[Federal Register Volume 73, Number 81 (Friday, April 25, 2008)]
[Rules and Regulations]
[Pages 22281-22287]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E8-9066]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

45 CFR Part 148

[CMS-2260-F]
RIN 0938-A046


Grants to States for Operation of Qualified High Risk Pools

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Final Rule.

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SUMMARY: This rule finalizes the interim final rule with comment period 
that was published on July 27, 2007, regarding extended funding for 
seed and operational grants for State High Risk Pools under the Public 
Health Service Act.

DATES: Effective Date: These regulations are effective May 27, 2008.

FOR FURTHER INFORMATION CONTACT: Jessica Kahn, (410) 786-9361, or John 
Young, (410) 786-0505.

SUPPLEMENTARY INFORMATION:

I. Background

    The Trade Adjustment Assistance Reform Act of 2002 (Pub. L. 107-
210) added section 2745 of the Public Health Service Act (PHS Act) to 
provide for two types of grants to States for the promotion of 
``qualified high risk pools.'' These pools provide health coverage to 
high-risk individuals who may find private health insurance unavailable 
or unaffordable. Under this provision, a pool could meet the definition 
of a ``qualified'' high risk pool for purposes of section 2745 only if 
it met the definition of a qualified high risk pool in section 
2744(c)(2) of the PHS Act. Section 2744 deals with how States can 
satisfy the requirement of section 2741 of the PHS Act to guarantee 
access to health coverage for individuals who meet the definition of an 
``eligible individual'' under section 2741, as added by the Health 
Insurance Portability and Accountability Act of 1996 (HIPAA). These 
individuals are commonly referred to as ``HIPAA-eligible'' individuals.
    Under section 2744(c)(2) of the PHS Act, a qualified high risk pool 
must provide health coverage without a pre-existing condition exclusion 
to ``all'' HIPAA-eligible individuals. This meant that State high risk 
pools that did not allow all HIPAA-eligible individuals into the pool 
without a pre-existing condition exclusion could not meet the 
definition of a ``qualified'' risk pool.
    The two types of grants authorized by the legislation were ``seed 
grants'' for States that had not yet created a high risk pool, and 
``operational'' grants to offset losses incurred by States that operate 
a qualified high risk pool. Under the prior law, in order for a risk 
pool to qualify for an operational grant, it could not charge premiums 
that exceeded 150 percent of the premium for applicable standard risk 
rates. Moreover, the amount of the grants was limited to 50 percent of 
the losses incurred by a State.
    Section 6202 of the Deficit Reduction Act of 2005 (Pub. L. 109-171) 
(DRA) and the State High Risk Pool Extension Act of 2006 (Pub. L. 109-
172) (Extension Act) extended funding for seed and operational grants 
for State High Risk Pools and amended section 2745 of the PHS Act. The 
Extension Act made the following changes:
    1. Expanded the definition of a ``qualified high risk pool.'' As 
noted above, section 2745(d) of the PHS Act previously defined the term 
to have the same meaning as in section 2744(c)(2) of the PHS Act, which 
required that the risk pool provide coverage to ``all'' HIPAA-eligible 
individuals (as defined in Sec.  148.103), without any pre-existing

[[Page 22282]]

