or
(III)
is located in a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 Fed. Reg. 6725)).
(ii)
A critical access hospital (as defined in section 1861(mm)(1)).
(iii)
A sole community hospital (as defined in section 1886(d)(5)(D)(iii)).
(iv)
A Medicare-dependent, small rural hospital (as defined in section 1886(d)(5)(G)(iv)).
(v)
A low-volume hospital (as defined in section 1886(d)(12)(C)).
(vi)
A rural emergency hospital (as defined in section 1861(kkk)(2)).
(vii)
A rural health clinic (as defined in section 1861(aa)(2)).
(viii)
A Federally qualified health center (as defined in section 1861(aa)(4)).
(ix)
A community mental health center (as defined in section 1861(ff)(3)(B)).
(x)
A health center that is receiving a grant under section 330 of the Public Health Service Act.
(xi)
An opioid treatment program (as defined in section 1861(jjj)(2)) that is located in a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 Fed. Reg. 6725)).
(xii)
A certified community behavioral health clinic (as defined in section 1905(jj)(2)) that is located in a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 Fed. Reg. 6725)).
(4)

No matching payment.—
A State approved for an allotment under this subsection for a fiscal year shall not be required to provide any matching funds as a condition for receiving payments from the allotment.
(5)

Terms and conditions.—
The Administrator shall specify such terms and conditions for allotments to States provided under this subsection as the Administrator deems appropriate, including the following:
(A)
Each State shall submit to the Administrator (at a time, and in a form and manner, specified by the Administrator)—
(i)
a plan for the State to use its allotment to carry out 3 or more of the activities described in paragraph (6); and
(ii)
annual reports on the use of allotments, including such additional information as the Administrator determines appropriate.
(B)
Not more than 10 percent of the amount allotted to a State for a fiscal year may be used by the State for administrative expenses.
(6)

Use of funds.—
Amounts allotted to a State under this subsection shall be used for 3 or more of the following health-related activities:
(A)
Promoting evidence-based, measurable interventions to improve prevention and chronic disease management.
(B)
Providing payments to health care providers for the provision of health care items or services, as specified by the Administrator.
(C)
Promoting consumer-facing, technology-driven solutions for the prevention and management of chronic diseases.
(D)
Providing training and technical assistance for the development and adoption of technology-enabled solutions that improve care delivery in rural hospitals, including remote monitoring, robotics, artificial intelligence, and other advanced technologies.
(E)
Recruiting and retaining clinical workforce talent to rural areas, with commitments to serve rural communities for a minimum of 5 years.
(F)
Providing technical assistance, software, and hardware for significant information technology advances designed to improve efficiency, enhance cybersecurity capability development, and improve patient health outcomes.
(G)
Assisting rural communities to right size their health care delivery systems by identifying needed preventative, ambulatory, pre-hospital, emergency, acute inpatient care, outpatient care, and post-acute care service lines.
(H)
Supporting access to opioid use disorder treatment services (as defined in section 1861(jjj)(1)), other substance use disorder treatment services, and mental health services.
(I)
Developing projects that support innovative models of care that include value-based care arrangements and alternative payment models, as appropriate.
(J)
Additional uses designed to promote sustainable access to high quality rural health care services, as determined by the Administrator.
(7)

Exemptions.—
Paragraphs (2), (3), (5), (6), (8), (10), (11), and (12) of subsection (c) do not apply to payments under this subsection.
(8)

Review.—
There shall be no administrative or judicial review under section 1116 or otherwise of amounts allotted or redistributed to States under this subsection, payments to States withheld or reduced under this subsection, or previous payments recovered from States under this subsection.
(9)

Health care provider defined.—
For purposes of this subsection, the term “health care provider” means a provider of services or supplier who is enrolled under this title, title XVIII, or title XIX.
SEC. 2106.
[42 U.S.C. 1397ff]

PROCESS FOR SUBMISSION, APPROVAL, AND AMENDMENT OF STATE CHILD HEALTH PLANS.
(a)

Initial Plan.—
(1)

In general.—
As a condition of receiving payment under subsection (a) or (g) of section 2105, a State shall submit to the Secretary a State child health plan that meets the applicable requirements of this title.
(2)

Approval.—
Except as the Secretary may provide under subsection (e), a State plan submitted under paragraph (1)—
(A)
shall be approved for purposes of this title, and
(B)
shall be effective beginning with a calendar quarter that is specified in the plan, but in no case earlier than October 1, 1997.
(b)

Plan Amendments.—
(1)

In general.—
A State may amend, in whole or in part, its State child health plan at any time through transmittal of a plan amendment.
(2)

Approval.—
Except as the Secretary may provide under subsection (e), an amendment to a State plan submitted under paragraph (1)—
(A)
shall be approved for purposes of this title, and
(B)
shall be effective as provided in paragraph (3).
(3)

Effective dates for amendments.—
(A)

In general.—
Subject to the succeeding provisions of this paragraph, an amendment to a State plan shall take effect on one or more effective dates specified in the amendment.
(B)

Amendments relating to eligibility or benefits.—
(i)

Notice requirement.—
Any plan amendment that eliminates or restricts eligibility or benefits under the plan may not take effect unless the State certifies that it has provided prior public notice of the change, in a form and manner provided under applicable State law.
(ii)

Timely transmittal.—
Any plan amendment that eliminates or restricts eligibility or benefits under the plan shall not be effective for longer than a 60-day period unless the amendment has been transmitted to the Secretary before the end of such period.
(C)

Other amendments.—
Any plan amendment that is not described in subparagraph (B) and that becomes effective in a State fiscal year may not remain in effect after the end of such fiscal year (or, if later, the end of the 90-day period on which it becomes effective) unless the amendment has been transmitted to the Secretary.
(c)

Disapproval of Plans and Plan Amendments.—
(1)

Prompt review of plan submittals.—
The Secretary shall promptly review State plans and plan amendments submitted under this section to determine if they substantially comply with the requirements of this title.
(2)

90-day approval deadlines.—
A State plan or plan amendment is considered approved unless the Secretary notifies the State in writing, within 90 days after receipt of the plan or amendment, that the plan or amendment is disapproved (and the reasons for disapproval) or that specified additional information is needed.
(3)

Correction.—
In the case of a disapproval of a plan or plan amendment, the Secretary shall provide a State with a reasonable opportunity for correction before taking financial sanctions against the State on the basis of such disapproval.
(d)

Program Operation.—
(1)

In general.—
The State shall conduct the program in accordance with the plan (and any amendments) approved under subsection (c) and with the requirements of this title.
(2)

Violations.—
The Secretary shall establish a process for enforcing requirements under this title. Such process shall provide for the withholding of funds in the case of substantial noncompliance with such requirements. In the case of an enforcement action against a State under this paragraph, the Secretary shall provide a State with a reasonable opportunity for correction before taking financial sanctions against the State on the basis of such an action.
(e)

Continued Approval.—
An approved State child health plan shall continue in effect unless and until the State amends the plan under subsection (b) or the Secretary finds, under subsection (d), substantial noncompliance of the plan with the requirements of this title.
SEC. 2107.
[42 U.S.C. 1397gg]

STRATEGIC OBJECTIVES AND PERFORMANCE GOALS; PLAN ADMINISTRATION.
(a)

Strategic Objectives and Performance Goals.—
(1)

Description.—
A State child health plan shall include a description of—
(A)
the strategic objectives,
(B)
the performance goals, and
(C)
the performance measures,
the State has established for providing child health assistance to targeted low-income children under the plan and otherwise for maximizing health benefits coverage for other low-income children and children generally in the State.
(2)

