[Congressional Bills 111th Congress]
[From the U.S. Government Printing Office]
[H.R. 2 Enrolled Bill (ENR)]
H.R.2
One Hundred Eleventh Congress
of the
United States of America
AT THE FIRST SESSION
Begun and held at the City of Washington on Tuesday,
the sixth day of January, two thousand and nine
An Act
To amend title XXI of the Social Security Act to extend and improve the
Children's Health Insurance Program, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,

da96eb3cfa3d94889518eb0101a2475cffcc1135065c982fbc90a9a312265358

TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Children's Health
Insurance Program Reauthorization Act of 2009''.
(b) Amendments to Social Security Act.--Except as otherwise
specifically provided, whenever in this Act an amendment is expressed
in terms of an amendment to or repeal of a section or other provision,
the reference shall be considered to be made to that section or other
provision of the Social Security Act.
(c) References to CHIP; Medicaid; Secretary.--In this Act:
(1) CHIP.--The term ``CHIP'' means the State Children's Health
Insurance Program established under title XXI of the Social
Security Act (42 U.S.C. 1397aa et seq.).
(2) Medicaid.--The term ``Medicaid'' means the program for
medical assistance established under title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.).
(3) Secretary.--The term ``Secretary'' means the Secretary of
Health and Human Services.
(d) Table of Contents.--The table of contents of this Act is as
follows:

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contingent effective date; reliance on law.
Subtitle A--Funding

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TITLE I

-FINANCING

costs resulting from enrollment and retention efforts.

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of the CHIP matching rate for Medicaid coverage of certain
children.

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Subtitle B--Focus on Low-Income Children and Pregnant Women

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CHIP; conditions for coverage of parents.

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children with effective family income that exceeds 300 percent
of the poverty line.

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Subtitle A--Outreach and Enrollment Activities

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TITLE II

-OUTREACH AND ENROLLMENT

to conduct simplified eligibility determinations.
Subtitle B--Reducing Barriers to Enrollment

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purposes of eligibility for Medicaid and CHIP.

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certain children and pregnant women under the Medicaid program
and CHIP.
Subtitle A--Additional State Option for Providing Premium Assistance

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Subtitle B--Coordinating Premium Assistance With Private Coverage

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TITLE III

-REDUCING BARRIERS TO PROVIDING PREMIUM ASSISTANCE

termination of Medicaid or CHIP coverage or eligibility for
assistance in purchase of employment-based coverage;
coordination of coverage.

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TITLE IV

-STRENGTHENING QUALITY OF CARE AND HEALTH OUTCOMES

enrollment of children in CHIP and Medicaid.

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provided by Federally-qualified health centers and rural
health clinics.

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TITLE V

-IMPROVING ACCESS TO BENEFITS

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Subtitle A--Program Integrity and Data Collection

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unauthorized expenditures.
Subtitle B--Miscellaneous Health Provisions

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TITLE VI

-PROGRAM INTEGRITY AND OTHER MISCELLANEOUS PROVISIONS

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extraordinary employer pension contribution.

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TITLE VII

-REVENUE PROVISIONS

It is the purpose of this Act to provide dependable and stable
funding for children's health insurance under titles XXI and XIX of the
Social Security Act in order to enroll all six million uninsured
children who are eligible, but not enrolled, for coverage today through
such titles.

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CONTINGENT EFFECTIVE DATE; RELIANCE ON LAW.
(a) General Effective Date.--Unless otherwise provided in this Act,
subject to subsections (b) through (d), this Act (and the amendments
made by this Act) shall take effect on April 1, 2009, and shall apply
to child health assistance and medical assistance provided on or after
that date.
(b) Exception for State Legislation.--In the case of a State plan
under title XIX or State child health plan under XXI of the Social
Security Act, which the Secretary of Health and Human Services
determines requires State legislation in order for the respective plan
to meet one or more additional requirements imposed by amendments made
by this Act, the respective plan shall not be regarded as failing to
comply with the requirements of such title solely on the basis of its
failure to meet such an additional requirement before the first day of
the first calendar quarter beginning after the close of the first
regular session of the State legislature that begins after the date of
enactment of this Act. For purposes of the previous sentence, in the
case of a State that has a 2-year legislative session, each year of the
session shall be considered to be a separate regular session of the
State legislature.
(c) Coordination of CHIP Funding for Fiscal Year 2009.--
Notwithstanding any other provision of law, insofar as funds have been
appropriated under section 2104(a)(11), 2104(k), or 2104(l) of the
Social Security Act, as amended by section 201 of Public Law 110-173,
to provide allotments to States under CHIP for fiscal year 2009--
(1) any amounts that are so appropriated that are not so
allotted and obligated before April 1, 2009 are rescinded; and
(2) any amount provided for CHIP allotments to a State under
this Act (and the amendments made by this Act) for such fiscal year
shall be reduced by the amount of such appropriations so allotted
and obligated before such date.
(d) Reliance on Law.--With respect to amendments made by this Act
(other than title VII) that become effective as of a date--
(1) such amendments are effective as of such date whether or
not regulations implementing such amendments have been issued; and
(2) Federal financial participation for medical assistance or
child health assistance furnished under title XIX or XXI,
respectively, of the Social Security Act on or after such date by a
State in good faith reliance on such amendments before the date of
promulgation of final regulations, if any, to carry out such
amendments (or before the date of guidance, if any, regarding the
implementation of such amendments) shall not be denied on the basis
of the State's failure to comply with such regulations or guidance.
Subtitle A--Funding

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Section 2104(a) (42 U.S.C. 1397dd(a)) is amended--
(1) in paragraph (10), by striking ``and'' at the end;
(2) by amending paragraph (11), by striking ``each of fiscal
years 2008 and 2009'' and inserting ``fiscal year 2008''; and
(3) by adding at the end the following new paragraphs:
``(12) for fiscal year 2009, $10,562,000,000;
``(13) for fiscal year 2010, $12,520,000,000;
``(14) for fiscal year 2011, $13,459,000,000;
``(15) for fiscal year 2012, $14,982,000,000; and
``(16) for fiscal year 2013, for purposes of making 2 semi-
annual allotments--
``(A) $2,850,000,000 for the period beginning on October 1,
2012, and ending on March 31, 2013, and
``(B) $2,850,000,000 for the period beginning on April 1,
2013, and ending on September 30, 2013.''.

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2009 THROUGH 2013.
Section 2104 (42 U.S.C. 1397dd) is amended--
(1) in subsection (b)(1), by striking ``subsection (d)'' and
inserting ``subsections (d) and (m)'';
(2) in subsection (c)(1), by striking ``subsection (d)'' and
inserting ``subsections (d) and (m)(4)''; and
(3) by adding at the end the following new subsection:
``(m) Allotments for Fiscal Years 2009 Through 2013.--
``(1) For fiscal year 2009.--
``(A) For the 50 states and the district of columbia.--
Subject to the succeeding provisions of this paragraph and
paragraph (4), the Secretary shall allot for fiscal year 2009
from the amount made available under subsection (a)(12), to
each of the 50 States and the District of Columbia 110 percent
of the highest of the following amounts for such State or
District:
``(i) The total Federal payments to the State under
this title for fiscal year 2008, multiplied by the
allotment increase factor determined under paragraph (5)
for fiscal year 2009.
``(ii) The amount allotted to the State for fiscal year
2008 under subsection (b), multiplied by the allotment
increase factor determined under paragraph (5) for fiscal
year 2009.
``(iii) The projected total Federal payments to the
State under this title for fiscal year 2009, as determined
on the basis of the February 2009 projections certified by
the State to the Secretary by not later than March 31,
2009.
``(B) For the commonwealths and territories.--Subject to
the succeeding provisions of this paragraph and paragraph (4),
the Secretary shall allot for fiscal year 2009 from the amount
made available under subsection (a)(12) to each of the
commonwealths and territories described in subsection (c)(3) an
amount equal to the highest amount of Federal payments to the
commonwealth or territory under this title for any fiscal year
occurring during the period of fiscal years 1999 through 2008,
multiplied by the allotment increase factor determined under
paragraph (5) for fiscal year 2009, except that subparagraph
(B) thereof shall be applied by substituting `the United
States' for `the State'.
``(C) Adjustment for qualifying states.--In the case of a
qualifying State described in paragraph (2) of section 2105(g),
the Secretary shall permit the State to submit a revised
projection described in subparagraph (A)(iii) in order to take
into account changes in such projections attributable to the
application of paragraph (4) of such section.
``(2) For fiscal years 2010 through 2012.--
``(A) In general.--Subject to paragraphs (4) and (6), from
the amount made available under paragraphs (13) through (15) of
subsection (a) for each of fiscal years 2010 through 2012,
respectively, the Secretary shall compute a State allotment for
each State (including the District of Columbia and each
commonwealth and territory) for each such fiscal year as
follows:
``(i) Growth factor update for fiscal year 2010.--For
fiscal year 2010, the allotment of the State is equal to
the sum of--
``(I) the amount of the State allotment under
paragraph (1) for fiscal year 2009; and
``(II) the amount of any payments made to the State
under subsection (k), (l), or (n) for fiscal year 2009,
multiplied by the allotment increase factor under paragraph
(5) for fiscal year 2010.
``(ii) Rebasing in fiscal year 2011.--For fiscal year
2011, the allotment of the State is equal to the Federal
payments to the State that are attributable to (and
countable towards) the total amount of allotments available
under this section to the State in fiscal year 2010
(including payments made to the State under subsection (n)
for fiscal year 2010 as well as amounts redistributed to
the State in fiscal year 2010), multiplied by the allotment
increase factor under paragraph (5) for fiscal year 2011.
``(iii) Growth factor update for fiscal year 2012.--For
fiscal year 2012, the allotment of the State is equal to
the sum of--
``(I) the amount of the State allotment under
clause (ii) for fiscal year 2011; and
``(II) the amount of any payments made to the State
under subsection (n) for fiscal year 2011,
multiplied by the allotment increase factor under paragraph
(5) for fiscal year 2012.
``(3) For fiscal year 2013.--
``(A) First half.--Subject to paragraphs (4) and (6), from
the amount made available under subparagraph (A) of paragraph
(16) of subsection (a) for the semi-annual period described in
such paragraph, increased by the amount of the appropriation
for such period under section 108 of the Children's Health
Insurance Program Reauthorization Act of 2009, the Secretary
shall compute a State allotment for each State (including the
District of Columbia and each commonwealth and territory) for
such semi-annual period in an amount equal to the first half
ratio (described in subparagraph (D)) of the amount described
in subparagraph (C).
``(B) Second half.--Subject to paragraphs (4) and (6), from
the amount made available under subparagraph (B) of paragraph
(16) of subsection (a) for the semi-annual period described in
such paragraph, the Secretary shall compute a State allotment
for each State (including the District of Columbia and each
commonwealth and territory) for such semi-annual period in an
amount equal to the amount made available under such
subparagraph, multiplied by the ratio of--
``(i) the amount of the allotment to such State under
subparagraph (A); to
``(ii) the total of the amount of all of the allotments
made available under such subparagraph.
``(C) Full year amount based on rebased amount.--The amount
described in this subparagraph for a State is equal to the
Federal payments to the State that are attributable to (and
countable towards) the total amount of allotments available
under this section to the State in fiscal year 2012 (including
payments made to the State under subsection (n) for fiscal year
2012 as well as amounts redistributed to the State in fiscal
year 2012), multiplied by the allotment increase factor under
paragraph (5) for fiscal year 2013.
``(D) First half ratio.--The first half ratio described in
this subparagraph is the ratio of--
``(i) the sum of--
``(I) the amount made available under subsection
(a)(16)(A); and
``(II) the amount of the appropriation for such
period under section 108 of the Children's Health
Insurance Program Reauthorization Act of 2009; to
``(ii) the sum of the--
``(I) amount described in clause (i); and
``(II) the amount made available under subsection
(a)(16)(B).
``(4) Proration rule.--If, after the application of this
subsection without regard to this paragraph, the sum of the
allotments determined under paragraph (1), (2), or (3) for a fiscal
year (or, in the case of fiscal year 2013, for a semi-annual period
in such fiscal year) exceeds the amount available under subsection
(a) for such fiscal year or period, the Secretary shall reduce each
allotment for any State under such paragraph for such fiscal year
or period on a proportional basis.
``(5) Allotment increase factor.--The allotment increase factor
under this paragraph for a fiscal year is equal to the product of
the following:
``(A) Per capita health care growth factor.--1 plus the
percentage increase in the projected per capita amount of
National Health Expenditures from the calendar year in which
the previous fiscal year ends to the calendar year in which the
fiscal year involved ends, as most recently published by the
Secretary before the beginning of the fiscal year.
``(B) Child population growth factor.--1 plus the
percentage increase (if any) in the population of children in
the State from July 1 in the previous fiscal year to July 1 in
the fiscal year involved, as determined by the Secretary based
on the most recent published estimates of the Bureau of the
Census before the beginning of the fiscal year involved, plus 1
percentage point.
``(6) Increase in allotment to account for approved program
expansions.--In the case of one of the 50 States or the District of
Columbia that--
``(A) has submitted to the Secretary, and has approved by
the Secretary, a State plan amendment or waiver request
relating to an expansion of eligibility for children or
benefits under this title that becomes effective for a fiscal
year (beginning with fiscal year 2010 and ending with fiscal
year 2013); and
``(B) has submitted to the Secretary, before the August 31
preceding the beginning of the fiscal year, a request for an
expansion allotment adjustment under this paragraph for such
fiscal year that specifies--
``(i) the additional expenditures that are attributable
to the eligibility or benefit expansion provided under the
amendment or waiver described in subparagraph (A), as
certified by the State and submitted to the Secretary by
not later than August 31 preceding the beginning of the
fiscal year; and
``(ii) the extent to which such additional expenditures
are projected to exceed the allotment of the State or
District for the year,
subject to paragraph (4), the amount of the allotment of the State
or District under this subsection for such fiscal year shall be
increased by the excess amount described in subparagraph (B)(i). A
State or District may only obtain an increase under this paragraph
for an allotment for fiscal year 2010 or fiscal year 2012.
``(7) Availability of amounts for semi-annual periods in fiscal
year 2013.--Each semi-annual allotment made under paragraph (3) for
a period in fiscal year 2013 shall remain available for expenditure
under this title for periods after the end of such fiscal year in
the same manner as if the allotment had been made available for the
entire fiscal year.''.

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Section 2104 (42 U.S.C. 1397dd), as amended by section 102, is
amended by adding at the end the following new subsection:
``(n) Child Enrollment Contingency Fund.--
``(1) Establishment.--There is hereby established in the
Treasury of the United States a fund which shall be known as the
`Child Enrollment Contingency Fund' (in this subsection referred to
as the `Fund'). Amounts in the Fund shall be available without
further appropriations for payments under this subsection.
``(2) Deposits into fund.--
``(A) Initial and subsequent appropriations.--Subject to
subparagraphs (B) and (D), out of any money in the Treasury of
the United States not otherwise appropriated, there are
appropriated to the Fund--
``(i) for fiscal year 2009, an amount equal to 20
percent of the amount made available under paragraph (12)
of subsection (a) for the fiscal year; and
``(ii) for each of fiscal years 2010 through 2012 (and
for each of the semi-annual allotment periods for fiscal
year 2013), such sums as are necessary for making payments
to eligible States for such fiscal year or period, but not
in excess of the aggregate cap described in subparagraph
(B).
``(B) Aggregate cap.--The total amount available for
payment from the Fund for each of fiscal years 2010 through
2012 (and for each of the semi-annual allotment periods for
fiscal year 2013), taking into account deposits made under
subparagraph (C), shall not exceed 20 percent of the amount
made available under subsection (a) for the fiscal year or
period.
``(C) Investment of fund.--The Secretary of the Treasury
shall invest, in interest bearing securities of the United
States, such currently available portions of the Fund as are
not immediately required for payments from the Fund. The income
derived from these investments constitutes a part of the Fund.
``(D) Availability of excess funds for performance
bonuses.--Any amounts in excess of the aggregate cap described
in subparagraph (B) for a fiscal year or period shall be made
available for purposes of carrying out section 2105(a)(3) for
any succeeding fiscal year and the Secretary of the Treasury
shall reduce the amount in the Fund by the amount so made
available.
``(3) Child enrollment contingency fund payments.--
``(A) In general.--If a State's expenditures under this
title in fiscal year 2009, fiscal year 2010, fiscal year 2011,
fiscal year 2012, or a semi-annual allotment period for fiscal
year 2013, exceed the total amount of allotments available
under this section to the State in the fiscal year or period
(determined without regard to any redistribution it receives
under subsection (f) that is available for expenditure during
such fiscal year or period, but including any carryover from a
previous fiscal year) and if the average monthly unduplicated
number of children enrolled under the State plan under this
title (including children receiving health care coverage
through funds under this title pursuant to a waiver under
section 1115) during such fiscal year or period exceeds its
target average number of such enrollees (as determined under
subparagraph (B)) for that fiscal year or period, subject to
subparagraph (D), the Secretary shall pay to the State from the
Fund an amount equal to the product of--
``(i) the amount by which such average monthly caseload
exceeds such target number of enrollees; and
``(ii) the projected per capita expenditures under the
State child health plan (as determined under subparagraph
(C) for the fiscal year), multiplied by the enhanced FMAP
(as defined in section 2105(b)) for the State and fiscal
year involved (or in which the period occurs).
``(B) Target average number of child enrollees.--In this
paragraph, the target average number of child enrollees for a
State--
``(i) for fiscal year 2009 is equal to the monthly
average unduplicated number of children enrolled in the
State child health plan under this title (including such
children receiving health care coverage through funds under
this title pursuant to a waiver under section 1115) during
fiscal year 2008 increased by the population growth for
children in that State for the year ending on June 30, 2007
(as estimated by the Bureau of the Census) plus 1
percentage point; or
``(ii) for a subsequent fiscal year (or semi-annual
period occurring in a fiscal year) is equal to the target
average number of child enrollees for the State for the
previous fiscal year increased by the child population
growth factor described in subsection (m)(5)(B) for the
State for the prior fiscal year.
``(C) Projected per capita expenditures.--For purposes of
subparagraph (A)(ii), the projected per capita expenditures
under a State child health plan--
``(i) for fiscal year 2009 is equal to the average per
capita expenditures (including both State and Federal
financial participation) under such plan for the targeted
low-income children counted in the average monthly caseload
for purposes of this paragraph during fiscal year 2008,
increased by the annual percentage increase in the
projected per capita amount of National Health Expenditures
(as estimated by the Secretary) for 2009; or
``(ii) for a subsequent fiscal year (or semi-annual
period occurring in a fiscal year) is equal to the
projected per capita expenditures under such plan for the
previous fiscal year (as determined under clause (i) or
this clause) increased by the annual percentage increase in
the projected per capita amount of National Health
Expenditures (as estimated by the Secretary) for the year
in which such subsequent fiscal year ends.
``(D) Proration rule.--If the amounts available for payment
from the Fund for a fiscal year or period are less than the
total amount of payments determined under subparagraph (A) for
the fiscal year or period, the amount to be paid under such
subparagraph to each eligible State shall be reduced
proportionally.
``(E) Timely payment; reconciliation.--Payment under this
paragraph for a fiscal year or period shall be made before the
end of the fiscal year or period based upon the most recent
data for expenditures and enrollment and the provisions of
subsection (e) of section 2105 shall apply to payments under
this subsection in the same manner as they apply to payments
under such section.
``(F) Continued reporting.--For purposes of this paragraph
and subsection (f), the State shall submit to the Secretary the
State's projected Federal expenditures, even if the amount of
such expenditures exceeds the total amount of allotments
available to the State in such fiscal year or period.
``(G) Application to commonwealths and territories.--No
payment shall be made under this paragraph to a commonwealth or
territory described in subsection (c)(3) until such time as the
Secretary determines that there are in effect methods,
satisfactory to the Secretary, for the collection and reporting
of reliable data regarding the enrollment of children described
in subparagraphs (A) and (B) in order to accurately determine
the commonwealth's or territory's eligibility for, and amount
of payment, under this paragraph.''.

