[Senate Report 106-323]
[From the U.S. Government Publishing Office]



                                                       Calendar No. 641
106th Congress                                                   Report
                                 SENATE
 2d Session                                                     106-323

======================================================================



 
                BREAST AND CERVICAL CANCER TREATMENT ACT

                                _______
                                

                 June 27, 2000.--Ordered to be printed

                                _______
                                

    Mr. Roth, from the Committee on Finance, submitted the following

                              R E P O R T

                         [To accompany S. 662]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Finance, to which was referred the bill 
(S. 662) to amend title XIX of the Social Security Act to 
provide medical assistance for certain woment screened and 
found to have breast cancer under a federally funded screening 
program, having considered the same, reports favorably thereon 
with an amendment and recommends that the bill (as amended) do 
pass.

                                CONTENTS

                                                                   Page
 I. Summary and Background............................................1
        A. Summary...............................................     1
        B. Background and Reasons for Legislation................     2
        C. Legislative History...................................     2
II. Explanation of the Bill...........................................2
        A. Coverage as Optional Categorically Needy Group........     2
        B. Presumptive Eligibility...............................     4
        C. Enhanced Match........................................     6
        D. Effective Date........................................     6
III.Budget Effects of the Bill........................................6

IV. Vote of the Committee............................................10
 V. Regulatory Impact................................................10
VI. Changes in Existing Law..........................................11

                       I. SUMMARY AND BACKGROUND


                               A. Summary

    S. 662, as reported by the Committee on Finance, creates a 
new option for states to extend Medicaid eligibility to 
individuals receiving a cancer diagnosis through the Centers 
for Disease Control's Breast and Cervical Cancer Early 
Detection Program.

               B. Background and Reasons for Legislation

    Nearly 10 years ago, Congress created the National Breast 
and Cervical Cancer Early Detection Program, through the 
Centers for Disease Control, to help lower-income women receive 
the early detection services that are the best protection 
against breast and cervical cancer. This important program has 
served more than a million women in subsequent years. However, 
the screening program does not include a treatment component. 
Instead, women who receive cancer diagnoses must rely on 
informal networks of donated care.
    S. 662 fulfills a promise made nearly 10 years ago. The 
federal government will continue to help lower-income, 
uninsured women access needed preventive health care services. 
But now the federal commitment will not stop with screening. If 
problems are found, the federal government will work with the 
states to provide necessary treatment services to women facing 
cancer diagnoses.
    S. 662 makes treatment available to eligible women through 
the Medicaid program. There are very valid concerns about 
creating disease-specific Medicaid eligibility categories. 
However, S. 662 deals with a thoroughly unique set of 
circumstances. The new Medicaid eligibility category created in 
S. 662 is specifically linked to a unique and existing federal 
screening program, and shall not be viewed as a precedent for 
extending Medicaid eligibility body-part by body-part.

                         C. Legislative History

    Senator John Chafee introduced S. 662 on March 18, 1999, 
and then on July 27th he chaired a Finance Committee Health 
Subcommittee hearing on the bill. At the hearing, witnesses 
from the health policy, medical, advocacy, and beneficiary 
communities discussed the pressing need for a treatment 
component to supplement the CDC screening programs.
    On June 14, 2000, the Finance Committee ordered S. 662, the 
Breast and Cervical Cancer Treatment Act, reported favorably, 
as amended by the Chairman's mark, by a voice vote.