Strategic objectives.—
Such plan shall identify specific strategic objectives relating to increasing the extent of creditable health coverage among targeted low-income children and other low-income children.
(3)

Performance goals.—
Such plan shall specify one or more performance goals for each such strategic objective so identified.
(4)

Performance measures.—
Such plan shall describe how performance under the plan will be—
(A)
measured through objective, independently verifiable means, and
(B)
compared against performance goals, in order to determine the State's performance under this title.
(b)

Records, Reports, Audits, and Evaluation.—
(1)

Data collection, records, and reports.—
A State child health plan shall include an assurance that the State will collect the data, maintain the records, and furnish the reports to the Secretary, at the times and in the standardized format the Secretary may require in order to enable the Secretary to monitor State program administration and compliance and to evaluate and compare the effectiveness of State plans under this title.
(2)

State assessment and study.—
A State child health plan shall include a description of the State's plan for the annual assessments and reports under section 2108(a) and the evaluation required by section 2108(b).
(3)

Audits.—
A State child health plan shall include an assurance that the State will afford the Secretary access to any records or information relating to the plan for the purposes of review or audit.
(c)

Program Development Process.—
A State child health plan shall include a description of the process used to involve the public in the design and implementation of the plan and the method for ensuring ongoing public involvement.
(d)

Program Budget.—
A State child health plan shall include a description of the budget for the plan. The description shall be updated periodically as necessary and shall include details on the planned use of funds and the sources of the non-Federal share of plan expenditures, including any requirements for cost-sharing by beneficiaries.
(e)

Application of Certain General Provisions.—
The following sections of this Act shall apply to States under this title in the same manner as they apply to a State under title XIX:
(1)

Title xix provisions.—
(A)
Section 1902(a)(4)(C) (relating to conflict of interest standards).
(B)
Section 1902(a)(25) (relating to third party liability).
(C)
Section 1902(a)(39) (relating to termination of participation of certain providers).
(D)
Section 1902(a)(78) (relating to enrollment of providers participating in State plans providing medical assistance on a fee-for-service basis).
(E)
Section 1902(a)(72) (relating to limiting FQHC contracting for provision of dental services).
(F)
Section 1902(a)(73) (relating to requiring certain States to seek advice from designees of Indian Health Programs and Urban Indian Organizations).
(G)
Subsections (a)(77) and (kk) of section 1902 (relating to provider and supplier screening, oversight, and reporting requirements)and subsection (a)(83) of section 1902 (relating to searchable directories of the providers described in subsection (mm) of such section).
(H)
Section 1902(a)(88) (relating to address information for enrollees and prevention of simultaneous enrollments).
(I)
Section 1902(e)(13) (relating to the State option to rely on findings from an Express Lane agency to help evaluate a child's eligibility for medical assistance).
(J)
Section 1902(e)(14) (relating to income determined using modified adjusted gross income and household income).
(K)
Paragraphs (5) and (16) of section 1902(e) (relating to the State option to provide medical assistance consisting of full benefits during pregnancy and throughout the 12-month postpartum period under title XIX), if the State provides child health assistance for targeted low-income children who are pregnant or to targeted low-income pregnant women and the State has elected to apply such paragraph (16) with respect to pregnant women under title XIX, the provision of assistance under the State child health plan or waiver for targeted low-income children or targeted low-income pregnant women during pregnancy and the 12-month postpartum period shall be required and not at the option of the State and shall include coverage of all items or services provided to a targeted low-income child or targeted low-income pregnant woman (as applicable) under the State child health plan or waiver).
(L)
Section 1902(e)(12) (relating to 1 year of continuous eligibility for children), except that a targeted low-income child enrolled under the State child health plan or waiver may be transferred to the Medicaid program under title XIX for the remaining duration of the 12-month continuous eligibility period, if the child becomes eligible for full benefits under title XIX during such period.
(M)
Section 1902(bb) (relating to payment for services provided by Federally-qualified health centers and rural health clinics).
(N)
Section 1902(ff) (relating to disregard of certain property for purposes of making eligibility determinations).
(O)
Paragraphs (2), (16), and (17) of section 1903(i) (relating to limitations on payment).
(P)
Section 1903(m)(3) (relating to limitation on payment with respect to managed care).
(Q)
Paragraph (4) of section 1903(v) (relating to optional coverage of categories of lawfully residing immigrant children or pregnant women), but only if the State has elected to apply such paragraph with respect to such category of children or pregnant women under title XIX.
(R)
Section 1903(v)(5) (relating to payments for medical assistance furnished to aliens), except in relation to payments for services provided under section 2105(a)(1)(D)(ii).
(S)
Section 1903(w) (relating to limitations on provider taxes and donations).
(T)
Section 1920A (relating to presumptive eligibility for children).
(U)
Subsections (a)(2)(C) (relating to Indian enrollment), (d)(5) (relating to contract requirement for managed care entities), (d)(6) (relating to enrollment of providers participating with a managed care entity), and (h) (relating to special rules with respect to Indian enrollees, Indian health care providers, and Indian managed care entities) of section 1932.
(V)
Section 1942 (relating to authorization to receive data directly relevant to eligibility determinations).
(W)
Section 1943(b) (relating to coordination with State Exchanges and the State Medicaid agency).
(2)

Title xi provisions.—
(A)
Section 1115 (relating to waiver authority).
(B)
Section 1116 (relating to administrative and judicial review), but only insofar as consistent with this title.
(C)
Section 1124 (relating to disclosure of ownership and related information).
(D)
Section 1126 (relating to disclosure of information about certain convicted individuals).
(E)
Section 1128A (relating to civil monetary penalties).
(F)
Section 1128B(d) (relating to criminal penalties for certain additional charges).
(G)
Section 1132 (relating to periods within which claims must be filed).
(f)

Limitation of Waiver Authority.—
Notwithstanding subsection (e)(2)(A) and section 1115(a)(1):
(1)
The Secretary may not approve a waiver, experimental, pilot, or demonstration project that would allow funds made available under this title to be used to provide child health assistance or other health benefits coverage to a nonpregnant childless adult or a parent (as defined in section 2111(c)(2)(A)), who is not pregnant, of a targeted low-income child.
(2)
The Secretary may not approve, extend, renew, or amend a waiver, experimental, pilot, or demonstration project with respect to a State after the date of enactment of the Children's Health Insurance Program Reauthorization Act of 2009 that would waive or modify the requirements of section 2111.
(g)

Use of Blended Risk Pools.—
(1)

In general.—
Nothing in this title (or any other provision of Federal law) shall be construed as preventing a State from considering children enrolled in a qualified CHIP look-alike program and children enrolled in a State child health plan under this title (or a waiver of such plan) as members of a single risk pool.
(2)

Qualified chip look-alike program.—
In this subsection, the term “qualified CHIP look-alike program” means a State program—
(A)
under which children who are under the age of 19 and are not eligible to receive medical assistance under title XIX or child health assistance under this title may purchase coverage through the State that provides benefits that are at least identical to the benefits provided under the State child health plan under this title (or a waiver of such plan); and
(B)
that is funded exclusively through non-Federal funds, including funds received by the State in the form of premiums for the purchase of such coverage.
SEC. 2108.
[42 U.S.C. 1397hh]

ANNUAL REPORTS; EVALUATIONS.
(a)

Annual Report.—
Subject to subsection (e), the State shall—
(1)
assess the operation of the State plan under this title in each fiscal year, including the progress made in reducing the number of uncovered low-income children; and
(2)
report to the Secretary, by January 1 following the end of the fiscal year, on the result of the assessment.
(b)

State Evaluations.—
(1)