condition exclusion. The revised definition specifies that, for 
purposes of grants under section 2745, a risk pool can be qualified 
even if the State uses other mechanisms beyond the risk pool to ensure 
that health coverage is provided to all HIPAA-eligibles.
    2. Expanded the definition of ``State.'' Section 2745 of the PHS 
Act previously defined this term to include only the 50 States and the 
District of Columbia, but has now been amended to include U.S. 
Territories.
    3. Increased the amount of premiums that a risk pool can charge and 
still qualify for an operational grant. Section 2745 of the PHS Act 
previously required that the premiums charged under the pool not exceed 
150 percent of the premium for applicable standard risk rates. As 
amended, it permits grants to States with premiums of up to 200 percent 
of the standard risk rates, as long as States with premiums greater 
than 150 percent of the standard rate use at least half of the grant 
funds to reduce high risk pool premiums for enrollees.
    4. Removed the limitation that a State's grant not exceed 50 
percent of its operating losses.
    5. Changed the funding allotment formula. Previously, the grant 
funds were to be allotted to States under a relatively simple formula 
based on the number of uninsured individuals in the State. Under the 
new legislation, the allotment formula is more complex. Of the total 
appropriation for a given year--if money is appropriated--two-thirds 
would be available for grants to cover operational losses. Of these 
funds, 40 percent is to be equally divided among any of the 50 States 
and the District of Columbia that apply. Another 30 percent of that 
amount is allotted among all States that apply for grants based on the 
ratio of uninsured individuals in the State to uninsured individuals in 
all States that apply. The final 30 percent is to be allotted based on 
the ratio of the number of individuals enrolled in a State's risk pool 
to the number enrolled through the risk pools of all the qualifying 
States that apply. (Territories are eligible for the proportional 
allotments, but only up to a total of $1 million for all Territories 
combined.)
    6. Provided authority for ``bonus grants'' to States (not including 
Territories) that qualify for operational grants. One-third of a total 
yearly appropriation will be used to provide grants to enable States to 
provide specified supplemental consumer benefits to enrollees or 
potential enrollees of the qualified high risk pool. (A bonus grant is 
not to exceed 10 percent of the total for any one State.)
    This final rule updates our regulations at 45 CFR Part 148, Subpart 
E, Grants to States for Operation of Qualified High Risk Pools, to 
implement the changes made by the Deficit Reduction Act of 2005 and the 
State High Risk Pool Extension Act of 2006. Specific instructions about 
the grant solicitation and award process will be addressed in official 
grant announcements or other appropriate documents.

II. Provisions of the Interim Final Rule

    On July 27, 2007, we published in the Federal Register an interim 
final rule with comment period (72 FR 41232). In that rule we revised 
the regulation text in 45 CFR part 148 to conform with the State High 
Risk Pool Extension Act of 2006 and the DRA. These revisions are 
discussed in detail below.

A. Definitions (Sec.  148.308)

    We amended Sec.  148.308 (Definitions) to
     Add a definition of ``bonus grants.''
     Revise the definition of ``qualified high risk pool;'' and
     Revise the definition of ``State.''
1. Bonus Grant
    We added the following definition for Bonus Grants--Funds that the 
Secretary provides from the appropriated grant funds to be used to 
provide supplemental consumer benefits to enrollees or potential 
enrollees in qualified high risk pools.
2. Qualified High Risk Pool
    We amended the definition at Sec.  148.308 to reflect the exception 
added by the Extension Act in section 2745(g)(1)(A) of the PHS Act. 
Specifically, a State may elect to meet the definition of a qualified 
high risk pool under Sec.  148.128(a)(2)(ii)(A) by providing for 
enrollment of eligible individuals through an acceptable alternative 
mechanism (as defined for purposes of section 2744 of the PHS) that 
includes a high risk pool as a component.
3. State
    In accordance with the Extension Act, we amended the definition to 
include any of the 50 States and the District of Columbia, and the U.S. 
Territories of Puerto Rico, the Virgin Islands, Guam, American Samoa 
and the Northern Mariana Islands.

B. Grants for Operational Losses (Sec.  148.310)

1. Eligibility Requirements for an Operational Grant
    This section specifies the eligibility requirements for operational 
grants. A State must meet all of the following requirements to be 
eligible for a grant:
    a. Maximum premium. We amended Sec.  148.310 to reflect that the 
statute has increased the maximum premium that a risk pool can charge 
and still qualify for a grant. The maximum has been changed from 150 
percent to 200 percent of the premium for applicable standard risk 
rates for the State.
    b. Continued funding. The statute previously required that the pool 
have in effect a mechanism reasonably designed to ensure continued 
funding of losses incurred by the State after the end of FY 2004, which 
was the last year that grants were authorized under the prior 
appropriation. The statute, as revised by the Extension Act, now 
requires that a risk pool have such a mechanism to ensure funding after 
the end of the last fiscal year for which a grant is provided. We 
interpret this to mean that the pool has capacity or mechanisms in 
place that can reasonably be expected to ensure that it may operate in 
the future without the benefit of Federal funding.
    In the case of a qualified high risk pool of a State that charges 
premiums that exceed 150 percent of the premium for applicable standard 
risks, the State must use at least 50 percent of the amount of the 
grant provided to the State to reduce premiums for enrollees. The 
application should demonstrate/attest that the funds will be used this 
way.
2. Amount of Grant Payment (Sec.  148.312)
    Two-thirds of any amounts appropriated are made available for 
operational grants. An eligible State may receive a grant to fund up to 
100 percent of the losses incurred in the operation of its qualified 
high risk pool during the fiscal year for which it is applying. The 
grant may be less than 100 percent after the allotment limits are 
applied, but in no case will it be more than 100 percent.
    Funds will be allocated in accordance with Sec.  148.312 to each 
State that meets the eligibility requirements of Sec.  148.310 and 
files an application in accordance with Sec.  148.316. Specifically:
     Forty percent of funds made available under that section 
will be equally divided among any of the 50 States and the District of 
Columbia that meet the eligibility criteria for an operational grant;
     Thirty percent of funds made available will be divided 
among States

[[Page 22283]]

(including territories) based on the number of uninsured residents in 
the State during the specified year as compared to the total number of 
uninsured residents in all States that apply for grants;
     Thirty percent will be divided among States (including 
territories) based on the number of people in State high risk pools 
during the specified year as compared to all States that apply.
    In accordance with the statute, in no case will the aggregate 
amount allotted and made available to the U.S. Territories for a fiscal 
year exceed $1 million.
    We will calculate the number of uninsured individuals for each 
eligible State by taking a 3-year average of the number of uninsured 
individuals in that State in the Current Population Survey (CPS) of the 
Census Bureau. The 3-year average will be calculated using numbers 
available as of March 1 of each year for the preceding 3-year period.

C. Bonus Grants

    One-third of the total appropriation will be available for the 
bonus grants. These grants will be available to any one of the 50 
States and the District of Columbia that receives an operational grant 
under Sec.  148.310. The grants must be used to provide one or more of 
the following benefits:
    (1) Low income premium subsidies;
    (2) Reduction in premium trends, actual premium or other cost-
sharing requirements;
    (3) An expansion or broadening of the pool of individuals eligible 
for coverage, such as through eliminating waiting lists, increasing 
enrollment caps, or providing flexibility in enrollment rules;
    (4) Less stringent rules or additional waiver authority with 
respect to coverage of pre-existing conditions;
    (5) Increased benefits; and
    (6) The establishment of disease management programs. In no case 
will a State receive bonus grants that exceed 10 percent of the total 
funds allotted for bonus grants in that fiscal year.

