Medicaid and SCHIP Provisions in H.R. 3162 and S. 1893/H.R. 976, and Agreement

Medicaid and SCHIP Provisions in
H.R. 3162, S. 1893/H.R. 976, and Agreement
Updated October 18, 2007
Evelyne P. Baumrucker, Coordinator,
Bernadette Fernandez, April Grady, Jean Hearne,
Elicia J. Herz, and Chris L. Peterson
Domestic Social Policy Division



Medicaid and SCHIP Provisions in
H.R. 3162, S. 1893/H.R. 976, and Agreement
Summary
Medicaid, authorized under Title XIX of the Social Security Act, is a federal-
state program providing medical assistance for low-income individuals who are aged,
blind, disabled, members of families with dependent children, or who have one of a
few specified medical conditions.
The Balanced Budget Act of 1997 (BBA 1997) established the State Children’s
Health Insurance Program (SCHIP) under a new Title XXI of the Social Security Act.
SCHIP builds on Medicaid by providing health insurance to uninsured children in
families with incomes above applicable Medicaid income standards. States provide
children with health insurance that meets specific standards for benefits and cost-
sharing through separate SCHIP programs, or through their Medicaid programs, or
through a combination of both. SCHIP has federal appropriations for the current
fiscal year, but none are slated for FY2008 and beyond.
The 110th Congress has considered legislation that would make important
changes to Medicaid and SCHIP. On August 1, 2007, the House passed H.R. 3162,
the Children’s Health and Medicare Protection (CHAMP) Act of 2007. The bill
would reauthorize and increase funding levels and state grant distributions for SCHIP
and make changes to the Medicare and Medicaid programs. The major SCHIP
provisions would enhance outreach and enrollment efforts to increase the number of
children covered by the program, modify the program’s citizenship verification
process, change minimum benefit requirements, among other changes.
On July 19, 2007, the Senate Finance Committee marked up the Children’s
Health Insurance Program Reauthorization Act of 2007 (S. 1893/H.R. 976). The
Senate struck the language in an unrelated House-passed tax measure (H.R. 976) and
replaced it with the language contained in S. 1893, as approved by the Senate Finance
Committee. A total of 92 amendments were offered, with 9 adopted. The bill passed
the Senate on August 2, 2007. The Senate bill provides authorized appropriations to
SCHIP through FY2012 and changes how federal SCHIP funds are allotted to states.
Other key provisions would enhance the program’s outreach and enrollment efforts,
extend coverage to pregnant women, and alter the citizenship verification process for
program eligibility.
A bicameral agreement on SCHIP reauthorization passed the House as an
amendment to H.R. 976 on September 25, and also passed the Senate on September
27. President Bush vetoed the legislation on October 3, 2007. The House sustained
the President’s veto with a vote on October 18, 2007.
The following side-by-side comparison provides a brief description of current
law and the changes that would be made to Medicaid and SCHIP under H.R. 3162,
S. 1893/H.R. 976, and the bicameral agreement. Medicare provisions in Titles II
through VII of H.R. 3162, provisions related to support to injured service members,
military family job protection, and Sense of the Senate regarding health care access
are not described here. This report will be updated as legislative activity warrants.



Key Policy Staff:
The Children's Health and Medicare Protection Act of 2007 and
The Children’s Health Insurance Program Reauthorization Act of 2007
Area of ExpertiseNamePhoneE-mail
CoordinatorEvelyne P. Baumrucker7-8913ebaumrucker@crs.loc.gov
Funding/FinancingChris L. Peterson7-4681cpeterson@crs.loc.gov
Funding for the TerritoriesChris L. Peterson7-4681cpeterson@crs.loc.gov
Evelyne P. Baumrucker7-8913ebaumrucker@crs.loc.gov
Federal Matching PaymentsApril Grady7-9578agrady@crs.loc.gov
EligibilityElicia J. Herz7-1377eherz@crs.loc.gov
Optional Coverage of Older
ChildrenElicia J. Herz7-1377eherz@crs.loc.gov
Optional Coverage of
Pregnant WomenElicia J. Herz7-1377eherz@crs.loc.gov
Coverage of Non-pregnant
Childless Adults and
Parents Evelyne P. Baumrucker7-8913ebaumrucker@crs.loc.gov
Legal ImmigrantsEvelyne P. Baumrucker7-8913ebaumrucker@crs.loc.gov
Medicaid Temporary
Medical Assistance (TMA)April Grady7-9578agrady@crs.loc.gov
Spousal Impoverishment
and Asset VerificationJulie L. Stone7-1386jstone@crs.loc.gov
Enrollment/AccessEvelyne P. Baumrucker7-8913ebaumrucker@crs.loc.gov
Citizenship DocumentationApril Grady7-9578agrady@crs.loc.gov
Crowd-OutElicia J. Herz7-1377eherz@crs.loc.gov
Chris Peterson7-4681cpeterson@crs.loc.gov
Premium Assistance/Employer
Buy-inEvelyne P. Baumrucker7-8913ebaumrucker@crs.loc.gov
BenefitsElicia J. Herz7-1377eherz@crs.loc.gov
Family Planning ServicesEvelyne P. Baumrucker7-8913ebaumrucker@crs.loc.gov
Monitoring QualityElicia J. Herz7-1377 eherz@crs.loc.gov
PaymentsElicia J. Herz7-1377 eherz@crs.loc.gov
Medicaid Drug RebateJean Hearne7-7362jhearne@crs.loc.gov
Disproportionate Share
Hospital Payments (DSH)Jean Hearne7-7362jhearne@crs.loc.gov