In general.—
By March 31, 2000, each State that has a State child health plan shall submit to the Secretary an evaluation that includes each of the following:
(A)
An assessment of the effectiveness of the State plan in increasing the number of children with creditable health coverage.
(B)
A description and analysis of the effectiveness of elements of the State plan, including—
(i)
the characteristics of the children and families assisted under the State plan including age of the children, family income, and the assisted child's access to or coverage by other health insurance prior to the State plan and after eligibility for the State plan ends,
(ii)
the quality of health coverage provided including the types of benefits provided,
(iii)
the amount and level (including payment of part or all of any premium) of assistance provided by the State,
(iv)
the service area of the State plan,
(v)
the time limits for coverage of a child under the State plan,
(vi)
the State's choice of health benefits coverage and other methods used for providing child health assistance, and
(vii)
the sources of non-Federal funding used in the State plan.
(C)
An assessment of the effectiveness of other public and private programs in the State in increasing the availability of affordable quality individual and family health insurance for children.
(D)
A review and assessment of State activities to coordinate the plan under this title with other public and private programs providing health care and health care financing, including medicaid and maternal and child health services.
(E)
An analysis of changes and trends in the State that affect the provision of accessible, affordable, quality health insurance and health care to children.
(F)
A description of any plans the State has for improving the availability of health insurance and health care for children.
(G)
Recommendations for improving the program under this title.
(H)
Any other matters the State and the Secretary consider appropriate.
(2)

Report of the secretary.—
The Secretary shall submit to Congress and make available to the public by December 31, 2001, a report based on the evaluations submitted by States under paragraph (1), containing any conclusions and recommendations the Secretary considers appropriate.
(c)

Federal Evaluation.—
(1)

In general.—
The Secretary, directly or through contracts or interagency agreements, shall conduct an independent evaluation of 10 States with approved child health plans.
(2)

Selection of states.—
In selecting States for the evaluation conducted under this subsection, the Secretary shall choose 10 States that utilize diverse approaches to providing child health assistance, represent various geographic areas (including a mix of rural and urban areas), and contain a significant portion of uncovered children.
(3)

Matters included.—
In addition to the elements described in subsection (b)(1), the evaluation conducted under this subsection shall include each of the following:
(A)
Surveys of the target population (enrollees, disenrollees, and individuals eligible for but not enrolled in the program under this title).
(B)
Evaluation of effective and ineffective outreach and enrollment practices with respect to children (for both the program under this title and the medicaid program under title XIX), and identification of enrollment barriers and key elements of effective outreach and enrollment practices, including practices (such as through community health workers and others) that have successfully enrolled hard-to-reach populations such as children who are eligible for medical assistance under title XIX but have not been enrolled previously in the medicaid program under that title.
(C)
Evaluation of the extent to which State medicaid eligibility practices and procedures under the medicaid program under title XIX are a barrier to the enrollment of children under that program, and the extent to which coordination (or lack of coordination) between that program and the program under this title affects the enrollment of children under both programs.
(D)
An assessment of the effect of cost-sharing on utilization, enrollment, and coverage retention.
(E)
Evaluation of disenrollment or other retention issues, such as switching to private coverage, failure to pay premiums, or barriers in the recertification process.
(4)

Submission to congress.—
Not later than December 31, 2001, the Secretary shall submit to Congress the results of the evaluation conducted under this subsection.
(5)

Subsequent evaluation using updated information.—
(A)

In general.—
The Secretary, directly or through contracts or interagency agreements, shall conduct an independent subsequent evaluation of 10 States with approved child health plans.
(B)

Selection of states and matters included.—
Paragraphs (2) and (3) shall apply to such subsequent evaluation in the same manner as such provisions apply to the evaluation conducted under paragraph (1).
(C)

Submission to congress.—
Not later than December 31, 2011, the Secretary shall submit to Congress the results of the evaluation conducted under this paragraph.
(D)

Funding.—
Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated $10,000,000 for fiscal year 2010 for the purpose of conducting the evaluation authorized under this paragraph. Amounts appropriated under this subparagraph shall remain available for expenditure through fiscal year 2012.
(d)5

Access to Records for IG and GAO Audits and Evaluations.—
For the purpose of evaluating and auditing the program established under this title, or title XIX, the Secretary, the Office of Inspector General, and the Comptroller General shall have access to any books, accounts, records, correspondence, and other documents that are related to the expenditure of Federal funds under this title and that are in the possession, custody, or control of States receiving Federal funds under this title or political subdivisions thereof, or any grantee or contractor of such States or political subdivisions.
^5
Subsection (e) of section 1301(e) of division G of Public Law 111–8 provides:
(e) Inspector General Audit and GAO Report on Enrollees Eligible for Medicaid.—Section 2108(d) of the Social Security Act (42 U.S.C. 1397hh(d)) is amended—
(1) in the heading by striking “and GAO Report”; and
(2) by striking paragraph (3).
The amendments made by such subsection do not execute.
(e)

Information Required for Inclusion in State Annual Report.—
The State shall include the following information in the annual report required under subsection (a):
(1)
Eligibility criteria, enrollment, and retention data (including data with respect to continuity of coverage or duration of benefits).
(2)
Data regarding the extent to which the State uses process measures with respect to determining the eligibility of children under the State child health plan, including measures such as 12-month continuous eligibility, self-declaration of income for applications or renewals, or presumptive eligibility.
(3)
Data regarding denials of eligibility and redeterminations of eligibility.
(4)
Data regarding access to primary and specialty services, access to networks of care, and care coordination provided under the State child health plan, using quality care and consumer satisfaction measures included in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.
(5)
If the State provides child health assistance in the form of premium assistance for the purchase of coverage under a group health plan, data regarding the provision of such assistance, including the extent to which employer-sponsored health insurance coverage is available for children eligible for child health assistance under the State child health plan, the range of the monthly amount of such assistance provided on behalf of a child or family, the number of children or families provided such assistance on a monthly basis, the income of the children or families provided such assistance, the benefits and cost-sharing protection provided under the State child health plan to supplement the coverage purchased with such premium assistance, the effective strategies the State engages in to reduce any administrative barriers to the provision of such assistance, and, the effects, if any, of the provision of such assistance on preventing the coverage provided under the State child health plan from substituting for coverage provided under employer-sponsored health insurance offered in the State.
(6)
To the extent applicable, a description of any State activities that are designed to reduce the number of uncovered children in the State, including through a State health insurance connector program or support for innovative private health coverage initiatives.
(7)6
Data collected and reported in accordance with section 3101 of the Public Health Service Act, with respect to individuals enrolled in the State child health plan (and, in the case of enrollees under 19 years of age, their parents or legal guardians), including data regarding the primary language of such individuals, parents, and legal guardians.
^6
Section 4302(b)(1)(B) of Public Law 111–148 provides for an amendment to add a new paragraph (7) at the end of section 2108(e). It did not specify to which version of subsection (e) to carry out this amendment but was executed to the first subsection (e) in order to reflect the probable intent of Congress.
(e)7

Information on Dental Care for Children.—
^7
So in law. Section 501(e)(2) of Public Law 111–3 added a second subsection (e) to this section.
(1)

In general.—
Each annual report under subsection (a) shall include the following information with respect to care and services described in section 1905(r)(3) provided to targeted low-income children enrolled in the State child health plan under this title at any time during the year involved:
(A)
The number of enrolled children by age grouping used for reporting purposes under section 1902(a)(43).
(B)
For children within each such age grouping, information of the type contained in questions 12(a)–(c) of CMS Form 416 (that consists of the number of enrolled targeted low income children who receive any, preventive, or restorative dental care under the State plan).
(C)
For the age grouping that includes children 8 years of age, the number of such children who have received a protective sealant on at least one permanent molar tooth.
(2)