D. Periods During Which Eligible States May Apply for a Grant (Sec.  
148.314)

    Funds were appropriated for Federal FY 2006 and are authorized for 
FY 2008 through FY 2010. Funding for FY 2008, FY 2009, and FY 2010 
under the Extension Act requires subsequent enactment of appropriations 
authority. States will be unable to apply for grants unless and until 
such funding becomes available. A State that meets the eligibility 
requirements in Sec.  148.310 may apply for a grant to fund losses that 
were incurred during the State's or pool's fiscal year ending prior to 
or during any federal fiscal year, 2007 through 2010 for which 
authorized funds are appropriated, in connection with the operation of 
its qualified high risk pool. Grant funding is administered on a 
retrospective basis (for example, pools with losses incurred in 2005 
may apply for Federal FY 2006 grant funds). If a State becomes eligible 
for a grant in the middle of its fiscal year, a State may apply for 
losses incurred in a partial fiscal year if a partial year audit is 
done. Only losses that are incurred after it is established that a pool 
is eligible (that is, that it is a qualified high risk pool as defined 
by Sec.  148.128(a)(2)(ii)) will qualify for a grant. An eligible State 
must apply for a grant no later than June 30 following the end of the 
State fiscal year during which it incurred losses. Each State may only 
be awarded one grant per fiscal year. A grant for a partial fiscal year 
counts as a full grant.
    States that meet all of the eligibility requirements in Sec.  
148.310 and submit timely requests in accordance with paragraph (c) of 
Sec.  148.314 will receive distribution of grant funds using the 
following methodology:
     Grant applications for losses will be on a retrospective 
basis. For example, grant applications for 2006 funds are based on the 
State's FY 2005 incurred losses.
     Grant allocations for each fiscal year will be determined 
by taking all grant applications received by June 30 of the Federal 
fiscal year and allocating grant funds in accordance with Sec.  
148.312. In no case will a State receive funds greater than 100 percent 
of its losses.
    If any excess funds remain after the initial calculation, these 
excess funds will be proportionately redistributed to the States whose 
allocations have not exceeded 100 percent of their losses. This process 
will occur at the time of the initial calculation and there will be one 
annual allocation and distribution by September 30 of each year.
Grant Application Instructions (Sec.  148.316)
    We amended Sec.  148.316 to reflect the addition of application 
requirements for bonus grants. We changed the heading of Sec.  
148.316(a), ``Application package,'' to ``Application for operational 
losses.'' We inserted a bonus grants section by redesignating Sec.  
148.316(a)(3) as Sec.  148.316(a)(4) and adding new paragraph (a)(3), 
the bonus grants requirements. The individual State applying for a 
bonus grant must provide:
    (i) A narrative description with detailed information about each 
one of the following supplemental consumer benefits to be provided to 
enrollees and/or potential enrollees in the high risk pool:
    (A) Low income premium subsidies;
    (B) Reduction in premium trends, actual premium or other cost-
sharing requirements;
    (C) An expansion or broadening of the pool of individuals eligible 
for coverage, such as through eliminating waiting lists, increasing 
enrollment caps, or providing flexibility in enrollment;
    (D) Less stringent rules, or additional waiver authority with 
respect to coverage of pre-existing conditions;
    (E) Increased benefits; and
    (F) The establishment of disease management programs.
    (ii) A description of the population or subset population that will 
be eligible for the supplemental consumer benefits.
    (iii) A projected budget for the use of bonus grant funds using the 
SF 424 and SF 424 A.
    We revised the ``Standard forms application kit'' in Sec.  
148.316(b). We eliminated the text ``Additional Assurances'' in 
``Standard forms application kit,'' paragraph (b)(1)(i).
    We also changed the Web site URL address for the ``Standard forms 
kit'' download at paragraph (b)(1)(ii) to http://www.grants.gov.
    There are no other changes to the content of the ``Standard forms 
application kit.''
    In Sec.  148.316(c), ``Submission of application package,'' we 
deleted paragraphs (c)(1) and (c)(2) and replaced with text that will 
read: All applications should be submitted electronically via http://www.grants.gov.
    In Sec.  148.316(d), ``Application deadlines,'' we changed the 
applications deadlines text to read: The deadline for States to submit 
an application for losses incurred in a State fiscal year is June 30 of 
the next Federal fiscal year that begins after the end of the State 
fiscal year.
    In Sec.  148.316(e), ``Where to submit an application,'' we changed 
the text to read: Applications must be submitted to http://www.grants.gov.
Funding Mechanism ( Sec.  148.318)
    We amended Sec.  148.318, dealing with continued funding of a risk 
pool. The State must outline funding sources, such as assessments and 
State general revenues, which can cover the projected costs and are 
reasonably designed to ensure continued funding of losses a State 
incurs in connection with the operation of the qualified high risk pool 
after the last fiscal year for which it is applying for grant funds.

[[Page 22284]]

Grant Awards ( Sec.  148.320)
    We amended this section to specify that the grantee will be 
required to submit quarterly progress and financial reports under part 
92 of this title and in accordance with section 2745(f) of the Public 
Health Service Act, requiring the Secretary to make an annual report to 
Congress that includes information on the use of these grant funds by 
the States.

III. Analysis of and Responses to Public Comments and Provisions of the 
Final Regulations

    We did not receive any public comments on the July 27, 2007 interim 
final rule with comment period. Therefore, this final rule implements 
the provisions of the interim final rule without change.

IV. Collection of Information Requirement

    Under the Paperwork Reduction Act of 1995, we are required to 
provide 30-day notice in the Federal Register and solicit public 
comment before a collection of information requirement is submitted to 
the Office of Management and Budget (OMB) for review and approval. In 
order to fairly evaluate whether an information collection should be 
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act 
of 1995 (PRA) requires that we solicit comment on the following issues:
     The need for the information collection and its usefulness 
in carrying out the proper functions of our agency.
     The accuracy of our estimate of the information collection 
burden.
     The quality, utility, and clarity of the information to be 
collected.
     Recommendations to minimize the information collection 
burden on the affected public, including automated collection 
techniques.
    We are soliciting public comment on each of these issues for the 
following sections of this document that contain information collection 
requirements (ICRs):

Section 148.316 Grant Application Instructions

    Section 148.316(a) requires each State to compile an application 
package that documents that it has met the requirements for a grant. If 
a risk pool entity applies on behalf of a State, it must provide 
documentation that it has been delegated appropriate authority by the 
State.
    The burden associated with this requirement is subject to the PRA; 
however, the structure of the application collection and grant 
monitoring reporting requirements of the grants has not been changed 
from the original grants program and is currently approved under OMB 
control number 0938-0887 ``Matching Grants to States for the Operation 
of High Risk Pools and Supporting Regulations at 42 CFR 148.316, 
148.318, and 148.320'' with a current expiration date of 01/31/2010. We 
are, however, revising this package to include the additional request 
under 148.316(a)(3) for (1) Description of Type of Consumer Benefits; 
(2) Description of the Eligible Population for the consumer benefits; 
and, (3) Projected Budget for the use of Bonus Grants. We believe the 
burden associated with the additional information is already captured 
in the currently approved OMB package (0938-0887).

Section 148.320 Grant Awards

    Section 148.320(a)(2)(iii) states that a grantee is required to 
submit quarterly progress and financial reports under part 92 of this 
title and in accordance with section 2745(f) of the Public Health 
Service Act, requiring the Secretary to make an annual report to 
Congress that includes information on the use of these grant funds by 
States.
    The burden associated with this requirement is the time it would 
take for a grantee to submit quarterly progress and financial reports. 
We estimate it will take one grantee 1 hour per quarter to comply with 
this requirement.
    If you comment on these information collection and record keeping 
requirements, please mail copies directly to the following:

Centers for Medicare & Medicaid Services, Office of Strategic 
Operations and Regulatory Affairs, Division of Regulations Development, 
Attn.: Melissa Musotto, CMS-2260-IFC, Room C5-14-03, 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
Office of Information and Regulatory Affairs, Office of Management and 
Budget, Room 10235, New Executive Office Building, Washington, DC 
20503, Attn: Katherine Astrich, CMS Desk Officer, CMS-2260-IFC, 
[email protected]. Fax (202) 395-6974.

V. Regulatory Impact Statement

    We have examined the impact of this rule as required by Executive 
Order 12866 (September 1993, Regulatory Planning and Review), the 
Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), 
the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive 
Order 13132.
    Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, if regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety 
effects, distributive impacts, and equity). A regulatory impact 
analysis (RIA) must be prepared for major rules with economically 
significant effects ($100 million or more in any 1 year). This rule 
does not reach the economic threshold and thus is not considered a 
major rule.
    The RFA requires agencies to analyze options for regulatory relief 
of small businesses. For purposes of the RFA, small entities include 
small businesses, nonprofit organizations, and small governmental 
jurisdictions. Most hospitals and most other providers and suppliers 
are small entities, either by nonprofit status or by having revenues of 
$6 million to $29 million in any 1 year. Individuals and States are not 
included in the definition of a small entity. We did not prepare an 
analysis for the RFA because we have determined that this rule will not 
have a significant economic impact on a substantial number of small 
entities.
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule whose mandates require spending in any 1 year of $100 
million in 1995 dollars, updated annually for inflation. That threshold 
level is currently approximately $120 million. This rule will have no 
consequential effect on State, local, or tribal governments or on the 
private sector.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications. Since this regulation does not impose any costs on State 
or local governments, the requirements of E.O. 13132 are not 
applicable.
    In accordance with the provisions of Executive Order 12866, this 
regulation was reviewed by the Office of Management and Budget.

List of Subjects in 45 CFR Part 148

    Administrative practice and procedure, Health care Health 
insurance, Penalties, Reporting and recordkeeping requirements.

0
For the reasons set forth in the preamble, the Centers for Medicare &

[[Page 22285]]

Medicaid Services amends 45 CFR chapter IV as set forth below:

PART 148--REQUIREMENTS FOR THE INDIVIDUAL HEALTH INSURANCE MARKET

0
1. The authority citation for part 148 continues to read as follows:

    Authority: Secs. 2741 through 2763, 2791, and 2792 of the Public 
Health Service Act (42 U.S.C. 300gg-41 through 300gg-63, 300gg-91, 
and 300gg-92).

Subpart E--Grants to States for Operation of Qualified High Risk 
Pools

0
2. Section 148.306 is revised to read as follows:


Sec.  148.306  Basis and scope.

    This subpart implements section 2745 of the Public Health Service 
Act (PHS Act). It extends grants to States that have qualified high 
risk pools that meet the specific requirements described in Sec.  
148.310. It also provides specific instructions on how to apply for the 
grants and outlines the grant review and grant award processes.

0
3. Section 148.308 is amended by--
0
A. Revising the definition for ``bonus grants.''
0
B. Revising the definition of ``qualified high risk pool.''
0
C. Revising the definition of ``State.''
    The revisions read as follows:


Sec.  148.308  Definitions.

* * * * *
    Bonus grants means funds that the Secretary provides from the 
appropriated grant funds to be used to provide supplemental consumer 
benefits to enrollees or potential enrollees in qualified high risk 
pools.
* * * * *
    Qualified high risk pool as defined in sections 2744(c)(2) and 
2745(g) of the PHS Act means a risk pool that--
    (1) Provides to all eligible individuals health insurance coverage 
(or comparable coverage) that does not impose any preexisting condition 
exclusion with respect to such coverage for all eligible individuals, 
except that it may provide for enrollment of eligible individuals 
through an acceptable alternative mechanism (as defined for purposes of 
section 2744 of the PHS Act) that includes a high risk pool as a 
component; and
    (2) Provides for premium rates and covered benefits for such 
coverage consistent with standards included in the NAIC Model Health 
Plan for Uninsurable Individuals Act that was in effect at the time of 
the enactment of the Health Insurance Portability and Accountability 
Act of 1996 (August 21, 1996) but only if the model has been revised in 
State regulations to meet all of the requirements of this part and 
title 27 of the PHS Act.
* * * * *
    State means any of the 50 States and the District of Columbia and 
includes the U.S. Territories of Puerto Rico, the Virgin Islands, Guam, 
American Samoa and the Northern Mariana Islands.
* * * * *

0
4. Section 148.310 is amended by--
0
A. Republishing the introductory text to the section.
0
B. Revising paragraph (b).
0
C. Revising paragraph (d).
0
D. Revising paragraphs (f), (g), and (h).
    The republication, revisions, and additions read as follows:


Sec.  148.310  Eligibility requirements for a grant.

    A State must meet all of the following requirements to be eligible 
for a grant:
* * * * *
    (b) The pool restricts premiums charged under the pool to no more 
than 200 percent of the premium for applicable standard risk rates for 
the State.
* * * * *
    (d) The pool has in effect a mechanism reasonably designed to 
ensure continued funding of losses incurred by the State after the end 
of each fiscal year for which the State applies for Federal Funding in 
fiscal year (FY) 2005 through FY 2010 in connection with the operation 
of the pool.
* * * * *
    (f) In the case of a qualified high risk pool in a State that 
charges premiums that exceed 150 percent of the premium for applicable 
standard risks, the State will use at least 50 percent of the amount of 
the grant provided to the State to reduce premiums for enrollees.
    (g) In no case will the aggregate amount allotted and made 
available to the U.S. Territories for a fiscal year exceed $1,000,000 
in total.
    (h) Bonus grant funding must be used for one or more of the 
following benefits:
    (1) Low income premium subsidies;
    (2) Reduction in premium trends, actual premium or other cost-
sharing requirements;
    (3) An expansion or broadening of the pool of individuals eligible 
for coverage, such as through eliminating waiting lists, increasing 
enrollment caps, or providing flexibility in enrollment rules;
    (4) Less stringent rules or additional waiver authority with 
respect to coverage of pre-existing conditions;
    (5) Increased benefits; and
    (6) The establishment of disease management programs.

0
5. Section 148.312 is amended by--
0
A. Revising paragraph (a).
0
B. Revising paragraph (b).
0
C. Revising paragraph (d).
    The revisions read as follows:


Sec.  148.312  Amount of grant payment.

    (a) An eligible State may receive a grant to fund up to 100 percent 
of the losses incurred in the operation of its qualified high risk pool 
during the period for which it is applying or a lesser amount based on 
the limits of the allotment under the formula.
    (b) Funds will be allocated in accordance with this paragraph to 
each State that meets the eligibility requirements of Sec.  148.310 and 
files an application in accordance with Sec.  148.316. The amount will 
be divided among the States that apply and are awarded grants according 
to the allotment rules that generally provide that: 40 percent will be 
equally divided among those States; 30 percent will be divided among 
States and territories based on their number of uninsured residents in 
the State during the specified year as compared to all States that 
apply; and 30 percent will be divided among States and territories 
based on the number of people in State high risk pools during the 
specified year as compared to all States that apply.
    For purposes of this paragraph:
    (1) The number of uninsured individuals is calculated for each 
eligible State by taking a 3-year average of the number of uninsured 
individuals in that State in the Current Population Survey (CPS) of the 
Census Bureau during the period for which it is applying. The 3-year 
average will be calculated using numbers available as of March 1 of 
each year.
    (2) The number of individuals enrolled in health care coverage 
through the qualified high risk pool of the State will be determined by 
attestation by the State in its grant application and verified for 
reasonability by the Secretary through acceptable industry data 
sources.
* * * * *
    (d) One-third of the total appropriation will be available for the 
bonus grants. In no case will a State for a fiscal year receive bonus 
grants that exceed 10 percent of the total allotted funds for bonus 
grants.

0
6. Section 148.314 is revised to read as follows:


Sec.  148.314  Periods during which eligible States may apply for a 
grant.

    (a) General rule. A State that meets the eligibility requirements 
in Sec.  148.310

[[Page 22286]]

may apply for a grant to fund losses that were incurred during the 
State's FYs 2005, 2006, 2007, 2008 and 2009 in connection with the 
operation of its qualified high risk pool. Funding for FY 2007 through 
FY 2010 under the Extension Act requires subsequent enactment of 
appropriations authority. States will be unable to apply for grants 
unless and until such funding becomes available. Grants funding is on a 
retrospective basis and applies to the States previous fiscal year. If 
a State becomes eligible for a grant in the middle of its fiscal year, 
a State may apply for losses incurred in a partial fiscal year if a 
partial year audit is done. Only losses that are incurred after 
eligibility is established will qualify for a grant.
    (b) Maximum number of grants. An eligible State may only be awarded 
a maximum of five grants, with one grant per fiscal year. A grant for a 
partial fiscal year counts as a full grant.
    (c) Deadline for submitting grant applications. The deadlines for 
submitting grant applications are stated in Sec.  148.316(d).
    (d) Distribution of grant funds. States that meet all of the 
eligibility requirements in Sec.  148.310 and submit timely requests in 
accordance with paragraph (c) of this section will receive an initial 
distribution of grant funds using the following methodology: Grant 
applications for losses will be on a retrospective basis. For example, 
grant applications for 2006 funds are based on the State's FY 2005 
incurred losses. Grant funding was appropriated for Federal FY 2006 and 
is authorized to be appropriated for Federal FYs 2008 through 2010.
    (e) Grant allocations. Grant allocations for each fiscal year will 
be determined by taking all grant applications during the period for 
which States are applying and allocating the funds in accordance with 
Sec.  148.312.
    (1) In no case will a State receive funds greater than 100 percent 
of their losses.
    (2) If any excess funds remain after the initial calculation, these 
excess funds will be proportionately redistributed to the States whose 
allocations have not exceeded 100 percent of their losses.

0
7. Section 148.316 is amended by--
0
A. Revising the introductory text to the section.
0
B. Amending paragraph (a) introductory text by revising the heading.
0
C. Revising paragraph (a)(3).
0
D. Revising paragraph (b).
0
E. Revising paragraph (c).
0
F. Revising paragraph (d).
0
G. Revising paragraph (e).
    The revisions read as follows:


Sec.  148.316  Grant application instructions.

    Funding for FY 2008, FY 2009, and FY 2010 under the Extension Act 
requires the subsequent enactment of appropriations authority. Funding 
was appropriated for Federal FY 2006. States will be unable to apply 
for FY 2008 through FY 2010 grants unless and until such funding 
becomes available.
    (a) Application for operational losses. * * *
* * * * *
    (3) Bonus grants for supplemental consumer benefits. Provide 
detailed information about the following supplemental consumer benefits 
for which the entity is applying:
    (i) A narrative description of one or more of the following of the 
supplemental consumer benefits to be provided to enrollees and/or 
potential enrollees in the high risk pool:
    (A) Low income premium subsidies;
    (B) Reduction in premium trends, actual premium or other cost-
sharing requirements;
    (C) An expansion or broadening of the pool of individuals eligible 
for coverage, such as through eliminating waiting lists, increasing 
enrollment caps, or providing flexibility in enrollment;
    (D) Less stringent rules, or additional waiver authority with 
respect to coverage of pre-existing conditions;
    (E) Increased benefits; and
    (F) The establishment of disease management programs.
    (ii) A description of the population or subset population that will 
be eligible for the supplemental consumer benefits.
    (iii) A projected budget for the use of bonus grant funds using the 
SF 424 A.
* * * * *
    (b) Standard form application kit--(1) Forms. (i) The following 
standard forms must be completed with an original signature and 
enclosed as part of the application package:

SF-424 Application for Federal Assistance.
SF-424A Budget Information.
SF-424B Assurances Non-Construction Programs.
SF-LLL Disclosure of Lobbying Activities Biographical Sketch.

    (ii) These forms can be accessed from the following Web site: 
http://www.grants.gov.
    (2) Other narrative. All other narrative in the application must be 
submitted on 8\1/2\ x 11 inches white paper.
    (c) Application submission. Submission of application package is 
through http://www.grants.gov. Submissions by facsimile (fax) 
transmissions will not be accepted.
    (d) Application deadlines. (1) The deadline for States to submit an 
application for losses incurred in a State fiscal year is June 30 of 
the next Federal fiscal year that begins after the end of the State 
fiscal year. Funding for FY 2008, FY 2009, and FY 2010 under the 
Extension Act requires the subsequent enactment of appropriations 
authority. Funding was appropriated for Federal FY 2006. States will be 
unable to apply for FY 2008 through FY 2010 grants unless and until 
such funding becomes available.
    (2) Deadline for States to submit an application for losses 
incurred in their fiscal year 2005. States had to submit an application 
to CMS no later than June 30, 2006.
    (3) Deadline for States to submit an application for losses 
incurred in their fiscal year 2006. States must submit an application 
to CMS by no later than June 30, 2007.
    (4) Deadline for States to submit an application for losses 
incurred in their fiscal year 2007. States must submit an application 
to CMS by no later than June 30, 2008.
    (5) Deadline for States to submit an application for losses 
incurred in their fiscal year 2008. States must submit an application 
to CMS by no later than June 30, 2009.
    (6) Deadline for States to submit an application for losses 
incurred in their fiscal year 2009. States must submit an application 
to CMS by no later than June 30, 2010.
    (e) Where to submit an application. Applications must be submitted 
to http://www.grants.gov. Submissions by facsimile (fax) transmissions 
will not be accepted.

0
8. Section 148.318 is amended by revising paragraph (d)(2) to read as 
follows:


Sec.  148.318  Grant application review.

* * * * *
    (d) * * *
    (2) Funding mechanism. The State has outlined funding sources, such 
as assessments and State general revenues, which can cover the 
projected costs and are reasonably designed to ensure continued funding 
of losses a State incurs in connection with the operation of the 
qualified high risk pool after each fiscal year for which it is 
applying for grant funds.

0
9. Section 148.320 is amended by revising paragraph (a)(2)(iii) to read 
as follows:


Sec.  148.320  Grant awards.

    (a) * * *
    (2) * * *
    (iii) The grantee will be required to submit quarterly progress and 
financial

[[Page 22287]]

reports under part 92 of this title and in accordance with section 
2745(f) of the Public Health Service Act, requiring the Secretary to 
make an annual report to Congress that includes information on the use 
of these grant funds by States.
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.778, Medical 
Assistance Program)

    Dated: January 17, 2008.
Kerry Weems,
Acting Administrator, Centers for Medicare & Medicaid Services.
    Approved: January 17, 2008.
Michael O. Leavitt,
Secretary.
 [FR Doc. E8-9066 Filed 4-24-08; 8:45 am]
BILLING CODE 4120-01-P