Contents
Background ......................................................1
Recent Legislative Activity......................................1
Medicaid and SCHIP Provisions in H.R. 3162, S. 1893/H.R. 976, and
the Bicameral Agreement ...................................3
Funding/Financing .........................................3
Eligibility ................................................4
Enrollment/Access .........................................5
Premium Assistance/Employer Buy-In.........................6
Benefits .................................................6
Monitoring Quality........................................7
Payments ................................................7
References to Title XXI; Elimination of Confusing Program References.......8
H§155. References to Title XXI...............................8
S§606. Elimination of confusing program references..............8
A§1. Short Title; Amendments to Social Security Act; References;
Table of Contents......................................8
A§612. References to Title XXI..............................8
Funding/Financing .................................................9
CHIP appropriations ...........................................9
H§101. Establishment of new base CHIP allotments..............9
S§101. Extension of CHIP. .................................9
A§101. Extension of CHIP...................................9
S§103. One-time appropriation................................9
A§108. One-time appropriation...............................9
Allotment of federal CHIP funds to states...........................9
H§101. Establishment of new base CHIP allotments..............9
S§102. Allotments for the 50 states and the District of Columbia. ...9
A§102. Allotments for states and territories......................9
Allotment of federal CHIP funds to territories ......................16
H§101. Establishment of new base CHIP allotments. ............16
S§104. Improving funding for the territories under CHIP and
Medicaid. ...........................................16
A§102. Allotments for states and territories.....................16
Period of availability of CHIP allotments ..........................17
H§102. 2-year initial availability of CHIP allotments.............17
S§109. Two-year availability of allotments; expenditures counted
against oldest allotments................................17
A§105. 2-year initial availability of CHIP allotments.............17
CHIP funds for shortfall states ..................................17
H§102. 2-year initial availability of CHIP allotments.............17
H§103. Redistribution of unused allotments to address state
funding shortfalls. ....................................17
S§105. Incentive bonuses for states. ..........................17
A§106. Redistribution of unused allotments to address state
funding shortfalls.....................................17



S§108. CHIP contingency fund. .............................19
A§103. Child enrollment contingency fund. ...................19
Extension of option for qualifying states ..........................22
H§104. Extension of option for qualifying states. ..............22
S§111. Option for qualifying states to receive the enhanced portion
of the CHIP matching rate for Medicaid coverage of certain
children. ............................................22
A§107. Option for qualifying states to receive the enhanced portion
of the CHIP matching rate for Medicaid coverage of certain
children. ............................................22
Bonuses for increasing enrollment of children ......................23
H§111. CHIP performance bonus payment to offset additional
enrollment costs resulting from enrollment and retention efforts. 23
S§105. Incentive bonuses for states. ..........................23
A§104. CHIP performance bonus payment to offset additional
enrollment costs resulting from enrollment and retention efforts. 23
H§135. No federal funding for illegal aliens....................29
A§605. No federal funding for illegal aliens....................29
Medicaid funding for the territories ..............................30
H§811. Payments for Puerto Rico and territories. ...............30
Enhanced matching funds for certain data systems in the territories......31
H§811. Payments for Puerto Rico and territories.................31
S§104. Improving funding for the territories under CHIP and
Medicaid. ...........................................31
A§109. Improving funding for the territories under CHIP and
Medicaid. ..........................................31
Medicaid FMAP .............................................32
H§813. Adjustment in computation of Medicaid FMAP to disregard
an extraordinary employer pension contribution.............32
A§615. Adjustment in computation of Medicaid FMAP to disregard
an extraordinary employer pension contribution.............32
CHIP E-FMAP...............................................34
S§110. Limitation on matching rate for states that propose to
cover children with effective family income that exceeds 300
percent of the poverty line..............................34
A§114. Limitation on matching rate for states that propose to
cover children with effective family income that exceeds 300
percent of the poverty line..............................34
Eligibility ......................................................36
Premium grace period .........................................36
H§123. Premium grace period...............................36
A§504. Premium grace period. .............................36
Optional coverage of older children under CHIP ....................37
H§131. Optional coverage of children up to age 21 under CHIP. ...37
Optional coverage of legal immigrants in Medicaid and CHIP .........37
H§132. Optional coverage of legal immigrants under the
Medicaid program and CHIP. ...........................37
Optional coverage of pregnant women under CHIP ..................38
H§133. State option to expand or add coverage of certain pregnant
women under CHIP....................................38