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ENROLLMENT COSTS RESULTING FROM ENROLLMENT AND RETENTION EFFORTS.
Section 2105(a) (42 U.S.C. 1397ee(a)) is amended by adding at the
end the following new paragraphs:
``(3) Performance bonus payment to offset additional medicaid
and chip child enrollment costs resulting from enrollment and
retention efforts.--
``(A) In general.--In addition to the payments made under
paragraph (1), for each fiscal year (beginning with fiscal year
2009 and ending with fiscal year 2013), the Secretary shall pay
from amounts made available under subparagraph (E), to each
State that meets the condition under paragraph (4) for the
fiscal year, an amount equal to the amount described in
subparagraph (B) for the State and fiscal year. The payment
under this paragraph shall be made, to a State for a fiscal
year, as a single payment not later than the last day of the
first calendar quarter of the following fiscal year.
``(B) Amount for above baseline medicaid child enrollment
costs.--Subject to subparagraph (E), the amount described in
this subparagraph for a State for a fiscal year is equal to the
sum of the following amounts:
``(i) First tier above baseline medicaid enrollees.--An
amount equal to the number of first tier above baseline
child enrollees (as determined under subparagraph (C)(i))
under title XIX for the State and fiscal year, multiplied
by 15 percent of the projected per capita State Medicaid
expenditures (as determined under subparagraph (D)) for the
State and fiscal year under title XIX.
``(ii) Second tier above baseline medicaid enrollees.--
An amount equal to the number of second tier above baseline
child enrollees (as determined under subparagraph (C)(ii))
under title XIX for the State and fiscal year, multiplied
by 62.5 percent of the projected per capita State Medicaid
expenditures (as determined under subparagraph (D)) for the
State and fiscal year under title XIX.
``(C) Number of first and second tier above baseline child
enrollees; baseline number of child enrollees.--For purposes of
this paragraph:
``(i) First tier above baseline child enrollees.--The
number of first tier above baseline child enrollees for a
State for a fiscal year under title XIX is equal to the
number (if any, as determined by the Secretary) by which--
``(I) the monthly average unduplicated number of
qualifying children (as defined in subparagraph (F))
enrolled during the fiscal year under the State plan
under title XIX, respectively; exceeds
``(II) the baseline number of enrollees described
in clause (iii) for the State and fiscal year under
title XIX, respectively;
but not to exceed 10 percent of the baseline number of
enrollees described in subclause (II).
``(ii) Second tier above baseline child enrollees.--The
number of second tier above baseline child enrollees for a
State for a fiscal year under title XIX is equal to the
number (if any, as determined by the Secretary) by which--
``(I) the monthly average unduplicated number of
qualifying children (as defined in subparagraph (F))
enrolled during the fiscal year under title XIX as
described in clause (i)(I); exceeds
``(II) the sum of the baseline number of child
enrollees described in clause (iii) for the State and
fiscal year under title XIX, as described in clause
(i)(II), and the maximum number of first tier above
baseline child enrollees for the State and fiscal year
under title XIX, as determined under clause (i).
``(iii) Baseline number of child enrollees.--Subject to
subparagraph (H), the baseline number of child enrollees
for a State under title XIX--
``(I) for fiscal year 2009 is equal to the monthly
average unduplicated number of qualifying children
enrolled in the State plan under title XIX during
fiscal year 2007 increased by the population growth for
children in that State from 2007 to 2008 (as estimated
by the Bureau of the Census) plus 4 percentage points,
and further increased by the population growth for
children in that State from 2008 to 2009 (as estimated
by the Bureau of the Census) plus 4 percentage points;
``(II) for each of fiscal years 2010, 2011, and
2012, is equal to the baseline number of child
enrollees for the State for the previous fiscal year
under title XIX, increased by the population growth for
children in that State from the calendar year in which
the respective fiscal year begins to the succeeding
calendar year (as estimated by the Bureau of the
Census) plus 3.5 percentage points;
``(III) for each of fiscal years 2013, 2014, and
2015, is equal to the baseline number of child
enrollees for the State for the previous fiscal year
under title XIX, increased by the population growth for
children in that State from the calendar year in which
the respective fiscal year begins to the succeeding
calendar year (as estimated by the Bureau of the
Census) plus 3 percentage points; and
``(IV) for a subsequent fiscal year is equal to the
baseline number of child enrollees for the State for
the previous fiscal year under title XIX, increased by
the population growth for children in that State from
the calendar year in which the fiscal year involved
begins to the succeeding calendar year (as estimated by
the Bureau of the Census) plus 2 percentage points.
``(D) Projected per capita state medicaid expenditures.--
For purposes of subparagraph (B), the projected per capita
State Medicaid expenditures for a State and fiscal year under
title XIX is equal to the average per capita expenditures
(including both State and Federal financial participation) for
children under the State plan under such title, including under
waivers but not including such children eligible for assistance
by virtue of the receipt of benefits under title XVI, for the
most recent fiscal year for which actual data are available (as
determined by the Secretary), increased (for each subsequent
fiscal year up to and including the fiscal year involved) by
the annual percentage increase in per capita amount of National
Health Expenditures (as estimated by the Secretary) for the
calendar year in which the respective subsequent fiscal year
ends and multiplied by a State matching percentage equal to 100
percent minus the Federal medical assistance percentage (as
defined in section 1905(b)) for the fiscal year involved.
``(E) Amounts available for payments.--
``(i) Initial appropriation.--Out of any money in the
Treasury not otherwise appropriated, there are appropriated
$3,225,000,000 for fiscal year 2009 for making payments
under this paragraph, to be available until expended.
``(ii) Transfers.--Notwithstanding any other provision
of this title, the following amounts shall also be
available, without fiscal year limitation, for making
payments under this paragraph:
``(I) Unobligated national allotment.--
``(aa) Fiscal years 2009 through 2012.--As of
December 31 of fiscal year 2009, and as of December
31 of each succeeding fiscal year through fiscal
year 2012, the portion, if any, of the amount
appropriated under subsection (a) for such fiscal
year that is unobligated for allotment to a State
under subsection (m) for such fiscal year or set
aside under subsection (a)(3) or (b)(2) of section
2111 for such fiscal year.
``(bb) First half of fiscal year 2013.--As of
December 31 of fiscal year 2013, the portion, if
any, of the sum of the amounts appropriated under
subsection (a)(16)(A) and under section 108 of the
Children's Health Insurance Reauthorization Act of
2009 for the period beginning on October 1, 2012,
and ending on March 31, 2013, that is unobligated
for allotment to a State under subsection (m) for
such fiscal year or set aside under subsection
(b)(2) of section 2111 for such fiscal year.
``(cc) Second half of fiscal year 2013.--As of
June 30 of fiscal year 2013, the portion, if any,
of the amount appropriated under subsection
(a)(16)(B) for the period beginning on April 1,
2013, and ending on September 30, 2013, that is
unobligated for allotment to a State under
subsection (m) for such fiscal year or set aside
under subsection (b)(2) of section 2111 for such
fiscal year.
``(II) Unexpended allotments not used for
redistribution.--As of November 15 of each of fiscal
years 2010 through 2013, the total amount of allotments
made to States under section 2104 for the second
preceding fiscal year (third preceding fiscal year in
the case of the fiscal year 2006, 2007, and 2008
allotments) that is not expended or redistributed under
section 2104(f) during the period in which such
allotments are available for obligation.
``(III) Excess child enrollment contingency
funds.--As of October 1 of each of fiscal years 2010
through 2013, any amount in excess of the aggregate cap
applicable to the Child Enrollment Contingency Fund for
the fiscal year under section 2104(n).
``(IV) Unexpended transitional coverage block grant
for nonpregnant childless adults.--As of October 1,
2011, any amounts set aside under section 2111(a)(3)
that are not expended by September 30, 2011.
``(iii) Proportional reduction.--If the sum of the
amounts otherwise payable under this paragraph for a fiscal
year exceeds the amount available for the fiscal year under
this subparagraph, the amount to be paid under this
paragraph to each State shall be reduced proportionally.
``(F) Qualifying children defined.--
``(i) In general.--For purposes of this subsection,
subject to clauses (ii) and (iii), the term `qualifying
children' means children who meet the eligibility criteria
(including income, categorical eligibility, age, and
immigration status criteria) in effect as of July 1, 2008,
for enrollment under title XIX, taking into account
criteria applied as of such date under title XIX pursuant
to a waiver under section 1115.
``(ii) Limitation.--A child described in clause (i) who
is provided medical assistance during a presumptive
eligibility period under section 1920A shall be considered
to be a `qualifying child' only if the child is determined
to be eligible for medical assistance under title XIX.
``(iii) Exclusion.--Such term does not include any
children for whom the State has made an election to provide
medical assistance under paragraph (4) of section 1903(v).
``(G) Application to commonwealths and territories.--The
provisions of subparagraph (G) of section 2104(n)(3) shall
apply with respect to payment under this paragraph in the same
manner as such provisions apply to payment under such section.
``(H)  Application to states that implement a Medicaid
expansion for children after fiscal year 2008.--In the case of
a State that provides coverage under section 115 of the
Children's Health Insurance Program Reauthorization Act of 2009
for any fiscal year after fiscal year 2008--
``(i) any child enrolled in the State plan under title
XIX through the application of such an election shall be
disregarded from the determination for the State of the
monthly average unduplicated number of qualifying children
enrolled in such plan during the first 3 fiscal years in
which such an election is in effect; and
``(ii) in determining the baseline number of child
enrollees for the State for any fiscal year subsequent to
such first 3 fiscal years, the baseline number of child
enrollees for the State under title XIX for the third of
such fiscal years shall be the monthly average unduplicated
number of qualifying children enrolled in the State plan
under title XIX for such third fiscal year.
``(4) Enrollment and retention provisions for children.--For
purposes of paragraph (3)(A), a State meets the condition of this
paragraph for a fiscal year if it is implementing at least 5 of the
following enrollment and retention provisions (treating each
subparagraph as a separate enrollment and retention provision)
throughout the entire fiscal year:
``(A) Continuous eligibility.--The State has elected the
option of continuous eligibility for a full 12 months for all
children described in section 1902(e)(12) under title XIX under
19 years of age, as well as applying such policy under its
State child health plan under this title.
``(B) Liberalization of asset requirements.--The State
meets the requirement specified in either of the following
clauses:
``(i) Elimination of asset test.--The State does not
apply any asset or resource test for eligibility for
children under title XIX or this title.
``(ii) Administrative verification of assets.--The
State--
``(I) permits a parent or caretaker relative who is
applying on behalf of a child for medical assistance
under title XIX or child health assistance under this
title to declare and certify by signature under penalty
of perjury information relating to family assets for
purposes of determining and redetermining financial
eligibility; and
``(II) takes steps to verify assets through means
other than by requiring documentation from parents and
applicants except in individual cases of discrepancies
or where otherwise justified.
``(C) Elimination of in-person interview requirement.--The
State does not require an application of a child for medical
assistance under title XIX (or for child health assistance
under this title), including an application for renewal of such
assistance, to be made in person nor does the State require a
face-to-face interview, unless there are discrepancies or
individual circumstances justifying an in-person application or
face-to-face interview.
``(D) Use of joint application for medicaid and chip.--The
application form and supplemental forms (if any) and
information verification process is the same for purposes of
establishing and renewing eligibility for children for medical
assistance under title XIX and child health assistance under
this title.
``(E) Automatic renewal (use of administrative renewal).--
``(i) In general.--The State provides, in the case of
renewal of a child's eligibility for medical assistance
under title XIX or child health assistance under this
title, a pre-printed form completed by the State based on
the information available to the State and notice to the
parent or caretaker relative of the child that eligibility
of the child will be renewed and continued based on such
information unless the State is provided other information.
Nothing in this clause shall be construed as preventing a
State from verifying, through electronic and other means,
the information so provided.
``(ii) Satisfaction through demonstrated use of ex
parte process.--A State shall be treated as satisfying the
requirement of clause (i) if renewal of eligibility of
children under title XIX or this title is determined
without any requirement for an in-person interview, unless
sufficient information is not in the State's possession and
cannot be acquired from other sources (including other
State agencies) without the participation of the applicant
or the applicant's parent or caretaker relative.
``(F) Presumptive eligibility for children.--The State is
implementing section 1920A under title XIX as well as, pursuant
to section 2107(e)(1), under this title.
``(G) Express lane.--The State is implementing the option
described in section 1902(e)(13) under title XIX as well as,
pursuant to section 2107(e)(1), under this title.
``(H) Premium assistance subsidies.--The State is
implementing the option of providing premium assistance
subsidies under section 2105(c)(10) or section 1906A.''.

604e56d8926fd562177a2a697dc61c92223ddc43798e9abe2b3b5474a64d0ba9

Section 2104(e) (42 U.S.C. 1397dd(e)) is amended to read as
follows:
``(e) Availability of Amounts Allotted.--
``(1) In general.--Except as provided in paragraph (2), amounts
allotted to a State pursuant to this section--
``(A) for each of fiscal years 1998 through 2008, shall
remain available for expenditure by the State through the end
of the second succeeding fiscal year; and
``(B) for fiscal year 2009 and each fiscal year thereafter,
shall remain available for expenditure by the State through the
end of the succeeding fiscal year.
``(2) Availability of amounts redistributed.--Amounts
redistributed to a State under subsection (f) shall be available
for expenditure by the State through the end of the fiscal year in
which they are redistributed.''.

325ab3772065abdf96b3207e27bd269e647acc4085c69ee6da6e4017583dddbe

(a) Beginning With Fiscal Year 2007.--
(1) In general.--Section 2104(f) (42 U.S.C. 1397dd(f)) is
amended--
(A) by striking ``The Secretary'' and inserting the
following:
``(1) In general.--The Secretary'';
(B) by striking ``States that have fully expended the
amount of their allotments under this section.'' and inserting
``States that the Secretary determines with respect to the
fiscal year for which unused allotments are available for
redistribution under this subsection, are shortfall States
described in paragraph (2) for such fiscal year, but not to
exceed the amount of the shortfall described in paragraph
(2)(A) for each such State (as may be adjusted under paragraph
(2)(C)).''; and
(C) by adding at the end the following new paragraph:
``(2) Shortfall states described.--
``(A) In general.--For purposes of paragraph (1), with
respect to a fiscal year, a shortfall State described in this
subparagraph is a State with a State child health plan approved
under this title for which the Secretary estimates on the basis
of the most recent data available to the Secretary, that the
projected expenditures under such plan for the State for the
fiscal year will exceed the sum of--
``(i) the amount of the State's allotments for any
preceding fiscal years that remains available for
expenditure and that will not be expended by the end of the
immediately preceding fiscal year;
``(ii) the amount (if any) of the child enrollment
contingency fund payment under subsection (n); and
``(iii) the amount of the State's allotment for the
fiscal year.
``(B) Proration rule.--If the amounts available for
redistribution under paragraph (1) for a fiscal year are less
than the total amounts of the estimated shortfalls determined
for the year under subparagraph (A), the amount to be
redistributed under such paragraph for each shortfall State
shall be reduced proportionally.
``(C) Retrospective adjustment.--The Secretary may adjust
the estimates and determinations made under paragraph (1) and
this paragraph with respect to a fiscal year as necessary on
the basis of the amounts reported by States not later than
November 30 of the succeeding fiscal year, as approved by the
Secretary.''.
(2) Effective date.--The amendments made by paragraph (1) shall
apply to redistribution of allotments made for fiscal year 2007 and
subsequent fiscal years.
(b) Redistribution of Unused Allotments for Fiscal Year 2006.--
Section 2104(k) (42 U.S.C. 1397dd(k)) is amended--
(1) in the subsection heading, by striking ``the First 2
Quarters of'';
(2) in paragraph (1), by striking ``the first 2 quarters of'';
and
(3) in paragraph (6)--
(A) by striking ``the first 2 quarters of''; and
(B) by striking ``March 31'' and inserting ``September
30''.

6b646d6e914be6d44788e94aa80a14577599efd866c74bf791399034ee2b0a6c

PORTION OF THE CHIP MATCHING RATE FOR MEDICAID COVERAGE OF
CERTAIN CHILDREN.
(a) In General.--Section 2105(g) (42 U.S.C. 1397ee(g)) is amended--
(1) in paragraph (1)(A), as amended by section 201(b)(1) of
Public Law 110-173--
(A) by inserting ``subject to paragraph (4),'' after
``Notwithstanding any other provision of law,''; and
(B) by striking ``2008, or 2009'' and inserting ``or
2008''; and
(2) by adding at the end the following new paragraph:
``(4) Option for allotments for fiscal years 2009 through
2013.--
``(A) Payment of enhanced portion of matching rate for
certain expenditures.--In the case of expenditures described in
subparagraph (B), a qualifying State (as defined in paragraph
(2)) may elect to be paid from the State's allotment made under
section 2104 for any of fiscal years 2009 through 2013 (insofar
as the allotment is available to the State under subsections
(e) and (m) of such section) an amount each quarter equal to
the additional amount that would have been paid to the State
under title XIX with respect to such expenditures if the
enhanced FMAP (as determined under subsection (b)) had been
substituted for the Federal medical assistance percentage (as
defined in section 1905(b)).
``(B) Expenditures described.--For purposes of subparagraph
(A), the expenditures described in this subparagraph are
expenditures made after the date of the enactment of this
paragraph and during the period in which funds are available to
the qualifying State for use under subparagraph (A), for the
provision of medical assistance to individuals residing in the
State who are eligible for medical assistance under the State
plan under title XIX or under a waiver of such plan and who
have not attained age 19 (or, if a State has so elected under
the State plan under title XIX, age 20 or 21), and whose family
income equals or exceeds 133 percent of the poverty line but
does not exceed the Medicaid applicable income level.''.
(b) Repeal of Limitation on Availability of Fiscal Year 2009
Allotments.--Paragraph (2) of section 201(b) of the Medicare, Medicaid,
and SCHIP Extension Act of 2007 (Public Law 110-173) is repealed.

e7151b2b1a181eac58e0312b5868c21ebbea721544a65dfa794da8f4215803ac

There is appropriated to the Secretary, out of any money in the
Treasury not otherwise appropriated, $11,706,000,000 to accompany the
allotment made for the period beginning on October 1, 2012, and ending
on March 31, 2013, under section 2104(a)(16)(A) of the Social Security
Act (42 U.S.C. 1397dd(a)(16)(A)) (as added by section 101), to remain
available until expended. Such amount shall be used to provide
allotments to States under paragraph (3) of section 2104(m) of the
Social Security Act (42 U.S.C. 1397dd(i)), as added by section 102, for
the first 6 months of fiscal year 2013 in the same manner as allotments
are provided under subsection (a)(16)(A) of such section 2104 and
subject to the same terms and conditions as apply to the allotments
provided from such subsection (a)(16)(A).

6f824583d56f6812eb65f90d7fd02f75d5f788ca8a3ce8179e4441ae2b85b191

MEDICAID.
Section 1108(g) (42 U.S.C. 1308(g)) is amended by adding at the end
the following new paragraph:
``(4) Exclusion of certain expenditures from payment limits.--
With respect to fiscal years beginning with fiscal year 2009, if
Puerto Rico, the Virgin Islands, Guam, the Northern Mariana
Islands, or American Samoa qualify for a payment under subparagraph
(A)(i), (B), or (F) of section 1903(a)(3) for a calendar quarter of
such fiscal year, the payment shall not be taken into account in
applying subsection (f) (as increased in accordance with paragraphs
(1), (2), and (3) of this subsection) to such commonwealth or
territory for such fiscal year.''.
Subtitle B--Focus on Low-Income Children and Pregnant Women

675c6ddabee62ee2af6b533f1b686cf6c8837c8ca6c1548c48c77c6281d53e1c

CHIP THROUGH A STATE PLAN AMENDMENT.
(a) In General.--Title XXI (42 U.S.C. 1397aa et seq.), as amended
by section 112(a), is amended by adding at the end the following new
section:
``SEC. 2112. OPTIONAL COVERAGE OF TARGETED LOW-INCOME PREGNANT WOMEN
THROUGH A STATE PLAN AMENDMENT.
``(a) In General.--Subject to the succeeding provisions of this
section, a State may elect through an amendment to its State child
health plan under section 2102 to provide pregnancy-related assistance
under such plan for targeted low-income pregnant women.
``(b) Conditions.--A State may only elect the option under
subsection (a) if the following conditions are satisfied:
``(1) Minimum income eligibility levels for pregnant women and
children.--The State has established an income eligibility level--
``(A) for pregnant women under subsection
(a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), or (l)(1)(A) of section
1902 that is at least 185 percent (or such higher percent as
the State has in effect with regard to pregnant women under
this title) of the poverty line applicable to a family of the
size involved, but in no case lower than the percent in effect
under any such subsection as of July 1, 2008; and
``(B) for children under 19 years of age under this title
(or title XIX) that is at least 200 percent of the poverty line
applicable to a family of the size involved.
``(2) No chip income eligibility level for pregnant women lower
than the state's medicaid level.--The State does not apply an
effective income level for pregnant women under the State plan
amendment that is lower than the effective income level (expressed
as a percent of the poverty line and considering applicable income
disregards) specified under subsection (a)(10)(A)(i)(III),
(a)(10)(A)(i)(IV), or (l)(1)(A) of section 1902, on the date of
enactment of this paragraph to be eligible for medical assistance
as a pregnant woman.
``(3) No coverage for higher income pregnant women without
covering lower income pregnant women.--The State does not provide
coverage for pregnant women with higher family income without
covering pregnant women with a lower family income.
``(4) Application of requirements for coverage of targeted low-
income children.--The State provides pregnancy-related assistance
for targeted low-income pregnant women in the same manner, and
subject to the same requirements, as the State provides child
health assistance for targeted low-income children under the State
child health plan, and in addition to providing child health
assistance for such women.
``(5) No preexisting condition exclusion or waiting period.--
The State does not apply any exclusion of benefits for pregnancy-
related assistance based on any preexisting condition or any
waiting period (including any waiting period imposed to carry out
section 2102(b)(3)(C)) for receipt of such assistance.
``(6) Application of cost-sharing protection.--The State
provides pregnancy-related assistance to a targeted low-income
woman consistent with the cost-sharing protections under section
2103(e) and applies the limitation on total annual aggregate cost
sharing imposed under paragraph (3)(B) of such section to the
family of such a woman.
``(7) No waiting list for children.--The State does not impose,
with respect to the enrollment under the State child health plan of
targeted low-income children during the quarter, any enrollment cap
or other numerical limitation on enrollment, any waiting list, any
procedures designed to delay the consideration of applications for
enrollment, or similar limitation with respect to enrollment.
``(c) Option To Provide Presumptive Eligibility.--A State that
elects the option under subsection (a) and satisfies the conditions
described in subsection (b) may elect to apply section 1920 (relating
to presumptive eligibility for pregnant women) to the State child
health plan in the same manner as such section applies to the State
plan under title XIX.
``(d) Definitions.--For purposes of this section:
``(1) Pregnancy-related assistance.--The term `pregnancy-
related assistance' has the meaning given the term `child health
assistance' in section 2110(a) with respect to an individual during
the period described in paragraph (2)(A).
``(2) Targeted low-income pregnant woman.--The term `targeted
low-income pregnant woman' means an individual--
``(A) during pregnancy and through the end of the month in
which the 60-day period (beginning on the last day of her
pregnancy) ends;
``(B) whose family income exceeds 185 percent (or, if
higher, the percent applied under subsection (b)(1)(A)) of the
poverty line applicable to a family of the size involved, but
does not exceed the income eligibility level established under
the State child health plan under this title for a targeted
low-income child; and
``(C) who satisfies the requirements of paragraphs (1)(A),
(1)(C), (2), and (3) of section 2110(b) in the same manner as a
child applying for child health assistance would have to
satisfy such requirements.
``(e) Automatic Enrollment for Children Born to Women Receiving
Pregnancy-Related Assistance.--If a child is born to a targeted low-
income pregnant woman who was receiving pregnancy-related assistance
under this section on the date of the child's birth, the child shall be
deemed to have applied for child health assistance under the State
child health plan and to have been found eligible for such assistance
under such plan or to have applied for medical assistance under title
XIX and to have been found eligible for such assistance under such
title, as appropriate, on the date of such birth and to remain eligible
for such assistance until the child attains 1 year of age. During the
period in which a child is deemed under the preceding sentence to be
eligible for child health or medical assistance, the child health or
medical assistance eligibility identification number of the mother
shall also serve as the identification number of the child, and all
claims shall be submitted and paid under such number (unless the State
issues a separate identification number for the child before such
period expires).
``(f) States Providing Assistance Through Other Options.--
``(1) Continuation of other options for providing assistance.--
The option to provide assistance in accordance with the preceding
subsections of this section shall not limit any other option for a
State to provide--
``(A) child health assistance through the application of
sections 457.10, 457.350(b)(2), 457.622(c)(5), and
457.626(a)(3) of title 42, Code of Federal Regulations (as in
effect after the final rule adopted by the Secretary and set
forth at 67 Fed. Reg. 61956-61974 (October 2, 2002)), or
``(B) pregnancy-related services through the application of
any waiver authority (as in effect on June 1, 2008).
``(2) Clarification of authority to provide postpartum
services.--Any State that provides child health assistance under
any authority described in paragraph (1) may continue to provide
such assistance, as well as postpartum services, through the end of
the month in which the 60-day period (beginning on the last day of
the pregnancy) ends, in the same manner as such assistance and
postpartum services would be provided if provided under the State
plan under title XIX, but only if the mother would otherwise
satisfy the eligibility requirements that apply under the State
child health plan (other than with respect to age) during such
period.
``(3) No inference.--Nothing in this subsection shall be
construed--
``(A) to infer congressional intent regarding the legality
or illegality of the content of the sections specified in
paragraph (1)(A); or
``(B) to modify the authority to provide pregnancy-related
services under a waiver specified in paragraph (1)(B).''.
(b) Additional Conforming Amendments.--
(1) No cost sharing for pregnancy-related benefits.--Section
2103(e)(2) (42 U.S.C. 1397cc(e)(2)) is amended--
(A) in the heading, by inserting ``<SUP>or pregnancy-
related assistance'' after ``<SUP>preventive services''; and
(B) by inserting before the period at the end the
following: ``or for pregnancy-related assistance''.
(2) No waiting period.--Section 2102(b)(1)(B) (42 U.S.C.
1397bb(b)(1)(B)) is amended--
(A) in clause (i), by striking ``, and'' at the end and
inserting a semicolon;
(B) in clause (ii), by striking the period at the end and
inserting ``; and''; and
(C) by adding at the end the following new clause:
``(iii) may not apply a waiting period (including a
waiting period to carry out paragraph (3)(C)) in the case
of a targeted low-income pregnant woman provided pregnancy-
related assistance under section 2112.''.

ca9e95a318f974cf096f096eebc762ff63b28ad981796d4e5a00faf5b518f893

UNDER CHIP; CONDITIONS FOR COVERAGE OF PARENTS.
(a) Phase-Out Rules.--
(1) In general.--Title XXI (42 U.S.C. 1397aa et seq.) is
amended by adding at the end the following new section:
``SEC. 2111. PHASE-OUT OF COVERAGE FOR NONPREGNANT CHILDLESS ADULTS;
CONDITIONS FOR COVERAGE OF PARENTS.
``(a) Termination of Coverage for Nonpregnant Childless Adults.--
``(1) No new chip waivers; automatic extensions at state option
through 2009.--Notwithstanding section 1115 or any other provision
of this title, except as provided in this subsection--
``(A) the Secretary shall not on or after the date of the
enactment of the Children's Health Insurance Program
Reauthorization Act of 2009, approve or renew a waiver,
experimental, pilot, or demonstration project that would allow
funds made available under this title to be used to provide
child health assistance or other health benefits coverage to a
nonpregnant childless adult; and
``(B) notwithstanding the terms and conditions of an
applicable existing waiver, the provisions of paragraph (2)
shall apply for purposes of any period beginning on or after
January 1, 2010, in determining the period to which the waiver
applies, the individuals eligible to be covered by the waiver,
and the amount of the Federal payment under this title.
``(2) Termination of chip coverage under applicable existing
waivers at the end of 2009.--
``(A) In general.--No funds shall be available under this
title for child health assistance or other health benefits
coverage that is provided to a nonpregnant childless adult
under an applicable existing waiver after December 31, 2009.
``(B) Extension upon state request.--If an applicable
existing waiver described in subparagraph (A) would otherwise
expire before January 1, 2010, notwithstanding the requirements
of subsections (e) and (f) of section 1115, a State may submit,
not later than September 30, 2009, a request to the Secretary
for an extension of the waiver. The Secretary shall approve a
request for an extension of an applicable existing waiver
submitted pursuant to this subparagraph, but only through
December 31, 2009.
``(C) Application of enhanced fmap.--The enhanced FMAP
determined under section 2105(b) shall apply to expenditures
under an applicable existing waiver for the provision of child
health assistance or other health benefits coverage to a
nonpregnant childless adult during the period beginning on the
date of the enactment of this subsection and ending on December
31, 2009.
``(3) State option to apply for medicaid waiver to continue
coverage for nonpregnant childless adults.--
``(A) In general.--Each State for which coverage under an
applicable existing waiver is terminated under paragraph (2)(A)
may submit, not later than September 30, 2009, an application
to the Secretary for a waiver under section 1115 of the State
plan under title XIX to provide medical assistance to a
nonpregnant childless adult whose coverage is so terminated (in
this subsection referred to as a `Medicaid nonpregnant
childless adults waiver').
``(B) Deadline for approval.--The Secretary shall make a
decision to approve or deny an application for a Medicaid
nonpregnant childless adults waiver submitted under
subparagraph (A) within 90 days of the date of the submission
of the application. If no decision has been made by the
Secretary as of December 31, 2009, on the application of a
State for a Medicaid nonpregnant childless adults waiver that
was submitted to the Secretary by September 30, 2009, the
application shall be deemed approved.
``(C) Standard for budget neutrality.--The budget
neutrality requirement applicable with respect to expenditures
for medical assistance under a Medicaid nonpregnant childless
adults waiver shall--
``(i) in the case of fiscal year 2010, allow
expenditures for medical assistance under title XIX for all
such adults to not exceed the total amount of payments made
to the State under paragraph (2)(B) for fiscal year 2009,
increased by the percentage increase (if any) in the
projected nominal per capita amount of National Health
Expenditures for 2010 over 2009, as most recently published
by the Secretary; and
``(ii) in the case of any succeeding fiscal year, allow
such expenditures to not exceed the amount in effect under
this subparagraph for the preceding fiscal year, increased
by the percentage increase (if any) in the projected
nominal per capita amount of National Health Expenditures
for the calendar year that begins during the year involved
over the preceding calendar year, as most recently
published by the Secretary.
``(b) Rules and Conditions for Coverage of Parents of Targeted Low-
Income Children.--
``(1) Two-year period; automatic extension at state option
through fiscal year 2011.--
``(A) No new chip waivers.--Notwithstanding section 1115 or
any other provision of this title, except as provided in this
subsection--
``(i) the Secretary shall not on or after the date of
the enactment of the Children's Health Insurance Program
Reauthorization Act of 2009 approve or renew a waiver,
experimental, pilot, or demonstration project that would
allow funds made available under this title to be used to
provide child health assistance or other health benefits
coverage to a parent of a targeted low-income child; and
``(ii) notwithstanding the terms and conditions of an
applicable existing waiver, the provisions of paragraphs
(2) and (3) shall apply for purposes of any fiscal year
beginning on or after October 1, 2011, in determining the
period to which the waiver applies, the individuals
eligible to be covered by the waiver, and the amount of the
Federal payment under this title.
``(B) Extension upon state request.--If an applicable
existing waiver described in subparagraph (A) would otherwise
expire before October 1, 2011, and the State requests an
extension of such waiver, the Secretary shall grant such an
extension, but only, subject to paragraph (2)(A), through
September 30, 2011.
``(C) Application of enhanced fmap.--The enhanced FMAP
determined under section 2105(b) shall apply to expenditures
under an applicable existing waiver for the provision of child
health assistance or other health benefits coverage to a parent
of a targeted low-income child during the third and fourth
quarters of fiscal year 2009 and during fiscal years 2010 and
2011.
``(2) Rules for fiscal years 2012 through 2013.--
``(A) Payments for coverage limited to block grant funded
from state allotment.--Any State that provides child health
assistance or health benefits coverage under an applicable
existing waiver for a parent of a targeted low-income child may
elect to continue to provide such assistance or coverage
through fiscal year 2012 or 2013, subject to the same terms and
conditions that applied under the applicable existing waiver,
unless otherwise modified in subparagraph (B).
``(B) Terms and conditions.--
``(i) Block grant set aside from state allotment.--If
the State makes an election under subparagraph (A), the
Secretary shall set aside for the State for each such
fiscal year an amount equal to the Federal share of 110
percent of the State's projected expenditures under the
applicable existing waiver for providing child health
assistance or health benefits coverage to all parents of
targeted low-income children enrolled under such waiver for
the fiscal year (as certified by the State and submitted to
the Secretary by not later than August 31 of the preceding
fiscal year). In the case of fiscal year 2013, the set
aside for any State shall be computed separately for each
period described in subparagraphs (A) and (B) of section
2104(a)(16) and any reduction in the allotment for either
such period under section 2104(m)(4) shall be allocated on
a pro rata basis to such set aside.
``(ii) Payments from block grant.--The Secretary shall
pay the State from the amount set aside under clause (i)
for the fiscal year, an amount for each quarter of such
fiscal year equal to the applicable percentage determined
under clause (iii) or (iv) for expenditures in the quarter
for providing child health assistance or other health
benefits coverage to a parent of a targeted low-income
child.
``(iii) Enhanced fmap only in fiscal year 2012 for
states with significant child outreach or that achieve
child coverage benchmarks; fmap for any other states.--For
purposes of clause (ii), the applicable percentage for any
quarter of fiscal year 2012 is equal to--
``(I) the enhanced FMAP determined under section
2105(b) in the case of a State that meets the outreach
or coverage benchmarks described in any of subparagraph
(A), (B), or (C) of paragraph (3) for fiscal year 2011;
or
``(II) the Federal medical assistance percentage
(as determined under section 1905(b) without regard to
clause (4) of such section) in the case of any other
State.
``(iv) Amount of federal matching payment in 2013.--For
purposes of clause (ii), the applicable percentage for any
quarter of fiscal year 2013 is equal to--
``(I) the REMAP percentage if--
``(aa) the applicable percentage for the State
under clause (iii) was the enhanced FMAP for fiscal
year 2012; and
``(bb) the State met either of the coverage
benchmarks described in subparagraph (B) or (C) of
paragraph (3) for fiscal year 2012; or
``(II) the Federal medical assistance percentage
(as so determined) in the case of any State to which
subclause (I) does not apply.
For purposes of subclause (I), the REMAP percentage is the
percentage which is the sum of such Federal medical
assistance percentage and a number of percentage points
equal to one-half of the difference between such Federal
medical assistance percentage and such enhanced FMAP.
``(v) No federal payments other than from block grant
set aside.--No payments shall be made to a State for
expenditures described in clause (ii) after the total
amount set aside under clause (i) for a fiscal year has
been paid to the State.
``(vi) No increase in income eligibility level for
parents.--No payments shall be made to a State from the
amount set aside under clause (i) for a fiscal year for
expenditures for providing child health assistance or
health benefits coverage to a parent of a targeted low-
income child whose family income exceeds the income
eligibility level applied under the applicable existing
waiver to parents of targeted low-income children on the
date of enactment of the Children's Health Insurance
Program Reauthorization Act of 2009.
``(3) Outreach or coverage benchmarks.--For purposes of
paragraph (2), the outreach or coverage benchmarks described in
this paragraph are as follows:
``(A) Significant child outreach campaign.--The State--
``(i) was awarded a grant under section 2113 for fiscal
year 2011;
``(ii) implemented 1 or more of the enrollment and
retention provisions described in section 2105(a)(4) for
such fiscal year; or
``(iii) has submitted a specific plan for outreach for
such fiscal year.
``(B) High-performing state.--The State, on the basis of
the most timely and accurate published estimates of the Bureau
of the Census, ranks in the lowest \1/3\ of States in terms of
the State's percentage of low-income children without health
insurance.
``(C) State increasing enrollment of low-income children.--
The State qualified for a performance bonus payment under
section 2105(a)(3)(B) for the most recent fiscal year
applicable under such section.
``(4) Rules of construction.--Nothing in this subsection shall
be construed as prohibiting a State from submitting an application
to the Secretary for a waiver under section 1115 of the State plan
under title XIX to provide medical assistance to a parent of a
targeted low-income child that was provided child health assistance
or health benefits coverage under an applicable existing waiver.
``(c) Applicable Existing Waiver.--For purposes of this section--
``(1) In general.--The term `applicable existing waiver' means
a waiver, experimental, pilot, or demonstration project under
section 1115, grandfathered under section 6102(c)(3) of the Deficit
Reduction Act of 2005, or otherwise conducted under authority
that--
``(A) would allow funds made available under this title to
be used to provide child health assistance or other health
benefits coverage to--
``(i) a parent of a targeted low-income child;
``(ii) a nonpregnant childless adult; or
``(iii) individuals described in both clauses (i) and
(ii); and
``(B) was in effect during fiscal year 2009.
``(2) Definitions.--
``(A) Parent.--The term `parent' includes a caretaker
relative (as such term is used in carrying out section 1931)
and a legal guardian.
``(B) Nonpregnant childless adult.--The term `nonpregnant
childless adult' has the meaning given such term by section
2107(f).''.
(2) Conforming amendments.--
(A) Section 2107(f) (42 U.S.C. 1397gg(f)) is amended--
(i) by striking ``, the Secretary'' and inserting ``:
``(1) The Secretary'';
(ii) in the first sentence, by inserting ``or a parent
(as defined in section 2111(c)(2)(A)), who is not pregnant,
of a targeted low-income child'' before the period;
(iii) by striking the second sentence; and
(iv) by adding at the end the following new paragraph:
``(2) The Secretary may not approve, extend, renew, or amend a
waiver, experimental, pilot, or demonstration project with respect
to a State after the date of enactment of the Children's Health
Insurance Program Reauthorization Act of 2009 that would waive or
modify the requirements of section 2111.''.
(B) Section 6102(c) of the Deficit Reduction Act of 2005
(Public Law 109-171; 120 Stat. 131) is amended by striking
``Nothing'' and inserting ``Subject to section 2111 of the
Social Security Act, as added by section 112 of the Children's
Health Insurance Program Reauthorization Act of 2009,
nothing''.
(b) GAO Study and Report.--
(1) In general.--The Comptroller General of the United States
shall conduct a study of whether--
(A) the coverage of a parent, a caretaker relative (as such
term is used in carrying out section 1931), or a legal guardian
of a targeted low-income child under a State health plan under
title XXI of the Social Security Act increases the enrollment
of, or the quality of care for, children, and
(B) such parents, relatives, and legal guardians who enroll
in such a plan are more likely to enroll their children in such
a plan or in a State plan under title XIX of such Act.
(2) Report.--Not later than 2 years after the date of the
enactment of this Act, the Comptroller General shall report the
results of the study to the Committee on Finance of the Senate and
the Committee on Energy and Commerce of the House of
Representatives, including recommendations (if any) for changes in
legislation.

d59f9a5e5aba12a0102eef86fe8dbe8bd1b60735fa78c4f6ee57cfef752ed84e

ELIGIBILITY COSTS AGAINST TITLE XXI ALLOTMENT.
(a) In General.--Section 2105(a)(1) (42 U.S.C. 1397ee(a)(1)) is
amended--
(1) in the matter preceding subparagraph (A), by striking
``(or, in the case of expenditures described in subparagraph (B),
the Federal medical assistance percentage (as defined in the first
sentence of section 1905(b)))''; and
(2) by striking subparagraph (B) and inserting the following
new subparagraph:
``(B) [reserved]''.
(b) Amendments to Medicaid.--
(1) Eligibility of a newborn.--Section 1902(e)(4) (42 U.S.C.
1396a(e)(4)) is amended in the first sentence by striking ``so long
as the child is a member of the woman's household and the woman
remains (or would remain if pregnant) eligible for such
assistance''.
(2) Application of qualified entities to presumptive
eligibility for pregnant women under medicaid.--Section 1920(b) (42
U.S.C. 1396r-1(b)) is amended by adding after paragraph (2) the
following flush sentence:
``The term `qualified provider' also includes a qualified entity, as
defined in section 1920A(b)(3).''.

7f878010d5f6d1d2d1827448cc3d9a0526e8c5eb5e683fdae465d9afcd4ab72f

COVER CHILDREN WITH EFFECTIVE FAMILY INCOME THAT EXCEEDS 300
PERCENT OF THE POVERTY LINE.
(a) FMAP Applied to Expenditures.--Section 2105(c) (42 U.S.C.
1397ee(c)) is amended by adding at the end the following new paragraph:
``(8) Limitation on matching rate for expenditures for child
health assistance provided to children whose effective family
income exceeds 300 percent of the poverty line.--
``(A) FMAP applied to expenditures.--Except as provided in
subparagraph (B), for fiscal years beginning with fiscal year
2009, the Federal medical assistance percentage (as determined
under section 1905(b) without regard to clause (4) of such
section) shall be substituted for the enhanced FMAP under
subsection (a)(1) with respect to any expenditures for
providing child health assistance or health benefits coverage
for a targeted low-income child whose effective family income
would exceed 300 percent of the poverty line but for the
application of a general exclusion of a block of income that is
not determined by type of expense or type of income.
``(B) Exception.--Subparagraph (A) shall not apply to any
State that, on the date of enactment of the Children's Health
Insurance Program Reauthorization Act of 2009, has an approved
State plan amendment or waiver to provide, or has enacted a
State law to submit a State plan amendment to provide,
expenditures described in such subparagraph under the State
child health plan.''.
(b) Rule of Construction.--Nothing in the amendments made by this
section shall be construed as--
(1) changing any income eligibility level for children under
title XXI of the Social Security Act; or
(2) changing the flexibility provided States under such title
to establish the income eligibility level for targeted low-income
children under a State child health plan and the methodologies used
by the State to determine income or assets under such plan.

35179cd524b6c4f7f1c7d784215177749d587c71603cea14c6b0e79665e8f16c

Notwithstanding any other provision of law, including the fourth
sentence of subsection (b) of section 1905 of the Social Security Act
(42 U.S.C. 1396d) or subsection (u) of such section, at State option,
the Secretary shall provide the State with the Federal medical
assistance percentage determined for the State for Medicaid with
respect to expenditures described in section 1905(u)(2)(A) of such Act
or otherwise made to provide medical assistance under Medicaid to a
child who could be covered by the State under CHIP.
Subtitle A--Outreach and Enrollment Activities