Inclusion of information on enrollees in managed care plans.—
The information under paragraph (1) shall include information on children who are enrolled in managed care plans and other private health plans and contracts with such plans under this title shall provide for the reporting of such information by such plans to the State.
SEC. 2109.
[42 U.S.C. 1397ii]

MISCELLANEOUS PROVISIONS.
(a)

Relation to Other Laws.—
(1)

HIPAA.—
Health benefits coverage provided under section 2101(a)(1) (and coverage provided under a waiver under section 2105(c)(2)(B)) shall be treated as creditable coverage for purposes of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974, title XXVII of the Public Health Service Act, and subtitle K of the Internal Revenue Code of 1986.
(2)

ERISA.—
Nothing in this title shall be construed as affecting or modifying section 514 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1144) with respect to a group health plan (as defined in section 2791(a)(1) of the Public Health Service Act (42 U.S.C. 300gg–91(a)(1))).
(b)

Adjustment to Current Population Survey To Include State-by-State Data Relating to Children Without Health Insurance Coverage.—
(1)

In general.—
The Secretary of Commerce shall make appropriate adjustments to the annual Current Population Survey conducted by the Bureau of the Census in order to produce statistically reliable annual State data on the number of low-income children who do not have health insurance coverage, so that real changes in the uninsurance rates of children can reasonably be detected. The Current Population Survey should produce data under this subsection that categorizes such children by family income, age, and race or ethnicity. The adjustments made to produce such data shall include, where appropriate, expanding the sample size used in the State sampling units, expanding the number of sampling units in a State, and an appropriate verification element.
(2)

Additional requirements.—
In addition to making the adjustments required to produce the data described in paragraph (1), with respect to data collection occurring for fiscal years beginning with fiscal year 2009, in appropriate consultation with the Secretary of Health and Human Services, the Secretary of Commerce shall do the following:
(A)
Make appropriate adjustments to the Current Population Survey to develop more accurate State-specific estimates of the number of children enrolled in health coverage under title XIX or this title.
(B)
Make appropriate adjustments to the Current Population Survey to improve the survey estimates used to determine a high-performing State under section 2111(b)(3)(B) and any other data necessary for carrying out this title.
(C)
Include health insurance survey information in the American Community Survey related to children.
(D)
Assess whether American Community Survey estimates, once such survey data are first available, produce more reliable estimates than the Current Population Survey with respect to the purposes described in subparagraph (B).
(E)
On the basis of the assessment required under subparagraph (D), recommend to the Secretary of Health and Human Services whether American Community Survey estimates should be used in lieu of, or in some combination with, Current Population Survey estimates for the purposes described in subparagraph (B).
(F)
Continue making the adjustments described in the last sentence of paragraph (1) with respect to expansion of the sample size used in State sampling units, the number of sampling units in a State, and using an appropriate verification element.
(3)

Authority for the secretary of health and human services to transition to the use of all, or some combination of, acs estimates upon recommendation of the secretary of commerce.—
If, on the basis of the assessment required under paragraph (2)(D), the Secretary of Commerce recommends to the Secretary of Health and Human Services that American Community Survey estimates should be used in lieu of, or in some combination with, Current Population Survey estimates for the purposes described in paragraph (2)(B), the Secretary of Health and Human Services, in consultation with the States, may provide for a period during which the Secretary may transition from carrying out such purposes through the use of Current Population Survey estimates to the use of American Community Survey estimates (in lieu of, or in combination with the Current Population Survey estimates, as recommended), provided that any such transition is implemented in a manner that is designed to avoid adverse impacts upon States with approved State child health plans under this title.
(4)

Appropriation.—
Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated $20,000,000 for fiscal year 2009 and each fiscal year thereafter for the purpose of carrying out this subsection (except that only with respect to fiscal year 2008, there are appropriated $20,000,000 for the purpose of carrying out this subsection, to remain available until expended).
SEC. 2110.
[42 U.S.C. 1397jj]

DEFINITIONS.
(a)

Child Health Assistance.—
For purposes of this title, the term “child health assistance” means payment for part or all of the cost of health benefits coverage for targeted low-income children that includes any of the following (and includes, in the case described in section 2105(a)(1)(D)(i), payment for part or all of the cost of providing any of the following), as specified under the State plan:
(1)
Inpatient hospital services.
(2)
Outpatient hospital services.
(3)
Physician services.
(4)
Surgical services.
(5)
Clinic services (including health center services) and other ambulatory health care services.
(6)
Prescription drugs and biologicals and the administration of such drugs and biologicals, only if such drugs and biologicals are not furnished for the purpose of causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a person.
(7)
Over-the-counter medications.
(8)
Laboratory and radiological services.
(9)
Prenatal care and prepregnancy family planning services and supplies.
(10)
Inpatient mental health services, other than services described in paragraph (18) but including services furnished in a State-operated mental hospital and including residential or other 24-hour therapeutically planned structured services.
(11)
Outpatient mental health services, other than services described in paragraph (19) but including services furnished in a State-operated mental hospital and including community-based services.
(12)
Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices).
(13)
Disposable medical supplies.
(14)
Home and community-based health care services and related supportive services (such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home).
(15)
Nursing care services (such as nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services) in a home, school, or other setting.
(16)
Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest.
(17)
Dental services.
(18)
Inpatient substance use treatment services and residential substance use treatment services.
(19)
Outpatient substance use treatment services.
(20)
Case management services.
(21)
Care coordination services.
(22)
Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders.
(23)
Hospice care (concurrent, in the case of an individual who is a child, with care related to the treatment of the child's condition with respect to which a diagnosis of terminal illness has been made8.
^8
Section 2302(b) of Public Law 111–148 amends paragraph (23) by inserting new language after “[h]ospice care”. The amendment probably should have been to insert such new language after “Hospice care” however, it was executed here in order to reflect the probable intent of Congress.
(24)
Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services (whether in a facility, home, school, or other setting) if recognized by State law and only if the service is—
(A)
prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as defined by State law,
(B)
performed under the general supervision or at the direction of a physician, or
(C)
furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.
(25)
Premiums for private health care insurance coverage.
(26)
Medical transportation.
(27)
Enabling services (such as transportation, translation, and outreach services) only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.
(28)
Any other health care services or items specified by the Secretary and not excluded under this section.
(b)

Targeted Low-Income Child Defined.—
For purposes of this title—
(1)

In general.—
Subject to paragraph (2), the term “targeted low-income child” means a child—
(A)
who has been determined eligible by the State for child health assistance under the State plan;
(B)
(i)
who is a low-income child, or
(ii)
is a child—
(I)
whose family income (as determined under the State child health plan) exceeds the medicaid applicable income level (as defined in paragraph (4)), but does not exceed 50 percentage points above the medicaid applicable income level;
(II)
whose family income (as so determined) does not exceed the medicaid applicable income level (as defined in paragraph (4) but determined as if “June 1, 1997” were substituted for “March 31, 1997”); or
(III)
who resides in a State that does not have a medicaid applicable income level (as defined in paragraph (4)); and
(C)
who is not found to be eligible for medical assistance under title XIX or, subject to paragraph (5), covered under a group health plan or under health insurance coverage (as such terms are defined in section 2791 of the Public Health Service Act).
(2)

Children excluded.—
Such term does not include—
(A)
except as provided in paragraph (7), a child who is an inmate of a public institution or a patient in an institution for mental diseases; or
(B)
except as provided in paragraph (6), a child who is a member of a family that is eligible for health benefits coverage under a State health benefits plan on the basis of a family member's employment with a public agency in the State.
(3)