CHIP through a state plan amendment.....................38
A§111. State option to cover low-income pregnant women under
CHIP through a state plan amendment.....................38
A§113. Elimination of counting Medicaid child presumptive
eligibility costs against title XXI allotment.................39
Nonpregnant childless adult coverage under CHIP ..................40
H§134. Limitation on waiver authority to cover adults............40
S§106. Phase-out coverage for nonpregnant childless adults under
CHIP. .............................................40
A§112. Phase-Out of coverage for nonpregnant childless adults
under CHIP; conditions for coverage of parents..............40
Parent coverage under CHIP ....................................43
S§106. Conditions for coverage of parents......................43
A§109. Phase-Out of coverage for nonpregnant childless adults
under CHIP; conditions for coverage of parents..............43
Medicaid TMA ..............................................45
H§801. Modernizing transitional Medicaid.....................45
A§115. State Authority Under Medicaid.......................46
Spousal impoverishment rules ..................................47
H§804. State option to protect community spouses of individuals
with disabilities.......................................47
Medicaid asset verification .....................................48
H§817. Extension of SSI web-based asset demonstration project to
the Medicaid program..................................48
A§619. Extension of SSI web-based asset demonstration project to
the Medicaid program..................................48
Enrollment/Access ...............................................49
“Express lane” eligibility determinations ..........................49
H§112. State option to rely on finding from an express lane agency
to conduct simplified eligibility determinations. ...........49
S§203. Demonstration project to permit States to rely on findings by
an Express Lane agency to determine components of a
child’s eligibility for Medicaid or CHIP. ..................49
A§203. State option to rely on finding from an Express Lane
agency to conduct simplified eligibility determinations........49
Out-stationed eligibility determinations ...........................54
H§113. Application of Medicaid outreach procedures to all children
and pregnant women. .................................54
Funding for outreach and enrollment .............................55
H§114. Encouraging culturally appropriate enrollment and
retention practices. ...................................55
S§201. Grants for outreach and enrollment.....................55
A§201. Grants and enhanced administrative funding for outreach
and enrollment.......................................55
Continuous eligibility under CHIP ...............................56
H§115. Continuous eligibility under CHIP......................56
Commission to monitor access and other matters ....................57
H§141. Children’s Access, Payment and Equality Commission.....57
Model enrollment practices .....................................58



process. ............................................58
A§213. Model of interstate coordinated enrollment and coverage
process..............................................58
Citizenship documentation .....................................59
H§143. Medicaid citizenship documentation requirements.........59
S§301. Verification of declaration of citizenship or nationality
for purposes of eligibility for Medicaid and CHIP............59
A§211. Verification of declaration of citizenship or nationality
for purposes of eligibility for Medicaid and CHIP............59
Elimination of Health Opportunity Accounts .......................66
H§145. Prohibiting initiation of new health opportunity
account demonstration programs.........................66
A§613. Prohibiting initiation of new health opportunity
account demonstration programs.........................66
Outreach and enrollment of Indians ..............................66
S§202. Increased outreach and enrollment of Indians.............66
A§202. Increased outreach and enrollment of Indians.............66
Eligibility information disclosure ................................67
S§204. Authorization of certain information disclosures to simplify
health coverage determinations. .........................67
A§203. State option to rely on finding from an Express Lane agency
to conduct simplified eligibility determinations..............67
Reducing administrative barriers to enrollment......................68
S§302. Reducing administrative barriers to enrollment............68
A§212. Reducing administrative barriers to enrollment............68
Preventing Crowd-Out.........................................69
A§116. Preventing substitution of CHIP coverage for private
coverage. ..........................................69
Medical Child Support Under SCHIP.............................72
A§116(f). Treatment of medical support order..................72
Premium Assistance/Employer Buy-In Programs ........................73
Employer Buy-in to CHIP ......................................73
H§821. Demonstration project for employer buy-in...............73
S§401. Additional State option for providing premium assistance. .75
A§301. Additional State option for providing premium assistance...75
Education and enrollment assistance in premium assistance programs ...79
S§402. Outreach, education, and enrollment assistance............79
A§302. Outreach, education, and enrollment assistance...........79
Special enrollment period ......................................80
S§411. Special enrollment period under group health plans in case of
termination of Medicaid or CHIP coverage or eligibility for
assistance in purchase of employment-based coverage;
coordination of coverage................................80
A§311. Special enrollment period under group health plans in case of
termination of Medicaid or CHIP coverage or eligibility for
assistance in purchase of employment-based coverage;
coordination of coverage................................80
Benefits ........................................................81
Dental services...............................................81