7a880a348384df7c142d602c7328c3fabcf030ce75950c55c73da1660316ecff

AND ENROLLMENT.
(a) Grants.--Title XXI (42 U.S.C. 1397aa et seq.), as amended by
section 111, is amended by adding at the end the following:
``SEC. 2113. GRANTS TO IMPROVE OUTREACH AND ENROLLMENT.
``(a) Outreach and Enrollment Grants; National Campaign.--
``(1) In general.--From the amounts appropriated under
subsection (g), subject to paragraph (2), the Secretary shall award
grants to eligible entities during the period of fiscal years 2009
through 2013 to conduct outreach and enrollment efforts that are
designed to increase the enrollment and participation of eligible
children under this title and title XIX.
``(2) Ten percent set aside for national enrollment campaign.--
An amount equal to 10 percent of such amounts shall be used by the
Secretary for expenditures during such period to carry out a
national enrollment campaign in accordance with subsection (h).
``(b) Priority for Award of Grants.--
``(1) In general.--In awarding grants under subsection (a), the
Secretary shall give priority to eligible entities that--
``(A) propose to target geographic areas with high rates
of--
``(i) eligible but unenrolled children, including such
children who reside in rural areas; or
``(ii) racial and ethnic minorities and health
disparity populations, including those proposals that
address cultural and linguistic barriers to enrollment; and
``(B) submit the most demonstrable evidence required under
paragraphs (1) and (2) of subsection (c).
``(2) Ten percent set aside for outreach to indian children.--
An amount equal to 10 percent of the funds appropriated under
subsection (g) shall be used by the Secretary to award grants to
Indian Health Service providers and urban Indian organizations
receiving funds under title V of the Indian Health Care Improvement
Act (25 U.S.C. 1651 et seq.) for outreach to, and enrollment of,
children who are Indians.
``(c) Application.--An eligible entity that desires to receive a
grant under subsection (a) shall submit an application to the Secretary
in such form and manner, and containing such information, as the
Secretary may decide. Such application shall include--
``(1) evidence demonstrating that the entity includes members
who have access to, and credibility with, ethnic or low-income
populations in the communities in which activities funded under the
grant are to be conducted;
``(2) evidence demonstrating that the entity has the ability to
address barriers to enrollment, such as lack of awareness of
eligibility, stigma concerns and punitive fears associated with
receipt of benefits, and other cultural barriers to applying for
and receiving child health assistance or medical assistance;
``(3) specific quality or outcomes performance measures to
evaluate the effectiveness of activities funded by a grant awarded
under this section; and
``(4) an assurance that the eligible entity shall--
``(A) conduct an assessment of the effectiveness of such
activities against the performance measures;
``(B) cooperate with the collection and reporting of
enrollment data and other information in order for the
Secretary to conduct such assessments; and
``(C) in the case of an eligible entity that is not the
State, provide the State with enrollment data and other
information as necessary for the State to make necessary
projections of eligible children and pregnant women.
``(d) Dissemination of Enrollment Data and Information Determined
From Effectiveness Assessments; Annual Report.--The Secretary shall--
``(1) make publicly available the enrollment data and
information collected and reported in accordance with subsection
(c)(4)(B); and
``(2) submit an annual report to Congress on the outreach and
enrollment activities conducted with funds appropriated under this
section.
``(e) Maintenance of Effort for States Awarded Grants; No Match
Required for Any Eligible Entity Awarded a Grant.--
``(1) State maintenance of effort.--In the case of a State that
is awarded a grant under this section, the State share of funds
expended for outreach and enrollment activities under the State
child health plan shall not be less than the State share of such
funds expended in the fiscal year preceding the first fiscal year
for which the grant is awarded.
``(2) No matching requirement.--No eligible entity awarded a
grant under subsection (a) shall be required to provide any
matching funds as a condition for receiving the grant.
``(f) Definitions.--In this section:
``(1) Eligible entity.--The term `eligible entity' means any of
the following:
``(A) A State with an approved child health plan under this
title.
``(B) A local government.
``(C) An Indian tribe or tribal consortium, a tribal
organization, an urban Indian organization receiving funds
under title V of the Indian Health Care Improvement Act (25
U.S.C. 1651 et seq.), or an Indian Health Service provider.
``(D) A Federal health safety net organization.
``(E) A national, State, local, or community-based public
or nonprofit private organization, including organizations that
use community health workers or community-based doula programs.
``(F) A faith-based organization or consortia, to the
extent that a grant awarded to such an entity is consistent
with the requirements of section 1955 of the Public Health
Service Act (42 U.S.C. 300x-65) relating to a grant award to
nongovernmental entities.
``(G) An elementary or secondary school.
``(2) Federal health safety net organization.--The term
`Federal health safety net organization' means--
``(A) a Federally-qualified health center (as defined in
section 1905(l)(2)(B));
``(B) a hospital defined as a disproportionate share
hospital for purposes of section 1923;
``(C) a covered entity described in section 340B(a)(4) of
the Public Health Service Act (42 U.S.C. 256b(a)(4)); and
``(D) any other entity or consortium that serves children
under a federally funded program, including the special
supplemental nutrition program for women, infants, and children
(WIC) established under section 17 of the Child Nutrition Act
of 1966 (42 U.S.C. 1786), the Head Start and Early Head Start
programs under the Head Start Act (42 U.S.C. 9801 et seq.), the
school lunch program established under the Richard B. Russell
National School Lunch Act, and an elementary or secondary
school.
``(3) Indians; indian tribe; tribal organization; urban indian
organization.--The terms `Indian', `Indian tribe', `tribal
organization', and `urban Indian organization' have the meanings
given such terms in section 4 of the Indian Health Care Improvement
Act (25 U.S.C. 1603).
``(4) Community health worker.--The term `community health
worker' means an individual who promotes health or nutrition within
the community in which the individual resides--
``(A) by serving as a liaison between communities and
health care agencies;
``(B) by providing guidance and social assistance to
community residents;
``(C) by enhancing community residents' ability to
effectively communicate with health care providers;
``(D) by providing culturally and linguistically
appropriate health or nutrition education;
``(E) by advocating for individual and community health or
nutrition needs; and
``(F) by providing referral and followup services.
``(g) Appropriation.--There is appropriated, out of any money in
the Treasury not otherwise appropriated, $100,000,000 for the period of
fiscal years 2009 through 2013, for the purpose of awarding grants
under this section. Amounts appropriated and paid under the authority
of this section shall be in addition to amounts appropriated under
section 2104 and paid to States in accordance with section 2105,
including with respect to expenditures for outreach activities in
accordance with subsections (a)(1)(D)(iii) and (c)(2)(C) of that
section.
``(h) National Enrollment Campaign.--From the amounts made
available under subsection (a)(2), the Secretary shall develop and
implement a national enrollment campaign to improve the enrollment of
underserved child populations in the programs established under this
title and title XIX. Such campaign may include--
``(1) the establishment of partnerships with the Secretary of
Education and the Secretary of Agriculture to develop national
campaigns to link the eligibility and enrollment systems for the
assistance programs each Secretary administers that often serve the
same children;
``(2) the integration of information about the programs
established under this title and title XIX in public health
awareness campaigns administered by the Secretary;
``(3) increased financial and technical support for enrollment
hotlines maintained by the Secretary to ensure that all States
participate in such hotlines;
``(4) the establishment of joint public awareness outreach
initiatives with the Secretary of Education and the Secretary of
Labor regarding the importance of health insurance to building
strong communities and the economy;
``(5) the development of special outreach materials for Native
Americans or for individuals with limited English proficiency; and
``(6) such other outreach initiatives as the Secretary
determines would increase public awareness of the programs under
this title and title XIX.''.
(b) Enhanced Administrative Funding for Translation or
Interpretation Services Under CHIP and Medicaid.--
(1) CHIP.--Section 2105(a)(1) (42 U.S.C. 1397ee(a)(1)), as
amended by section 113, is amended--
(A) in the matter preceding subparagraph (A), by inserting
``(or, in the case of expenditures described in subparagraph
(D)(iv), the higher of 75 percent or the sum of the enhanced
FMAP plus 5 percentage points)'' after ``enhanced FMAP''; and
(B) in subparagraph (D)--
(i) in clause (iii), by striking ``and'' at the end;
(ii) by redesignating clause (iv) as clause (v); and
(iii) by inserting after clause (iii) the following new
clause:
``(iv) for translation or interpretation services in
connection with the enrollment of, retention of, and use of
services under this title by, individuals for whom English
is not their primary language (as found necessary by the
Secretary for the proper and efficient administration of
the State plan); and''.
(2) Medicaid.--
(A) Use of medicaid funds.--Section 1903(a)(2) (42 U.S.C.
1396b(a)(2)) is amended by adding at the end the following new
subparagraph:
``(E) an amount equal to 75 percent of so much of the sums
expended during such quarter (as found necessary by the Secretary
for the proper and efficient administration of the State plan) as
are attributable to translation or interpretation services in
connection with the enrollment of, retention of, and use of
services under this title by, children of families for whom English
is not the primary language; plus''.
(B) Use of community health workers for outreach
activities.--
(i) In general.--Section 2102(c)(1) of such Act (42
U.S.C. 1397bb(c)(1)) is amended by inserting ``(through
community health workers and others)'' after ``Outreach''.
(ii) In federal evaluation.--Section 2108(c)(3)(B) of
such Act (42 U.S.C. 1397hh(c)(3)(B)) is amended by
inserting ``(such as through community health workers and
others)'' after ``including practices''.

bfa8da633f986e4cdb1a1c61706af5503a3e38ba0ff92116a512b1af563427fd

(a) In General.--Section 1139 (42 U.S.C. 1320b-9) is amended to
read as follows:
``SEC. 1139. IMPROVED ACCESS TO, AND DELIVERY OF, HEALTH CARE FOR
INDIANS UNDER TITLES XIX AND XXI.
``(a) Agreements With States for Medicaid and CHIP Outreach On or
Near Reservations To Increase the Enrollment of Indians in Those
Programs.--
``(1) In general.--In order to improve the access of Indians
residing on or near a reservation to obtain benefits under the
Medicaid and State children's health insurance programs established
under titles XIX and XXI, the Secretary shall encourage the State
to take steps to provide for enrollment on or near the reservation.
Such steps may include outreach efforts such as the outstationing
of eligibility workers, entering into agreements with the Indian
Health Service, Indian Tribes, Tribal Organizations, and Urban
Indian Organizations to provide outreach, education regarding
eligibility and benefits, enrollment, and translation services when
such services are appropriate.
``(2) Construction.--Nothing in paragraph (1) shall be
construed as affecting arrangements entered into between States and
the Indian Health Service, Indian Tribes, Tribal Organizations, or
Urban Indian Organizations for such Service, Tribes, or
Organizations to conduct administrative activities under such
titles.
``(b) Requirement To Facilitate Cooperation.--The Secretary, acting
through the Centers for Medicare & Medicaid Services, shall take such
steps as are necessary to facilitate cooperation with, and agreements
between, States and the Indian Health Service, Indian Tribes, Tribal
Organizations, or Urban Indian Organizations with respect to the
provision of health care items and services to Indians under the
programs established under title XIX or XXI.
``(c) Definition of Indian; Indian Tribe; Indian Health Program;
Tribal Organization; Urban Indian Organization.--In this section, the
terms `Indian', `Indian Tribe', `Indian Health Program', `Tribal
Organization', and `Urban Indian Organization' have the meanings given
those terms in section 4 of the Indian Health Care Improvement Act.''.
(b) Nonapplication of 10 Percent Limit on Outreach and Certain
Other Expenditures.--Section 2105(c)(2) (42 U.S.C. 1397ee(c)(2)) is
amended by adding at the end the following:
``(C) Nonapplication to certain expenditures.--The
limitation under subparagraph (A) shall not apply with respect
to the following expenditures:
``(i) Expenditures to increase outreach to, and the
enrollment of, indian children under this title and title
xix.--Expenditures for outreach activities to families of
Indian children likely to be eligible for child health
assistance under the plan or medical assistance under the
State plan under title XIX (or under a waiver of such
plan), to inform such families of the availability of, and
to assist them in enrolling their children in, such plans,
including such activities conducted under grants,
contracts, or agreements entered into under section
1139(a).''.

3bf46125d83e80d2a338b1e25dc809677bd66796551643056db9e3bd347762de

6b36bbd887d290d0276693191e5532cadebcb3cf7f7c2417ad567240b893daf8

FOR PURPOSES OF ELIGIBILITY FOR MEDICAID AND CHIP.
(a) Alternative State Process for Verification of Declaration of
Citizenship or Nationality for Purposes of Eligibility for Medicaid.--
(1) Alternative to documentation requirement.--
(A) In general.--Section 1902 (42 U.S.C. 1396a), as amended
by section 203(c), is amended--
(i) in subsection (a)(46)--
(I) by inserting ``(A)'' after ``(46)'';
(II) by adding ``and'' after the semicolon; and
(III) by adding at the end the following new
subparagraph:
``(B) provide, with respect to an individual declaring to be a
citizen or national of the United States for purposes of
establishing eligibility under this title, that the State shall
satisfy the requirements of--
``(i) section 1903(x); or
``(ii) subsection (ee);''; and
(ii) by adding at the end the following new subsection:
``(ee)(1) For purposes of subsection (a)(46)(B)(ii), the
requirements of this subsection with respect to an individual declaring
to be a citizen or national of the United States for purposes of
establishing eligibility under this title, are, in lieu of requiring
the individual to present satisfactory documentary evidence of
citizenship or nationality under section 1903(x) (if the individual is
not described in paragraph (2) of that section), as follows:
``(A) The State submits the name and social security number of
the individual to the Commissioner of Social Security as part of
the program established under paragraph (2).
``(B) If the State receives notice from the Commissioner of
Social Security that the name or social security number, or the
declaration of citizenship or nationality, of the individual is
inconsistent with information in the records maintained by the
Commissioner--
``(i) the State makes a reasonable effort to identify and
address the causes of such inconsistency, including through
typographical or other clerical errors, by contacting the
individual to confirm the accuracy of the name or social
security number submitted or declaration of citizenship or
nationality and by taking such additional actions as the
Secretary, through regulation or other guidance, or the State
may identify, and continues to provide the individual with
medical assistance while making such effort; and
``(ii) in the case such inconsistency is not resolved under
clause (i), the State--
``(I) notifies the individual of such fact;
``(II) provides the individual with a period of 90 days
from the date on which the notice required under subclause
(I) is received by the individual to either present
satisfactory documentary evidence of citizenship or
nationality (as defined in section 1903(x)(3)) or resolve
the inconsistency with the Commissioner of Social Security
(and continues to provide the individual with medical
assistance during such 90-day period); and
``(III) disenrolls the individual from the State plan
under this title within 30 days after the end of such 90-
day period if no such documentary evidence is presented or
if such inconsistency is not resolved.
``(2)(A) Each State electing to satisfy the requirements of this
subsection for purposes of section 1902(a)(46)(B) shall establish a
program under which the State submits at least monthly to the
Commissioner of Social Security for comparison of the name and social
security number, of each individual newly enrolled in the State plan
under this title that month who is not described in section 1903(x)(2)
and who declares to be a United States citizen or national, with
information in records maintained by the Commissioner.
``(B) In establishing the State program under this paragraph, the
State may enter into an agreement with the Commissioner of Social
Security--
``(i) to provide, through an on-line system or otherwise, for
the electronic submission of, and response to, the information
submitted under subparagraph (A) for an individual enrolled in the
State plan under this title who declares to be citizen or national
on at least a monthly basis; or
``(ii) to provide for a determination of the consistency of the
information submitted with the information maintained in the
records of the Commissioner through such other method as agreed to
by the State and the Commissioner and approved by the Secretary,
provided that such method is no more burdensome for individuals to
comply with than any burdens that may apply under a method
described in clause (i).
``(C) The program established under this paragraph shall provide
that, in the case of any individual who is required to submit a social
security number to the State under subparagraph (A) and who is unable
to provide the State with such number, shall be provided with at least
the reasonable opportunity to present satisfactory documentary evidence
of citizenship or nationality (as defined in section 1903(x)(3)) as is
provided under clauses (i) and (ii) of section 1137(d)(4)(A) to an
individual for the submittal to the State of evidence indicating a
satisfactory immigration status.
``(3)(A) The State agency implementing the plan approved under this
title shall, at such times and in such form as the Secretary may
specify, provide information on the percentage each month that the
inconsistent submissions bears to the total submissions made for
comparison for such month. For purposes of this subparagraph, a name,
social security number, or declaration of citizenship or nationality of
an individual shall be treated as inconsistent and included in the
determination of such percentage only if--
``(i) the information submitted by the individual is not
consistent with information in records maintained by the
Commissioner of Social Security;
``(ii) the inconsistency is not resolved by the State;
``(iii) the individual was provided with a reasonable period of
time to resolve the inconsistency with the Commissioner of Social
Security or provide satisfactory documentation of citizenship
status and did not successfully resolve such inconsistency; and
``(iv) payment has been made for an item or service furnished
to the individual under this title.
``(B) If, for any fiscal year, the average monthly percentage
determined under subparagraph (A) is greater than 3 percent--
``(i) the State shall develop and adopt a corrective plan to
review its procedures for verifying the identities of individuals
seeking to enroll in the State plan under this title and to
identify and implement changes in such procedures to improve their
accuracy; and
``(ii) pay to the Secretary an amount equal to the amount which
bears the same ratio to the total payments under the State plan for
the fiscal year for providing medical assistance to individuals who
provided inconsistent information as the number of individuals with
inconsistent information in excess of 3 percent of such total
submitted bears to the total number of individuals with
inconsistent information.
``(C) The Secretary may waive, in certain limited cases, all or
part of the payment under subparagraph (B)(ii) if the State is unable
to reach the allowable error rate despite a good faith effort by such
State.
``(D) Subparagraphs (A) and (B) shall not apply to a State for a
fiscal year if there is an agreement described in paragraph (2)(B) in
effect as of the close of the fiscal year that provides for the
submission on a real-time basis of the information described in such
paragraph.
``(4) Nothing in this subsection shall affect the rights of any
individual under this title to appeal any disenrollment from a State
plan.''.
(B) Costs of implementing and maintaining system.--Section
1903(a)(3) (42 U.S.C. 1396b(a)(3)) is amended--
(i) by striking ``plus'' at the end of subparagraph (E)
and inserting ``and'', and
(ii) by adding at the end the following new
subparagraph:
``(F)(i) 90 percent of the sums expended during the quarter
as are attributable to the design, development, or installation
of such mechanized verification and information retrieval
systems as the Secretary determines are necessary to implement
section 1902(ee) (including a system described in paragraph
(2)(B) thereof), and
``(ii) 75 percent of the sums expended during the quarter
as are attributable to the operation of systems to which clause
(i) applies, plus''.
(2) Limitation on waiver authority.--Notwithstanding any
provision of section 1115 of the Social Security Act (42 U.S.C.
1315), or any other provision of law, the Secretary may not waive
the requirements of section 1902(a)(46)(B) of such Act (42 U.S.C.
1396a(a)(46)(B)) with respect to a State.
(3) Conforming amendments.--Section 1903 (42 U.S.C. 1396b) is
amended--
(A) in subsection (i)(22), by striking ``subsection (x)''
and inserting ``section 1902(a)(46)(B)''; and
(B) in subsection (x)(1), by striking ``subsection
(i)(22)'' and inserting ``section 1902(a)(46)(B)(i)''.
(4) Appropriation.--Out of any money in the Treasury of the
United States not otherwise appropriated, there are appropriated to
the Commissioner of Social Security $5,000,000 to remain available
until expended to carry out the Commissioner's responsibilities
under section 1902(ee) of the Social Security Act, as added by
subsection (a).
(b) Clarification of Requirements Relating to Presentation of
Satisfactory Documentary Evidence of Citizenship or Nationality.--
(1) Acceptance of documentary evidence issued by a federally
recognized indian tribe.--Section 1903(x)(3)(B) (42 U.S.C.
1396b(x)(3)(B)) is amended--
(A) by redesignating clause (v) as clause (vi); and
(B) by inserting after clause (iv), the following new
clause:
``(v)(I) Except as provided in subclause (II), a document
issued by a federally recognized Indian tribe evidencing membership
or enrollment in, or affiliation with, such tribe (such as a tribal
enrollment card or certificate of degree of Indian blood).
``(II) With respect to those federally recognized Indian tribes
located within States having an international border whose
membership includes individuals who are not citizens of the United
States, the Secretary shall, after consulting with such tribes,
issue regulations authorizing the presentation of such other forms
of documentation (including tribal documentation, if appropriate)
that the Secretary determines to be satisfactory documentary
evidence of citizenship or nationality for purposes of satisfying
the requirement of this subsection.''.
(2) Requirement to provide reasonable opportunity to present
satisfactory documentary evidence.--Section 1903(x) (42 U.S.C.
1396b(x)) is amended by adding at the end the following new
paragraph:
``(4) In the case of an individual declaring to be a citizen or
national of the United States with respect to whom a State requires the
presentation of satisfactory documentary evidence of citizenship or
nationality under section 1902(a)(46)(B)(i), the individual shall be
provided at least the reasonable opportunity to present satisfactory
documentary evidence of citizenship or nationality under this
subsection as is provided under clauses (i) and (ii) of section
1137(d)(4)(A) to an individual for the submittal to the State of
evidence indicating a satisfactory immigration status.''.
(3) Children born in the united states to mothers eligible for
medicaid.--
(A) Clarification of rules.--Section 1903(x) (42 U.S.C.
1396b(x)), as amended by paragraph (2), is amended--
(i) in paragraph (2)--
(I) in subparagraph (C), by striking ``or'' at the
end;
(II) by redesignating subparagraph (D) as
subparagraph (E); and
(III) by inserting after subparagraph (C) the
following new subparagraph:
``(D) pursuant to the application of section 1902(e)(4) (and,
in the case of an individual who is eligible for medical assistance
on such basis, the individual shall be deemed to have provided
satisfactory documentary evidence of citizenship or nationality and
shall not be required to provide further documentary evidence on
any date that occurs during or after the period in which the
individual is eligible for medical assistance on such basis); or'';
and
(ii) by adding at the end the following new paragraph:
``(5) Nothing in subparagraph (A) or (B) of section 1902(a)(46),
the preceding paragraphs of this subsection, or the Deficit Reduction
Act of 2005, including section 6036 of such Act, shall be construed as
changing the requirement of section 1902(e)(4) that a child born in the
United States to an alien mother for whom medical assistance for the
delivery of such child is available as treatment of an emergency
medical condition pursuant to subsection (v) shall be deemed eligible
for medical assistance during the first year of such child's life.''.
(B) State requirement to issue separate identification
number.--Section 1902(e)(4) (42 U.S.C. 1396a(e)(4)) is amended
by adding at the end the following new sentence:
``Notwithstanding the preceding sentence, in the case of a
child who is born in the United States to an alien mother for
whom medical assistance for the delivery of the child is made
available pursuant to section 1903(v), the State immediately
shall issue a separate identification number for the child upon
notification by the facility at which such delivery occurred of
the child's birth.''.
(4) Technical amendments.--Section 1903(x)(2) (42 U.S.C.
1396b(x)) is amended--
(A) in subparagraph (B)--
(i) by realigning the left margin of the matter
preceding clause (i) 2 ems to the left; and
(ii) by realigning the left margins of clauses (i) and
(ii), respectively, 2 ems to the left; and
(B) in subparagraph (C)--
(i) by realigning the left margin of the matter
preceding clause (i) 2 ems to the left; and
(ii) by realigning the left margins of clauses (i) and
(ii), respectively, 2 ems to the left.
(c) Application of Documentation System to CHIP.--
(1) In general.--Section 2105(c) (42 U.S.C. 1397ee(c)), as
amended by section 114(a), is amended by adding at the end the
following new paragraph:
``(9) Citizenship documentation requirements.--
``(A) In general.--No payment may be made under this
section with respect to an individual who has, or is, declared
to be a citizen or national of the United States for purposes
of establishing eligibility under this title unless the State
meets the requirements of section 1902(a)(46)(B) with respect
to the individual.
``(B) Enhanced payments.--Notwithstanding subsection (b),
the enhanced FMAP with respect to payments under subsection (a)
for expenditures described in clause (i) or (ii) of section
1903(a)(3)(F) necessary to comply with subparagraph (A) shall
in no event be less than 90 percent and 75 percent,
respectively.''.
(2) Nonapplication of administrative expenditures cap.--Section
2105(c)(2)(C) (42 U.S.C. 1397ee(c)(2)(C)), as amended by section
202(b), is amended by adding at the end the following:
``(ii) Expenditures to comply with citizenship or
nationality verification requirements.--Expenditures
necessary for the State to comply with paragraph (9)(A).''.
(d) Effective Date.--
(1) In general.--
(A) In general.--Except as provided in subparagraph (B),
the amendments made by this section shall take effect on
January 1, 2010.
(B) Technical amendments.--The amendments made by--
(i) paragraphs (1), (2), and (3) of subsection (b)
shall take effect as if included in the enactment of
section 6036 of the Deficit Reduction Act of 2005 (Public
Law 109-171; 120 Stat. 80); and
(ii) paragraph (4) of subsection (b) shall take effect
as if included in the enactment of section 405 of division
B of the Tax Relief and Health Care Act of 2006 (Public Law
109-432; 120 Stat. 2996).
(2) Restoration of eligibility.--In the case of an individual
who, during the period that began on July 1, 2006, and ends on
October 1, 2009, was determined to be ineligible for medical
assistance under a State Medicaid plan, including any waiver of
such plan, solely as a result of the application of subsections
(i)(22) and (x) of section 1903 of the Social Security Act (as in
effect during such period), but who would have been determined
eligible for such assistance if such subsections, as amended by
subsection (b), had applied to the individual, a State may deem the
individual to be eligible for such assistance as of the date that
the individual was determined to be ineligible for such medical
assistance on such basis.
(3) Special transition rule for indians.--During the period
that begins on July 1, 2006, and ends on the effective date of
final regulations issued under subclause (II) of section
1903(x)(3)(B)(v) of the Social Security Act (42 U.S.C.
1396b(x)(3)(B)(v)) (as added by subsection (b)(1)(B)), an
individual who is a member of a federally-recognized Indian tribe
described in subclause (II) of that section who presents a document
described in subclause (I) of such section that is issued by such
Indian tribe, shall be deemed to have presented satisfactory
evidence of citizenship or nationality for purposes of satisfying
the requirement of subsection (x) of section 1903 of such Act.

5a093af2cd1738cdc14325f60b448136cc1f3348f8ff7d9c15584e4e57d03ea8

Section 2102(b) (42 U.S.C. 1397bb(b)) is amended--
(1) by redesignating paragraph (4) as paragraph (5); and
(2) by inserting after paragraph (3) the following new
paragraph:
``(4) Reduction of administrative barriers to enrollment.--
``(A) In general.--Subject to subparagraph (B), the plan
shall include a description of the procedures used to reduce
administrative barriers to the enrollment of children and
pregnant women who are eligible for medical assistance under
title XIX or for child health assistance or health benefits
coverage under this title. Such procedures shall be established
and revised as often as the State determines appropriate to
take into account the most recent information available to the
State identifying such barriers.
``(B) Deemed compliance if joint application and renewal
process that permits application other than in person.--A State
shall be deemed to comply with subparagraph (A) if the State's
application and renewal forms and supplemental forms (if any)
and information verification process is the same for purposes
of establishing and renewing eligibility for children and
pregnant women for medical assistance under title XIX and child
health assistance under this title, and such process does not
require an application to be made in person or a face-to-face
interview.''.

4cd5d4e65a07d59cfcb4efcec79985bf595d8030bdde6438114a6bdecce9112b

PROCESS.
(a) In General.--In order to assure continuity of coverage of low-
income children under the Medicaid program and the State Children's
Health Insurance Program (CHIP), not later than 18 months after the
date of the enactment of this Act, the Secretary of Health and Human
Services, in consultation with State Medicaid and CHIP directors and
organizations representing program beneficiaries, shall develop a model
process for the coordination of the enrollment, retention, and coverage
under such programs of children who, because of migration of families,
emergency evacuations, natural or other disasters, public health
emergencies, educational needs, or otherwise, frequently change their
State of residency or otherwise are temporarily located outside of the
State of their residency.
(b) Report to Congress.--After development of such model process,
the Secretary of Health and Human Services shall submit to Congress a
report describing additional steps or authority needed to make further
improvements to coordinate the enrollment, retention, and coverage
under CHIP and Medicaid of children described in subsection (a).

5eff39f769ee43938906b68ad575243149be44a51cf3b4c33bcbe096bf87177c

DELAY OF CERTAIN CHILDREN AND PREGNANT WOMEN UNDER THE MEDICAID
PROGRAM AND CHIP.
(a) Medicaid Program.--Section 1903(v) (42 U.S.C. 1396b(v)) is
amended--
(1) in paragraph (1), by striking ``paragraph (2)'' and
inserting ``paragraphs (2) and (4)''; and
(2) by adding at the end the following new paragraph:
``(4)(A) A State may elect (in a plan amendment under this title)
to provide medical assistance under this title, notwithstanding
sections 401(a), 402(b), 403, and 421 of the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996, to children and
pregnant women who are lawfully residing in the United States
(including battered individuals described in section 431(c) of such
Act) and who are otherwise eligible for such assistance, within either
or both of the following eligibility categories:
``(i) Pregnant women.--Women during pregnancy (and during the
60-day period beginning on the last day of the pregnancy).
``(ii) Children.--Individuals under 21 years of age, including
optional targeted low-income children described in section
1905(u)(2)(B).
``(B) In the case of a State that has elected to provide medical
assistance to a category of aliens under subparagraph (A), no debt
shall accrue under an affidavit of support against any sponsor of such
an alien on the basis of provision of assistance to such category and
the cost of such assistance shall not be considered as an unreimbursed
cost.
``(C) As part of the State's ongoing eligibility redetermination
requirements and procedures for an individual provided medical
assistance as a result of an election by the State under subparagraph
(A), a State shall verify that the individual continues to lawfully
reside in the United States using the documentation presented to the
State by the individual on initial enrollment. If the State cannot
successfully verify that the individual is lawfully residing in the
United States in this manner, it shall require that the individual
provide the State with further documentation or other evidence to
verify that the individual is lawfully residing in the United
States.''.
(b) CHIP.--Section 2107(e)(1) (42 U.S.C. 1397gg(e)(1)), as amended
by sections 203(a)(2) and 203(d)(2), is amended by redesignating
subparagraphs (E) and (F) as subparagraphs (F) and (G), respectively
and by inserting after subparagraph (D) the following new subparagraph:
``(E) Paragraph (4) of section 1903(v) (relating to
optional coverage of categories of lawfully residing immigrant
children or pregnant women), but only if the State has elected
to apply such paragraph with respect to such category of
children or pregnant women under title XIX.''.
Subtitle A--Additional State Option for Providing Premium Assistance

be5b18ba3c1614aa64c90c1bc8055ceb3152ad23b4fd566c3e356f12b2b39e99

(a) CHIP.--
(1) In general.--Section 2105(c) (42 U.S.C. 1397ee(c)), as
amended by sections 114(a) and 211(c), is amended by adding at the
end the following:
``(10) State option to offer premium assistance.--
``(A) In general.--A State may elect to offer a premium
assistance subsidy (as defined in subparagraph (C)) for
qualified employer-sponsored coverage (as defined in
subparagraph (B)) to all targeted low-income children who are
eligible for child health assistance under the plan and have
access to such coverage in accordance with the requirements of
this paragraph. No subsidy shall be provided to a targeted low-
income child under this paragraph unless the child (or the
child's parent) voluntarily elects to receive such a subsidy. A
State may not require such an election as a condition of
receipt of child health assistance.
``(B) Qualified employer-sponsored coverage.--
``(i) In general.--Subject to clause (ii), in this
paragraph, the term `qualified employer-sponsored coverage'
means a group health plan or health insurance coverage
offered through an employer--
``(I) that qualifies as creditable coverage as a
group health plan under section 2701(c)(1) of the
Public Health Service Act;
``(II) for which the employer contribution toward
any premium for such coverage is at least 40 percent;
and
``(III) that is offered to all individuals in a
manner that would be considered a nondiscriminatory
eligibility classification for purposes of paragraph
(3)(A)(ii) of section 105(h) of the Internal Revenue
Code of 1986 (but determined without regard to clause
(i) of subparagraph (B) of such paragraph).
``(ii) Exception.--Such term does not include coverage
consisting of--
``(I) benefits provided under a health flexible
spending arrangement (as defined in section 106(c)(2)
of the Internal Revenue Code of 1986); or
``(II) a high deductible health plan (as defined in
section 223(c)(2) of such Code), without regard to
whether the plan is purchased in conjunction with a
health savings account (as defined under section 223(d)
of such Code).
``(C) Premium assistance subsidy.--
``(i) In general.--In this paragraph, the term `premium
assistance subsidy' means, with respect to a targeted low-
income child, the amount equal to the difference between
the employee contribution required for enrollment only of
the employee under qualified employer-sponsored coverage
and the employee contribution required for enrollment of
the employee and the child in such coverage, less any
applicable premium cost-sharing applied under the State
child health plan (subject to the limitations imposed under
section 2103(e), including the requirement to count the
total amount of the employee contribution required for
enrollment of the employee and the child in such coverage
toward the annual aggregate cost-sharing limit applied
under paragraph (3)(B) of such section).
``(ii) State payment option.--A State may provide a
premium assistance subsidy either as reimbursement to an
employee for out-of-pocket expenditures or, subject to
clause (iii), directly to the employee's employer.
``(iii) Employer opt-out.--An employer may notify a
State that it elects to opt-out of being directly paid a
premium assistance subsidy on behalf of an employee. In the
event of such a notification, an employer shall withhold
the total amount of the employee contribution required for
enrollment of the employee and the child in the qualified
employer-sponsored coverage and the State shall pay the
premium assistance subsidy directly to the employee.
``(iv) Treatment as child health assistance.--
Expenditures for the provision of premium assistance
subsidies shall be considered child health assistance
described in paragraph (1)(C) of subsection (a) for
purposes of making payments under that subsection.
``(D) Application of secondary payor rules.--The State
shall be a secondary payor for any items or services provided
under the qualified employer-sponsored coverage for which the
State provides child health assistance under the State child
health plan.
``(E) Requirement to provide supplemental coverage for
benefits and cost-sharing protection provided under the state
child health plan.--
``(i) In general.--Notwithstanding section
2110(b)(1)(C), the State shall provide for each targeted
low-income child enrolled in qualified employer-sponsored
coverage, supplemental coverage consisting of--
``(I) items or services that are not covered, or
are only partially covered, under the qualified
employer-sponsored coverage; and
``(II) cost-sharing protection consistent with
section 2103(e).
``(ii) Record keeping requirements.--For purposes of
carrying out clause (i), a State may elect to directly pay
out-of-pocket expenditures for cost-sharing imposed under
the qualified employer-sponsored coverage and collect or
not collect all or any portion of such expenditures from
the parent of the child.
``(F) Application of waiting period imposed under the
state.--Any waiting period imposed under the State child health
plan prior to the provision of child health assistance to a
targeted low-income child under the State plan shall apply to
the same extent to the provision of a premium assistance
subsidy for the child under this paragraph.
``(G) Opt-out permitted for any month.--A State shall
establish a process for permitting the parent of a targeted
low-income child receiving a premium assistance subsidy to
disenroll the child from the qualified employer-sponsored
coverage and enroll the child in, and receive child health
assistance under, the State child health plan, effective on the
first day of any month for which the child is eligible for such
assistance and in a manner that ensures continuity of coverage
for the child.
``(H) Application to parents.--If a State provides child
health assistance or health benefits coverage to parents of a
targeted low-income child in accordance with section 2111(b),
the State may elect to offer a premium assistance subsidy to a
parent of a targeted low-income child who is eligible for such
a subsidy under this paragraph in the same manner as the State
offers such a subsidy for the enrollment of the child in
qualified employer-sponsored coverage, except that--
``(i) the amount of the premium assistance subsidy
shall be increased to take into account the cost of the
enrollment of the parent in the qualified employer-
sponsored coverage or, at the option of the State if the
State determines it cost-effective, the cost of the
enrollment of the child's family in such coverage; and
``(ii) any reference in this paragraph to a child is
deemed to include a reference to the parent or, if
applicable under clause (i), the family of the child.
``(I) Additional state option for providing premium
assistance.--
``(i) In general.--A State may establish an employer-
family premium assistance purchasing pool for employers
with less than 250 employees who have at least 1 employee
who is a pregnant woman eligible for assistance under the
State child health plan (including through the application
of an option described in section 2112(f)) or a member of a
family with at least 1 targeted low-income child and to
provide a premium assistance subsidy under this paragraph
for enrollment in coverage made available through such
pool.
``(ii) Access to choice of coverage.--A State that
elects the option under clause (i) shall identify and offer
access to not less than 2 private health plans that are
health benefits coverage that is equivalent to the benefits
coverage in a benchmark benefit package described in
section 2103(b) or benchmark-equivalent coverage that meets
the requirements of section 2103(a)(2) for employees
described in clause (i).
``(iii) Clarification of payment for administrative
expenditures.--Nothing in this subparagraph shall be
construed as permitting payment under this section for
administrative expenditures attributable to the
establishment or operation of such pool, except to the
extent that such payment would otherwise be permitted under
this title.
``(J) No effect on premium assistance waiver programs.--
Nothing in this paragraph shall be construed as limiting the
authority of a State to offer premium assistance under section
1906 or 1906A, a waiver described in paragraph (2)(B) or (3), a
waiver approved under section 1115, or other authority in
effect prior to the date of enactment of the Children's Health
Insurance Program Reauthorization Act of 2009.
``(K) Notice of availability.--If a State elects to provide
premium assistance subsidies in accordance with this paragraph,
the State shall--
``(i) include on any application or enrollment form for
child health assistance a notice of the availability of
premium assistance subsidies for the enrollment of targeted
low-income children in qualified employer-sponsored
coverage;
``(ii) provide, as part of the application and
enrollment process under the State child health plan,
information describing the availability of such subsidies
and how to elect to obtain such a subsidy; and
``(iii) establish such other procedures as the State
determines necessary to ensure that parents are fully
informed of the choices for receiving child health
assistance under the State child health plan or through the
receipt of premium assistance subsidies.
``(L) Application to qualified employer-sponsored benchmark
coverage.--If a group health plan or health insurance coverage
offered through an employer is certified by an actuary as
health benefits coverage that is equivalent to the benefits
coverage in a benchmark benefit package described in section
2103(b) or benchmark-equivalent coverage that meets the
requirements of section 2103(a)(2), the State may provide
premium assistance subsidies for enrollment of targeted low-
income children in such group health plan or health insurance
coverage in the same manner as such subsidies are provided
under this paragraph for enrollment in qualified employer-
sponsored coverage, but without regard to the requirement to
provide supplemental coverage for benefits and cost-sharing
protection provided under the State child health plan under
subparagraph (E).
``(M) Satisfaction of cost-effectiveness test.--Premium
assistance subsidies for qualified employer-sponsored coverage
offered under this paragraph shall be deemed to meet the
requirement of subparagraph (A) of paragraph (3).
``(N) Coordination with medicaid.--In the case of a
targeted low-income child who receives child health assistance
through a State plan under title XIX and who voluntarily elects
to receive a premium assistance subsidy under this section, the
provisions of section 1906A shall apply and shall supersede any
other provisions of this paragraph that are inconsistent with
such section.''.
(2) Determination of cost-effectiveness for premium assistance
or purchase of family coverage.--
(A) In general.--Section 2105(c)(3)(A) (42 U.S.C.
1397ee(c)(3)(A)) is amended by striking ``relative to'' and all
that follows through the comma and inserting ``relative to
``(i) the amount of expenditures under the State child
health plan, including administrative expenditures, that
the State would have made to provide comparable coverage of
the targeted low-income child involved or the family
involved (as applicable); or
``(ii) the aggregate amount of expenditures that the
State would have made under the State child health plan,
including administrative expenditures, for providing
coverage under such plan for all such children or
families.''.
(B) Nonapplication to previously approved coverage.--The
amendment made by subparagraph (A) shall not apply to coverage
the purchase of which has been approved by the Secretary under
section 2105(c)(3) of the Social Security Act prior to the date
of enactment of this Act.
(b) Medicaid.--Title XIX is amended by inserting after section 1906
the following new section:
``premium assistance option for children
``Sec. 1906A.  (a) In General.--A State may elect to offer a
premium assistance subsidy (as defined in subsection (c)) for qualified
employer-sponsored coverage (as defined in subsection (b)) to all
individuals under age 19 who are entitled to medical assistance under
this title (and to the parent of such an individual) who have access to
such coverage if the State meets the requirements of this section.
``(b) Qualified Employer-Sponsored Coverage.--
``(1) In general.--Subject to paragraph (2)), in this
paragraph, the term `qualified employer-sponsored coverage' means a
group health plan or health insurance coverage offered through an
employer--
``(A) that qualifies as creditable coverage as a group
health plan under section 2701(c)(1) of the Public Health
Service Act;
``(B) for which the employer contribution toward any
premium for such coverage is at least 40 percent; and
``(C) that is offered to all individuals in a manner that
would be considered a nondiscriminatory eligibility
classification for purposes of paragraph (3)(A)(ii) of section
105(h) of the Internal Revenue Code of 1986 (but determined
without regard to clause (i) of subparagraph (B) of such
paragraph).
``(2) Exception.--Such term does not include coverage
consisting of--
``(A) benefits provided under a health flexible spending
arrangement (as defined in section 106(c)(2) of the Internal
Revenue Code of 1986); or
``(B) a high deductible health plan (as defined in section
223(c)(2) of such Code), without regard to whether the plan is
purchased in conjunction with a health savings account (as
defined under section 223(d) of such Code).
``(3) Treatment as third party liability.--The State shall
treat the coverage provided under qualified employer-sponsored
coverage as a third party liability under section 1902(a)(25).
``(c) Premium Assistance Subsidy.--In this section, the term
`premium assistance subsidy' means the amount of the employee
contribution for enrollment in the qualified employer-sponsored
coverage by the individual under age 19 or by the individual's family.
Premium assistance subsidies under this section shall be considered,
for purposes of section 1903(a), to be a payment for medical
assistance.
``(d) Voluntary Participation.--
``(1) Employers.--Participation by an employer in a premium
assistance subsidy offered by a State under this section shall be
voluntary. An employer may notify a State that it elects to opt-out
of being directly paid a premium assistance subsidy on behalf of an
employee.
``(2) Beneficiaries.--No subsidy shall be provided to an
individual under age 19 under this section unless the individual
(or the individual's parent) voluntarily elects to receive such a
subsidy. A State may not require such an election as a condition of
receipt of medical assistance. State may not require, as a
condition of an individual under age 19 (or the individual's
parent) being or remaining eligible for medical assistance under
this title, apply for enrollment in qualified employer-sponsored
coverage under this section.
``(3) Opt-out permitted for any month.--A State shall establish
a process for permitting the parent of an individual under age 19
receiving a premium assistance subsidy to disenroll the individual
from the qualified employer-sponsored coverage.
``(e) Requirement To Pay Premiums and Cost-Sharing and Provide
Supplemental Coverage.--In the case of the participation of an
individual under age 19 (or the individual's parent) in a premium
assistance subsidy under this section for qualified employer-sponsored
coverage, the State shall provide for payment of all enrollee premiums
for enrollment in such coverage and all deductibles, coinsurance, and
other cost-sharing obligations for items and services otherwise covered
under the State plan under this title (exceeding the amount otherwise
permitted under section 1916 or, if applicable, section 1916A). The
fact that an individual under age 19 (or a parent) elects to enroll in
qualified employer-sponsored coverage under this section shall not
change the individual's (or parent's) eligibility for medical
assistance under the State plan, except insofar as section 1902(a)(25)
provides that payments for such assistance shall first be made under
such coverage.''.
(c) GAO Study and Report.--Not later than January 1, 2010, the
Comptroller General of the United States shall study cost and coverage
issues relating to any State premium assistance programs for which
Federal matching payments are made under title XIX or XXI of the Social
Security Act, including under waiver authority, and shall submit a
report to the Committee on Finance of the Senate and the Committee on
Energy and Commerce of the House of Representatives on the results of
such study.

c9342c6edbdff5718840501850927ceeaac153fd6141c71f0afe9a4855813fa8

(a) Requirement To Include Description of Outreach, Education, and
Enrollment Efforts Related to Premium Assistance Subsidies in State
Child Health Plan.--Section 2102(c) (42 U.S.C. 1397bb(c)) is amended by
adding at the end the following new paragraph:
``(3) Premium assistance subsidies.--In the case of a State
that provides for premium assistance subsidies under the State
child health plan in accordance with paragraph (2)(B), (3), or (10)
of section 2105(c), or a waiver approved under section 1115,
outreach, education, and enrollment assistance for families of
children likely to be eligible for such subsidies, to inform such
families of the availability of, and to assist them in enrolling
their children in, such subsidies, and for employers likely to
provide coverage that is eligible for such subsidies, including the
specific, significant resources the State intends to apply to
educate employers about the availability of premium assistance
subsidies under the State child health plan.''.
(b) Nonapplication of 10 Percent Limit on Outreach and Certain
Other Expenditures.--Section 2105(c)(2)(C) (42 U.S.C. 1397ee(c)(2)(C)),
as amended by section 211(c)(2), is amended by adding at the end the
following new clause:
``(iii) Expenditures for outreach to increase the
enrollment of children under this title and title xix
through premium assistance subsidies.--Expenditures for
outreach activities to families of children likely to be
eligible for premium assistance subsidies in accordance
with paragraph (2)(B), (3), or (10), or a waiver approved
under section 1115, to inform such families of the
availability of, and to assist them in enrolling their
children in, such subsidies, and to employers likely to
provide qualified employer-sponsored coverage (as defined
in subparagraph (B) of such paragraph), but not to exceed
an amount equal to 1.25 percent of the maximum amount
permitted to be expended under subparagraph (A) for items
described in subsection (a)(1)(D).''.
Subtitle B--Coordinating Premium Assistance With Private Coverage

d64e50892c35be880096861f7a7cc7d42c1b58530d63b5e4e7f967275aca4641

e5a622a2233cdc941b8c6e5331b10ff15b569b4722a5c3de7ccdf336c9194b4d

f62214799fac3f0148ac8f7d89faa9ebaab179c0d2a9350872780e0499afee65

ENROLLMENT OF CHILDREN IN CHIP AND MEDICAID.
(a) Inclusion of Process and Access Measures in Annual State
Reports.--Section 2108 (42 U.S.C. 1397hh) is amended--
(1) in subsection (a), in the matter preceding paragraph (1),
by striking ``The State'' and inserting ``Subject to subsection
(e), the State''; and
(2) by adding at the end the following new subsection:
``(e) Information Required for Inclusion in State Annual Report.--
The State shall include the following information in the annual report
required under subsection (a):
``(1) Eligibility criteria, enrollment, and retention data
(including data with respect to continuity of coverage or duration
of benefits).
``(2) Data regarding the extent to which the State uses process
measures with respect to determining the eligibility of children
under the State child health plan, including measures such as 12-
month continuous eligibility, self-declaration of income for
applications or renewals, or presumptive eligibility.
``(3) Data regarding denials of eligibility and
redeterminations of eligibility.
``(4) Data regarding access to primary and specialty services,
access to networks of care, and care coordination provided under
the State child health plan, using quality care and consumer
satisfaction measures included in the Consumer Assessment of
Healthcare Providers and Systems (CAHPS) survey.
``(5) If the State provides child health assistance in the form
of premium assistance for the purchase of coverage under a group
health plan, data regarding the provision of such assistance,
including the extent to which employer-sponsored health insurance
coverage is available for children eligible for child health
assistance under the State child health plan, the range of the
monthly amount of such assistance provided on behalf of a child or
family, the number of children or families provided such assistance
on a monthly basis, the income of the children or families provided
such assistance, the benefits and cost-sharing protection provided
under the State child health plan to supplement the coverage
purchased with such premium assistance, the effective strategies
the State engages in to reduce any administrative barriers to the
provision of such assistance, and, the effects, if any, of the
provision of such assistance on preventing the coverage provided
under the State child health plan from substituting for coverage
provided under employer-sponsored health insurance offered in the
State.
``(6) To the extent applicable, a description of any State
activities that are designed to reduce the number of uncovered
children in the State, including through a State health insurance
connector program or support for innovative private health coverage
initiatives.''.
(b) Standardized Reporting Format.--
(1) In general.--Not later than 1 year after the date of
enactment of this Act, the Secretary shall specify a standardized
format for States to use for reporting the information required
under section 2108(e) of the Social Security Act, as added by
subsection (a)(2).
(2) Transition period for states.--Each State that is required
to submit a report under subsection (a) of section 2108 of the
Social Security Act that includes the information required under
subsection (e) of such section may use up to 3 reporting periods to
transition to the reporting of such information in accordance with
the standardized format specified by the Secretary under paragraph
(1).
(c) Additional Funding for the Secretary To Improve Timeliness of
Data Reporting and Analysis for Purposes of Determining Enrollment
Increases Under Medicaid and CHIP.--
(1) Appropriation.--There is appropriated, out of any money in
the Treasury not otherwise appropriated, $5,000,000 to the
Secretary for fiscal year 2009 for the purpose of improving the
timeliness of the data reported and analyzed from the Medicaid
Statistical Information System (MSIS) for purposes of providing
more timely data on enrollment and eligibility of children under
Medicaid and CHIP and to provide guidance to States with respect to
any new reporting requirements related to such improvements.
Amounts appropriated under this paragraph shall remain available
until expended.
(2) Requirements.--The improvements made by the Secretary under
paragraph (1) shall be designed and implemented (including with
respect to any necessary guidance for States to report such
information in a complete and expeditious manner) so that,
beginning no later than October 1, 2009, data regarding the
enrollment of low-income children (as defined in section 2110(c)(4)
of the Social Security Act (42 U.S.C. 1397jj(c)(4)) of a State
enrolled in the State plan under Medicaid or the State child health
plan under CHIP with respect to a fiscal year shall be collected
and analyzed by the Secretary within 6 months of submission.
(d) GAO Study and Report on Access to Primary and Speciality
Services.--
(1) In general.--The Comptroller General of the United States
shall conduct a study of children's access to primary and specialty
services under Medicaid and CHIP, including--
(A) the extent to which providers are willing to treat
children eligible for such programs;
(B) information on such children's access to networks of
care;
(C) geographic availability of primary and specialty
services under such programs;
(D) the extent to which care coordination is provided for
children's care under Medicaid and CHIP; and
(E) as appropriate, information on the degree of
availability of services for children under such programs.
(2) Report.--Not later than 2 years after the date of enactment
of this Act, the Comptroller General shall submit a report to the
Committee on Finance of the Senate and the Committee on Energy and
Commerce of the House of Representatives on the study conducted
under paragraph (1) that includes recommendations for such Federal
and State legislative and administrative changes as the Comptroller
General determines are necessary to address any barriers to access
to children's care under Medicaid and CHIP that may exist.

