[Congressional Record Volume 151, Number 39 (Thursday, April 7, 2005)]
[Senate]
[Pages S3359-S3362]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BINGAMAN (for himself, Mr. Lugar, Mrs. Lincoln, Mrs. 
        Murray, Mr. Kerry, Ms. Cantwell, Mr. Kohl, Mr. Lautenberg, Mrs. 
        Boxer, and Mr. Corzine):
  S. 740. A bill to amend title XIX and XXI of the Social Security Act 
to expand or add coverage of pregnant women under the medicaid and 
State children's health insurance program, and for other purposes; to 
the Committee on Finance.
  Mr. BINGAMAN. Mr. President, I rise today to introduce bipartisan 
legislation with Senators Lugar, Lincoln, Murray, Kerry, Cantwell, 
Kohl, Lautenberg, Boxer and Corzine. This legislation, entitled the 
``Start Healthy, Stay Healthy Act of 2005,'' would significantly reduce 
the number of uninsured pregnant women and newborns by expanding 
coverage to pregnant women through Medicaid and the Children's Health 
Insurance Program, or CHIP, and to newborns through the first full year 
of life.
  Today is World Health Day 2005 and the message this year is ``Make 
Every Mother and Child Count''. I can think of no better way to honor 
our Nation's mothers and children than to increase their access to 
health care services and improve their overall health.
  According to a recent report by Save the Children entitled ``The 
State of the World's Mothers,'' the United States fares no better than 
11th in the world. Why is this? According to the report, ``The United 
States earned its 11th place rank this year based on several factors: 
One of the key indicators used to calculate the well-being for mothers 
is lifetime risk of maternal mortality. . . . Canada, Australia, and 
all the Western and Northern European countries in the study performed 
better than the United States in this indicator.''
  The study adds, ``Similarly, the United States did not do as well as 
the top 10 countries with regard to infant mortality rates.''
  In fact, the United States ranks 21st in maternal mortality and 28th 
in infant mortality, the worst among developed nations. We should and 
must do

[[Page S3360]]

better by our Nation's mothers and infants.
  There has been long-standing policy in this country linking programs 
for pregnant women to programs for infants, including Medicaid, WIC, 
and the Maternal and Child Health Block Grant. Yet the CHIP program, 
unfortunately, fails to provide coverage to pregnant women beyond the 
age of 18. As a result, it is more likely that newborns eligible for 
CHIP are not covered from the moment of birth, and therefore, often 
miss having comprehensive prenatal care and care during those first 
critical months of life until their CHIP application is processed.
  By expanding coverage to pregnant women through CHIP, the ``Start 
Healthy, Stay Healthy Act'' 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 has written, ``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 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 in 2003. The result is often 
quite costly--both in terms of the health of the mother and newborn but 
also in terms of the long-term expenses for society 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).'' In addition to 
reduced infant mortality and morbidity, the provision to expand 
coverage to pregnant women is cost effective.
  The ``Start Healthy, Stay Healthy Act'' also eliminates the 
unintended federal policy through CHIP that covers pregnant women only 
through the age of 18 and cuts off that coverage once the women turn 19 
years of age. Certainly, everybody can agree that the government should 
not be telling women that they are more likely to receive prenatal care 
coverage only if they become pregnant as a teenager.
  This bipartisan legislation has been supported in the past by: the 
March of Dimes, the American Academy of Pediatrics, the American 
College of Obstetricians and Gynecologists, the What to Expect 
Foundation, 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, Premier, 
Catholic Health Association, Catholic Charities USA, 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, the United Cerebral Palsy Associations, the Society for Maternal-
Fetal Medicine, and Families USA.
  This legislation is a reintroduction of a bill that was introduced in 
2001 and 2003. Throughout 2001, the Administration made numerous 
statements in support of the passage of this type of legislation, but 
unfortunately, reversed course in October 2002 after publishing a 
regulation allowing states to redefine a ``child'' as an ``unborn 
child'' only and to provide prenatal care, but not postnatal care 
through CHIP in that manner. In a letter to Senator Nickles dated 
October 8, 2002, Secretary Thompson argued, ``I believe the regulation 
is a more effective and comprehensive solution to this issue.''
  While a number of senators strongly disagreed with Secretary 
Thompson's assertion and sent him letters to that effect on October 10, 
2002, and on October 23, 2002, we felt it was important to get the 
testimony of our nation's medical experts on the health and well-being 
of both pregnant women and newborns. We called for a hearing in the 
Senate Health, Education, Labor and Pensions Committee on October 24, 
2002. Witnesses included representatives from the March of Dimes, the 
American College of Obstetricians and Gynecologists, the American 
Academy of Pediatrics, and the What to Expect Foundation. They were 
asked to compare the regulation to the legislation and I will let their 
testimony speak for itself.
  Dr. Nancy Green testified on behalf of the March of Dimes Birth 
Defects Foundation. She said:

       We support giving states the flexibility they need to cover 
     income-eligible pregnant women age 19 and older, and to 
     automatically enroll infants born to SCHIP-eligible mothers. 
     By establishing a uniform eligibility threshold for coverage 
     for pregnant women and infants, states will be able to 
     improve maternal health, eliminate waiting periods for 
     infants and streamline administration of publicly supported 
     health programs. Currently, according to the Department of 
     Health and Human Services' Centers for Medicare and Medicaid 
     Services and the National Governors' Association, 36 states 
     and the District of Columbia have income eligibility 
     thresholds that are more restrictive for women than for their 
     newborns. Encouraging states to eliminate this disparity by 
     allowing them to establish a uniform eligibility threshold 
     for pregnant women and their infants should be a national 
     policy priority.

  Dr. Green adds:

       Specifically, we are deeply concerned that final regulation 
     fails to provide to the mother the standard scope of 
     maternity care services recommended by the American College 
     of Obstetricians and Gynecologists (ACOG) and the American 
     Academy of Pediatrics (AAP). Of particular concern, the 
     regulation explicitly states that postpartum care is not 
     covered and, therefore, federal reimbursement will not be 
     available for these services. In addition, because of the 
     contentious collateral issues raised by this regulation 
     groups like the March of Dimes will find it even more 
     difficult to work in the states to generate support for 
     legislation to extend coverage to uninsured pregnant women.

  Dr. Laura Riley testified on behalf of ACOG. In her testimony, she 
stated:

       ACOG is very concerned that mothers will not have access to 
     postpartum services under the regulation. The rule clearly 
     states that ``. . . care after delivery, such as postpartum 
     services could not be covered as part of the Title XXI State 
     Plan . . . because they are not services for an eligible 
     child.

  On the importance of postpartum care, Dr. Riley adds:

       When new mothers develop postpartum complications, quick 
     access to their physicians is absolutely critical. Postpartum 
     care is especially important for women who have preexisting 
     medical conditions, and for those whose medical conditions 
     were induced by their pregnancies, such as gestational 
     diabetes or hypertension, and for whom it is necessary to 
     ensure that their conditions are stabilized and treated.

  As a result, Dr. Riley concludes:

       Limiting coverage to the fetus instead of the mother omits 
     a critical component of postpartum care that physicians 
     regard as essential for the health of the mother and the 
     child. Covering the fetus as opposed to the mother also 
     raises questions of whether certain services will be 
     available during pregnancy and labor if the condition is one 
     that directly affects the woman. The best way to address this 
     coverage issue is to pass S. 724, supported by Senators 
     Bond, Bingaman and Lincoln and many others, and which 
     provides a full range of medical services during and after 
     pregnancy directly to the pregnant woman.

  Dr. Richard Bucciarelli testified on behalf of the American Academy 
of Pediatrics. He said:

       Recently, the Administration published a final rule 
     expanding SCHIP to cover unborn children. The Academy is 
     concerned that, as written, this regulation falls dangerously 
     short of the clinical standards of care outlined in our 
     guidelines, which describe the importance of covering all 
     stages of a birth--pregnancy, delivery, and postpartum care.

  It is important to note that the regulation subtracts the time that 
an ``unborn child'' is covered from the period of continuously 
eligibility after birth. Consequently, children would be denied 
insurance coverage at very critical points during the first full year 
of life. As such, Dr. Bucciarelli expressed support for the legislation 
over the regulation because it, in his words:

       . . . takes an important step to decrease the number of 
     uninsured children by providing 12 months of continuous 
     eligibility for those children born . . . This legislation 
     ensures that children born to women enrolled in Medicaid or 
     SCHIP are immediately enrolled in the program for which they 
     are eligible. Additionally, this provision prevents newborns 
     eligible for SCHIP from being subject to enrollment waiting 
     periods, ensuring that infants receive appropriate health 
     care in their first year of life.


[[Page S3361]]


  And finally, Lisa Bernstein testified as Executive Director of The 
What to Expect Foundation, which takes its name from the bestselling 
What to Expect pregnancy and parenting series that has helped over 20 
million families from pregnancy through their child's toddler years. 
Ms. Bernstein also supported the legislation as a far superior option 
over the regulation and make this simple but eloquent point:

  . . . only a healthy parent can provide a healthy future for a 
healthy child.

  The testimony of these experts speaks for itself and I urge my 
colleagues to pass this legislation as soon as possible.
  I ask unanimous consent that the text of this bill be printed in the 
Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                 S. 740

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

     SECTION 1. SHORT TITLE.

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

     SEC. 2. STATE OPTION TO EXPAND OR ADD COVERAGE OF CERTAIN 
                   PREGNANT WOMEN UNDER MEDICAID AND SCHIP.

       (a) Medicaid.--
       (1) Authority to expand coverage.--Section 1902(l)(2)(A)(i) 
     of the Social Security Act (42 U.S.C. 1396a(l)(2)(A)(i)) is 
     amended by inserting ``(or such higher percent as the State 
     may elect for purposes of expenditures for medical assistance 
     for pregnant women described in section 1905(u)(4)(A))'' 
     after ``185 percent''.
       (2) Enhanced matching funds available if certain conditions 
     met.--Section 1905 of the Social Security Act (42 U.S.C. 
     1396d) is amended--
       (A) in the fourth sentence of subsection (b), by striking 
     ``or subsection (u)(3)'' and inserting ``, (u)(3), or 
     (u)(4)''; and
       (B) in subsection (u)--
       (i) by redesignating paragraph (4) as paragraph (5); and
       (ii) by inserting after paragraph (3) the following:
       ``(4) For purposes of the fourth sentence of subsection (b) 
     and section 2105(a), the expenditures described in this 
     paragraph are the following:
       ``(A) Certain pregnant women.--If the conditions described 
     in subparagraph (B) are met, expenditures for medical 
     assistance for pregnant women described in subsection (n) or 
     under section 1902(l)(1)(A) in a family the income of which 
     exceeds the effective income level (expressed as a percent of 
     the poverty line and considering applicable income 
     disregards) that has been specified under subsection 
     (a)(10)(A)(i)(III) or (l)(2)(A) of section 1902, as of 
     January 1, 2005, but does not exceed the income eligibility 
     level established under title XXI for a targeted low-income 
     child.
       ``(B) Conditions.--The conditions described in this 
     subparagraph are the following:
       ``(i) The State plans under this title and title XXI do not 
     provide coverage for pregnant women described in subparagraph 
     (A) with higher family income without covering such pregnant 
     women with a lower family income.
       ``(ii) The State does not apply an effective income level 
     for pregnant women that is lower than the effective income 
     level (expressed as a percent of the poverty line and 
     considering applicable income disregards) that has been 
     specified under the State plan under subsection 
     (a)(10)(A)(i)(III) or (l)(2)(A) of section 1902, as of 
     January 1, 2005, to be eligible for medical assistance as a 
     pregnant woman.
       ``(C) Definition of poverty line.--In this subsection, the 
     term `poverty line' has the meaning given such term in 
     section 2110(c)(5).''.
       (3) Payment from title xxi allotment for medicaid expansion 
     costs; elimination of counting medicaid child presumptive 
     eligibility costs against title xxi allotment.--Section 
     2105(a)(1) of the Social Security Act (42 U.S.C. 
     1397ee(a)(1)) is amended--
       (A) in the matter preceding subparagraph (A), by striking 
     ``(or, in the case of expenditures described in subparagraph 
     (B), the Federal medical assistance percentage (as defined in 
     the first sentence of section 1905(b)))''; and
       (B) by striking subparagraph (B) and inserting the 
     following:
       ``(B) for the provision of medical assistance that is 
     attributable to expenditures described in section 
     1905(u)(4)(A);''.
       (4) Additional amendments to medicaid.--
       (A) Eligibility of a newborn.--Section 1902(e)(4) of the 
     Social Security Act (42 U.S.C. 1396a(e)(4)) is amended in the 
     first sentence by striking ``so long as the child is a member 
     of the woman's household and the woman remains (or would 
     remain if pregnant) eligible for such assistance''.
       (B) Application of qualified entities to presumptive 
     eligibility for pregnant women under medicaid.--Section 
     1920(b) of the Social Security Act (42 U.S.C. 1396r-1(b)) is 
     amended by adding at the end after and below paragraph (2) 
     the following flush sentence:
       ``The term `qualified provider' includes a qualified entity 
     as defined in section 1920A(b)(3).''.
       (b) SCHIP.--
       (1) Coverage.--Title XXI of the Social Security Act (42 
     U.S.C. 1397aa et seq.) is amended by adding at the end the 
     following:

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

       ``(a) Optional Coverage.--Notwithstanding any other 
     provision of this title, a State may provide for coverage, 
     through an amendment to its State child health plan under 
     section 2102, of pregnancy-related assistance for targeted 
     low-income pregnant women in accordance with this section, 
     but only if the State meets the conditions described in 
     section 1905(u)(4)(B).
       ``(b) Definitions.--For purposes of this title:
       ``(1) Pregnancy-related assistance.--The term `pregnancy-
     related assistance' has the meaning given the term child 
     health assistance in section 2110(a) as if any reference to 
     targeted low-income children were a reference to targeted 
     low-income pregnant women, except that the assistance shall 
     be limited to services related to pregnancy (which include 
     prenatal, delivery, and postpartum services and services 
     described in section 1905(a)(4)(C)) and to other conditions 
     that may complicate pregnancy.
       ``(2) Targeted low-income pregnant woman.--The term 
     `targeted low-income pregnant woman' means a woman--
       ``(A) during pregnancy and through the end of the month in 
     which the 60-day period (beginning on the last day of her 
     pregnancy) ends;
       ``(B) whose family income exceeds the effective income 
     level (expressed as a percent of the poverty line and 
     considering applicable income disregards) that has been 
     specified under subsection (a)(10)(A)(i)(III) or (l)(2)(A) of 
     section 1902, as of January 1, 2005, to be eligible for 
     medical assistance as a pregnant woman under title XIX but 
     does not exceed the income eligibility level established 
     under the State child health plan under this title for a 
     targeted low-income child; and
       ``(C) who satisfies the requirements of paragraphs (1)(A), 
     (1)(C), (2), and (3) of section 2110(b).
       ``(c) References to Terms and Special Rules.--In the case 
     of, and with respect to, a State providing for coverage of 
     pregnancy-related assistance to targeted low-income pregnant 
     women under subsection (a), the following special rules 
     apply:
       ``(1) Any reference in this title (other than in subsection 
     (b)) to a targeted low-income child is deemed to include a 
     reference to a targeted low-income pregnant woman.
       ``(2) Any such reference to child health assistance with 
     respect to such women is deemed a reference to pregnancy-
     related assistance.
       ``(3) Any such reference to a child is deemed a reference 
     to a woman during pregnancy and the period described in 
     subsection (b)(2)(A).
       ``(4) In applying section 2102(b)(3)(B), any reference to 
     children found through screening to be eligible for medical 
     assistance under the State medicaid plan under title XIX is 
     deemed a reference to pregnant women.
       ``(5) There shall be no exclusion of benefits for services 
     described in subsection (b)(1) based on any preexisting 
     condition and no waiting period (including any waiting period 
     imposed to carry out section 2102(b)(3)(C)) shall apply.
       ``(6) Subsection (a) of section 2103 (relating to required 
     scope of health insurance coverage) shall not apply insofar 
     as a State limits coverage to services described in 
     subsection (b)(1) and the reference to such section in 
     section 2105(a)(1)(C) is deemed not to require, in such case, 
     compliance with the requirements of section 2103(a).
       ``(7) In applying section 2103(e)(3)(B) in the case of a 
     pregnant woman provided coverage under this section, the 
     limitation on total annual aggregate cost-sharing shall be 
     applied to the entire family of such pregnant woman.
       ``(d) Automatic Enrollment for Children Born to Women 
     Receiving Pregnancy-Related Assistance.--If a child is born 
     to a targeted low-income pregnant woman who was receiving 
     pregnancy-related assistance under this section on the date 
     of the child's birth, the child shall be deemed to have 
     applied for child health assistance under the State child 
     health plan and to have been found eligible for such 
     assistance under such plan or to have applied for medical 
     assistance under title XIX and to have been found eligible 
     for such assistance under such title, as appropriate, on the 
     date of such birth and to remain eligible for such assistance 
     until the child attains 1 year of age. During the period in 
     which a child is deemed under the preceding sentence to be 
     eligible for child health or medical assistance, the child 
     health or medical assistance eligibility identification 
     number of the mother shall also serve as the identification 
     number of the child, and all claims shall be submitted and 
     paid under such number (unless the State issues a separate 
     identification number for the child before such period 
     expires).''.
       (2) Additional allotments for providing coverage of 
     pregnant women.--
       (A) In general.--Section 2104 of the Social Security Act 
     (42 U.S.C. 1397dd) is amended by inserting after subsection 
     (c) the following:
       ``(d) Additional Allotments for Providing Coverage of 
     Pregnant Women.--
       ``(1) Appropriation; total allotment.--For the purpose of 
     providing additional allotments to States under this title, 
     there is

[[Page S3362]]

     appropriated, out of any money in the Treasury not otherwise 
     appropriated, for each of fiscal years 2006 and 2007, 
     $200,000,000.
       ``(2) State and territorial allotments.--In addition to the 
     allotments provided under subsections (b) and (c), subject to 
     paragraphs (3) and (4), of the amount available for the 
     additional allotments under paragraph (1) for a fiscal year, 
     the Secretary shall allot to each State with a State child 
     health plan approved under this title--
       ``(A) in the case of such a State other than a commonwealth 
     or territory described in subparagraph (B), the same 
     proportion as the proportion of the State's allotment under 
     subsection (b) (determined without regard to subsection (f)) 
     to the total amount of the allotments under subsection (b) 
     for such States eligible for an allotment under this 
     paragraph for such fiscal year; and
       ``(B) in the case of a commonwealth or territory described 
     in subsection (c)(3), the same proportion as the proportion 
     of the commonwealth's or territory's allotment under 
     subsection (c) (determined without regard to subsection (f)) 
     to the total amount of the allotments under subsection (c) 
     for commonwealths and territories eligible for an allotment 
     under this paragraph for such fiscal year.
       ``(3) Use of additional allotment.--Additional allotments 
     provided under this subsection are not available for amounts 
     expended before October 1, 2005. Such amounts are available 
     for amounts expended on or after such date for child health 
     assistance for targeted low-income children, as well as for 
     pregnancy-related assistance for targeted low-income pregnant 
     women.
       ``(4) No payments unless election to expand coverage of 
     pregnant women.--No payments may be made to a State under 
     this title from an allotment provided under this subsection 
     unless the State provides pregnancy-related assistance for 
     targeted low-income pregnant women under this title, or 
     provides medical assistance for pregnant women under title 
     XIX, whose family income exceeds the effective income level 
     applicable under subsection (a)(10)(A)(i)(III) or (l)(2)(A) 
     of section 1902 to a family of the size involved as of 
     January 1, 2005.''.
       (B) Conforming amendments.--Section 2104 of the Social 
     Security Act (42 U.S.C. 1397dd) is amended--
       (i) in subsection (a), in the matter preceding paragraph 
     (1), by inserting ``subject to subsection (d),'' after 
     ``under this section,'';
       (ii) in subsection (b)(1), by inserting ``and subsection 
     (d)'' after ``Subject to paragraph (4)''; and
       (iii) in subsection (c)(1), by inserting ``subject to 
     subsection (d),'' after ``for a fiscal year,''.
       (3) Presumptive eligibility under title xxi.--
       (A) Application to pregnant women.--Section 2107(e)(1)(D) 
     of the Social Security Act (42 U.S.C. 1397gg(e)(1)) is 
     amended to read as follows:
       ``(D) Sections 1920 and 1920A (relating to presumptive 
     eligibility).''.
       (B) Exception from limitation on administrative expenses.--
     Section 2105(c)(2) of the Social Security Act (42 U.S.C. 
     1397ee(c)(2)) is amended by adding at the end the following 
     new subparagraph:
       ``(C) Exception for presumptive eligibility expenditures.--
     The limitation under subparagraph (A) on expenditures shall 
     not apply to expenditures attributable to the application of 
     section 1920 or 1920A (pursuant to section 2107(e)(1)(D)), 
     regardless of whether the child or pregnant woman is 
     determined to be ineligible for the program under this title 
     or title XIX.''.
       (4) Additional amendments to title xxi.--
       (A) No cost-sharing for pregnancy-related services.--
     Section 2103(e)(2) of the Social Security Act (42 U.S.C. 
     1397cc(e)(2)) is amended--
       (i) in the heading, by inserting ``Or pregnancy-related 
     services'' after ``Preventive services''; and
       (ii) by inserting before the period at the end the 
     following: ``or for pregnancy-related services''.
       (B) No waiting period.--Section 2102(b)(1)(B) of the Social 
     Security Act (42 U.S.C. 1397bb(b)(1)(B)) is amended--
       (i) by striking ``, and'' at the end of clause (i) and 
     inserting a semicolon;
       (ii) by striking the period at the end of clause (ii) and 
     inserting ``; and''; and
       (iii) by adding at the end the following:
       ``(iii) may not apply a waiting period (including a waiting 
     period to carry out paragraph (3)(C)) in the case of a 
     targeted low-income pregnant woman.''.
       (c) Effective Date.--The amendments made by this section 
     apply to items and services furnished on or after October 1, 
     2005, without regard to whether regulations implementing such 
     amendments have been promulgated.

     SEC. 3. COORDINATION WITH THE MATERNAL AND CHILD HEALTH 
                   PROGRAM.

       (a) In General.--Section 2102(b)(3) of the Social Security 
     Act (42 U.S.C. 1397bb(b)(3)) is amended--
       (1) in subparagraph (D), by striking ``and'' at the end;
       (2) in subparagraph (E), by striking the period and 
     inserting ``; and''; and
       (3) by adding at the end the following new subparagraph:
       ``(F) that operations and activities under this title are 
     developed and implemented in consultation and coordination 
     with the program operated by the State under title V in areas 
     including outreach and enrollment, benefits and services, 
     service delivery standards, public health and social service 
     agency relationships, and quality assurance and data 
     reporting.''.
       (b) Conforming Medicaid Amendment.--Section 1902(a)(11) of 
     such Act (42 U.S.C. 1396a(a)(11)) is amended--
       (1) by striking ``and'' before ``(C)''; and
       (2) by inserting before the semicolon at the end the 
     following: ``, and (D) provide that operations and activities 
     under this title are developed and implemented in 
     consultation and coordination with the program operated by 
     the State under title V in areas including outreach and 
     enrollment, benefits and services, service delivery 
     standards, public health and social service agency 
     relationships, and quality assurance and data reporting''.
       (c) Effective Date.--The amendments made by this section 
     take effect on January 1, 2006.

     SEC. 4. INCREASE IN SCHIP INCOME ELIGIBILITY.

       (a) Definition of Low-Income Child.--Section 2110(c)(4) of 
     the Social Security Act (42 U.S.C. 42 U.S.C. 1397jj(c)(4)) is 
     amended by striking ``200'' and inserting ``250''.
       (b) Effective Date.--The amendment made by subsection (a) 
     applies to child health assistance provided, and allotments 
     determined under section 2104 of the Social Security Act (42 
     U.S.C. 1397dd) for fiscal years beginning with fiscal year 
     2006.

                          ____________________