H§144. Access to dental care for children. .....................81
S§608. Dental health grants.................................81
A§501. Dental benefits....................................81
Federally qualified health centers (FQHCs) and rural health centers (RHCs)
services ................................................83
H§121. Ensuring child-centered coverage......................83
Mental health services .........................................84
H§121. Ensuring child-centered coverage......................84
S§607. Mental health parity in CHIP plans.....................84
A§502. Mental health parity in CHIP plans.....................84
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services
.......................................................85
H§121. Ensuring child-centered coverage......................85
S§605. Deficit Reduction Act technical corrections...............85
A§611(a). Deficit Reduction Act technical corrections - Clarification
of requirement to provide EPSDT services for all children in
benchmark benefit packages under Medicaid................85
School-based health centers services .............................85
H§121. Ensuring child-centered coverage......................85
A§506. Clarification of coverage of services provided through
school-based health centers..............................85
Benchmark coverage options ...................................86
H§121. Ensuring child-centered coverage......................86
H§122. Improving benchmark coverage options.................86
Extension of family planning services and supplies ..................87
H§802. Family planning services.............................87
Adult day health services ......................................88
H§803. Authority to continue providing adult day health services
approved under a State Medicaid plan.....................88
Monitoring Quality ...............................................89
Quality measurement .........................................89
H§151. Pediatric health quality measurement program............89
S§501. Child health quality improvement activities for children
enrolled in Medicaid or CHIP............................89
A§401. Child health quality improvement activities for children
enrolled in Medicaid or CHIP............................89
Information on access to coverage under CHIP .....................92
S§502. Improved information regarding access to coverage under
CHIP. ..............................................92
A§402. Improved availability of public information regarding
enrollment of children in CHIP and Medicaid...............92
Federal evaluation ............................................93
H§153. Updated federal evaluation of CHIP....................93
A§603. Updated federal evaluation of CHIP....................93
Payments .......................................................95
Medicaid Drug Rebate ........................................95
H§812. Medicaid Drug Rebate...............................95
Moratorium on certain payment restrictions ........................96
H§814. Moratorium on certain payment restrictions..............96



Tennessee and Hawaii DSH ....................................97
H§ 815. Tennessee DSH....................................97
A§617. Medicaid DSH allotments for Tennessee and Hawaii.......97
Monitoring erroneous payments .................................98
S§602. Payment error rate measurement (“PERM”)..............98
A§601. Payment error rate measurement (“PERM”)..............98
Payments for FQHCs and RHCs under CHIP ......................100
H§121. Ensuring child-centered coverage.....................100
S§609. Application of prospective payment system for services
provided by Federally-qualified health centers and rural health
clinics. ............................................100
A§503. Application of prospective payment system for services
provided by federally-qualified health centers and rural health
clinics. ............................................100
Miscellaneous ..................................................101
Purpose of Title XXI .........................................101
H§100. Purpose.........................................101
A§2. Purpose...........................................101
Citizenship auditing .........................................101
H§136. Auditing requirement to enforce citizenship restrictions on
eligibility for Medicaid and CHIP benefits.................101
Managed care safeguards .....................................103
H§152. Application of certain managed care quality safeguards to
CHIP. .............................................103
S§503. Application of certain managed care quality safeguards to
CHIP. .............................................103
A§403. Application of certain managed care quality safeguards to
CHIP. .............................................103
Access to records for CHIP ....................................103
H§154. Access to records for IG and GAO audits...............103
A§604. Access to records for IG and GAO audits...............103
Effective date ..............................................104
H§156. Reliance on law; exception for state legislation..........104
S§801. