[Congressional Record Volume 147, Number 81 (Tuesday, June 12, 2001)]
[Senate]
[Pages S6130-S6135]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BINGAMAN (for himself, Mr. Lugar, Mr. McCain, Mr. Corzine, 
        and Mrs. Lincoln):
  S. 1016. A bill to amend titles XIX and XXI of the Social Security 
Act to improve the health benefits coverage of infants and children 
under the medicaid and State children's health insurance program, and 
for other purposes; to the Committee on Finance.
  Mr. BINGAMAN. Mr. President, I rise today to introduce bipartisan 
legislation with Senators Lugar, McCain, Corzine, and Lincoln. This 
legislation is entitled the ``Start Healthy, Stay Healthy Act of 
2001.'' The purpose of the legislation is to significantly reduce the 
number of uninsured children

[[Page S6131]]

and pregnant women by improving outreach to and enrollment of children 
and by expanding coverage to pregnant women through Medicaid and CHIP.
  An estimated 11 million children under age 19 were without health 
insurance in 1999, including 129,000 in New Mexico, representing 15 
percent of all children in the United States and 22 percent of children 
in New Mexico. Unfortunately, due to variety of factors, including the 
lack of knowledge by families about CHIP and bureaucratic barriers to 
coverage such as lengthy and complex applications, an estimated 6.7 
million of our Nation's uninsured children are eligible for but 
unenrolled in either Medicaid or CHIP.
  In addition, an estimated 4.3 million, or 32 percent, of mothers 
below 200 percent of poverty are uninsured. According to the March of 
Dimes, ``Over 95 percent of all uninsured pregnant women could be 
covered through a combination of aggressive Medicaid outreach, 
maximizing coverage for young women through [CHIP], and expanding CHIP 
to cover income-eligible pregnant women regardless of age.''
  It is a travesty that our Nation ranks 25th in infant mortality and 
21st in maternal mortality in the world, which is the worst among 
developed nations. Our legislation would address the problems related 
to these issues.
  Giving children a healthy start: The legislation provides States with 
an enhanced Medicaid matching rate to ensure that children eligible for 
Medicaid or CHIP leave the hospital insured and remain so through the 
first year of life. The legislation provides States with the option to 
further extend coverage to pregnant women through Medicaid and CHIP to 
reduce infant and maternal mortality and low birthweight babies.
  Helping children stay healthy: The legislation provides States with 
an enhanced Medicaid matching rate to reduce the barriers to care for 
children to keep them healthy throughout their childhood. And, the 
legislation provides States with the option to increase CHIP 
eligibility from 200 percent of federal poverty level to 250 percent 
and to extend coverage to children through age 20.
  As an example of an imposed barrier to health coverage, as of March 
of this year, eight States continued to impose an asset test on 
children and their families prior to receiving Medicaid coverage. This 
results in a rather burdensome and complicated application in each of 
these States. For example, in Colorado, the Denver Department of Human 
Services received 15,330 application for Medicaid and 3,700 were denied 
for having an asset, such as a car, in 1999. As the Denver Post pointed 
out, ``Acquire an asset more than $1,500, such as a car, and you've 
traded in health insurance for your children.''
  In addition to creating a high percentage of denials, the imposition 
of an assets test significantly complicates the Medicaid or CHIP 
enrollment applications. For example, some States require reporting on 
everything from whether anyone in the household has any resource such 
as a checking account, life insurance, burial insurance, a saving 
account, or any personal items above a certain amount to documenting 
things such as work income, alimony, child support, interest from 
savings, CD's, etc. over a period of time, including several months in 
the past.
  This can be a nightmare for some families. In Colorado, of the 
families that do attempt to fill out the Medicaid or CHIP application, 
it is estimated that 37 percent of all families are denied coverage 
because the application is incomplete. In Texas, Medicaid applicants 
can face a 17-page application, up to 14 forms and up to 20 
verifications of those forms.
  As a story in last Friday's Washington Post entitled ``Health 
Coverage for Kids Low-Cost but Little Used,'' it was noted that about 
100 students from Yale Medical School, likely some of our Nation's best 
and brightest, filled out applications forms as part of their training 
to enroll families and that not one was able to complete the form 
adequately. If Yale Medical School students cannot fill out the forms 
properly, is it any wonder that families across the country are having 
a difficult time with the bureaucratic paperwork?
  Fortunately, New Mexico eliminated its assets test a few years ago in 
an effort to simplify its Medicaid application and make it easier for 
families to apply. According to a recent report by the Kaiser Family 
Foundation, States that have eliminated the asset test from Medicaid 
have been able to streamline the eligibility determination process, 
adopt automated eligibility determination systems, improve the 
productivity of eligibility workers, establish Medicaid's identity as a 
health insurance program distinct from welfare, make the enrollment 
process for families friendlier and more accessible, and achieve 
Medicaid administrative cost savings.
  In addition, the State of Texas has enacted legislation in recent 
days that seeks to simplify its enrollment process.
  And yet, there are also reports from other States such as Kentucky 
and Idaho that are moving to impose additional bureaucratic barriers to 
coverage.
  As the Denver Rocky Mountain News writes, ``The logic of erecting 
such paperwork obstacles escapes us. Government doesn't have to offer 
insurance to the children of the working poor, but having made the 
decision to do so, it's hardly fair then to smother the program beneath 
layers of red tape.''
  There are also problems related to the poor coordination between 
government agencies that are supposed to serve low-income families.
  My good friend, Senator Lugar, recognized this very point and 
successfully passed language in the ``Agricultural Risk Protection Act 
of 2000'' to improve the coordination between the school lunch program 
and both Medicaid and CHIP. His language makes it easier to disclose 
information from the school lunch program application to Medicaid and 
CHIP agencies. Since children that qualify for the school lunch program 
are almost certainly eligible for either Medicaid or CHIP, this simple 
but important language is already having an important impact on the 
enrollment of children into Medicaid or CHIP.
  According to a report by Covering Kids, the Albuquerque Public 
Schools have successfully worked to improve coordination between 
Medicaid and the school lunch program. As the report reads, ``The 
team's record of success shows that a well-designed process and 
dedicated staff can make [Medicaid enrollment] work. In August and 
September of 2000, Albuquerque Public Schools determined 386 children 
to be presumptively eligible for health coverage. Of these, 371 were 
enrolled and only 15 were denied. That's a 96 percent acceptance rate. 
And the numbers are growing.''
  This coordination between Medicaid and the school lunch program is 
being replicated across the country as a result of Senator Lugar's 
language. However, we still have a number of problems with regard to 
coordination between Medicaid and CHIP across the states that this bill 
seeks to address.
  Why is this important? Why should we make additional efforts to 
reduce the number of uninsured children? According to the American 
College of Physicians--American Society of Internal Medicine, uninsured 
children, compared to the insured, are: up to 6 times more likely to 
have gone without needed medical, dental or other health care; 2 times 
more likely to have gone without a physician visit during the previous 
year; up to 4 times more likely to have delayed seeking medical care; 
up to 10 times less likely to have a regular source of medical care; 
1.7 times less likely to receive medical treatment for asthma; and, up 
to 30 percent less likely to receive medical attention for any injury.
  This is equally true of expanded coverage to children and pregnant 
women in government health programs. In fact, one study has ``estimated 
that the 15 percent rise in the number of children eligible for 
Medicaid between 1984 and 1992 decreased child mortality by 5 
percent.'' This expansion of coverage for children occurred, I would 
add, during the Reagan and Bush Administrations, so this is clearly a 
bipartisan issue that deserves further bipartisan action.
  We, as a Nation, should be doing much better by our children. It 
should be unacceptable to all of us that the United States ranks 25th 
in infant mortality and 21st in maternal mortality in the world.
  Therefore, in addition to seeking to improve health insurance 
coverage

[[Page S6132]]

among children, the bill builds off legislation sponsored in the last 
Congress by Senator Lincoln entitled the ``Improved Maternal and 
Children's Health Coverage Act'' and makes an important change to CHIP 
to allow pregnant women to be covered. Thus, the first two words of our 
bill, ``Start Healthy.''
  Throughout our Nation's history, there has been long-standing Federal 
policy linking programs for pregnant women and infants, including 
Medicaid, WIC, and the Maternal Child Health Block Grant. CHIP, 
unfortunately, failed to provide coverage to pregnant women beyond the 
age of 18. As a result, it is more likely that children eligible for 
CHIP are not covered from the moment of birth, and therefore, miss 
those first critical months of life until their CHIP application is 
processed. They are also more likely not to have had prenatal care.
  By expanding coverage to pregnant women in the Children's Health 
Insurance Program, this legislation recognizes the importance of 
prenatal care to the health and development of a child. As Dr. Alan 
Waxman of the University of New Mexico School of Medicine notes, 
``Prenatal care is an important factor in the prevention of birth 
defects and the prevention of prematurity, the most common causes of 
infant death and disability. Babies born to women with no prenatal care 
or late prenatal care are nearly twice as likely to [be] low 
birthweight or very low birthweight as infants born to women who 
received early prenatal care.''
  Unfortunately, according to a recent report by the Centers for 
Disease Control and Prevention, New Mexico ranked worst in the nation 
in the percentage of mothers receiving late or no prenatal care last 
year. The result is often quite costly, both in terms of the health of 
the mother and child but also in terms of long-term expenses since the 
result can be chronic, lifelong health problems.
  In fact, according to the Agency for Healthcare Research and Quality, 
``four of the top 10 most expensive conditions in the hospital are 
related to care of infants with complications (respiratory distress, 
prematurity, heart defects, and lack of oxygen).'' As a result, in 
addition to reduced infant mortality and morbidity, the provision to 
expand coverage of pregnant women and prenatal care can be cost 
effective.
  The Start Healthy, Stay Healthy Act also eliminates the unintended 
Federal incentives through CHIP that covers pregnant women only through 
the age of 18 and cut off that coverage once the women turn 19 years of 
age. Should the government tell women that they are more likely to 
receive prenatal care coverage only if they become pregnant as a 
teenager?
  I certainly think not, and certainly it is unlikely there is a single 
Senator that would think it wise to send such a message. This 
legislation corrects this unfortunate and unintentional policy 
by allowing pregnant women to be covered through CHIP regardless of 
age.

  And finally, this legislation imposes no Federal mandates on States 
to achieve these goals. Rather, through financial incentives, States 
that adopt ``best practices'' and less cumbersome enrollment processes 
for children would be rewarded.
  The budget resolution contains $28 billion over 10 years to reduce 
the number of uninsured in this country. Although the Congress passed 
CHIP in 1997, 11 million children remain uninsured. It is time we 
finish the job of ensuring that we, as the President says, ``leave no 
child behind.''
  This bipartisan legislation has already received the endorsement of 
the following organizations: the March of Dimes, the American Academy 
of Pediatrics, the American College of Obstetricians and Gynecologists, 
the American Academy of Family Physicians, the American Academy of 
Pediatric Dentistry, the American Academy of Child and Adolescent 
Psychiatry, the National Association of Community Health Centers, the 
American Hospital Association, the National Association of Children's 
Hospitals, the Federation of American Health Systems, the National 
Association of Public Hospitals and Health Systems, Catholic Health 
Association, Premier, Family Voices, the Association of Maternal and 
Child Health Programs, the National Health Law Program, the National 
Association of Social Workers, Every Child By Two, and the United 
Cerebral Palsy Associations. I urge its passage as soon as possible.
  I ask unanimous consent that the text of the bill and a fact sheet be 
printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                S. 1016

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Start 
     Healthy, Stay Healthy Act of 2001''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.

                         TITLE I--START HEALTHY

Sec. 101. Enhanced Federal medicaid match for States that opt to 
              continuously enroll infants during the first year of life 
              without regard to the mother's eligibility status.
Sec. 102. Optional coverage of low-income, uninsured pregnant women 
              under a State child health plan.
Sec. 103. Increase in SCHIP income eligibility.

                         TITLE II--STAY HEALTHY

Sec. 201. Enhanced Federal medicaid match for increased expenditures 
              for medical assistance for children.
Sec. 202. Increase in SCHIP appropriations.
Sec. 203. Optional coverage of children through age 20 under the 
              medicaid program and SCHIP.

                         TITLE I--START HEALTHY

     SEC. 101. ENHANCED FEDERAL MEDICAID MATCH FOR STATES THAT OPT 
                   TO CONTINUOUSLY ENROLL INFANTS DURING THE FIRST 
                   YEAR OF LIFE WITHOUT REGARD TO THE MOTHER'S 
                   ELIGIBILITY STATUS.

       (a) State Option.--Section 1902(e)(4) of the Social 
     Security Act (42 U.S.C. 1396a(e)(4)) is amended by adding at 
     the end the following new sentence: ``A State may elect 
     (through a State plan amendment) to apply the first sentence 
     of this paragraph without regard to the requirements that the 
     child remain a member of the woman's household and the woman 
     remains (or would remain if pregnant) eligible for medical 
     assistance.''.
       (b) Enhanced FMAP.--The first sentence of section 1905(b) 
     of the Social Security Act (42 U.S.C. 1396d(b)) is amended--
       (1) by inserting ``(A)'' after ``only''; and
       (2) by inserting ``, or (B) on the basis of a State 
     election made under the third sentence of section 
     1902(e)(4)'' before the period.
       (c) Effective Date.--The amendments made by this section 
     apply to medical assistance provided on or after October 1, 
     2001.

     SEC. 102. OPTIONAL COVERAGE OF LOW-INCOME, UNINSURED PREGNANT 
                   WOMEN UNDER A STATE CHILD HEALTH PLAN.

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

     ``SEC. 2111. OPTIONAL COVERAGE OF LOW-INCOME, UNINSURED 
                   PREGNANT WOMEN.

       ``(a) Optional Coverage.--Notwithstanding any other 
     provision of this title, a State child health plan (whether 
     implemented under this title or title XIX) may provide for 
     coverage of pregnancy-related assistance for targeted low-
     income pregnant women in accordance with this section, but 
     only if the State has established an income eligibility level 
     under section 1902(l)(2)(A) for women described in section 
     1902(l)(1)(A) that is 185 percent of the income official 
     poverty line.
       ``(b) 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) as if any reference to 
     targeted low-income children were a reference to targeted 
     low-income pregnant women, except that the assistance shall 
     be limited to services related to pregnancy (which include 
     prenatal, delivery, and postpartum services) and to other 
     conditions that may complicate pregnancy.
       ``(2) Targeted low-income pregnant woman.--The term 
     `targeted low-income pregnant woman' has the meaning given 
     the term targeted low-income child in section 2110(b) as if 
     any reference to a child were deemed a reference to a woman 
     during pregnancy and through the end of the month in which 
     the 60-day period (beginning on the last day of her 
     pregnancy) ends.
       ``(c) References to Terms and Special Rules.--In the case 
     of, and with respect to, a State providing for coverage of 
     pregnancy-related assistance to targeted low-income pregnant 
     women under subsection (a), the following special rules 
     apply:
       ``(1) Any reference in this title (other than subsection 
     (b)) to a targeted low income child is deemed to include a 
     reference to a targeted low-income pregnant woman.
       ``(2) Any such reference to child health assistance with 
     respect to such women is deemed a reference to pregnancy-
     related assistance.
       ``(3) Any such reference to a child is deemed a reference 
     to a woman during pregnancy and the period described in 
     subsection (b)(2).

[[Page S6133]]

       ``(4) The medicaid applicable income level is deemed a 
     reference to the income level established under section 
     1902(l)(2)(A).
       ``(5) Subsection (a) of section 2103 (relating to required 
     scope of health insurance coverage) shall not apply insofar 
     as a State limits coverage to services described in 
     subsection (b)(1) and the reference to such section in 
     section 2105(a)(1) is deemed not to require, in such case, 
     compliance with the requirements of section 2103(a).
       ``(6) There shall be no exclusion of benefits for services 
     described in subsection (b)(1) based on any pre-existing 
     condition and no waiting period (including any waiting period 
     imposed to carry out section 2102(b)(3)(C)) shall apply.
       ``(d) No Impact on Allotments.--Nothing in this section 
     shall be construed as affecting the amount of any initial 
     allotment provided to a State under section 2104(b).
       ``(e) Application of Funding Restrictions.--The coverage 
     under this section (and the funding of such coverage) is 
     subject to the restrictions of section 2105(c).
       ``(f) Automatic Enrollment for Children Born to Women 
     Receiving Pregnancy-Related Assistance.--Notwithstanding any 
     other provision of this title or title XIX, 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 children'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, in the case of a State that 
     provides such assistance through the provision of medical 
     assistance under a plan under title XIX, to have applied for 
     medical assistance under such title and to have been found 
     eligible for such assistance under such title) 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).''.
       (b) State Option To Use Enhanced FMAP and SCHIP Allotment 
     for Coverage of Additional Pregnant Women under the Medicaid 
     Program.--Section 1905 of the Social Security Act (42 U.S.C. 
     1396d) is amended--
       (A) in the fourth sentence of subsection (b), by inserting 
     ``and in the case of a State plan that meets the condition 
     described in subsections (u)(1) and (u)(4)(A), with respect 
     to expenditures described in subsection (u)(4)(B) for the 
     State for a fiscal year'' after ``for a fiscal year,''; and
       (B) in subsection (u)--
       (i) by redesignating paragraph (4) as paragraph (5); and
       (ii) by inserting after paragraph (3) the following new 
     paragraph:
       ``(4)(A) The condition described in this subparagraph for a 
     State plan is that the plan has established an income level 
     under section 1902(l)(2)(A) with respect to individuals 
     described in section 1902(l)(1)(A) that is 185 percent of the 
     income official poverty line.
       ``(B) For purposes of subsection (b), the expenditures 
     described in this paragraph are expenditures for medical 
     assistance for women described in section 1902(l)(1)(A) whose 
     income exceeds the income level established for such women 
     under section 1902(l)(2)(A)(i) as of the date of the 
     enactment of this paragraph but does not exceed 185 percent 
     of the income official poverty line.''.
       (c) No Waiting Periods or Cost-Sharing.--
       (1) No waiting period.--Section 2102(b)(1)(B) of the Social 
     Security Act (42 U.S.C. 1397bb(b)(1)(B)) is amended--
       (A) by striking ``, and'' at the end of clause (i) and 
     inserting a semicolon;
       (B) by striking the period at the end of clause (ii) and 
     inserting ``; and''; and
       (C) by adding at the end the following new clause:
       ``(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, if the State provides for 
     coverage of pregnancy-related assistance for such women in 
     accordance with section 2111.''.
       (2) No cost-sharing for pregnancy-related benefits.--
     Section 2103(e)(2) of such Act (42 U.S.C. 1397cc(e)(2)) is 
     amended--
       (A) in the heading, by inserting ``and pregnancy-related 
     services'' after ``preventive services''; and
       (B) by inserting before the period at the end the 
     following: ``or for pregnancy-related services, if the State 
     provides for coverage of pregnancy-related assistance for 
     targeted low-income pregnant women in accordance section 
     2111''.
       (d) Presumptive Eligibility.--
       (1) In general.--Section 1920A(b)(3)(A)(i)(III) of the 
     Social Security Act (42 U.S.C. 1396r-1a(b)(3)(A)(i)(III)) is 
     amended by inserting ``a child care resource and referral 
     agency,'' after ``a State or tribal child support enforcement 
     agency,''.
       (2) Application to presumptive eligibility for pregnant 
     women under medicaid.--Section 1920(b) of the Social Security 
     Act (42 U.S.C. 1396r-1(b)) is amended by adding at the end 
     after and below paragraph (2) the following flush sentence:
     ``The term `qualified provider' includes a qualified entity 
     as defined in section 1920A(b)(3).''.
       (3) Application under title xxi.--
       (A) In general.--Section 2107(e)(1)(D) of the Social 
     Security Act (42 U.S.C. 1397gg(e)(1)) is amended to read as 
     follows:
       ``(D) Sections 1920 and 1920A (relating to presumptive 
     eligibility).''.
       (B) Exception from limitation on administrative expenses.--
     Section 2105(c)(2) of the Social Security Act (42 U.S.C. 
     1397ee(c)(2)) is amended by adding at the end the following 
     new subparagraph:
       ``(C) Exception for presumptive eligibility expenditures.--
     The limitation under subparagraph (A) on expenditures shall 
     not apply to expenditures attributable to the application of 
     section 1920 or 1920A (pursuant to section 2107(e)(1)(D)), 
     regardless of whether the child or pregnant woman is 
     determined to be ineligible for the program under this title 
     or title XIX.''.
       (e) Program Coordination With the Maternal and Child Health 
     Program (Title V).--
       (1) In general.--Section 2102(b)(3) of the Social Security 
     Act (42 U.S.C. 1397bb(b)(3)) is amended--
       (A) in subparagraph (D), by striking ``and'' at the end;
       (B) in subparagraph (E), by striking the period and 
     inserting ``; and''; and
       (C) by adding at the end the following new subparagraph:
       ``(F) that operations and activities under this title are 
     developed and implemented in consultation and coordination 
     with the program operated by the State under title V in areas 
     including outreach and enrollment, benefits and services, 
     service delivery standards, public health and social service 
     agency relationships, and quality assurance and data 
     reporting.''.
       (2) Conforming medicaid amendment.--Section 1902(a)(11) of 
     such Act (42 U.S.C. 1396a(a)(11)) is amended--
       (A) by striking ``and'' before ``(C)''; and
       (B) by inserting before the semicolon at the end the 
     following: ``, and (D) provide that operations and activities 
     under this title are developed and implemented in 
     consultation and coordination with the program operated by 
     the State under title V in areas including outreach and 
     enrollment, benefits and services, service delivery 
     standards, public health and social service agency 
     relationships, and quality assurance and data reporting''.
       (3) Effective date.--The amendments made by this subsection 
     take effect on January 1, 2002.
       (f) Application of Annual Aggregate Cost-Sharing Limit.--
     Section 2103(e)(3)(B) of the Social Security Act (42 U.S.C. 
     1397cc(e)(3)(B)) is amended by adding at the end the 
     following new sentence: ``In the case of a targeted low-
     income pregnant woman provided coverage under section 2111, 
     or the parents of a targeted low-income child provided 
     coverage under this title under an 1115 waiver or otherwise, 
     the limitation on total annual aggregate cost-sharing 
     described in the preceding sentence shall be applied to the 
     entire family of such woman or parents.''.
       (g) Effective Date.--Except as provided in subsection (e), 
     the amendments made by this section take effect on the date 
     of the enactment of this Act and apply to expenditures 
     incurred on or after that date.

     SEC. 103. INCREASE IN SCHIP INCOME ELIGIBILITY.

       (a) Definition of Low-Income Child.--Section 2110(c)(4) of 
     the Social Security Act (42 U.S.C. 42 U.S.C. 1397jj(c)(4)) is 
     amended by striking ``200'' and inserting ``250''.
       (b) Effective Date.--The amendment made by subsection (a) 
     applies to child health assistance provided, and allotments 
     determined under section 2104 of the Social Security Act (42 
     U.S.C. 1397dd), for fiscal years beginning with fiscal year 
     2002.

                         TITLE II--STAY HEALTHY

     SEC. 201. ENHANCED FEDERAL MEDICAID MATCH FOR INCREASED 
                   EXPENDITURES FOR MEDICAL ASSISTANCE FOR 
                   CHILDREN.

       (a) Enhanced FMAP.--Section 1905(b) of the Social Security 
     Act (42 U.S.C. 1396d(b)) is amended by adding at the end the 
     following new sentence: ``Notwithstanding the first sentence 
     of this subsection, in the case of a State plan that meets at 
     least 7 of the conditions described in subsection (x)(1) (as 
     determined by the Secretary in consultation with States 
     (including the State agencies responsible for the 
     administration of this title and title V), beneficiaries 
     under this title, providers of services under this title, and 
     advocates for children), with respect to expenditures 
     described in subsection (x)(2) for the State for a fiscal 
     year, the Federal medical assistance percentage is equal to 
     the percentage determined for the State under subsection 
     (x)(3).''.
       (b) Conditions and Expenditures Described.--Section 1905 of 
     the Social Security Act (42 U.S.C. 1396d) is amended by 
     adding at the end the following new subsection:
       ``(x)(1) For purposes of subsection (b), the conditions 
     described in this subsection are the following:
       ``(A) Highest schip income eligibility.--The State has a 
     State child health plan under title XXI which (whether 
     implemented under such title or under this title) has the 
     highest income eligibility standard permitted under title XXI 
     as of January 1, 2001, does not limit the acceptance of 
     applications, and provides benefits to all children in

[[Page S6134]]

     the State who apply for and meet eligibility standards.
       ``(B) Uniform, simplified application form.--With respect 
     to children under age 19 (or such higher age as the State has 
     elected under section 1902(l)(1)(D)) who are eligible for 
     medical assistance under section 1902(a)(10)(A), the State 
     uses the same uniform, simplified application form 
     (including, if applicable, permitting application other than 
     in person) for purposes of establishing eligibility for 
     benefits under this title and also under title XXI.
       ``(C) Coordinated enrollment process.--The State has an 
     enrollment process that is coordinated with that under title 
     XXI so that a family need only interact with a single agency 
     in order to determine whether a child is eligible for 
     benefits under this title or title XXI, and that allows for 
     the transfer of enrollment, without a gap in coverage, for a 
     child whose income eligibility status changes but who remains 
     eligible for benefits under either title.
       ``(D) Same verification and redetermination policies; 
     automatic reassessment of eligibility.--With respect to 
     children under age 19 (or such higher age as the State has 
     elected under section 1902(l)(1)(D)) who are eligible for 
     medical assistance under section 1902(a)(10)(A), the State 
     provides for initial eligibility determinations and 
     redeterminations of eligibility using the same verification 
     policies (including with respect to face-to-face interviews), 
     forms, and frequency as the State uses for such purposes 
     under title XXI, and, as part of such redeterminations, 
     provides for the automatic reassessment of the eligibility of 
     such children for assistance under this title and title XXI.
       ``(E) No asset test.--The State does not impose an asset 
     test for eligibility under section 1902(l) or title XXI with 
     respect to children.
       ``(F) 12-month continuous enrollment.--The State has 
     elected the option of continuing enrollment under section 
     1902(e)(12) and has elected a 12-month period under 
     subparagraph (A) of such section.
       ``(G) Compliance with outstationing requirement.--The State 
     is providing for the receipt and initial processing of 
     applications of children for medical assistance under this 
     title at facilities defined as disproportionate share 
     hospitals under section 1923(a)(1)(A) and Federally-qualified 
     health centers described in subsection (l)(2)(B) of this 
     section consistent with the requirements of section 
     1902(a)(55).
       ``(H) No waiting period longer than 6 months.--The State 
     does not impose a waiting period for children who meet 
     eligibility standards to qualify for assistance under such 
     plan that exceeds 6 months (and may impose a shorter period 
     or no period) for purposes of complying with regulations 
     promulgated under title XXI to ensure that the insurance 
     provided under the State child health plan under such title 
     does not substitute for coverage under group health plans.
       ``(I) Sufficient provider payment rates.--The State 
     demonstrates that it is meeting the requirements of section 
     1902(a)(30)(A) through payment rates sufficient to enlist 
     enough providers so that care and pediatric, obstetrical, 
     gynecologic, and dental services are available under the plan 
     at least to the extent that such care and services are 
     available to the general population in the geographic area.
       ``(2)(A) For purposes of subsection (b), the expenditures 
     described in this paragraph are expenditures for medical 
     assistance for children described in subparagraph (B) for a 
     fiscal year, but only to the extent that such expenditures 
     exceed the base expenditure amount, as defined in 
     subparagraph (C).
       ``(B) For purposes of subparagraph (A), the children 
     described in this subparagraph are--
       ``(i) individuals who are under 19 years of age (or such 
     higher age as the State may have elected under section 
     1902(l)(1)(D)) who are eligible and enrolled for medical 
     assistance under this title; and
       ``(ii) individuals who--
       ``(I) would be described in clause (i) but for having 
     family income that exceeds the highest income eligibility 
     level applicable to such individuals under the State plan; 
     and
       ``(II) would be considered disabled under section 
     1614(a)(3)(C) (determined without regard to the reference to 
     age in that section but for having earnings or deemed income 
     or resources (as determined under title XVI for children) 
     that exceed the requirements for receipt of supplemental 
     security income benefits.
       ``(C) For purposes of subparagraph (A), the term `base 
     expenditure amount' means the total expenditures for medical 
     assistance for children described in subparagraph (B) for 
     fiscal year 1996.
       ``(3) For purposes of subsection (b), the Federal medical 
     assistance percentage with respect to expenditures described 
     in paragraph (2) for a fiscal year is equal to the following:
       ``(A) In the case of a State that meets 7 of the conditions 
     described in paragraph (1), the Federal medical assistance 
     percentage (as defined in the first sentence of subsection 
     (b)) for the State increased by a number of percentage points 
     equal to 50 percent of the number of percentage points by 
     which (1) such Federal medical assistance percentage for the 
     State is less than (2) the enhanced FMAP for the State 
     described in section 2105(b).
       ``(B) In the case of a State that meets 8 of the conditions 
     described in paragraph (1), the Federal medical assistance 
     percentage (as so defined) for the State increased by a 
     number of percentage points equal to 75 percent of the number 
     of percentage points by which (1) such Federal medical 
     assistance percentage for the State is less than (2) the 
     enhanced FMAP for the State (as so described).
       ``(C) In the case of a State that meets all of the 
     conditions described in paragraph (1), the enhanced FMAP (as 
     so described).''.
       (c) Collection of Data.--The Secretary of Health and Human 
     Services shall modify such data collection and reporting 
     requirements under title XIX of the Social Security Act as 
     are necessary to determine the expenditures and base 
     expenditure amount described in section 1905(x)(2) of that 
     Act (as added by subsection (b)), particularly with respect 
     to expenditures and the base expenditure amount related to 
     children described in section 1905(x)(2)(B)(ii) of that Act.
       (d) Effective Date.--The amendments made by subsections (a) 
     and (b) apply to medical assistance provided on or after 
     October 1, 2001.

     SEC. 202. INCREASE IN SCHIP APPROPRIATIONS.

       Section 2104(a) of the Social Security Act (42 U.S.C. 
     1397dd(a)) is amended by striking paragraphs (5) through (9) 
     and inserting the following:
       ``(5) for fiscal year 2002, $3,500,000,000;
       ``(6) for fiscal year 2003, $4,000,000,000;
       ``(7) for fiscal year 2004, $4,300,000,000;
       ``(8) for fiscal year 2005, $4,500,000,000;
       ``(9) for fiscal year 2006, $4,500,000,000; and''.

     SEC. 203. OPTIONAL COVERAGE OF CHILDREN THROUGH AGE 20 UNDER 
                   THE MEDICAID PROGRAM AND SCHIP.

       (a) Medicaid.--
       (1) In general.--Section 1902(l)(1)(D) of the Social 
     Security Act (42 U.S.C. 1396a(l)(1)(D)) is amended by 
     inserting ``(or, at the election of a State, 20 or 21 years 
     of age)'' after ``19 years of age''.
       (2) Conforming amendments.--
       (A) Section 1902(e)(3)(A) of such Act (42 U.S.C. 
     1396a(e)(3)(A)) is amended by inserting ``(or 1 year less 
     than the age the State has elected under subsection 
     (l)(1)(D))'' after ``18 years of age''.
       (B) Section 1902(e)(12) of such Act (42 U.S.C. 
     1396a(e)(12)) is amended by inserting ``or such higher age as 
     the State has elected under subsection (l)(1)(D)'' after ``19 
     years of age''.
       (C) Section 1920A(b)(1) of such Act (42 U.S.C. 1396r-
     1a(b)(1)) is amended by inserting ``or such higher age as the 
     State has elected under section 1902(l)(1)(D)'' after ``19 
     years of age''.
       (D) Section 1928(h)(1) of such Act (42 U.S.C. 1396s(h)(1)) 
     is amended by inserting ``or 1 year less than the age the 
     State has elected under section 1902(l)(1)(D)'' before the 
     period at the end.
       (E) Section 1932(a)(2)(A) of such Act (42 U.S.C. 1396u-
     2(a)(2)(A)) is amended by inserting ``(or such higher age as 
     the State has elected under section 1902(l)(1)(D))'' after 
     ``19 years of age''.
       (b) Title XXI.--Section 2110(c)(1) of such Act (42 U.S.C. 
     1397jj(c)(1)) is amended by inserting ``(or such higher age 
     as the State has elected under section 1902(l)(1)(D))''.
       (c) Effective Date.--The amendments made by this section 
     take effect on October 1, 2001, and apply to medical 
     assistance and child health assistance provided on or after 
     such date.
                                  ____


          Fact Sheet--Start Healthy, Stay Healthy Act of 2001

       Sens. Jeff Bingaman (D-NM), Richard Lugar (R-IN), John 
     McCain (R-AZ), Jon Corzine (D-NJ), and Blanche Lincoln (D-AR) 
     introduced the ``Start Healthy, Stay Healthy Act of 2001'' on 
     June 12, 2001. The legislation would significantly reduce the 
     number of uninsured children and pregnant women by improving 
     outreach to and enrollment of children and by expanding 
     coverage to pregnant women through Medicaid and the State 
     Children's Health Insurance Program (CHIP).
       An estimated 11 million children under age 19 were without 
     health insurance in 1999, representing 15% of all children in 
     the United States. Due to a variety of factors, including 
     governmental barriers to coverage, such as bureaucratic ``red 
     tape,'' and the lack of knowledge of families about CHIP, an 
     estimated 6.7 million of our nation's uninsured children are 
     eligible for but are unenrolled in either Medicaid or CHIP.
       In addition, an estimated 4.3 million, or 32%, of mothers 
     below 200% of poverty are uninsured. According to the March 
     of Dimes, ``Over 95 percent of all uninsured pregnant women 
     could be covered through a combination of aggressive Medicaid 
     outreach, maximizing coverage for young women through [CHIP], 
     and expanding CHIP to cover income-eligible pregnant women 
     regardless of age.''
       The legislation would reduce the number of uninsured 
     children and pregnant women by:
     Start healthy
       Providing states with an enhanced Medicaid matching rate to 
     ensure that children eligible for Medicaid or CHIP leave the 
     hospital insured and remain so through the first year of 
     life.
       Providing states with the option to further extend coverage 
     to pregnant women through Medicaid and CHIP to reduce infant 
     and maternal mortality and low birthweight babies.
     Stay healthy
       Providing states with an enhanced Medicaid matching rate to 
     reduce the barriers to care for children to keep them healthy 
     throughout their childhood.

[[Page S6135]]

       Providing states with the option to increase CHIP 
     eligibility from 200% of federal poverty level to 250% and to 
     extend coverage to children through age 20.
       As a result of these provisions, the legislation would 
     achieve the following additional objectives:
       Reduces Infant and Maternal Mortality: The United States 
     ranks 25th in infant mortality and 21st in maternal 
     mortality, the worst among developed nations. Studies with 
     respect to the previous expansions of Medicaid coverage to 
     pregnant women and children during the Reagan and Bush 
     Administrations indicate those expansions reduced infant 
     mortality and improved child health (GAO, ``Insurance and 
     Health Care Access,'' November 1997). By reducing the number 
     of uninsured children and pregnant women in this country, the 
     legislation would also reduce infant and maternal mortality 
     as well.
       Eliminates Bureaucratic Barriers to Coverage and Promotes 
     Best Practices by States: Building on the successful 
     enactment of Senator Lugar's amendment to the ``Agricultural 
     Risk Protection Act of 2000'' to make it easier to disclose 
     information from the school lunch program application to 
     Medicaid and CHIP agencies, this legislation seeks to further 
     improve coordination between Medicaid, CHIP, and the Maternal 
     and Child Health (MCH) Block Grant in order to expand health 
     insurance coverage to eligible but unenrolled children. The 
     bill also provides states financial incentives to remove 
     bureaucratic barriers to health insurance coverage in 
     Medicaid and CHIP for children. These provisions reward 
     states for ``best practices'' and also eliminates the 
     negative incentive for states to enroll children improperly 
     in CHIP (with the higher matching rate, higher cost sharing, 
     and reduced benefits) rather than Medicaid (with a lower 
     matching rate, reduced cost sharing, and increased benefits).
       Addresses the ``CHIP Dip'': There is a ``dip'' in federal 
     funding, known as the ``CHIP dip'' in fiscal years 2002 
     through 2006 that states have complained will cause them to 
     limit their CHIP programs out of fear of not having enough 
     funding in those years. The bill addresses that problem by 
     raising CHIP funding levels in fiscal years FY 2002 through 
     2006.
       Eliminates Unintended Federal Incentives Regarding Teenage 
     Pregnant Women: Current federal law allows pregnant women to 
     receive coverage through CHIP through age 18--creating a 
     perverse federal incentive of covering only teenage pregnant 
     women and cutting off that coverage once they turn 19 years 
     of age. This legislation would eliminate this problem by 
     allowing states to cover pregnant women through CHIP, 
     regardless of age. This also eliminates the unfortunate 
     separation between pregnant women and infants that has been 
     created through CHIP, which has been contrary to long-
     standing federal policy through programs such as Medicaid, 
     WIC, MCH, etc.
       Imposes No Mandates on States: This legislation imposes no 
     mandates on states. However, states would, just as we have 
     done in the Temporary Assistance for Needy Families (TANF), 
     be provided financial incentives and accountability for the 
     additional money this legislation provides in return for 
     reducing governmental barriers to coverage for children and 
     pregnant women.
       Remains Within the Budget Framework: The budget provides 
     for $28 billion over 10 yeas for the purpose of reducing the 
     number of uninsured. This proposal will meet those budgetary 
     limits.
       This bipartisan legislation has received the endorsement of 
     the following organizations: the March of Dimes, the American 
     Academy of Pediatrics, the American College of Obstetricians 
     and Gynecologists, the American Academy of the Family 
     Physicians, the American Academy of Pediatric Dentistry, the 
     American Academy of Child and Adolescent Psychiatry, the 
     National Association of Community Health Centers, the 
     American Hospital Association, the National Association of 
     Children's Hospitals, the Federation of American Health 
     Systems, the National Association of Public Hospitals and 
     Health Systems, Catholic Health Association, Premier, Family 
     Voices, the Association of Maternal and Child Health 
     Programs, the National Health Law Program, the National 
     Association of Social Workers, Every Child by Two, and the 
     United Cerebral Palsy Associations.


                          legislative summary

       This legislation is split into two titles:
     Title I: Start healthy
       Provides states through Medicaid with the CHIP enhanced 
     matching rate if they choose the option to continuously 
     enroll infants from birth through the first year of life, as 
     allowed under current law, regardless of the woman's status 
     during that year.
       Provides states with an option to further cover pregnant 
     women through Medicaid and CHIP (above 185% of poverty up to 
     the full CHIP eligibility levels) in order to reduce infant 
     mortality and the delivery of low birthweight babies.
     Title II: Stay healthy
       Provides states through Medicaid with the CHIP enhanced 
     matching rate for children above a certain base expenditure 
     level such as a state's spending on children in 1996) if they 
     choose to meet the following conditions: States must expand 
     coverage to children up to the full extent that is allowed 
     under CHIP (to 200% of poverty or 50 percentage points above 
     where the coverage levels were prior to passage of Title 
     XXI); adoption of a simplified, joint mail-in application; 
     adoption of application procedures (e.g., verification and 
     face-to-face interview requirements) that are no more 
     extensive, onerous, or burdensome in Medicaid than in CHIP, 
     elimination of assets test; adoption of 12-month continuous 
     enrollment; adoption of procedures that simplify the 
     redetermination/coverage renewal process by allowing families 
     to establish their child's continuing eligibility by mail 
     and, in states with separate CHIP programs, by establishing 
     effective procedures that allow children to be transferred 
     between Medicaid and the separate program without a new 
     application a gap in coverage when a child's eligibility 
     status changes; compliance with the OBRA-89 outstationed 
     workers requirement, which provide for outstationed 
     eligibility workers in Medicaid DSH hospitals and community 
     health centers, impose waiting periods no longer than 6 
     months for children seeking to enroll in CHIP (ensure 
     flexibility for states to impose shorter periods, if at all); 
     and demonstrate that the State has adopted payments rates 
     sufficient to enlist enough providers so that care and 
     pediatric, obstetrical/gynecologic and dental services are 
     available at least to the extent such care and services are 
     available to the general population in the geographic area.
       States meeting these conditions would receive the full 
     enhanced CHIP matching rate. If a state meets 8 of these 
     conditions, it would receive 75% of the difference between 
     the regular Medicaid matching rate and the CHIP enhanced 
     matching rate. If a state meets 7 of the conditions, it would 
     receive 50% of the difference.
       Expand CHIP eligibility to 250% of poverty for children and 
     pregnant women.
       Expand CHIP eligibility up to age 21 (adding 19 and 20 
     year-olds).
       The legislation also increases the CHIP allotments in FY 
     2002 to $3.5 billion, in FY 2003 to $4 billion, in FY 2004 to 
     $4.3 billion in FY 2005 to $4.5 billion, and in FY 2006 to 
     $4.5 billion.
                                 ______