                      II. EXPLANATION OF THE BILL


           A. Coverage as Optional Categorically Needy Group


Current law

    The requirements of federal law, coupled with decisions by 
individual states in structuring their Medicaid programs, 
determine who is eligible for Medicaid in a given state. In 
general, federal law places limits on the categories or groups 
of individuals that can be covered and establishes specific 
eligibility rules for each category. Within these parameters, 
states are given additional options. Medicaid is also a means-
tested entitlement program. To qualify, applicants' income and 
resources must be within certain limits, most of which are 
determined by states, again within federal statutory 
parameters. Moreover, states have flexibility in defining 
countable income and resources.
    States must provide Medicaid coverage to certain groups and 
have the option of covering others. Examples of major mandatory 
eligibility groups relevant to individuals targeted by S. 662 
(i.e., non-institutionalized adult females) include: (1) 
persons who would be eligible for cash assistance under former 
rules of the Aid to Families with Dependent Children (AFDC) 
program (in effect on July 16, 1996, as adjusted) even if they 
do not qualify for cash grants under the new Temporary 
Assistance for Needy Families (TANF) program, (2) disabled 
individuals receiving supplemental security income (SSI) and/or 
state supplemental payments (except in those states that use 
more restrictive disability or income standards for determining 
Medicaid eligibility for such persons), (3) individuals 
qualifying for transitional medical assistance for up to 12 
months after Medicaid eligibility is lost due to increases in 
hours of employment, support payments or earned income, and (4) 
pregnant women who are in families with income up to 133 
percent of the federal poverty level.
    Examples of major optional coverage groups relevant to S. 
662 include: (1) pregnant women in families with income between 
133 percent and 185 percent of the federal poverty level, and 
(2) persons qualifying as ``medically needy,'' that is, those 
who fall into one of Medicaid's categorical coverage groups and 
meet the (usually higher) income and resource requirements for 
medically needy coverage. States may further expand eligibility 
through waivers of federal rules, or use of existing provisions 
that permit changes in income and resource standards or 
calculation methods.
    With the exception of the medically needy and special 
categories for pregnant women, all of the above groups have 
access to the full range of Medicaid benefits offered in a 
state. States may specify a narrower set of benefits for the 
medically needy, within federal parameters. Persons who qualify 
as pregnant women are limited to pregnancy-related benefits 
during the period of pregnancy (and for 60 days postpartum).
    In general, Medicaid beneficiaries are permitted to have 
other forms of health insurance. When a Medicaid beneficiary 
has other insurance, Medicaid becomes the secondary payer and 
would, for example, cover cost-sharing obligations under the 
primary insurance plan, and would also pay for Medicaid covered 
services not offered by the primary insurance plan. In some 
circumstances, Medicaid pays the premiums required for other 
insurance.
    The Breast and Cervical Cancer Mortality Prevention Act of 
1990 (P.L. 101-354) authorized the Centers for Disease Control 
and Prevention (CDC) to begin a national program to increase 
screening services for all women, with priority given to low-
income women. The CDC's National Breast and Cervical Cancer 
Early Detection Program (Public Health Service Act, Title XV) 
was reauthorized through FY2003 by P.L. 105-340. States are 
required to contribute $1 for every $3 of federal grant funds. 
To receive a grant, states must cover specified screening 
services under Medicaid. The specified screening services for 
breast cancer are physical breastexamination and mammography; 
for cervical cancer, pelvic examination and pap smear. If a superior 
screening procedure becomes available and is recommended for use, the 
superior procedure is to be utilized. The law for this program does not 
specify financial eligibility standards. Cost-sharing can be imposed on 
a sliding scale based on income only for women above 100% of FPL. If 
the woman is covered by other health benefits programs (e.g., private 
insurance, Medicare, Medicaid) that pay for these screening services, 
that other program is the first payer. The upper payment limit for 
covered screening services is the Medicare rate.

Explanation of provision

    S. 662 would establish a new optional categorically needy 
coverage group under Medicaid. Eligible individuals are those 
women who are under age 65, have been screened under the 
Centers for Disease Control's Breast and Cervical Cancer Early 
Detection Program, and need treatment for breast or cervical 
cancer. In addition, such individuals must not otherwise be 
eligible for Medicaid under a mandatory coverage group and must 
not have other creditable health insurance coverage (as defined 
in Section 2701(c) of the Public Health Service Act).
    This definition of creditable health insurance coverage 
does not include state programs to provide treatment services 
to women diagnosed with breast or cervical cancer through the 
National Breast and Cervical Cancer Early Detection Program. As 
a result, women currently eligible for state-funded treatment 
programs will not be disqualified from receiving Medicaid 
services under this legislation.
    As of March 1999, the upper income eligibility level in 
most states (45 of 50) for individuals screened under the CDC 
program was 200 to 250 percent of the federal poverty level.
    Medicaid coverage would be limited to medical assistance 
provided during the period in which the individual requires 
breast or cervical cancer treatment.

Reason for change

    Since its inception in 1990, the Center for Disease 
Control's National Breast and Cervical Cancer Early Detection 
Program has provided screening services to more than a million 
women across the country. In the process, more than 6,000 cases 
of breast cancer and 500 cases of cervical cancer have been 
detected. Currently, women facing these diagnoses have to rely 
upon informal systems of donated care to meet the costs 
associated with treating their disease. S. 662 will give the 
states the option of making women diagnosed through the CDC 
screening programs eligible for Medicaid, bypassing the need to 
rely on informal systems of care.

                       B. Presumptive Eligibility


Current law

    Medicaid law stipulates that state Medicaid plans must 
provide safeguards to assure that eligibility is determined in 
a manner consistent with simplicity of administration and in 
the best interests of beneficiaries. Regulations further 
specify that state Medicaid agencies must establish and inform 
applicants of time limits for determining eligibility and must 
determine eligibility within those limits, except in unusual 
circumstances. The largest permissible time limits are 90 days 
for disability-based applications and 45 days for other 
applications. The time standards must cover the period from the 
date of application to the date the agency mails notice of its 
decision to the applicant.
    Currently, states have the option of extending what is 
known as ``presumptive eligibility'' to two categories of 
Medicaid beneficiaries--pregnant women and children under 19 
years of age. Presumptive eligibility allows such individuals 
whose family income appears to be below the state's Medicaid 
income standards to enroll temporarily in Medicaid, until a 
final formal determination of eligibility is made. The primary 
purpose of this option is to make needed services immediately 
available to these specified groups. Presumptive eligibility 
has been permitted for pregnant women since 1986, and for 
children under 19 since 1997.
    For pregnant women and children, current law defines the 
period of presumptive eligibility, entities qualified to 
determine presumptive eligibility, and administrative 
requirements for state Medicaid agencies and qualified entities 
that make such determinations. The period of presumptive 
eligibility begins with the date on which a qualified entity 
determines, on the basis of preliminary information, that the 
applicant's income does not exceed the applicable income 
standard. The period ends with the earlier of either: (a) the 
day on which the final eligibility determination is made, or 
(b) for those beneficiaries who fail to submit an application, 
the last day of the month following the month in which the 
qualified entity established presumptive eligibility. Qualified 
entities include Medicaid providers; Head Start programs; 
Women, Infants and Children (WIC) supplemental nutrition 
programs; and agencies that determine eligibility for 
subsidized child care. Finally, state Medicaid agencies must 
provide qualified entities with the necessary forms for 
application, and information on how to assist individuals in 
completing applications. In turn, qualifying entities must 
notify the state Medicaid agency of presumptive eligibility 
determinations within 5 working days, and inform applicants 
that formal application is required within a specified time 
frame using an appropriate form.
    Payments for covered items and services provided to 
beneficiaries during the period of presumptive eligibility will 
be matched at the applicable federal medical assistance 
percentage for those items and services.

Explanation of provision

    S. 662 includes the option of extending presumptive 
eligibility to individuals qualifying for Medicaid under the 
new optional coverage group. With one exception, the rules 
governing presumptive eligibility are the same as those already 
specified in current law for pregnant women and children under 
19 years of age. In S. 662, qualifying entities for determining 
presumptiveeligibility would be limited to Medicaid providers 
only.

Reason for change

    Presumptive eligibility would give states the option to 
ensure that no time lag exists between a diagnosis received 
through the CDC screening program and Medicaid eligibility for 
treatment.

                           C. Enhanced Match


Current law

    Medicaid is a federal-state matching program. The federal 
share of a state's payments for Medicaid benefits is called the 
federal medical assistance percentage (FMAP). The FMAP for a 
given state is determined by a formula that considers the 
state's per capita income compared to the national average. The 
law establishes a minimum FMAP of 50 percent and a maximum of 
83 percent. The federal share of Medicaid payments for benefits 
is higher in poor states. In FY2000, FMAPs range from 50 
percent to 76.8 percent.
    The law provides some exceptions to the FMAP for Medicaid 
benefits. For example, family planning services (instruction in 
contraceptive methods and family planning supplies) are 
federally matched at a 90 percent rate. Benefits provided to 
children who qualify for Medicaid via an expansion of 
eligibility under the State Children's Health Insurance Program 
are matched at an enhanced rate that can range from 65 percent 
to 85 percent. Medicaid services received through an Indian 
Health Service facility are fully funded by the federal 
government with no state share.
    With specific exceptions, Medicaid administrative expenses 
are generally matched at the rate of 50 percent.

Explanation of provision

    The Chairman's mark makes a change to S. 662 to fit within 
the budget reserve account of $250 million over 5 years 
included in the concurrent resolution on the budget for fiscal 
year 2001. S. 662 as introduced stipulates that states would 
receive a federal matching rate equal to 75 percent for 
activities related to offering, arranging and furnishing 
medical assistance to individuals eligible under the new 
optional categorically needy group. However, S. 662 is scored 
by the Congressional Budget Office as costing $360 million over 
5 years. The Chairman's mark uses the enhanced matching rate 
structure used for the state children's health insurance 
program, which averages a 68 to 32 percent match rate (compared 
to the Medicaid average match of 57 to 43 percent). This model, 
with an October 1, 2000 start date, is scored at $250 million 
over 5 years.

Reason for change

    The enhanced match rate included in the bill is intended to 
give states a financial incentive to take up the new option to 
extend Medicaid eligibility to women receiving breast or 
cervical cancer diagnoses through CDC's screening program.

                           D. Effective Date

    All amendments made by S. 662 apply to medical assistance 
provided on or after October 1, 2000, without regard to whether 
final regulations to carry out these amendments have been 
promulgated by that date.

                    III. BUDGET EFFECTS OF THE BILL

    In compliance with sections 308 and 403 of the 
Congressional Budget Act of 1974, and paragraph 11(a) of Rule 
XXVI of the Standing Rules of the Senate, the following letter 
has been received from the Congressional Budget Office on the 
budgetary impact of the legislation:

                                     U.S. Congress,
                               Congressional Budget Office,
                                     Washington, DC, June 20, 2000.
Hon. William V. Roth, Jr.
Chairman, Committee on Finance,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 662, the Breast and 
Cervical Cancer prevention and Treatment Act of 2000.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contacts are Eric 
Rollins (for federal costs) and Leo Lex (for impacts on state 
and local governments).
            Sincerely,
                                           Steven Lieberman
                                    (For Dan L. Crippen, Director).
    Enclosure.

               CONGRESSIONAL BUDGET OFFICE COST ESTIMATE

S.662--Breast and Cervical Cancer Prevention and Treatment Act of 2000

    Sumary: S. 662 would allow states to receive federal 
Medicaid funds for providing medical care to low-income women 
who have been screened under a Centers for Disease Control and 
Prevention (CDC) screening program and found to have breast or 
cervical cancer. CBO estimates that S. 662 would increase 
direct spending by $250 million over the 2000-2005 period. 
Since this bill would affect direct spending, pay-as-you-go-
procedures would apply.
    S. 662 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA). 
A new coverage option in the bill would allow states to 
increase spending in their Medicaid programs for the treatment 
of breast and cervical cancer. CBO estimates that the state 
portion of Medicaid expenditures for this optional coverage 
would total $107 million over the 2000-2005 period.
    Estimated cost to the Federal Government: The estimated 
budgetary impact of S. 662 is shown in the following table. The 
costs of this legislation fall within budget function 550 
(health).

----------------------------------------------------------------------------------------------------------------
                                                                  By fiscal year, in millions of dollars--
                                                           -----------------------------------------------------
                                                              2000     2001     2002     2003     2004     2005
----------------------------------------------------------------------------------------------------------------
                                           CHANGES IN DIRECT SPENDING

Estimated budget authority................................        0       15       35       50       65       85
Estimated outlays.........................................        0       15       35       50       65       85
----------------------------------------------------------------------------------------------------------------

    Basis of estimate: S. 662 would give states the option of 
providing Medicaid coverage to women who have been screened 
under the CDC's National Breast and Cervical Cancer Early 
Detection Program and found to have breast or cervical cancer. 
States would receive an enhanced federal Medicaid match rate 
for services provided to women who become eligible for Medicaid 
under the bill. (This enhanced federal match rate, which is 
already used for services provided under the State Children's 
Health Insurance Program, averages about 70 percent, compared 
to 57 percent for the regular match rate.) Federal Medicaid 
funds would be available beginning in fiscal year 2001.
    Under current law, women with breast and cervical cancer 
are eligible for Medicaid only if they fall into an existing 
eligibility category. The principal eligibility categories for 
low-income women are pregnancy, and welfare-related or 
disability-related coverage (which is largely based on receipt 
of either Temporary Assistance for Needy Families or 
Supplemental Security Income). If a women is found to have 
breast or cervical cancer, does not have health insurance, and 
does not qualify for Medicaid, she either pays for the 
treatment with her own funds, receives treatment through a 
state, local, or privately funded program, receives charity 
care, or goes without treatment.
    The Congress created the National Breast and Cervical 
Cancer Early Detection Program in 1990 and appropriated $166 
million for the program for fiscal year 2000. The funds support 
screening activities in all 50 states, in the District of 
Columbia and U.S. territories, and for several American Indian/
Alaska Native organizations. States set their own income 
eligibility levels, at or below 250 percent of the federal 
poverty line. Most states have set eligibility criteria at 
about 200 percent of poverty. The CDC estimates that the 
program currently screens about 15 percent of the eligible 
population. Program funds are not available for treating breast 
and cervical cancer.
    The bill's effect on federal Medicaid spending depends on 
the number of women who would receive Medicaid-funded treatment 
as a result of the bill, the cost of the treatment, and the 
number of states that would choose the option. The following 
discussion focuses on the estimate for breast cancer treatment, 
which accounts for over 90 percent of the estimated costs of 
the bill. A brief discussion of the cost of cervical cancer 
treatment can be found at the end of the section.
    Number of beneficiaries.--The states provided 224,000 
mammograms with funds available under the CDC screening program 
in 1998. Some states currently supplement the CDC screening 
funds with their own funds for screening, diagnosis, and 
treatment. Under the bill, CBO expects that the number of 
mammograms under the CDC program would rise to 540,000 by 2005, 
as states that fund diagnosis and treatment services redirect 
their funds tosuplement the screening funds in the CDC program. 
Because participation in that program would provide access to federal 
Medicaid funds for diagnosis and treatment of breast cancer, states 
would have an incentive to redirect their own funds into the CDC 
screening program.
    Of women screened for breast cancer by the CDC program 
since its inception, about 0.5 percent, or 5 per 1,000, have 
been found to have breast cancer. Another 7 percent have had 
abnormal screens that required additional diagnosis and perhaps 
minor treatment. CBO assumes that the same incidence of cancer 
and other abnormal results would continue under the bill, 
resulting in the identification of about 2,700 new cancers and 
36,000 abnormal mammograms each year by 2005.
    In addition to these new cases, CDC reports that it has 
already diagnosed over 5,800 breast cancers. CBO anticipates 
that about 2,400 of these women would receive coverage under 
the bill if states adopt the option.
    Cost of treatment--Based on data from a large health 
maintenance organization, CBO has estimated the average cost of 
breast cancer treatment by age and year since diagnosis. In the 
first year after diagnosis, CBO estimates that cancer treatment 
would cost about $20,000. In subsequent years, CBO estimates 
about $6,000 a year in ongoing care costs, until the last year 
of a patient's life, when costs total about $33,000. CBO used 
information from the National Cancer Institute's Surveillance, 
Epidemiology, and End Results Program to estimate age-specific 
mortality rates from the time of diagnosis.
    For women who have an abnormal mammogram, but who are not 
ultimately diagnosed with cancer, CBO estimates average 
treatment costs of about $2,000 in the year after the mammogram 
for follow-up diagnostic and treatment services.
    The costs discussed above are for cancer treatment only and 
are expressed in fiscal year 2001 dollars. Because the bill 
would extend full Medicaid coverage during the time the woman 
needs cancer treatment, CBO added about $1,000 a year to the 
costs of cancer treatment (one-third of the average per capita 
Medicaid costs for adults) to determine total Medicaid costs 
for women newly eligible because of the bill. CBO expects that 
the average annual cost of treatment would rise at the same 
rate as the Consumer Price Index for medical care (CPI-M)
    State participation.--In 2001, CBO anticipates, that states 
with 25 percent of potential Medicaid costs would choose to 
cover breast cancer patients screened through the CDC program 
in their Medicaid programs. By 2005, CBO projects that 
proportion would rise to 50 percent.
    Cervical cancer.--The costs of cervical cancer treatment 
under the bill stem principally from treatment of pre-cancerous 
conditions since screening often results in an abnormal finding 
at an early stage of the disease. CBO anticipates that about 
120 new cases of cervical cancer would be diagnosed each year 
under the screening program, with average annual treatment 
costs similar to the treatment costs for breast cancer. CBO 
expects about 10,000 abnormal pap smears each year, with 
treatment costs averaging $1,000 to $2,000. In total, CBO 
estimates that treatment of cervical cancer under the bill 
would cost $15 million over the 2000-2005 period.
    Pay-as-you-go considerations: The Balanced Budget and 
Emergency Deficit Control Act sets up pay-as-you-go procedures 
for legislation affecting direct spending or receipts. The net 
changes in outlays that are subject to pay-as-you-go procedures 
are shown in the following table. (S. 662 would not affect 
receipts.) For the purposes of enforcing pay-as-you-go 
procedures, only the effects in the current year, the budget 
year, and the succeeding four years are counted.

----------------------------------------------------------------------------------------------------------------
                                                       By fiscal year, in millions of dollars--
                                    ----------------------------------------------------------------------------
                                      2000   2001   2002   2003   2004   2005   2006   2007   2008   2009   2010
----------------------------------------------------------------------------------------------------------------
Changes in outlays.................      0     15     35     50     65     85    105    120    145    165    190
Changes in receipts................                                 Not applicable.
----------------------------------------------------------------------------------------------------------------

    Intergovernmental and private-sector impact: S. 662 
contains no intergovernmental or private-sector mandates as 
defined in the Unfunded Mandates Reform Act. The bill would 
allow states to increase spending in their Medicaid programs 
for the treatment of breast and cervical cancer. CBO estimates 
that the state portion of Medicaid expenditures for this 
optional coverage would total $107 million over the 2000-2005 
period.
    State spending for the treatment of breast and cervical 
cancer among certain women who would otherwise be ineligible 
for Medicaid would qualify for a 70 percent federal match on 
average. Some states may already be covering this type of 
treatment in state-funded public health programs. In those 
cases, the federal matching funds would allow states to 
increase their overall level of spending for existing programs 
or to redirect a portion of their current spending to screening 
or other state programs.
    Previous CBO estimate: On November 10, 1999, CBO estimated 
that section 2 of H.R. 1070, as ordered reported by the House 
Committee on Commerce on October 28, 1999, would increase 
federal Medicaid spending by $205 million over the 2000-2004 
period. The provisions of that section are almost identical to 
those in S. 662, except for the federal match rate that would 
apply to Medicaid services provided under the new state option. 
Under H.R. 1070, the federal match rate would be 75 percent or 
the state's regular rate, whichever is higher. Since the 
federal match rate under S. 662 would generally be lower (70 
percent, on average), CBO assumed that state participation in 
the new Medicaid option would also be lower. CBO's estimate for 
S. 662 also incorporates more recent data on the CDC screening 
program, new projections for the CPI-M, and budgetary effects 
in 2005.
    Estimate prepared by: Federal costs: Eric Rollins; impact 
on State, local, and tribal governments: Leo Lex; impact on the 
private sector: Rekha Ramesh.
    Estimate approved by: Robert A. Sunshine, Assistant 
Director for Budget Analysis.

                       IV. VOTE OF THE COMMITTEE

    In compliance with section 133 of the Legislative 
Reorganization Act of 1946, the Committee states that S. 662, 
as amended by the Chairman's mark, was ordered reported 
favorably by a voice vote, a quorum being present.

                          V. REGULATORY IMPACT

    In compliance with paragraph 11(b) of Rule XXVI of the 
Standing Rules of the Senate, the Committee states that the 
legislation will not significantly regulate any individuals or 
businesses, will not impact the personal privacy of 
individuals, and will result in no significant additional 
paperwork. The regulatory impact of the bill on the government 
will be limited to the need for the Health Care Financing 
Administration to develop regulations for the implementation of 
the new state option.
    This new option set forth in the bill will not impose a 
federal intergovernmental mandate on state, local, or tribal 
governments.

                      VI. CHANGES IN EXISTING LAW

    In compliance with paragraph 12 of rule XXVI of the 
Standing Rules of the Senate, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
opposed to be omitted is enclosed in black brackets, new matter 
is printed in italic, existing law in which no change is 
proposed is shown in roman):

                         SOCIAL SECURITY ACT

           *       *       *       *       *       *       *



       TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

           *       *       *       *       *       *       *



                   state plans for medical assistance

    Sec. 1902. (a) A State plan for medical assistance must--
          (1)  * * *

           *       *       *       *       *       *       *

          (10) provide--
                  (A) for making medical assistance available, 
                including at least the care and services listed 
                in paragraphs (1) through (5), (17) and (21) of 
                section 1905(a), to--
                          (i) * * *
                          (ii) at the option of the State, to 
                        any group or groups of individuals 
                        described in section 1905(a) (or, in 
                        the case of individuals described in 
                        section 1905(a)(i), to any reasonable 
                        categories of such individuals) who are 
                        not individuals described in clause (i) 
                        of this subparagraph but--
                                  (I) * * *

           *       *       *       *       *       *       *

                                  (XVI) who are employed 
                                individuals with a medically 
                                improved disability described 
                                in section 1905(v)(1) and whose 
                                assets, resources, and earned 
                                or unearned income (or both) do 
                                not exceed such limitations (if 
                                any) as the State may 
                                establish, only if the State 
                                provides medical assistance to 
                                individuals described in 
                                subclause (XV); [or]
                                  (XVII) who are independent 
                                foster care adolescents (as 
                                defined in section 1905(w)(1)), 
                                or who are within any 
                                reasonable categories of such 
                                adolescents specified by the 
                                State; or
                                  (XVIII) who are described in 
                                subsection (aa) (relating to 
                                certain breast or cervical 
                                cancer patients);

           *       *       *       *       *       *       *

                  (G) that, in applying eligibility criteria of 
                the supplemental security income program under 
                title XVI for purposes of determining 
                eligibility for medical assistance under the 
                State plan of an individual who is not 
                receiving supplemental security income, the 
                State will disregard the provisions of 
                subsections (c) and (e) of section 1613;
        except that (I) the making available of the services 
        described in paragraph (4), (14), or (16) of section 
        1905(a) to individuals meeting the age requirements 
        prescribed therein shall not, by reason of this 
        paragraph (10), require the making available of any 
        such services, or the making available of such services 
        of the same amount, duration, and scope, to individuals 
        of any other ages, (II) the making available of 
        supplementary medical insurance benefits under part B 
        of title XVIII of individuals eligible therefore 
        (either pursuant to an agreement entered into under 
        section 1843 or by reason of the payment of premiums 
        under such title by the State agency on behalf of such 
        individuals), or cost sharing, or similar charges under 
        part B of title XVIII for individuals eligible for 
        benefits under such part, shall not, by reason of this 
        paragraph (10), require the making available of any 
        such benefits, of the making available of services of 
        the same amount, duration, and scope, to any other 
        individuals, (III) the making available of medical 
        assistance equal in amount, duration, and scope to the 
        medical assistance made available to individuals 
        described in clause (A) to any classification of 
        individuals approved by the Secretary with respect to 
        whom there is being paid, or who are eligible, or would 
        be eligible if they were not in a medical institution, 
        to have paid with respect to them, a State 
        supplementary payment shall not, by reason of this 
        paragraph (10), require the making available of any 
        such assistance, or the making available of such 
        assistance of the same amount, duration, and scope, to 
        any other individuals not described in clause (A), (IV) 
        the imposition of a deductible, cost sharing , or 
        similar charge for any item or service furnished to an 
        individual not eligible for the exemption under section 
        1916(a)(2) or (b)(2) shall not require the imposition 
        of a deductible, cost sharing, or similar charge for 
        the same item or service furnished to an individual who 
        is eligible for such exemption, (V) the making 
        available to pregnant women covered under the plan of 
        services relating to pregnancy (including prenatal, 
        delivery, and postpartum services) or to any other 
condition which may complicate pregnancy shall not, by reason for this 
paragraph (10), require the making available of such services, or the 
making available of such services of the same amount, duration, and 
scope, to any other individuals, provided such services are made 
available (in the same amount duration, and scope) to all pregnant 
women covered under the State plan, (VI) with respect to the making 
available of medical assistance for hospice care to terminally ill 
individuals who have made a voluntary election described in section 
1905(o) to receive hospice care instead of medical assistance for 
certain other services, such assistance may not be made available in an 
amount, duration, or scope less than that provided under title XVIII, 
and the making available of such assistance shall not, by reason of 
this paragraph (10), require the making available to medical assistance 
for hospice care to other individuals or the making available of 
medical assistance for services waived by such terminally ill 
individuals, (VII) the medical assistance made available to an 
individual described in subsection (l)(1)(A) who is eligible for 
medical assistance only because of subparagraph (A)(i)(IV) or 
(A)(ii)(IX) shall be limited to medical assistance for services related 
to pregnancy (including prenatal, delivery, postpartum, and family 
planning services) and to other conditions which may complicate 
pregnancy, (VIII) the medical assistance made available to a qualified 
medicare beneficiary described in section 1905(p)(1) who is only 
entitle to medical assistance because the individual is such a 
beneificary shall be limited to medical assistance for medicare cost-
sharing (described in section 1905(p)(3)), subject to the provisions of 
subsection (n) and section 1916(b), (IX) the making available of 
respiratory care services in accordance with subsection (e)(9) shall 
not, by reason of this paragraph (10) require the making available of 
such services, or the making available of such services of the same 
amount, duration, and scope, to any individuals not included under 
subsection (e)(9)(A), provided such services are made available (in the 
same amount, duration, and scope) to all individuals described in such 
subsection, (X) if the plan provides for any fixed durational limit on 
medical assistance for inpatient hospital services (whether or not such 
a limit varies by medical condition or diagnosis), the plan must 
establish exceptions to such a limit for medically necessary inpatient 
hospital services furnished with respect to individuals under one year 
of age in a hospital defined under the State plan, pursuant to section 
1923(a)(1)(A), as a disproportionate share hospital and subparagraph 
(B) (relating to comparability) shall not be construed as requiring 
such an exception for other individuals, services, or hospitals, (XI) 
the making available of medical assistance to cover to the costs of 
premiums, deductibles, coinsurance, and other cost-sharing obligations 
for certain individuals for private health coverage as described in 
section 1906 shall not, by reason of paragraph (10), require the making 
available of any such benefits or the making available of services of 
the same amounts, duration, and scope of such private coverage to any 
other individuals, (XII) the medical assistance made available to an 
individual described in subsection (u)(1) who is eligible for medical 
assistance only because of subparagraph (F) shall be limited to medical 
assistance for COBRA continuation premiums (as defined in subsection 
(u)(2)), [and (XIII)] (XIII) the medical assistance made available to 
an individual described in subsection (z)(1) who is eligible for 
medical assistance only because of subparagraph (A)(ii)(XII) shall be 
limited to medical assistance for TB-related services (described in 
subsection (z)(2), and (XIV) the medical assistance made available to 
an individual described in subsection (aa) who is eligible for medical 
assistance only because of subparagraph (A)(10)(ii)(XVIII) shall be 
limited to medical assistance provided during the period in which such 
an individual requires treatment for breast or cervical cancer;

           *       *       *       *       *       *       *

          (47) at the option of the State, provide for making 
        ambulatory prenatal care available to pregnant women 
        during a presumptive eligibility period in accordance 
        with section 1920 and provide for making medical 
        assistance for items and services described in 
        subsection (a) of section 1920A available to children 
        during a presumptive eligibility period in accordance 
        with such section and provide for making medical 
        assistance available to individuals described in 
        subsection (a) of section 1920B during a presumptive 
        eligibility period in accordance with such section:

           *       *       *       *       *       *       *

    (aa) Individuals described in this subsection individuals 
who--
          (1) are not described in subsection (a)(10)(a)(i);
          (2) have not attained age 65;
          (3) have been screened for breast and cervical 
        concern under the Centers for Disease Control and 
        Prevention breast and cervical cancer early detection 
        program established under title XV of the Public Health 
        Service Act (42 U.S.C. 300k et seq.) in accordance with 
        the requirements of section 1504 of that Act (42 U.S.C. 
        300n) and need treatment for breast or cervical cancer; 
        and
          (4) are not otherwise covered under creditable 
        coverage, as defined in section 2701(c) of the Public 
        Health Service Act (45 U.S.C. 300gg(c)).

                           payment to states

    Sec. 1903. (a) * * *

           *       *       *       *       *       *       *

     (u)(1)(A) * * *

           *       *       *       *       *       *       *

     (D)(i) * * *

           *       *       *       *       *       *       *

    (v) In determining the amount of erroneous excess payments, 
there shall not be included any erroneous payments made for 
ambulatory prenatal care provided during a presumptive 
eligibility period (as defined in section 1920(b)(1)) [or for], 
for items and services described in subsection (a) of section 
1920A provided to a child during a presumptive eligibility 
period under such section, or for medical assistance provided 
to an individual described in subsection (a) of section 1920B 
during a presumptive eligibility period under such section.

           *       *       *       *       *       *       *


                              Definitions

    Sec. 1905. For purposes of this title--
    (a) The term ``medical assistance'' means payment of part 
or all of the cost of the following care and services (if 
provided in or after the third month before the month in which 
the recipient makes application for assistance or, in the case 
of medicare cost-sharing with respect to a qualified medicare 
beneficiary described in subsection (p)(1), if provided after 
the month in which the individual becomes such a beneficiary) 
for individuals, and, with respect to physicians' or dentists' 
servcies, at the option of the State, to individuals (other 
than individuals with respect to whom there is being paid, or 
who are eligible, or would be eligible if they were not in a 
medical institution, to have paid with respect to them a State 
supplementary payment and are eligible for medical assistance 
equal in amount, duration, and scope to the medical assistance 
made available to individuals described in section 
1902(a)(10)(A)) not receiving aid or assistance under any plan 
of the State approved under title I, X, XIV, or XVI, or part A 
of title IV, and with respect to whom supplemental security 
income benefits are not being paid under title XVI, who are--
          (i) * * *

           *       *       *       *       *       *       *

          (xi) individuals described in section 1902(z)(1), 
        [or]
          (xii) employed individuals with a medically improved 
        disability (as defined in subsection (v)), or
          (xiii) individuals described in section 1902(aa),
but whose income and resources are insufficient to meet all of 
such cost--
          (1) inpatient hospital services (other than services 
        in an institution for mental diseases);

           *       *       *       *       *       *       *

    (b) Subject to section 1933(d), the term ``Federal medical 
assistance percentage'' for any State shall be 100 per centum 
less the State percentage; and the State percentage shall be 
that percentage which bears the same ratio to 45 per centum as 
the square of the per capital income of such State bears to the 
square of the per capital income of the continental United 
States (including Alaska) and Hawaii; except that (1) the 
Federal medical assistance percentage shall in no case be less 
than 50 per centum or more than 83 per centum, (2) the Federal 
medical assistance percentage for Puerto Rico, the Virgin 
Islands, Guam, the Northern Mariana Islands, and American Samoa 
shall be 50 per centum, [and] (3) for purposes of this title 
and title XXI, the Federal medical assistance percentage for 
the District of Columbia shall be 70 percent, and (4) the 
Federal medical assistance percentage shall be equal to the 
enhanced FMAP described in section 2105(b) with respect to 
medical assistance provided to individuals who are eligible for 
such assistance only on the basis of section 
1902(a)(10)(A)(ii)(XVIII). The Federal medical assistance 
percentage for any State shall be determined and promulgated in 
accordance with the provisions of section 1101(a)(8)(B). 
Notwithstanding the first sentence of this section, the Federal 
medical assistance percentage shall be 100 per centum with 
respect to amounts expended as medical assistance for services 
which are received through an Indian Health Service facility 
whether operated by the Indian Health Service or by an Indian 
tribe or tribal organization (as defined in section 4o of the 
Indian Health Care Improvement Act). Notwithstanding the first 
sentence of this subsection, in the case of a State plan that 
meets the condition described in subsection (u)(1), with 
respect to expenditures (other than expenditures under section 
1923) described in subsection (u)(2)(A) or subsection (u)(3) 
for the State for a fiscal year, and that do not exceed the 
amount of the State's allotment under section 2104 (not taking 
into account reductions under section 2104(d)(2)) for the 
fiscal year reduced by the amount of any payments made under 
section 2105 to the State from such allotment for such fiscal 
year, the Federal medical assistance percentage is equal to the 
enhanced FMAP described in section 2105(b).

           *       *       *       *       *       *       *


                  presumptive eligibility for children

    Sec. 1920A. * * *

           *       *       *       *       *       *       *



presumptive eligibility for certain breast and cervical cancer patients


    Sec. 1920B. (a) State Option.--A State plan approved under 
section 1902 may provide for making medical assistance 
available to an individual described in section 1902(aa) 
(relating to certain breast and cervical cancer patients) 
during a presumptive eligibility period.
    (b) Definitions.--For purposes of this section:
          (1) Presumptive Eligibility period.--The term 
        ``presumptive eligibility period'' means, with respect 
        to an individual described in subsection (a), the 
        period that--
                  (A) begins with the date on which a qualified 
                entity determines, on the basis of preliminary 
                information, that the individual is described 
                in section 1902(aa); and
                  (B) ends with (and includes) the earlier of--
                          (i) the day on which a determination 
                        is made with respect to the eligibility 
                        of such individual for services under 
                        the State plan; or
                          (ii) in the case of such an 
                        individual who does not file an 
                        application by the last day of the 
                        month following the month during which 
                        the entity makes the determination 
                        referred to in subparagraph (A), such 
                        last day.
          (2) Qualified entity.--
                  (A) In general.--Subject to subparagraph (B), 
                the term ``qualified entity'' means any entity 
                that--
                          (i) is eligible for payments under a 
                        State plan approved under this title; 
                        and
                          (ii) is determined by the State 
                        agency to be capable of making 
                        determinations of the type described in 
                        paragraph (1)(A).
                  (B) Regulations.--The Secretary may issue 
                regulations further limiting those entities 
                that may become qualified entities in order to 
                prevent fraud and abuse and for other reasons.
                  (C) Rule of construction.--Nothing in this 
                paragraph shall be construed as preventing a 
                State from limiting the classes of entities 
                that may become qualified entities, consistent 
                with any limitations imposed under subparagraph 
                (B).
    (c) Administration.--
          (1) In general.--The State agency shall provide 
        qualified entities with--
                  (A) such forms as are necessary for an 
                application to be made by an individual 
                described in subsection (a) for medical 
                assistance under the State plan; and
                  (B) information on how to assist such 
                individuals in completing and filing such 
                forms.
          (2) Notification requirements.--A qualified entity 
        that determines under subsection (b)(1)(A) that an 
        individual described in subsection (a) is presumptively 
        eligible for medical assistance under a State plan 
        shall--
                  (A) notify the State agency of the 
                determination within 5 working days after the 
                date on which determination is made; and
                  (B) inform such individual at the time the 
                determination is made that an application for 
                medical assistance under the State plan is 
                required to be made by not later than the last 
                day of the month following the month during 
                which the determination is made.
          (3) Application for medical assistance.--In the case 
        of an individual described in subsection (a) who is 
        determined by a qualified entity to be presumptively 
        eligible for medical assistance under a State plan, the 
        individual shall apply for medical assistance under 
        such plan by not later than the last day of the month 
        following the month during which the determination is 
        made.
    (d) Payment.--Notwithstanding any other provision of this 
title, medical assistance that--
          (1) is furnished to an individual described in 
        subsection (a)--
                  (A) during a presumptive eligibility period;
                  (B) by a entity that is eligible for payments 
                under the State plan; and
          (2) is included in the care and services covered by 
        the State plan;
shall be treated as medical assistance provided by such plan 
for purposes of clause (4) of the first sentence of section 
1905(b).

           *       *       *       *       *       *       *


                                  
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