1f7f3ab77ad6fb8913bfb7de5703e63058db0a589509068481e4f29dde496eed

CHIP.
(a) In General.--Section 2103(f) of Social Security Act (42 U.S.C.
1397bb(f)) is amended by adding at the end the following new paragraph:
``(3) Compliance with managed care requirements.--The State
child health plan shall provide for the application of subsections
(a)(4), (a)(5), (b), (c), (d), and (e) of section 1932 (relating to
requirements for managed care) to coverage, State agencies,
enrollment brokers, managed care entities, and managed care
organizations under this title in the same manner as such
subsections apply to coverage and such entities and organizations
under title XIX.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to contract years for health plans beginning on or after July 1,
2009.

db11caeecaf7ae5047bfdf12af54f29e699408a51a1bb02a6da43ad59e2dea82

(a) Coverage.--
(1) In general.--Section 2103 (42 U.S.C. 1397cc) is amended--
(A) in subsection (a)--
(i) in the matter before paragraph (1), by striking
``subsection (c)(5)'' and inserting ``paragraphs (5) and
(7) of subsection (c)''; and
(ii) in paragraph (1), by inserting ``at least'' after
``that is''; and
(B) in subsection (c)--
(i) by redesignating paragraph (5) as paragraph (7);
and
(ii) by inserting after paragraph (4), the following:
``(5) Dental benefits.--
``(A) In general.--The child health assistance provided to
a targeted low-income child shall include coverage of dental
services necessary to prevent disease and promote oral health,
restore oral structures to health and function, and treat
emergency conditions.
``(B) Permitting use of dental benchmark plans by certain
states.--A State may elect to meet the requirement of
subparagraph (A) through dental coverage that is equivalent to
a benchmark dental benefit package described in subparagraph
(C).
``(C) Benchmark dental benefit packages.--The benchmark
dental benefit packages are as follows:
``(i) FEHBP children's dental coverage.--A dental
benefits plan under chapter 89A of title 5, United States
Code, that has been selected most frequently by employees
seeking dependent coverage, among such plans that provide
such dependent coverage, in either of the previous 2 plan
years.
``(ii) State employee dependent dental coverage.--A
dental benefits plan that is offered and generally
available to State employees in the State involved and that
has been selected most frequently by employees seeking
dependent coverage, among such plans that provide such
dependent coverage, in either of the previous 2 plan years.
``(iii) Coverage offered through commercial dental
plan.--A dental benefits plan that has the largest insured
commercial, non-medicaid enrollment of dependent covered
lives of such plans that is offered in the State
involved.''.
(2) Assuring access to care.--Section 2102(a)(7)(B) (42 U.S.C.
1397bb(c)(2)) is amended by inserting ``and services described in
section 2103(c)(5)'' after ``emergency services''.
(3) Effective date.--The amendments made by paragraphs (1) and
(2) shall apply to coverage of items and services furnished on or
after October 1, 2009.
(b) State Option To Provide Dental-Only Supplemental Coverage.--
(1) In general.--Section 2110(b) (42 U.S.C. 1397jj(b)) is
amended--
(A) in paragraph (1)(C), by inserting ``, subject to
paragraph (5),'' after ``under title XIX or''; and
(B) by adding at the end the following new paragraph:
``(5) Option for states with a separate chip program to provide
dental-only supplemental coverage.--
``(A) In general.--Subject to subparagraphs (B) and (C), in
the case of any child who is enrolled in a group health plan or
health insurance coverage offered through an employer who
would, but for the application of paragraph (1)(C), satisfy the
requirements for being a targeted low-income child under a
State child health plan that is implemented under this title, a
State may waive the application of such paragraph to the child
in order to provide--
``(i) dental coverage consistent with the requirements
of subsection (c)(5) of section 2103; or
``(ii) cost-sharing protection for dental coverage
consistent with such requirements and the requirements of
subsection (e)(3)(B) of such section.
``(B) Limitation.--A State may limit the application of a
waiver of paragraph (1)(C) to children whose family income does
not exceed a level specified by the State, so long as the level
so specified does not exceed the maximum income level otherwise
established for other children under the State child health
plan.
``(C) Conditions.--A State may not offer dental-only
supplemental coverage under this paragraph unless the State
satisfies the following conditions:
``(i) Income eligibility.--The State child health plan
under this title--
``(I) has the highest income eligibility standard
permitted under this title (or a waiver) as of January
1, 2009;
``(II) does not limit the acceptance of
applications for children or impose any numerical
limitation, waiting list, or similar limitation on the
eligibility of such children for child health
assistance under such State plan; and
``(III) provides benefits to all children in the
State who apply for and meet eligibility standards.
``(ii) No more favorable treatment.--The State child
health plan may not provide more favorable dental coverage
or cost-sharing protection for dental coverage to children
provided dental-only supplemental coverage under this
paragraph than the dental coverage and cost-sharing
protection for dental coverage provided to targeted low-
income children who are eligible for the full range of
child health assistance provided under the State child
health plan.''.
(2) State option to waive waiting period.--Section
2102(b)(1)(B) (42 U.S.C. 1397bb(b)(1)(B)), as amended by section
111(b)(2), is amended--
(A) in clause (ii), by striking ``and'' at the end;
(B) in clause (iii), by striking the period and inserting
``; and''; and
(C) by adding at the end the following new clause:
``(iv) at State option, may not apply a waiting period
in the case of a child provided dental-only supplemental
coverage under section 2110(b)(5).''.
(c) Dental Education for Parents of Newborns.--The Secretary shall
develop and implement, through entities that fund or provide perinatal
care services to targeted low-income children under a State child
health plan under title XXI of the Social Security Act, a program to
deliver oral health educational materials that inform new parents about
risks for, and prevention of, early childhood caries and the need for a
dental visit within their newborn's first year of life.
(d) Provision of Dental Services Through FQHCs.--
(1) Medicaid.--Section 1902(a) (42 U.S.C. 1396a(a)) is
amended--
(A) by striking ``and'' at the end of paragraph (70);
(B) by striking the period at the end of paragraph (71) and
inserting ``; and''; and
(C) by inserting after paragraph (71) the following new
paragraph:
``(72) provide that the State will not prevent a Federally-
qualified health center from entering into contractual
relationships with private practice dental providers in the
provision of Federally-qualified health center services.''.
(2) CHIP.--Section 2107(e)(1) (42 U.S.C. 1397g(e)(1)), as
amended by subsections (a)(2) and (d)(2) of section 203, is amended
by inserting after subparagraph (B) the following new subparagraph
(and redesignating the succeeding subparagraphs accordingly):
``(C) Section 1902(a)(72) (relating to limiting FQHC
contracting for provision of dental services).''.
(3) Effective date.--The amendments made by this subsection
shall take effect on January 1, 2009.
(e) Reporting Information on Dental Health.--
(1) Medicaid.--Section 1902(a)(43)(D)(iii) (42 U.S.C.
1396a(a)(43)(D)(iii)) is amended by inserting ``and other
information relating to the provision of dental services to such
children described in section 2108(e)'' after ``receiving dental
services,''.
(2) CHIP.--Section 2108 (42 U.S.C. 1397hh) is amended by adding
at the end the following new subsection:
``(e) Information on Dental Care for Children.--
``(1) In general.--Each annual report under subsection (a)
shall include the following information with respect to care and
services described in section 1905(r)(3) provided to targeted low-
income children enrolled in the State child health plan under this
title at any time during the year involved:
``(A) The number of enrolled children by age grouping used
for reporting purposes under section 1902(a)(43).
``(B) For children within each such age grouping,
information of the type contained in questions 12(a)-(c) of CMS
Form 416 (that consists of the number of enrolled targeted low
income children who receive any, preventive, or restorative
dental care under the State plan).
``(C) For the age grouping that includes children 8 years
of age, the number of such children who have received a
protective sealant on at least one permanent molar tooth.
``(2) Inclusion of information on enrollees in managed care
plans.--The information under paragraph (1) shall include
information on children who are enrolled in managed care plans and
other private health plans and contracts with such plans under this
title shall provide for the reporting of such information by such
plans to the State.''.
(3) Effective date.--The amendments made by this subsection
shall be effective for annual reports submitted for years beginning
after date of enactment.
(f) Improved Accessibility of Dental Provider Information to
Enrollees Under Medicaid and CHIP.--The Secretary shall--
(1) work with States, pediatric dentists, and other dental
providers (including providers that are, or are affiliated with, a
school of dentistry) to include, not later than 6 months after the
date of the enactment of this Act, on the Insure Kids Now website
(http://www.insurekidsnow.gov/) and hotline (1-877-KIDS-NOW) (or on
any successor websites or hotlines) a current and accurate list of
all such dentists and providers within each State that provide
dental services to children enrolled in the State plan (or waiver)
under Medicaid or the State child health plan (or waiver) under
CHIP, and shall ensure that such list is updated at least
quarterly; and
(2) work with States to include, not later than 6 months after
the date of the enactment of this Act, a description of the dental
services provided under each State plan (or waiver) under Medicaid
and each State child health plan (or waiver) under CHIP on such
Insure Kids Now website, and shall ensure that such list is updated
at least annually.
(g) Inclusion of Status of Efforts To Improve Dental Care in
Reports on the Quality of Children's Health Care Under Medicaid and
CHIP.--Section 1139A(a), as added by section 401(a), is amended--
(1) in paragraph (3)(B)(ii), by inserting ``and, with respect
to dental care, conditions requiring the restoration of teeth,
relief of pain and infection, and maintenance of dental health''
after ``chronic conditions''; and
(2) in paragraph (6)(A)(ii), by inserting ``dental care,''
after ``preventive health services,''.
(h) GAO Study and Report.--
(1) Study.--The Comptroller General of the United States shall
provide for a study that examines--
(A) access to dental services by children in underserved
areas;
(B) children's access to oral health care, including
preventive and restorative services, under Medicaid and CHIP,
including--
(i) the extent to which dental providers are willing to
treat children eligible for such programs;
(ii) information on such children's access to networks
of care, including such networks that serve special needs
children; and
(iii) geographic availability of oral health care,
including preventive and restorative services, under such
programs; and
(C) the feasibility and appropriateness of using qualified
mid-level dental health providers, in coordination with
dentists, to improve access for children to oral health
services and public health overall.
(2) Report.--Not later than 18 months year after the date of
the enactment of this Act, the Comptroller General shall submit to
Congress a report on the study conducted under paragraph (1). The
report shall include recommendations for such Federal and State
legislative and administrative changes as the Comptroller General
determines are necessary to address any barriers to access to oral
health care, including preventive and restorative services, under
Medicaid and CHIP that may exist.

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(a) Assurance of Parity.--Section 2103(c) (42 U.S.C. 1397cc(c)), as
amended by section 501(a)(1)(B), is amended by inserting after
paragraph (5), the following:
``(6) Mental health services parity.--
``(A) In general.--In the case of a State child health plan
that provides both medical and surgical benefits and mental
health or substance use disorder benefits, such plan shall
ensure that the financial requirements and treatment
limitations applicable to such mental health or substance use
disorder benefits comply with the requirements of section
2705(a) of the Public Health Service Act in the same manner as
such requirements apply to a group health plan.
``(B) Deemed compliance.--To the extent that a State child
health plan includes coverage with respect to an individual
described in section 1905(a)(4)(B) and covered under the State
plan under section 1902(a)(10)(A) of the services described in
section 1905(a)(4)(B) (relating to early and periodic
screening, diagnostic, and treatment services defined in
section 1905(r)) and provided in accordance with section
1902(a)(43), such plan shall be deemed to satisfy the
requirements of subparagraph (A).''.
(b) Conforming Amendments.--Section 2103 (42 U.S.C. 1397cc) is
amended--
(1) in subsection (a), as amended by section 501(a)(1)(A)(i),
in the matter preceding paragraph (1), by inserting ``, (6),''
after ``(5)''; and
(2) in subsection (c)(2), by striking subparagraph (B) and
redesignating subparagraphs (C) and (D) as subparagraphs (B) and
(C), respectively.

23229568fad20486d428c3435d10d68b15224bda27e9275f16c209d5c126604b

PROVIDED BY FEDERALLY-QUALIFIED HEALTH CENTERS AND RURAL HEALTH
CLINICS.
(a) Application of Prospective Payment System.--
(1) In general.--Section 2107(e)(1) (42 U.S.C. 1397gg(e)(1)),
as amended by section 501(c)(2) is amended by inserting after
subparagraph (C) the following new subparagraph (and redesignating
the succeeding subparagraphs accordingly):
``(D) Section 1902(bb) (relating to payment for services
provided by Federally-qualified health centers and rural health
clinics).''.
(2) Effective date.--The amendment made by paragraph (1) shall
apply to services provided on or after October 1, 2009.
(b) Transition Grants.--
(1) Appropriation.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to the Secretary for
fiscal year 2009, $5,000,000, to remain available until expended,
for the purpose of awarding grants to States with State child
health plans under CHIP that are operated separately from the State
Medicaid plan under title XIX of the Social Security Act (including
any waiver of such plan), or in combination with the State Medicaid
plan, for expenditures related to transitioning to compliance with
the requirement of section 2107(e)(1)(D) of the Social Security Act
(as added by subsection (a)) to apply the prospective payment
system established under section 1902(bb) of the such Act (42
U.S.C. 1396a(bb)) to services provided by Federally-qualified
health centers and rural health clinics.
(2) Monitoring and report.--The Secretary shall monitor the
impact of the application of such prospective payment system on the
States described in paragraph (1) and, not later than October 1,
2011, shall report to Congress on any effect on access to benefits,
provider payment rates, or scope of benefits offered by such States
as a result of the application of such payment system.

f4bd59fe6b10af88d3b189c07d93fad2a8d590c22b4cbe9e706529e1176c9f3e

(a) In General.--Section 2103(e)(3) (42 U.S.C. 1397cc(e)(3)) is
amended by adding at the end the following new subparagraph:
``(C) Premium grace period.--The State child health plan--
``(i) shall afford individuals enrolled under the plan
a grace period of at least 30 days from the beginning of a
new coverage period to make premium payments before the
individual's coverage under the plan may be terminated; and
``(ii) shall provide to such an individual, not later
than 7 days after the first day of such grace period,
notice--
``(I) that failure to make a premium payment within
the grace period will result in termination of coverage
under the State child health plan; and
``(II) of the individual's right to challenge the
proposed termination pursuant to the applicable Federal
regulations.
For purposes of clause (i), the term `new coverage period'
means the month immediately following the last month for which
the premium has been paid.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to new coverage periods beginning on or after the date of the
enactment of this Act.

40541643d0933f2cd35b6d371b73a058c092f9437588e3f89971ed53cbf25069

SCHOOL-BASED HEALTH CENTERS.
(a) In General.--Section 2103(c) (42 U.S.C. 1397cc(c)), as amended
by section 501(a)(1)(B), is amended by adding at the end the following
new paragraph:
``(8) Availability of coverage for items and services furnished
through school-based health centers.--Nothing in this title shall
be construed as limiting a State's ability to provide child health
assistance for covered items and services that are furnished
through school-based health centers (as defined in section
2110(c)(9)).''.
(b) Definition.--Section 2110(c) (42 U.S.C. 1397jj) is amended by
adding at the end the following:
``(9) School-based health center.--
``(A) In general.--The term `school-based health center'
means a health clinic that--
``(i) is located in or near a school facility of a
school district or board or of an Indian tribe or tribal
organization;
``(ii) is organized through school, community, and
health provider relationships;
``(iii) is administered by a sponsoring facility;
``(iv) provides through health professionals primary
health services to children in accordance with State and
local law, including laws relating to licensure and
certification; and
``(v) satisfies such other requirements as a State may
establish for the operation of such a clinic.
``(B) Sponsoring facility.--For purposes of subparagraph
(A)(iii), the term `sponsoring facility' includes any of the
following:
``(i) A hospital.
``(ii) A public health department.
``(iii) A community health center.
``(iv) A nonprofit health care agency.
``(v) A school or school system.
``(vi) A program administered by the Indian Health
Service or the Bureau of Indian Affairs or operated by an
Indian tribe or a tribal organization.''.

2441189a64f6cba37347dda1551d05ac59cca9063be3ce3c198ecec1b252a0ba

(a) In General.--Title XIX (42 U.S.C. 1396 et seq.) is amended by
inserting before section 1901 the following new section:
``medicaid and chip payment and access commission
``Sec. 1900.  (a) Establishment.--There is hereby established the
Medicaid and CHIP Payment and Access Commission (in this section
referred to as `MACPAC').
``(b) Duties.--
``(1) Review of access policies and annual reports.--MACPAC
shall--
``(A) review policies of the Medicaid program established
under this title (in this section referred to as `Medicaid')
and the State Children's Health Insurance Program established
under title XXI (in this section referred to as `CHIP')
affecting children's access to covered items and services,
including topics described in paragraph (2);
``(B) make recommendations to Congress concerning such
access policies;
``(C) by not later than March 1 of each year (beginning
with 2010), submit a report to Congress containing the results
of such reviews and MACPAC's recommendations concerning such
policies; and
``(D) by not later than June 1 of each year (beginning with
2010), submit a report to Congress containing an examination of
issues affecting Medicaid and CHIP, including the implications
of changes in health care delivery in the United States and in
the market for health care services on such programs.
``(2) Specific topics to be reviewed.--Specifically, MACPAC
shall review and assess the following:
``(A) Medicaid and chip payment policies.--Payment policies
under Medicaid and CHIP, including--
``(i) the factors affecting expenditures for items and
services in different sectors, including the process for
updating hospital, skilled nursing facility, physician,
Federally-qualified health center, rural health center, and
other fees;
``(ii) payment methodologies; and
``(iii) the relationship of such factors and
methodologies to access and quality of care for Medicaid
and CHIP beneficiaries.
``(B) Interaction of medicaid and chip payment policies
with health care delivery generally.--The effect of Medicaid
and CHIP payment policies on access to items and services for
children and other Medicaid and CHIP populations other than
under this title or title XXI and the implications of changes
in health care delivery in the United States and in the general
market for health care items and services on Medicaid and CHIP.
``(C) Other access policies.--The effect of other Medicaid
and CHIP policies on access to covered items and services,
including policies relating to transportation and language
barriers.
``(3) Creation of early-warning system.--MACPAC shall create an
early-warning system to identify provider shortage areas or any
other problems that threaten access to care or the health care
status of Medicaid and CHIP beneficiaries.
``(4) Comments on certain secretarial reports.--If the
Secretary submits to Congress (or a committee of Congress) a report
that is required by law and that relates to access policies,
including with respect to payment policies, under Medicaid or CHIP,
the Secretary shall transmit a copy of the report to MACPAC. MACPAC
shall review the report and, not later than 6 months after the date
of submittal of the Secretary's report to Congress, shall submit to
the appropriate committees of Congress written comments on such
report. Such comments may include such recommendations as MACPAC
deems appropriate.
``(5) Agenda and additional reviews.--MACPAC shall consult
periodically with the chairmen and ranking minority members of the
appropriate committees of Congress regarding MACPAC's agenda and
progress towards achieving the agenda. MACPAC may conduct
additional reviews, and submit additional reports to the
appropriate committees of Congress, from time to time on such
topics relating to the program under this title or title XXI as may
be requested by such chairmen and members and as MACPAC deems
appropriate.
``(6) Availability of reports.--MACPAC shall transmit to the
Secretary a copy of each report submitted under this subsection and
shall make such reports available to the public.
``(7) Appropriate committee of congress.--For purposes of this
section, the term `appropriate committees of Congress' means the
Committee on Energy and Commerce of the House of Representatives
and the Committee on Finance of the Senate.
``(8) Voting and reporting requirements.--With respect to each
recommendation contained in a report submitted under paragraph (1),
each member of MACPAC shall vote on the recommendation, and MACPAC
shall include, by member, the results of that vote in the report
containing the recommendation.
``(9) Examination of budget consequences.--Before making any
recommendations, MACPAC shall examine the budget consequences of
such recommendations, directly or through consultation with
appropriate expert entities.
``(c) Membership.--
``(1) Number and appointment.--MACPAC shall be composed of 17
members appointed by the Comptroller General of the United States.
``(2) Qualifications.--
``(A) In general.--The membership of MACPAC shall include
individuals who have had direct experience as enrollees or
parents of enrollees in Medicaid or CHIP and individuals with
national recognition for their expertise in Federal safety net
health programs, health finance and economics, actuarial
science, health facility management, health plans and
integrated delivery systems, reimbursement of health
facilities, health information technology, pediatric
physicians, dentists, and other providers of health services,
and other related fields, who provide a mix of different
professionals, broad geographic representation, and a balance
between urban and rural representatives.
``(B) Inclusion.--The membership of MACPAC shall include
(but not be limited to) physicians and other health
professionals, employers, third-party payers, and individuals
with expertise in the delivery of health services. Such
membership shall also include consumers representing children,
pregnant women, the elderly, and individuals with disabilities,
current or former representatives of State agencies responsible
for administering Medicaid, and current or former
representatives of State agencies responsible for administering
CHIP.
``(C) Majority nonproviders.--Individuals who are directly
involved in the provision, or management of the delivery, of
items and services covered under Medicaid or CHIP shall not
constitute a majority of the membership of MACPAC.
``(D) Ethical disclosure.--The Comptroller General of the
United States shall establish a system for public disclosure by
members of MACPAC of financial and other potential conflicts of
interest relating to such members. Members of MACPAC shall be
treated as employees of Congress for purposes of applying title
I of the Ethics in Government Act of 1978 (Public Law 95-521).
``(3) Terms.--
``(A) In general.--The terms of members of MACPAC shall be
for 3 years except that the Comptroller General of the United
States shall designate staggered terms for the members first
appointed.
``(B) Vacancies.--Any member appointed to fill a vacancy
occurring before the expiration of the term for which the
member's predecessor was appointed shall be appointed only for
the remainder of that term. A member may serve after the
expiration of that member's term until a successor has taken
office. A vacancy in MACPAC shall be filled in the manner in
which the original appointment was made.
``(4) Compensation.--While serving on the business of MACPAC
(including travel time), a member of MACPAC shall be entitled to
compensation at the per diem equivalent of the rate provided for
level IV of the Executive Schedule under section 5315 of title 5,
United States Code; and while so serving away from home and the
member's regular place of business, a member may be allowed travel
expenses, as authorized by the Chairman of MACPAC. Physicians
serving as personnel of MACPAC may be provided a physician
comparability allowance by MACPAC in the same manner as Government
physicians may be provided such an allowance by an agency under
section 5948 of title 5, United States Code, and for such purpose
subsection (i) of such section shall apply to MACPAC in the same
manner as it applies to the Tennessee Valley Authority. For
purposes of pay (other than pay of members of MACPAC) and
employment benefits, rights, and privileges, all personnel of
MACPAC shall be treated as if they were employees of the United
States Senate.
``(5) Chairman; vice chairman.--The Comptroller General of the
United States shall designate a member of MACPAC, at the time of
appointment of the member as Chairman and a member as Vice Chairman
for that term of appointment, except that in the case of vacancy of
the Chairmanship or Vice Chairmanship, the Comptroller General of
the United States may designate another member for the remainder of
that member's term.
``(6) Meetings.--MACPAC shall meet at the call of the Chairman.
``(d) Director and Staff; Experts and Consultants.--Subject to such
review as the Comptroller General of the United States deems necessary
to assure the efficient administration of MACPAC, MACPAC may--
``(1) employ and fix the compensation of an Executive Director
(subject to the approval of the Comptroller General of the United
States) and such other personnel as may be necessary to carry out
its duties (without regard to the provisions of title 5, United
States Code, governing appointments in the competitive service);
``(2) seek such assistance and support as may be required in
the performance of its duties from appropriate Federal departments
and agencies;
``(3) enter into contracts or make other arrangements, as may
be necessary for the conduct of the work of MACPAC (without regard
to section 3709 of the Revised Statutes (41 U.S.C. 5));
``(4) make advance, progress, and other payments which relate
to the work of MACPAC;
``(5) provide transportation and subsistence for persons
serving without compensation; and
``(6) prescribe such rules and regulations as it deems
necessary with respect to the internal organization and operation
of MACPAC.
``(e) Powers.--
``(1) Obtaining official data.--MACPAC may secure directly from
any department or agency of the United States information necessary
to enable it to carry out this section. Upon request of the
Chairman, the head of that department or agency shall furnish that
information to MACPAC on an agreed upon schedule.
``(2) Data collection.--In order to carry out its functions,
MACPAC shall--
``(A) utilize existing information, both published and
unpublished, where possible, collected and assessed either by
its own staff or under other arrangements made in accordance
with this section;
``(B) carry out, or award grants or contracts for, original
research and experimentation, where existing information is
inadequate; and
``(C) adopt procedures allowing any interested party to
submit information for MACPAC's use in making reports and
recommendations.
``(3) Access of gao to information.--The Comptroller General of
the United States shall have unrestricted access to all
deliberations, records, and nonproprietary data of MACPAC,
immediately upon request.
``(4) Periodic audit.--MACPAC shall be subject to periodic
audit by the Comptroller General of the United States.
``(f) Authorization of Appropriations.--
``(1) Request for appropriations.--MACPAC shall submit requests
for appropriations in the same manner as the Comptroller General of
the United States submits requests for appropriations, but amounts
appropriated for MACPAC shall be separate from amounts appropriated
for the Comptroller General of the United States.
``(2) Authorization.--There are authorized to be appropriated
such sums as may be necessary to carry out the provisions of this
section.''.
(b) Deadline for Initial Appointments.--Not later than January 1,
2010, the Comptroller General of the United States shall appoint the
initial members of the Medicaid and CHIP Payment and Access Commission
established under section 1900 of the Social Security Act (as added by
subsection (a)).
(c) Annual Report on Medicaid.--Not later than January 1, 2010, and
annually thereafter, the Secretary, in consultation with the Secretary
of the Treasury, the Secretary of Labor, and the States (as defined for
purposes of Medicaid), shall submit an annual report to Congress on the
financial status of, enrollment in, and spending trends for, Medicaid
for the fiscal year ending on September 30 of the preceding year.
Subtitle A--Program Integrity and Data Collection

c9f03f22e66f0e8eae5f19b10832bed8c21e3db40ce2341dd2cdbb7a62b56325

(a) Expenditures Related to Compliance With Requirements.--
(1) Enhanced payments.--Section 2105(c) (42 U.S.C. 1397ee(c)),
as amended by section 301(a), is amended by adding at the end the
following new paragraph:
``(11) Enhanced payments.--Notwithstanding subsection (b), the
enhanced FMAP with respect to payments under subsection (a) for
expenditures related to the administration of the payment error
rate measurement (PERM) requirements applicable to the State child
health plan in accordance with the Improper Payments Information
Act of 2002 and parts 431 and 457 of title 42, Code of Federal
Regulations (or any related or successor guidance or regulations)
shall in no event be less than 90 percent.''.
(2) Exclusion of from cap on administrative expenditures.--
Section 2105(c)(2)(C) (42 U.S.C. 1397ee(c)(2)C)), as amended by
section 302(b)), is amended by adding at the end the following:
``(iv) Payment error rate measurement (perm)
expenditures.--Expenditures related to the administration
of the payment error rate measurement (PERM) requirements
applicable to the State child health plan in accordance
with the Improper Payments Information Act of 2002 and
parts 431 and 457 of title 42, Code of Federal Regulations
(or any related or successor guidance or regulations).''.
(b) Final Rule Required To Be in Effect for All States.--
Notwithstanding parts 431 and 457 of title 42, Code of Federal
Regulations (as in effect on the date of enactment of this Act), the
Secretary shall not calculate or publish any national or State-specific
error rate based on the application of the payment error rate
measurement (in this section referred to as ``PERM'') requirements to
CHIP until after the date that is 6 months after the date on which a
new final rule (in this section referred to as the ``new final rule'')
promulgated after the date of the enactment of this Act and
implementing such requirements in accordance with the requirements of
subsection (c) is in effect for all States. Any calculation of a
national error rate or a State specific error rate after such new final
rule in effect for all States may only be inclusive of errors, as
defined in such new final rule or in guidance issued within a
reasonable time frame after the effective date for such new final rule
that includes detailed guidance for the specific methodology for error
determinations.
(c) Requirements for New Final Rule.--For purposes of subsection
(b), the requirements of this subsection are that the new final rule
implementing the PERM requirements shall--
(1) include--
(A) clearly defined criteria for errors for both States and
providers;
(B) a clearly defined process for appealing error
determinations by--
(i) review contractors; or
(ii) the agency and personnel described in section
431.974(a)(2) of title 42, Code of Federal Regulations, as
in effect on September 1, 2007, responsible for the
development, direction, implementation, and evaluation of
eligibility reviews and associated activities; and
(C) clearly defined responsibilities and deadlines for
States in implementing any corrective action plans; and
(2) provide that the payment error rate determined for a State
shall not take into account payment errors resulting from the
State's verification of an applicant's self-declaration or self-
certification of eligibility for, and the correct amount of,
medical assistance or child health assistance, if the State process
for verifying an applicant's self-declaration or self-certification
satisfies the requirements for such process applicable under
regulations promulgated by the Secretary or otherwise approved by
the Secretary.
(d) Option for Application of Data for States in First Application
Cycle Under the Interim Final Rule.--After the new final rule
implementing the PERM requirements in accordance with the requirements
of subsection (c) is in effect for all States, a State for which the
PERM requirements were first in effect under an interim final rule for
fiscal year 2007 or under a final rule for fiscal year 2008 may elect
to accept any payment error rate determined in whole or in part for the
State on the basis of data for that fiscal year or may elect to not
have any payment error rate determined on the basis of such data and,
instead, shall be treated as if fiscal year 2010 or fiscal year 2011
were the first fiscal year for which the PERM requirements apply to the
State.
(e) Harmonization of MEQC and PERM.--
(1) Reduction of redundancies.--The Secretary shall review the
Medicaid Eligibility Quality Control (in this subsection referred
to as the ``MEQC'') requirements with the PERM requirements and
coordinate consistent implementation of both sets of requirements,
while reducing redundancies.
(2) State option to apply perm data.--A State may elect, for
purposes of determining the erroneous excess payments for medical
assistance ratio applicable to the State for a fiscal year under
section 1903(u) of the Social Security Act (42 U.S.C. 1396b(u)) to
substitute data resulting from the application of the PERM
requirements to the State after the new final rule implementing
such requirements is in effect for all States for data obtained
from the application of the MEQC requirements to the State with
respect to a fiscal year.
(3) State option to apply meqc data.--For purposes of
satisfying the requirements of subpart Q of part 431 of title 42,
Code of Federal Regulations, relating to Medicaid eligibility
reviews, a State may elect to substitute data obtained through MEQC
reviews conducted in accordance with section 1903(u) of the Social
Security Act (42 U.S.C. 1396b(u)) for data required for purposes of
PERM requirements, but only if the State MEQC reviews are based on
a broad, representative sample of Medicaid applicants or enrollees
in the States.
(f) Identification of Improved State-Specific Sample Sizes.--The
Secretary shall establish State-specific sample sizes for application
of the PERM requirements with respect to State child health plans for
fiscal years beginning with the first fiscal year that begins on or
after the date on which the new final rule is in effect for all States,
on the basis of such information as the Secretary determines
appropriate. In establishing such sample sizes, the Secretary shall, to
the greatest extent practicable--
(1) minimize the administrative cost burden on States under
Medicaid and CHIP; and
(2) maintain State flexibility to manage such programs.
(g) Time for Promulgation of Final Rule.--The final rule
implementing the PERM requirements under subsection (b) shall be
promulgated not later than 6 months after the date of enactment of this
Act.

903c9e54d35e0a091f68387695d3a727fb7f47a99232352ae46ce4be50e275cf

(a) Increased Appropriation.--Section 2109(b)(2) (42 U.S.C.
1397ii(b)(2)) is amended by striking ``$10,000,000 for fiscal year
2000'' and inserting ``$20,000,000 for fiscal year 2009''.
(b) Use of Additional Funds.--Section 2109(b) (42 U.S.C.
1397ii(b)), as amended by subsection (a), is amended--
(1) by redesignating paragraph (2) as paragraph (4); and
(2) by inserting after paragraph (1), the following new
paragraphs:
``(2) Additional requirements.--In addition to making the
adjustments required to produce the data described in paragraph
(1), with respect to data collection occurring for fiscal years
beginning with fiscal year 2009, in appropriate consultation with
the Secretary of Health and Human Services, the Secretary of
Commerce shall do the following:
``(A) Make appropriate adjustments to the Current
Population Survey to develop more accurate State-specific
estimates of the number of children enrolled in health coverage
under title XIX or this title.
``(B) Make appropriate adjustments to the Current
Population Survey to improve the survey estimates used to
determine the child population growth factor under section
2104(m)(5)(B) and any other data necessary for carrying out
this title.
``(C) Include health insurance survey information in the
American Community Survey related to children.
``(D) Assess whether American Community Survey estimates,
once such survey data are first available, produce more
reliable estimates than the Current Population Survey with
respect to the purposes described in subparagraph (B).
``(E) On the basis of the assessment required under
subparagraph (D), recommend to the Secretary of Health and
Human Services whether American Community Survey estimates
should be used in lieu of, or in some combination with, Current
Population Survey estimates for the purposes described in
subparagraph (B).
``(F) Continue making the adjustments described in the last
sentence of paragraph (1) with respect to expansion of the
sample size used in State sampling units, the number of
sampling units in a State, and using an appropriate
verification element.
``(3) Authority for the secretary of health and human services
to transition to the use of all, or some combination of, acs
estimates upon recommendation of the secretary of commerce.--If, on
the basis of the assessment required under paragraph (2)(D), the
Secretary of Commerce recommends to the Secretary of Health and
Human Services that American Community Survey estimates should be
used in lieu of, or in some combination with, Current Population
Survey estimates for the purposes described in paragraph (2)(B),
the Secretary of Health and Human Services, in consultation with
the States, may provide for a period during which the Secretary may
transition from carrying out such purposes through the use of
Current Population Survey estimates to the use of American
Community Survey estimates (in lieu of, or in combination with the
Current Population Survey estimates, as recommended), provided that
any such transition is implemented in a manner that is designed to
avoid adverse impacts upon States with approved State child health
plans under this title.''.

7fd4a87a594c228fac7d1a6fc6d58314cecc8009a3099e56e6ed530d999e4183

Section 2108(c) (42 U.S.C. 1397hh(c)) is amended by striking
paragraph (5) and inserting the following:
``(5) Subsequent evaluation using updated information.--
``(A) In general.--The Secretary, directly or through
contracts or interagency agreements, shall conduct an
independent subsequent evaluation of 10 States with approved
child health plans.
``(B) Selection of states and matters included.--Paragraphs
(2) and (3) shall apply to such subsequent evaluation in the
same manner as such provisions apply to the evaluation
conducted under paragraph (1).
``(C) Submission to congress.--Not later than December 31,
2011, the Secretary shall submit to Congress the results of the
evaluation conducted under this paragraph.
``(D) Funding.--Out of any money in the Treasury of the
United States not otherwise appropriated, there are
appropriated $10,000,000 for fiscal year 2010 for the purpose
of conducting the evaluation authorized under this paragraph.
Amounts appropriated under this subparagraph shall remain
available for expenditure through fiscal year 2012.''.

8a62171222e7b2d7965866313a17626451c99ecd306f42fcc270745f821165b6

Section 2108(d) (42 U.S.C. 1397hh(d)) is amended to read as
follows:
``(d) Access to Records for IG and GAO Audits and Evaluations.--For
the purpose of evaluating and auditing the program established under
this title, or title XIX, the Secretary, the Office of Inspector
General, and the Comptroller General shall have access to any books,
accounts, records, correspondence, and other documents that are related
to the expenditure of Federal funds under this title and that are in
the possession, custody, or control of States receiving Federal funds
under this title or political subdivisions thereof, or any grantee or
contractor of such States or political subdivisions.''.

27d10d429f3c28db69dfa362b572516ae03c325f32d15e5bd9a7d5164cc0c269

UNAUTHORIZED EXPENDITURES.
Nothing in this Act allows Federal payment for individuals who are
not legal residents. Titles XI, XIX, and XXI of the Social Security Act
provide for the disallowance of Federal financial participation for
erroneous expenditures under Medicaid and under CHIP, respectively.
Subtitle B--Miscellaneous Health Provisions

2af66d22fa7e9c9dd04e2db5c269c9615194a697de379e0a7f91302da623eb43

(a) Clarification of Requirement To Provide EPSDT Services for All
Children in Benchmark Benefit Packages Under Medicaid.--Section
1937(a)(1) (42 U.S.C. 1396u-7(a)(1)), as inserted by section 6044(a) of
the Deficit Reduction Act of 2005 (Public Law 109-171, 120 Stat. 88),
is amended--
(1) in subparagraph (A)--
(A) in the matter before clause (i)--
(i) by striking ``Notwithstanding any other provision
of this title'' and inserting ``Notwithstanding section
1902(a)(1) (relating to statewideness), section
1902(a)(10)(B) (relating to comparability) and any other
provision of this title which would be directly contrary to
the authority under this section and subject to subsection
(E)''; and
(ii) by striking ``enrollment in coverage that
provides'' and inserting ``coverage that'';
(B) in clause (i), by inserting ``provides'' after ``(i)'';
and
(C) by striking clause (ii) and inserting the following:
``(ii) for any individual described in section
1905(a)(4)(B) who is eligible under the State plan in
accordance with paragraphs (10) and (17) of section
1902(a), consists of the items and services described in
section 1905(a)(4)(B) (relating to early and periodic
screening, diagnostic, and treatment services defined in
section 1905(r)) and provided in accordance with the
requirements of section 1902(a)(43).'';
(2) in subparagraph (C)--
(A) in the heading, by striking ``<SUP>wrap-around'' and
inserting ``<SUP>additional''; and
(B) by striking ``wrap-around or''; and
(3) by adding at the end the following new subparagraph:
``(E) Rule of construction.--Nothing in this paragraph
shall be construed as--
``(i) requiring a State to offer all or any of the
items and services required by subparagraph (A)(ii) through
an issuer of benchmark coverage described in subsection
(b)(1) or benchmark equivalent coverage described in
subsection (b)(2);
``(ii) preventing a State from offering all or any of
the items and services required by subparagraph (A)(ii)
through an issuer of benchmark coverage described in
subsection (b)(1) or benchmark equivalent coverage
described in subsection (b)(2); or
``(iii) affecting a child's entitlement to care and
services described in subsections (a)(4)(B) and (r) of
section 1905 and provided in accordance with section
1902(a)(43) whether provided through benchmark coverage,
benchmark equivalent coverage, or otherwise.''.
(b) Correction of Reference to Children in Foster Care Receiving
Child Welfare Services.--Section 1937(a)(2)(B)(viii) (42 U.S.C. 1396u-
7(a)(2)(B)(viii)), as inserted by section 6044(a) of the Deficit
Reduction Act of 2005, is amended by striking ``aid or assistance is
made available under part B of title IV to children in foster care and
individuals'' and inserting ``child welfare services are made available
under part B of title IV on the basis of being a child in foster care
or''.
(c) Transparency.--Section 1937 (42 U.S.C. 1396u-7), as inserted by
section 6044(a) of the Deficit Reduction Act of 2005, is amended by
adding at the end the following:
``(c) Publication of Provisions Affected.--With respect to a State
plan amendment to provide benchmark benefits in accordance with
subsections (a) and (b) that is approved by the Secretary, the
Secretary shall publish on the Internet website of the Centers for
Medicare & Medicaid Services, a list of the provisions of this title
that the Secretary has determined do not apply in order to enable the
State to carry out the plan amendment and the reason for each such
determination on the date such approval is made, and shall publish such
list in the Federal Register and not later than 30 days after such date
of approval.''.
(d) Effective Date.--The amendments made by subsections (a), (b),
and (c) of this section shall take effect as if included in the
amendment made by section 6044(a) of the Deficit Reduction Act of 2005.

fb21fcd00a6ebb0ab19f929745173209acb7e48cf5198187ab55c5bb1ad990ed

Section 704 of the Medicare, Medicaid, and SCHIP Balanced Budget
Refinement Act of 1999, as enacted into law by division B of Public Law
106-113 (113 Stat. 1501A-402) is repealed.

844f541025610f00e9333c6c200c32ed137ab6890cd5c2efae2761c3fccac41c

DEMONSTRATION PROGRAMS.
After the date of the enactment of this Act, the Secretary of
Health and Human Services may not approve any new demonstration
programs under section 1938 of the Social Security Act (42 U.S.C.
1396u-8).

dc82e40cf80e98a1b111c5994380e7d87f68646b0fef952e4c8d7951cf911614

AN EXTRAORDINARY EMPLOYER PENSION CONTRIBUTION.
(a) In General.--Only for purposes of computing the FMAP (as
defined in subsection (e)) for a State for a fiscal year (beginning
with fiscal year 2006) and applying the FMAP under title XIX of the
Social Security Act, any significantly disproportionate employer
pension or insurance fund contribution described in subsection (b)
shall be disregarded in computing the per capita income of such State,
but shall not be disregarded in computing the per capita income for the
continental United States (and Alaska) and Hawaii.
(b) Significantly Disproportionate Employer Pension and Insurance
Fund Contribution.--
(1) In general.--For purposes of this section, a significantly
disproportionate employer pension and insurance fund contribution
described in this subsection with respect to a State is any
identifiable employer contribution towards pension or other
employee insurance funds that is estimated to accrue to residents
of such State for a calendar year (beginning with calendar year
2003) if the increase in the amount so estimated exceeds 25 percent
of the total increase in personal income in that State for the year
involved.
(2) Data to be used.--For estimating and adjustment a FMAP
already calculated as of the date of the enactment of this Act for
a State with a significantly disproportionate employer pension and
insurance fund contribution, the Secretary shall use the personal
income data set originally used in calculating such FMAP.
(3) Special adjustment for negative growth.--If in any calendar
year the total personal income growth in a State is negative, an
employer pension and insurance fund contribution for the purposes
of calculating the State's FMAP for a calendar year shall not
exceed 125 percent of the amount of such contribution for the
previous calendar year for the State.
(c) Hold Harmless.--No State shall have its FMAP for a fiscal year
reduced as a result of the application of this section.
(d) Report.--Not later than May 15, 2009, the Secretary shall
submit to the Congress a report on the problems presented by the
current treatment of pension and insurance fund contributions in the
use of Bureau of Economic Affairs calculations for the FMAP and for
Medicaid and on possible alternative methodologies to mitigate such
problems.
(e) FMAP Defined.--For purposes of this section, the term ``FMAP''
means the Federal medical assistance percentage, as defined in section
1905(b) of the Social Security Act (42 U.S.C. 1396(d)).

382af26a0c9130921d981ae7a8603154495fd201325e3c8f7af2e06a33b20b52

(a) In General.--Nothing in section 1903(w) of the Social Security
Act (42 U.S.C. 1396b(w)) shall be construed by the Secretary of Health
and Human Services as prohibiting a State's use of funds as the non-
Federal share of expenditures under title XIX of such Act where such
funds are transferred from or certified by a publicly-owned regional
medical center located in another State and described in subsection
(b), so long as the Secretary determines that such use of funds is
proper and in the interest of the program under title XIX.
(b) Center Described.--A center described in this subsection is a
publicly-owned regional medical center that--
(1) provides level 1 trauma and burn care services;
(2) provides level 3 neonatal care services;
(3) is obligated to serve all patients, regardless of ability
to pay;
(4) is located within a Standard Metropolitan Statistical Area
(SMSA) that includes at least 3 States;
(5) provides services as a tertiary care provider for patients
residing within a 125-mile radius; and
(6) meets the criteria for a disproportionate share hospital
under section 1923 of such Act (42 U.S.C. 1396r-4) in at least one
State other than the State in which the center is located.

3fed82b163b0dd2de53c387572fe6f4b859edc5dcd9b7c0fe45eec990adcf203

HAWAII.
Section 1923(f)(6) (42 U.S.C. 1396r-4(f)(6)), as amended by section
202 of the Medicare Improvements for Patients and Providers Act of 2008
(Public Law 110-275) is amended--
(1) in the paragraph heading, by striking ``2009 and the first
calendar quarter of fiscal year 2010'' and inserting ``2011 and the
first calendar quarter of fiscal year 2012'';
(2) in subparagraph (A)--
(A) in clause (i)--
(i) in the second sentence--
(I) by striking ``and 2009'' and inserting ``,
2009, 2010, and 2011''; and
(II) by striking ``such portion of''; and
(ii) in the third sentence, by striking ``2010 for the
period ending on December 31, 2009'' and inserting ``2012
for the period ending on December 31, 2011'';
(B) in clause (ii), by striking ``or for a period in fiscal
year 2010'' and inserting ``2010, 2011, or for period in fiscal
year 2012''; and
(C) in clause (iv)--
(i) in the clause heading, by striking ``2009 and the
first calendar quarter of fiscal year 2010'' and inserting
``2011 and the first calendar quarter of fiscal year
2012''; and
(ii) in each of subclauses (I) and (II), by striking ``
or for a period in fiscal year 2010'' and inserting ``2010,
2011, or for a period in fiscal year 2012''; and
(3) in subparagraph (B)--
(A) in clause (i)--
(i) in the first sentence, by striking ``2009'' and
inserting ``2011''; and
(ii) in the second sentence, by striking ``2010 for the
period ending on December 31, 2009'' and inserting ``2012
for the period ending on December 31, 2011''.

a42acf4b711dfd7c1e7b8b663e778cdb7e813744cbc0a17be8bb12f08e86e421

Not later than 18 months after the date of the enactment of this
Act, the Comptroller General of the United States shall submit a report
to the Committee on Finance of the Senate and the Committee on Energy
and Commerce of the House of Representatives analyzing the extent to
which State payment rates for medicaid managed care organizations under
Medicaid are actuarially sound.
Subtitle C--Other Provisions

e075f84b02925fc189a3066f95ad4b82d47b69cc08546048a1323ddd2e2f8d8c

CHILDREN.
(a) Definitions.--In this section--
(1) the terms ``Administration'' and ``Administrator'' means
the Small Business Administration and the Administrator thereof,
respectively;
(2) the term ``certified development company'' means a
development company participating in the program under title V of
the Small Business Investment Act of 1958 (15 U.S.C. 695 et seq.);
(3) the term ``Medicaid program'' means the program established
under title XIX of the Social Security Act (42 U.S.C. 1396 et
seq.);
(4) the term ``Service Corps of Retired Executives'' means the
Service Corps of Retired Executives authorized by section 8(b)(1)
of the Small Business Act (15 U.S.C. 637(b)(1));
(5) the term ``small business concern'' has the meaning given
that term in section 3 of the Small Business Act (15 U.S.C. 632);
(6) the term ``small business development center'' means a
small business development center described in section 21 of the
Small Business Act (15 U.S.C. 648);
(7) the term ``State'' has the meaning given that term for
purposes of title XXI of the Social Security Act (42 U.S.C. 1397aa
et seq.);
(8) the term ``State Children's Health Insurance Program''
means the State Children's Health Insurance Program established
under title XXI of the Social Security Act (42 U.S.C. 1397aa et
seq.);
(9) the term ``task force'' means the task force established
under subsection (b)(1); and
(10) the term ``women's business center'' means a women's
business center described in section 29 of the Small Business Act
(15 U.S.C. 656).
(b) Establishment of Task Force.--
(1) Establishment.--There is established a task force to
conduct a nationwide campaign of education and outreach for small
business concerns regarding the availability of coverage for
children through private insurance options, the Medicaid program,
and the State Children's Health Insurance Program.
(2) Membership.--The task force shall consist of the
Administrator, the Secretary of Health and Human Services, the
Secretary of Labor, and the Secretary of the Treasury.
(3) Responsibilities.--The campaign conducted under this
subsection shall include--
(A) efforts to educate the owners of small business
concerns about the value of health coverage for children;
(B) information regarding options available to the owners
and employees of small business concerns to make insurance more
affordable, including Federal and State tax deductions and
credits for health care-related expenses and health insurance
expenses and Federal tax exclusion for health insurance options
available under employer-sponsored cafeteria plans under
section 125 of the Internal Revenue Code of 1986;
(C) efforts to educate the owners of small business
concerns about assistance available through public programs;
and
(D) efforts to educate the owners and employees of small
business concerns regarding the availability of the hotline
operated as part of the Insure Kids Now program of the
Department of Health and Human Services.
(4) Implementation.--In carrying out this subsection, the task
force may--
(A) use any business partner of the Administration,
including--
(i) a small business development center;
(ii) a certified development company;
(iii) a women's business center; and
(iv) the Service Corps of Retired Executives;
(B) enter into--
(i) a memorandum of understanding with a chamber of
commerce; and
(ii) a partnership with any appropriate small business
concern or health advocacy group; and
(C) designate outreach programs at regional offices of the
Department of Health and Human Services to work with district
offices of the Administration.
(5) Website.--The Administrator shall ensure that links to
information on the eligibility and enrollment requirements for the
Medicaid program and State Children's Health Insurance Program of
each State are prominently displayed on the website of the
Administration.
(6) Report.--
(A) In general.--Not later than 2 years after the date of
enactment of this Act, and every 2 years thereafter, the
Administrator shall submit to the Committee on Small Business
and Entrepreneurship of the Senate and the Committee on Small
Business of the House of Representatives a report on the status
of the nationwide campaign conducted under paragraph (1).
(B) Contents.--Each report submitted under subparagraph (A)
shall include a status update on all efforts made to educate
owners and employees of small business concerns on options for
providing health insurance for children through public and
private alternatives.

83894887e872b37c6da4f0c1d99441ff4df1ea94a136f00b677ba9168234d2d8

MEANINGFUL HEALTH INSURANCE COVERAGE.
(a) Findings.--The Senate finds the following:
(1) There are approximately 45 million Americans currently
without health insurance.
(2) More than half of uninsured workers are employed by
businesses with less than 25 employees or are self-employed.
(3) Health insurance premiums continue to rise at more than
twice the rate of inflation for all consumer goods.
(4) Individuals in the small group and individual health
insurance markets usually pay more for similar coverage than those
in the large group market.
(5) The rapid growth in health insurance costs over the last
few years has forced many employers, particularly small employers,
to increase deductibles and co-pays or to drop coverage completely.
(b) Sense of the Senate.--The Senate--
(1) recognizes the necessity to improve affordability and
access to health insurance for all Americans;
(2) acknowledges the value of building upon the existing
private health insurance market; and
(3) affirms its intent to enact legislation this year that,
with appropriate protection for consumers, improves access to
affordable and meaningful health insurance coverage for employees
of small businesses and individuals by--
(A) facilitating pooling mechanisms, including pooling
across State lines, and
(B) providing assistance to small businesses and
individuals, including financial assistance and tax incentives,
for the purchase of private insurance coverage.

6e30450c75c590a5565e974b13d386723d480e303f6beb2f7fddd6aecc875fb4

(a) Cigars.--Section 5701(a) of the Internal Revenue Code of 1986
is amended--
(1) by striking ``$1.828 cents per thousand ($1.594 cents per
thousand on cigars removed during 2000 or 2001)'' in paragraph (1)
and inserting ``$50.33 per thousand'',
(2) by striking ``20.719 percent (18.063 percent on cigars
removed during 2000 or 2001)'' in paragraph (2) and inserting
``52.75 percent'', and
(3) by striking ``$48.75 per thousand ($42.50 per thousand on
cigars removed during 2000 or 2001)'' in paragraph (2) and
inserting ``40.26 cents per cigar''.
(b) Cigarettes.--Section 5701(b) of such Code is amended--
(1) by striking ``$19.50 per thousand ($17 per thousand on
cigarettes removed during 2000 or 2001)'' in paragraph (1) and
inserting ``$50.33 per thousand'', and
(2) by striking ``$40.95 per thousand ($35.70 per thousand on
cigarettes removed during 2000 or 2001)'' in paragraph (2) and
inserting ``$105.69 per thousand''.
(c) Cigarette Papers.--Section 5701(c) of such Code is amended by
striking ``1.22 cents (1.06 cents on cigarette papers removed during
2000 or 2001)'' and inserting ``3.15 cents''.
(d) Cigarette Tubes.--Section 5701(d) of such Code is amended by
striking ``2.44 cents (2.13 cents on cigarette tubes removed during
2000 or 2001)'' and inserting ``6.30 cents''.
(e) Smokeless Tobacco.--Section 5701(e) of such Code is amended--
(1) by striking ``58.5 cents (51 cents on snuff removed during
2000 or 2001)'' in paragraph (1) and inserting ``$1.51'', and
(2) by striking ``19.5 cents (17 cents on chewing tobacco
removed during 2000 or 2001)'' in paragraph (2) and inserting
``50.33 cents''.
(f) Pipe Tobacco.--Section 5701(f) of such Code is amended by
striking ``$1.0969 cents (95.67 cents on pipe tobacco removed during
2000 or 2001)'' and inserting ``$2.8311 cents''.
(g) Roll-Your-Own Tobacco.--Section 5701(g) of such Code is amended
by striking ``$1.0969 cents (95.67 cents on roll-your-own tobacco
removed during 2000 or 2001)'' and inserting ``$24.78''.
(h) Floor Stocks Taxes.--
(1) Imposition of tax.--On tobacco products (other than cigars
described in section 5701(a)(2) of the Internal Revenue Code of
1986) and cigarette papers and tubes manufactured in or imported
into the United States which are removed before April 1, 2009, and
held on such date for sale by any person, there is hereby imposed a
tax in an amount equal to the excess of--
(A) the tax which would be imposed under section 5701 of
such Code on the article if the article had been removed on
such date, over
(B) the prior tax (if any) imposed under section 5701 of
such Code on such article.
(2) Credit against tax.--Each person shall be allowed as a
credit against the taxes imposed by paragraph (1) an amount equal
to $500. Such credit shall not exceed the amount of taxes imposed
by paragraph (1) on April 1, 2009, for which such person is liable.
(3) Liability for tax and method of payment.--
(A) Liability for tax.--A person holding tobacco products,
cigarette papers, or cigarette tubes on April 1, 2009, to which
any tax imposed by paragraph (1) applies shall be liable for
such tax.
(B) Method of payment.--The tax imposed by paragraph (1)
shall be paid in such manner as the Secretary shall prescribe
by regulations.
(C) Time for payment.--The tax imposed by paragraph (1)
shall be paid on or before August 1, 2009.
(4) Articles in foreign trade zones.--Notwithstanding the Act
of June 18, 1934 (commonly known as the Foreign Trade Zone Act, 48
Stat. 998, 19 U.S.C. 81a et seq.) or any other provision of law,
any article which is located in a foreign trade zone on April 1,
2009, shall be subject to the tax imposed by paragraph (1) if--
(A) internal revenue taxes have been determined, or customs
duties liquidated, with respect to such article before such
date pursuant to a request made under the 1st proviso of
section 3(a) of such Act, or
(B) such article is held on such date under the supervision
of an officer of the United States Customs and Border
Protection of the Department of Homeland Security pursuant to
the 2d proviso of such section 3(a).
(5) Definitions.--For purposes of this subsection--
(A) In general.--Any term used in this subsection which is
also used in section 5702 of the Internal Revenue Code of 1986
shall have the same meaning as such term has in such section.
(B) Secretary.--The term ``Secretary'' means the Secretary
of the Treasury or the Secretary's delegate.
(6) Controlled groups.--Rules similar to the rules of section
5061(e)(3) of such Code shall apply for purposes of this
subsection.
(7) Other laws applicable.--All provisions of law, including
penalties, applicable with respect to the taxes imposed by section
5701 of such Code shall, insofar as applicable and not inconsistent
with the provisions of this subsection, apply to the floor stocks
taxes imposed by paragraph (1), to the same extent as if such taxes
were imposed by such section 5701. The Secretary may treat any
person who bore the ultimate burden of the tax imposed by paragraph
(1) as the person to whom a credit or refund under such provisions
may be allowed or made.
(i) Effective Date.--The amendments made by this section shall
apply to articles removed (as defined in section 5702(j) of the
Internal Revenue Code of 1986) after March 31, 2009.

fcca8eaa805a9569841cedb5af8d4c0721ab502f1502e5def78e54d4c47c2685

(a) Permit, Inventories, Reports, and Records Requirements for
Manufacturers and Importers of Processed Tobacco.--
(1) Permit.--
(A) Application.--Section 5712 of the Internal Revenue Code
of 1986 is amended by inserting ``or processed tobacco'' after
``tobacco products''.
(B) Issuance.--Section 5713(a) of such Code is amended by
inserting ``or processed tobacco'' after ``tobacco products''.
(2) Inventories, reports, and packages.--
(A) Inventories.--Section 5721 of such Code is amended by
inserting ``, processed tobacco,'' after ``tobacco products''.
(B) Reports.--Section 5722 of such Code is amended by
inserting ``, processed tobacco,'' after ``tobacco products''.
(C) Packages, marks, labels, and notices.--Section 5723 of
such Code is amended by inserting ``, processed tobacco,''
after ``tobacco products'' each place it appears.
(3) Records.--Section 5741 of such Code is amended by inserting
``, processed tobacco,'' after ``tobacco products''.
(4) Manufacturer of processed tobacco.--Section 5702 of such
Code is amended by adding at the end the following new subsection:
``(p) Manufacturer of Processed Tobacco.--
``(1) In general.--The term `manufacturer of processed tobacco'
means any person who processes any tobacco other than tobacco
products.
``(2) Processed tobacco.--The processing of tobacco shall not
include the farming or growing of tobacco or the handling of
tobacco solely for sale, shipment, or delivery to a manufacturer of
tobacco products or processed tobacco.''.
(5) Conforming amendments.--
(A) Section 5702(h) of such Code is amended by striking
``tobacco products and cigarette papers and tubes'' and
inserting ``tobacco products or cigarette papers or tubes or
any processed tobacco''.
(B) Sections 5702(j) and 5702(k) of such Code are each
amended by inserting ``, or any processed tobacco,'' after
``tobacco products or cigarette papers or tubes''.
(6) Effective date.--The amendments made by this subsection
shall take effect on April 1, 2009.
(b) Basis for Denial, Suspension, or Revocation of Permits.--
(1) Denial.--Paragraph (3) of section 5712 of such Code is
amended to read as follows:
``(3) such person (including, in the case of a corporation, any
officer, director, or principal stockholder and, in the case of a
partnership, a partner)--
``(A) is, by reason of his business experience, financial
standing, or trade connections or by reason of previous or
current legal proceedings involving a felony violation of any
other provision of Federal criminal law relating to tobacco
products, processed tobacco, cigarette paper, or cigarette
tubes, not likely to maintain operations in compliance with
this chapter,
``(B) has been convicted of a felony violation of any
provision of Federal or State criminal law relating to tobacco
products, processed tobacco, cigarette paper, or cigarette
tubes, or
``(C) has failed to disclose any material information
required or made any material false statement in the
application therefor.''.
(2) Suspension or revocation.--Subsection (b) of section 5713
of such Code is amended to read as follows:
``(b) Suspension or Revocation.--
``(1) Show cause hearing.--If the Secretary has reason to
believe that any person holding a permit--
``(A) has not in good faith complied with this chapter, or
with any other provision of this title involving intent to
defraud,
``(B) has violated the conditions of such permit,
``(C) has failed to disclose any material information
required or made any material false statement in the
application for such permit,
``(D) has failed to maintain his premises in such manner as
to protect the revenue,
``(E) is, by reason of previous or current legal
proceedings involving a felony violation of any other provision
of Federal criminal law relating to tobacco products, processed
tobacco, cigarette paper, or cigarette tubes, not likely to
maintain operations in compliance with this chapter, or
``(F) has been convicted of a felony violation of any
provision of Federal or State criminal law relating to tobacco
products, processed tobacco, cigarette paper, or cigarette
tubes,
the Secretary shall issue an order, stating the facts charged,
citing such person to show cause why his permit should not be
suspended or revoked.
``(2) Action following hearing.--If, after hearing, the
Secretary finds that such person has not shown cause why his permit
should not be suspended or revoked, such permit shall be suspended
for such period as the Secretary deems proper or shall be
revoked.''.
(3) Effective date.--The amendments made by this subsection
shall take effect on the date of the enactment of this Act.
(c) Application of Internal Revenue Code Statute of Limitations for
Alcohol and Tobacco Excise Taxes.--
(1) In general.--Section 514(a) of the Tariff Act of 1930 (19
U.S.C. 1514(a)) is amended by striking ``and section 520 (relating
to refunds)'' and inserting ``section 520 (relating to refunds),
and section 6501 of the Internal Revenue Code of 1986 (but only
with respect to taxes imposed under chapters 51 and 52 of such
Code)''.
(2) Effective date.--The amendment made by this subsection
shall apply to articles imported after the date of the enactment of
this Act.
(d) Expansion of Definition of Roll-Your-Own Tobacco.--
(1) In general.--Section 5702(o) of the Internal Revenue Code
of 1986 is amended by inserting ``or cigars, or for use as wrappers
thereof'' before the period at the end.
(2) Effective date.--The amendment made by this subsection
shall apply to articles removed (as defined in section 5702(j) of
the Internal Revenue Code of 1986) after March 31, 2009.
(e) Time of Tax for Unlawfully Manufactured Tobacco Products.--
(1) In general.--Section 5703(b)(2) of such Code is amended by
adding at the end the following new subparagraph:
``(F) Special rule for unlawfully manufactured tobacco
products.--In the case of any tobacco products, cigarette
paper, or cigarette tubes manufactured in the United States at
any place other than the premises of a manufacturer of tobacco
products, cigarette paper, or cigarette tubes that has filed
the bond and obtained the permit required under this chapter,
tax shall be due and payable immediately upon manufacture.''.
(2) Effective date.--The amendment made by this subsection
shall take effect on the date of the enactment of this Act.
(f) Disclosure.--
(1) In general.--Paragraph (1) of section 6103(o) of such Code
is amended by designating the text as subparagraph (A), moving such
text 2 ems to the right, striking ``Returns'' and inserting ``(a)
in general.--Returns'', and by inserting after subparagraph (A) (as
so redesignated) the following new subparagraph:
``(B) Use in certain proceedings.--Returns and return
information disclosed to a Federal agency under subparagraph
(A) may be used in an action or proceeding (or in preparation
for such action or proceeding) brought under section 625 of the
American Jobs Creation Act of 2004 for the collection of any
unpaid assessment or penalty arising under such Act.''.
(2) Conforming amendment.--Section 6103(p)(4) of such Code is
amended by striking ``(o)(1)'' both places it appears and inserting
``(o)(1)(A)''.
(3) Effective date.--The amendments made by this subsection
shall apply on or after the date of the enactment of this Act.
(g) Transitional Rule.--Any person who--
(1) on April 1, 2009 is engaged in business as a manufacturer
of processed tobacco or as an importer of processed tobacco, and
(2) before the end of the 90-day period beginning on such date,
submits an application under subchapter B of chapter 52 of such
Code to engage in such business, may, notwithstanding such
subchapter B, continue to engage in such business pending final
action on such application. Pending such final action, all
provisions of such chapter 52 shall apply to such applicant in the
same manner and to the same extent as if such applicant were a
holder of a permit under such chapter 52 to engage in such
business.

14ecd930cff17ef1da4cc3c60828af892350f21e559df2a840bfabdeb8e76bcf

IN THE UNITED STATES.
Not later than one year after the date of the enactment of this
Act, the Secretary of the Treasury shall conduct a study concerning the
magnitude of tobacco smuggling in the United States and submit to
Congress recommendations for the most effective steps to reduce tobacco
smuggling. Such study shall also include a review of the loss of
Federal tax receipts due to illicit tobacco trade in the United States
and the role of imported tobacco products in the illicit tobacco trade
in the United States.

788e4c55f93d34ef52ea2e498778f5332bae6a6658a019ae2d70c6c04c55fe81

The percentage under subparagraph (C) of section 401(1) of the Tax
Increase Prevention and Reconciliation Act of 2005 in effect on the
date of the enactment of this Act is increased by 0.5 percentage point.
Speaker of the House of Representatives.
Vice President of the United States and
President of the Senate.

d96bf35da15b2dc894605e35cb68f0ca9436c8105b13fc66ed50ae63b1ce1c4f

Children's Health Insurance Program Reauthorization Act of 2009

Other Sections