Special rule.—
A child shall not be considered to be described in paragraph (1)(C) notwithstanding that the child is covered under a health insurance coverage program that has been in operation since before July 1, 1997, and that is offered by a State which receives no Federal funds for the program's operation.
(4)

Medicaid applicable income level.—
The term “medicaid applicable income level” means, with respect to a child, the effective income level (expressed as a percent of the poverty line) that has been specified under the State plan under title XIX (including under a waiver authorized by the Secretary or under section 1902(r)(2)), as of March 31, 1997, for the child to be eligible for medical assistance under section 1902(l)(2) or 1905(n)(2) (as selected by a State) for the age of such child.
(5)

Option for states with a separate chip program to provide dental-only supplemental coverage.—
(A)

In general.—
Subject to subparagraphs (B) and (C), in the case of any child who is enrolled in a group health plan or health insurance coverage offered through an employer who would, but for the application of paragraph (1)(C), satisfy the requirements for being a targeted low-income child under a State child health plan that is implemented under this title, a State may waive the application of such paragraph to the child in order to provide—
(i)
dental coverage consistent with the requirements of subsection (c)(6) of section 2103; or
(ii)
cost-sharing protection for dental coverage consistent with such requirements and the requirements of subsection (e)(3)(B) of such section.
(B)

Limitation.—
A State may limit the application of a waiver of paragraph (1)(C) to children whose family income does not exceed a level specified by the State, so long as the level so specified does not exceed the maximum income level otherwise established for other children under the State child health plan.
(C)

Conditions.—
A State may not offer dental-only supplemental coverage under this paragraph unless the State satisfies the following conditions:
(i)

Income eligibility.—
The State child health plan under this title—
(I)
has the highest income eligibility standard permitted under this title (or a waiver) as of January 1, 2009;
(II)
does not limit the acceptance of applications for children or impose any numerical limitation, waiting list, or similar limitation on the eligibility of such children for child health assistance under such State plan; and
(III)
provides benefits to all children in the State who apply for and meet eligibility standards.
(ii)

No more favorable treatment.—
The State child health plan may not provide more favorable dental coverage or cost-sharing protection for dental coverage to children provided dental-only supplemental coverage under this paragraph than the dental coverage and cost-sharing protection for dental coverage provided to targeted low-income children who are eligible for the full range of child health assistance provided under the State child health plan.
(6)

Exceptions to exclusion of children of employees of a public agency in the state.—
(A)

In general.—
A child shall not be considered to be described in paragraph (2)(B) if—
(i)
the public agency that employs a member of the child's family to which such paragraph applies satisfies subparagraph (B); or
(ii)
subparagraph (C) applies to such child.
(B)

Maintenance of effort with respect to agency contribution for family coverage.—
For purposes of subparagraph (A)(i), a public agency satisfies this subparagraph if the amount of annual agency expenditures made on behalf of employees enrolled in health coverage paid for by the agency that includes dependent coverage for the most recent State fiscal year is not less than the amount of such expenditures made by the agency for the 1997 State fiscal year, increased by the percentage increase in the medical care expenditure category of the Consumer Price Index for All-Urban Consumers (all items: U.S. City Average) for such preceding fiscal year.
(C)

Hardship exception.—
For purposes of subparagraph (A)(ii), this subparagraph applies to a child if the State determines that the annual aggregate amount of premiums and cost-sharing imposed for coverage of the family of the child would exceed 5 percent of such family's income for the year involved.
(7)

Exceptions to exclusion of children who are inmates of a public institution.—
In the case of a child who is an inmate of a public institution, during the 30 days prior to the release of the child from such institution the child shall not be considered to be described in paragraph (2)(A) with respect to the screenings, diagnostic services, referrals, and case management services otherwise covered under the State child health plan (or waiver of such plan) that the State is required to provide under section 2102(d)(2). At the option of the State, a child who is an inmate of a public institution shall not be considered to be described in paragraph (2)(A) during the period that the child is an inmate of such institution pending disposition of charges.
(c)

Additional Definitions.—
For purposes of this title:
(1)

Child.—
The term “child” means an individual under 19 years of age.
(2)

Creditable health coverage.—
The term “creditable health coverage” has the meaning given the term “creditable coverage” under section 2701(c) of the Public Health Service Act (42 U.S.C. 300gg(c)) and includes coverage that meets the requirements of section 2103 provided to a targeted low-income child under this title or under a waiver approved under section 2105(c)(2)(B) (relating to a direct service waiver).
(3)

Group health plan; health insurance coverage; etc.—
The terms “group health plan”, “group health insurance coverage”, and “health insurance coverage” have the meanings given such terms in section 2791 of the Public Health Service Act.
(4)

Low-income.—
The term “low-income child” means a child whose family income is at or below 200 percent of the poverty line for a family of the size involved.
(5)

Poverty line defined.—
The term “poverty line” has the meaning given such term in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section.
(6)

Preexisting condition exclusion.—
The term “preexisting condition exclusion” has the meaning given such term in section 2701(b)(1)(A) of the Public Health Service Act (42 U.S.C. 300gg(b)(1)(A)).
(7)

State child health plan; plan.—
Unless the context otherwise requires, the terms “State child health plan” and “plan” mean a State child health plan approved under section 2106.
(8)

Uncovered child.—
The term “uncovered child” means a child that does not have creditable health coverage.
(9)

School-based health center.—
(A)

In general.—
The term “school-based health center” means a health clinic that—
(i)
is located in or near a school facility of a school district or board or of an Indian tribe or tribal organization;
(ii)
is organized through school, community, and health provider relationships;
(iii)
is administered by a sponsoring facility;
(iv)
provides through health professionals primary health services to children in accordance with State and local law, including laws relating to licensure and certification; and
(v)
satisfies such other requirements as a State may establish for the operation of such a clinic.
(B)

Sponsoring facility.—
For purposes of subparagraph (A)(iii), the term “sponsoring facility” includes any of the following:
(i)
A hospital.
(ii)
A public health department.
(iii)
A community health center.
(iv)
A nonprofit health care agency.
(v)
A local educational agency (as defined under section 8101 of the Elementary and Secondary Education Act of 19659.
^9
A close parenthesis should appear after “Act of 1965”.
(vi)
A program administered by the Indian Health Service or the Bureau of Indian Affairs or operated by an Indian tribe or a tribal organization.
SEC. 2111.
[42 U.S.C. 1397kk]

PHASE-OUT OF COVERAGE FOR NONPREGNANT CHILDLESS ADULTS; CONDITIONS FOR COVERAGE OF PARENTS.
(a)

Termination of Coverage for Nonpregnant Childless Adults.—
(1)

No new chip waivers; automatic extensions at state option through 2009.—
Notwithstanding section 1115 or any other provision of this title, except as provided in this subsection—
(A)
the Secretary shall not on or after the date of the enactment of the Children's Health Insurance Program Reauthorization Act of 2009, approve or renew a waiver, experimental, pilot, or demonstration project that would allow funds made available under this title to be used to provide child health assistance or other health benefits coverage to a nonpregnant childless adult; and
(B)
notwithstanding the terms and conditions of an applicable existing waiver, the provisions of paragraph (2) shall apply for purposes of any period beginning on or after January 1, 2010, in determining the period to which the waiver applies, the individuals eligible to be covered by the waiver, and the amount of the Federal payment under this title.
(2)

Termination of chip coverage under applicable existing waivers at the end of 2009.—
(A)

In general.—
No funds shall be available under this title for child health assistance or other health benefits coverage that is provided to a nonpregnant childless adult under an applicable existing waiver after December 31, 2009.
(B)

Extension upon state request.—
If an applicable existing waiver described in subparagraph (A) would otherwise expire before January 1, 2010, notwithstanding the requirements of subsections (e) and (f) of section 1115, a State may submit, not later than September 30, 2009, a request to the Secretary for an extension of the waiver. The Secretary shall approve a request for an extension of an applicable existing waiver submitted pursuant to this subparagraph, but only through December 31, 2009.
(C)

Application of enhanced fmap.—
The enhanced FMAP determined under section 2105(b) shall apply to expenditures under an applicable existing waiver for the provision of child health assistance or other health benefits coverage to a nonpregnant childless adult during the period beginning on the date of the enactment of this subsection and ending on December 31, 2009.
(3)

State option to apply for medicaid waiver to continue coverage for nonpregnant childless adults.—
(A)

In general.—
Each State for which coverage under an applicable existing waiver is terminated under paragraph (2)(A) may submit, not later than September 30, 2009, an application to the Secretary for a waiver under section 1115 of the State plan under title XIX to provide medical assistance to a nonpregnant childless adult whose coverage is so terminated (in this subsection referred to as a “Medicaid nonpregnant childless adults waiver”).
(B)

Deadline for approval.—
The Secretary shall make a decision to approve or deny an application for a Medicaid nonpregnant childless adults waiver submitted under subparagraph (A) within 90 days of the date of the submission of the application. If no decision has been made by the Secretary as of December 31, 2009, on the application of a State for a Medicaid nonpregnant childless adults waiver that was submitted to the Secretary by September 30, 2009, the application shall be deemed approved.
(C)

Standard for budget neutrality.—
The budget neutrality requirement applicable with respect to expenditures for medical assistance under a Medicaid nonpregnant childless adults waiver shall—
(i)
in the case of fiscal year 2010, allow expenditures for medical assistance under title XIX for all such adults to not exceed the total amount of payments made to the State under paragraph (2)(B) for fiscal year 2009, increased by the percentage increase (if any) in the projected nominal per capita amount of National Health Expenditures for 2010 over 2009, as most recently published by the Secretary; and
(ii)
in the case of any succeeding fiscal year, allow such expenditures to not exceed the amount in effect under this subparagraph for the preceding fiscal year, increased by the percentage increase (if any) in the projected nominal per capita amount of National Health Expenditures for the calendar year that begins during the year involved over the preceding calendar year, as most recently published by the Secretary.
(b)

Rules and Conditions for Coverage of Parents of Targeted Low-Income Children.—
(1)

Two-year period; automatic extension at state option through fiscal year 2011.—
(A)

No new chip waivers.—
Notwithstanding section 1115 or any other provision of this title, except as provided in this subsection—
(i)
the Secretary shall not on or after the date of the enactment of the Children's Health Insurance Program Reauthorization Act of 2009 approve or renew a waiver, experimental, pilot, or demonstration project that would allow funds made available under this title to be used to provide child health assistance or other health benefits coverage to a parent of a targeted low-income child; and
(ii)
notwithstanding the terms and conditions of an applicable existing waiver, the provisions of paragraphs (2) and (3) shall apply for purposes of any fiscal year beginning on or after October 1, 2011, in determining the period to which the waiver applies, the individuals eligible to be covered by the waiver, and the amount of the Federal payment under this title.
(B)

Extension upon state request.—
If an applicable existing waiver described in subparagraph (A) would otherwise expire before October 1, 2011, and the State requests an extension of such waiver, the Secretary shall grant such an extension, but only, subject to paragraph (2)(A), through September 30, 2011.
(C)

Application of enhanced fmap.—
The enhanced FMAP determined under section 2105(b) shall apply to expenditures under an applicable existing waiver for the provision of child health assistance or other health benefits coverage to a parent of a targeted low-income child during the third and fourth quarters of fiscal year 2009 and during fiscal years 2010 and 2011.
(2)

Rules for fiscal years 2012 through 2013.—
(A)

Payments for coverage limited to block grant funded from state allotment.—
Any State that provides child health assistance or health benefits coverage under an applicable existing waiver for a parent of a targeted low-income child may elect to continue to provide such assistance or coverage through fiscal year 2012 or 2013, subject to the same terms and conditions that applied under the applicable existing waiver, unless otherwise modified in subparagraph (B).
(B)

Terms and conditions.—
(i)

Block grant set aside from state allotment.—
If the State makes an election under subparagraph (A), the Secretary shall set aside for the State for each such fiscal year an amount equal to the Federal share of 110 percent of the State's projected expenditures under the applicable existing waiver for providing child health assistance or health benefits coverage to all parents of targeted low-income children enrolled under such waiver for the fiscal year (as certified by the State and submitted to the Secretary by not later than August 31 of the preceding fiscal year). In the case of fiscal year 2013, the set aside for any State shall be computed separately for each period described in subparagraphs (A) and (B) of section 2104(a)(16) and any reduction in the allotment for either such period under section 2104(m)(5) shall be allocated on a pro rata basis to such set aside.
(ii)

Payments from block grant.—
The Secretary shall pay the State from the amount set aside under clause (i) for the fiscal year, an amount for each quarter of such fiscal year equal to the applicable percentage determined under clause (iii) or (iv) for expenditures in the quarter for providing child health assistance or other health benefits coverage to a parent of a targeted low-income child.
(iii)

Enhanced fmap only in fiscal year 2012 for states with significant child outreach or that achieve child coverage benchmarks; fmap for any other states.—
For purposes of clause (ii), the applicable percentage for any quarter of fiscal year 2012 is equal to—
(I)
the enhanced FMAP determined under section 2105(b) in the case of a State that meets the outreach or coverage benchmarks described in any of subparagraph (A), (B), or (C) of paragraph (3) for fiscal year 2011; or
(II)
the Federal medical assistance percentage (as determined under section 1905(b) without regard to clause (4) of such section) in the case of any other State.
(iv)

Amount of federal matching payment in 2013.—
For purposes of clause (ii), the applicable percentage for any quarter of fiscal year 2013 is equal to—
(I)
the REMAP percentage if—
- (aa)
the applicable percentage for the State under clause (iii) was the enhanced FMAP for fiscal year 2012; and
- (bb)
the State met either of the coverage benchmarks described in subparagraph (B) or (C) of paragraph (3) for fiscal year 2012; or
(II)
the Federal medical assistance percentage (as so determined) in the case of any State to which subclause (I) does not apply.
For purposes of subclause (I), the REMAP percentage is the percentage which is the sum of such Federal medical assistance percentage and a number of percentage points equal to one-half of the difference between such Federal medical assistance percentage and such enhanced FMAP.
(v)

No federal payments other than from block grant set aside.—
No payments shall be made to a State for expenditures described in clause (ii) after the total amount set aside under clause (i) for a fiscal year has been paid to the State.
(vi)

No increase in income eligibility level for parents.—
No payments shall be made to a State from the amount set aside under clause (i) for a fiscal year for expenditures for providing child health assistance or health benefits coverage to a parent of a targeted low-income child whose family income exceeds the income eligibility level applied under the applicable existing waiver to parents of targeted low-income children on the date of enactment of the Children's Health Insurance Program Reauthorization Act of 2009.
(3)

Outreach or coverage benchmarks.—
For purposes of paragraph (2), the outreach or coverage benchmarks described in this paragraph are as follows:
(A)

Significant child outreach campaign.—
The State—
(i)
was awarded a grant under section 2113 for fiscal year 2011;
(ii)
implemented 1 or more of the enrollment and retention provisions described in section 2105(a)(4) for such fiscal year; or
(iii)
has submitted a specific plan for outreach for such fiscal year.
(B)

High-performing state.—
The State, on the basis of the most timely and accurate published estimates of the Bureau of the Census, ranks in the lowest ⅓ of States in terms of the State's percentage of low-income children without health insurance.
(C)

State increasing enrollment of low-income children.—
The State qualified for a performance bonus payment under section 2105(a)(3)(B) for the most recent fiscal year applicable under such section.
(4)

Rules of construction.—
Nothing in this subsection shall be construed as prohibiting a State from submitting an application to the Secretary for a waiver under section 1115 of the State plan under title XIX to provide medical assistance to a parent of a targeted low-income child that was provided child health assistance or health benefits coverage under an applicable existing waiver.
(c)

Applicable Existing Waiver.—
For purposes of this section—
(1)

In general.—
The term “applicable existing waiver” means a waiver, experimental, pilot, or demonstration project under section 1115, grandfathered under section 6102(c)(3) of the Deficit Reduction Act of 2005, or otherwise conducted under authority that—
(A)
would allow funds made available under this title to be used to provide child health assistance or other health benefits coverage to—
(i)
a parent of a targeted low-income child;
(ii)
a nonpregnant childless adult; or
(iii)
individuals described in both clauses (i) and (ii); and
(B)
was in effect during fiscal year 2009.
(2)

Definitions.—
(A)

Parent.—
The term “parent” includes a caretaker relative (as such term is used in carrying out section 1931) and a legal guardian.
(B)

Nonpregnant childless adult.—
The term “nonpregnant childless adult” has the meaning given such term by section 2107(f).
SEC. 2112.
[42 U.S.C. 1397ll]

OPTIONAL COVERAGE OF TARGETED LOW-INCOME PREGNANT WOMEN THROUGH A STATE PLAN AMENDMENT.
(a)

In General.—
Subject to the succeeding provisions of this section, a State may elect through an amendment to its State child health plan under section 2102 to provide pregnancy-related assistance under such plan for targeted low-income pregnant women.
(b)

Conditions.—
A State may only elect the option under subsection (a) if the following conditions are satisfied:
(1)

Minimum income eligibility levels for pregnant women and children.—
The State has established an income eligibility level—
(A)
for pregnant women under subsection (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), or (l)(1)(A) of section 1902 that is at least 185 percent (or such higher percent as the State has in effect with regard to pregnant women under this title) of the poverty line applicable to a family of the size involved, but in no case lower than the percent in effect under any such subsection as of July 1, 2008; and
(B)
for children under 19 years of age under this title (or title XIX) that is at least 200 percent of the poverty line applicable to a family of the size involved.
(2)

No chip income eligibility level for pregnant women lower than the state's medicaid level.—
The State does not apply an effective income level for pregnant women under the State plan amendment that is lower than the effective income level (expressed as a percent of the poverty line and considering applicable income disregards) specified under subsection (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), or (l)(1)(A) of section 1902, on the date of enactment of this paragraph to be eligible for medical assistance as a pregnant woman.
(3)

No coverage for higher income pregnant women without covering lower income pregnant women.—
The State does not provide coverage for pregnant women with higher family income without covering pregnant women with a lower family income.
(4)

Application of requirements for coverage of targeted low-income children.—
The State provides pregnancy-related assistance for targeted low-income pregnant women in the same manner, and subject to the same requirements under section 2103(c), as the State provides child health assistance for targeted low-income children under the State child health plan, and in addition to providing child health assistance for such women.
(5)

No preexisting condition exclusion or waiting period.—
The State does not apply any exclusion of benefits for pregnancy-related assistance based on any preexisting condition or any waiting period (including any waiting period imposed to carry out section 2102(b)(3)(C)) for receipt of such assistance.
(6)

Application of cost-sharing protection.—
The State provides pregnancy-related assistance to a targeted low-income woman consistent with the cost-sharing protections under section 2103(e) and applies the limitation on total annual aggregate cost sharing imposed under paragraph (3)(B) of such section to the family of such a woman.
(7)

No waiting list for children.—
The State does not impose, with respect to the enrollment under the State child health plan of targeted low-income children during the quarter, any enrollment cap or other numerical limitation on enrollment, any waiting list, any procedures designed to delay the consideration of applications for enrollment, or similar limitation with respect to enrollment.
(c)

Option To Provide Presumptive Eligibility.—
A State that elects the option under subsection (a) and satisfies the conditions described in subsection (b) may elect to apply section 1920 (relating to presumptive eligibility for pregnant women) to the State child health plan in the same manner as such section applies to the State plan under title XIX.
(d)

Definitions.—
For purposes of this section:
(1)

Pregnancy-related assistance.—
The term “pregnancy-related assistance” has the meaning given the term “child health assistance” in section 2110(a) with respect to an individual during the period described in paragraph (2)(A).
(2)

Targeted low-income pregnant woman.—
The term “targeted low-income pregnant woman” means an individual—
(A)
during pregnancy and through the end of the month in which the 60-day period, or, in the case that subparagraph (A) of section 1902(e)(16) applies to the State child health plan (or waiver of such plan), pursuant to section 2107(e)(1), the 12-month period, (beginning on the last day of her pregnancy) ends;
(B)
whose family income exceeds 185 percent (or, if higher, the percent applied under subsection (b)(1)(A)) of the poverty line applicable to a family of the size involved, 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) in the same manner as a child applying for child health assistance would have to satisfy such requirements.
(e)

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).
(f)

States Providing Assistance Through Other Options.—
(1)

Continuation of other options for providing assistance.—
The option to provide assistance in accordance with the preceding subsections of this section shall not limit any other option for a State to provide—
(A)
child health assistance through the application of sections 457.10, 457.350(b)(2), 457.622(c)(5), and 457.626(a)(3) of title 42, Code of Federal Regulations (as in effect after the final rule adopted by the Secretary and set forth at 67 Fed. Reg. 61956–61974 (October 2, 2002)), or
(B)
pregnancy-related services through the application of any waiver authority (as in effect on June 1, 2008).
(2)

Clarification of authority to provide postpartum services.—
Any State that provides child health assistance under any authority described in paragraph (1) may continue to provide such assistance, as well as postpartum services, through the end of the month in which the 60-day period (beginning on the last day of the pregnancy) ends, in the same manner as such assistance and postpartum services would be provided if provided under the State plan under title XIX, but only if the mother would otherwise satisfy the eligibility requirements that apply under the State child health plan (other than with respect to age) during such period.
(3)

No inference.—
Nothing in this subsection shall be construed—
(A)
to infer congressional intent regarding the legality or illegality of the content of the sections specified in paragraph (1)(A); or
(B)
to modify the authority to provide pregnancy-related services under a waiver specified in paragraph (1)(B).
SEC. 2113.
[42 U.S.C. 1397mm]

GRANTS TO IMPROVE OUTREACH AND ENROLLMENT.
(a)

Outreach and Enrollment Grants; National Campaign.—
(1)

In general.—
From the amounts appropriated under subsection (g), subject to paragraphs (2) and (3), the Secretary shall award grants to eligible entities during the period of fiscal years 2009 through 2029 to conduct outreach and enrollment efforts that are designed to increase the enrollment and participation of eligible children under this title and title XIX.
(2)

Ten percent set aside for national enrollment campaign.—
An amount equal to 10 percent of such amounts shall be used by the Secretary for expenditures during such period to carry out a national enrollment campaign in accordance with subsection (h).
(3)

Ten percent set aside for evaluating and providing technical assistance to grantees.—
For the period of fiscal years 2024 through 2029, an amount equal to 10 percent of such amounts shall be used by the Secretary for the purpose of evaluating and providing technical assistance to eligible entities awarded grants under this section.
(b)

Priority for Award of Grants.—
(1)

In general.—
In awarding grants under subsection (a), the Secretary shall give priority to eligible entities that—
(A)
propose to target geographic areas with high rates of—
(i)
eligible but unenrolled children, including such children who reside in rural areas; or
(ii)
racial and ethnic minorities and health disparity populations, including those proposals that address cultural and linguistic barriers to enrollment; and
(B)
submit the most demonstrable evidence required under paragraphs (1) and (2) of subsection (c).
(2)

Ten percent set aside for outreach to indian children.—
An amount equal to 10 percent of the funds appropriated under subsection (g) shall be used by the Secretary to award grants to Indian Health Service providers and urban Indian organizations receiving funds under title V of the Indian Health Care Improvement Act (25 U.S.C. 1651 et seq.) for outreach to, and enrollment of, children who are Indians.
(c)

Application.—
An eligible entity that desires to receive a grant under subsection (a) shall submit an application to the Secretary in such form and manner, and containing such information, as the Secretary may decide. Such application shall include—
(1)
evidence demonstrating that the entity includes members who have access to, and credibility with, ethnic or low-income populations in the communities in which activities funded under the grant are to be conducted;
(2)
evidence demonstrating that the entity has the ability to address barriers to enrollment, such as lack of awareness of eligibility, stigma concerns and punitive fears associated with receipt of benefits, and other cultural barriers to applying for and receiving child health assistance or medical assistance;
(3)
specific quality or outcomes performance measures to evaluate the effectiveness of activities funded by a grant awarded under this section; and
(4)
an assurance that the eligible entity shall—
(A)
conduct an assessment of the effectiveness of such activities against the performance measures;
(B)
cooperate with the collection and reporting of enrollment data and other information in order for the Secretary to conduct such assessments; and
(C)
in the case of an eligible entity that is not the State, provide the State with enrollment data and other information as necessary for the State to make necessary projections of eligible children and pregnant women.
(d)

Dissemination of Enrollment Data and Information Determined From Effectiveness Assessments; Annual Report.—
The Secretary shall—
(1)
make publicly available the enrollment data and information collected and reported in accordance with subsection (c)(4)(B); and
(2)
submit an annual report to Congress on the outreach and enrollment activities conducted with funds appropriated under this section.
(e)

Maintenance of Effort for States Awarded Grants; No Match Required for Any Eligible Entity Awarded a Grant.—
(1)

State maintenance of effort.—
In the case of a State that is awarded a grant under this section, the State share of funds expended for outreach and enrollment activities under the State child health plan shall not be less than the State share of such funds expended in the fiscal year preceding the first fiscal year for which the grant is awarded.
(2)

No matching requirement.—
No eligible entity awarded a grant under subsection (a) shall be required to provide any matching funds as a condition for receiving the grant.
(f)

Definitions.—
In this section:
(1)

Eligible entity.—
The term “eligible entity” means any of the following:
(A)
A State with an approved child health plan under this title.
(B)
A local government.
(C)
An Indian tribe or tribal consortium, a tribal organization, an urban Indian organization receiving funds under title V of the Indian Health Care Improvement Act (25 U.S.C. 1651 et seq.), or an Indian Health Service provider.
(D)
A Federal health safety net organization.
(E)
A national, State, local, or community-based public or nonprofit private organization, including organizations that use community health workers , community-based doula programs, or parent mentors.
(F)
A faith-based organization or consortia, to the extent that a grant awarded to such an entity is consistent with the requirements of section 1955 of the Public Health Service Act (42 U.S.C. 300x–65) relating to a grant award to nongovernmental entities.
(G)
An elementary or secondary school.
(2)

Federal health safety net organization.—
The term “Federal health safety net organization” means—
(A)
a Federally-qualified health center (as defined in section 1905(l)(2)(B));
(B)
a hospital defined as a disproportionate share hospital for purposes of section 1923;
(C)
a covered entity described in section 340B(a)(4) of the Public Health Service Act (42 U.S.C. 256b(a)(4)); and
(D)
any other entity or consortium that serves children under a federally funded program, including the special supplemental nutrition program for women, infants, and children (WIC) established under section 17 of the Child Nutrition Act of 1966 (42 U.S.C. 1786), the Head Start and Early Head Start programs under the Head Start Act (42 U.S.C. 9801 et seq.), the school lunch program established under the Richard B. Russell National School Lunch Act, and an elementary or secondary school.
(3)

Indians; indian tribe; tribal organization; urban indian organization.—
The terms “Indian”, “Indian tribe”, “tribal organization”, and “urban Indian organization” have the meanings given such terms in section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603).
(4)

Community health worker.—
The term “community health worker” means an individual who promotes health or nutrition within the community in which the individual resides—
(A)
by serving as a liaison between communities and health care agencies;
(B)
by providing guidance and social assistance to community residents;
(C)
by enhancing community residents' ability to effectively communicate with health care providers;
(D)
by providing culturally and linguistically appropriate health or nutrition education;
(E)
by advocating for individual and community health or nutrition needs; and
(F)
by providing referral and followup services.
(5)

Parent mentor.—
The term “parent mentor” means an individual who—
(A)
is a parent or guardian of at least one child who is an eligible child under this title or title XIX; and
(B)
is trained to assist families with children who have no health insurance coverage with respect to improving the social determinants of the health of such children, including by providing—
(i)
education about health insurance coverage, including, with respect to obtaining such coverage, eligibility criteria and application and renewal processes;
(ii)
assistance with completing and submitting applications for health insurance coverage;
(iii)
a liaison between families and representatives of State plans under title XIX or State child health plans under this title;
(iv)
guidance on identifying medical and dental homes and community pharmacies for children; and
(v)
assistance and referrals to successfully address social determinants of children’s health, including poverty, food insufficiency, and housing.
(g)

Appropriation.—
There is appropriated, out of any money in the Treasury not otherwise appropriated, $140,000,000 for the period of fiscal years 2009 through 2015 , $40,000,000 for the period of fiscal years 2016 and 2017, $120,000,000 for the period of fiscal years 2018 through 2023, $48,000,000 for the period of fiscal years 2024 through 2027, and $40,000,000 for the period of fiscal years 2028 and 2029, for the purpose of awarding grants under this section. Amounts appropriated and paid under the authority of this section shall be in addition to amounts appropriated under section 2104 and paid to States in accordance with section 2105, including with respect to expenditures for outreach activities in accordance with subsections (a)(1)(D)(iii) and (c)(2)(C) of that section.
(h)

National Enrollment Campaign.—
From the amounts made available under subsection (a)(2), the Secretary shall develop and implement a national enrollment campaign to improve the enrollment of underserved child populations in the programs established under this title and title XIX. Such campaign may include—
(1)
the establishment of partnerships with the Secretary of Education and the Secretary of Agriculture to develop national campaigns to link the eligibility and enrollment systems for the assistance programs each Secretary administers that often serve the same children;
(2)
the integration of information about the programs established under this title and title XIX in public health awareness campaigns administered by the Secretary;
(3)
increased financial and technical support for enrollment hotlines maintained by the Secretary to ensure that all States participate in such hotlines;
(4)
the establishment of joint public awareness outreach initiatives with the Secretary of Education and the Secretary of Labor regarding the importance of health insurance to building strong communities and the economy;
(5)
the development of special outreach materials for Native Americans or for individuals with limited English proficiency;
(6)
the development of materials and toolkits and the provision of technical assistance to States regarding enrollment and retention strategies for eligible children under this title and title XIX; and
(7)
such other outreach initiatives as the Secretary determines would increase public awareness of the programs under this title and title XIX.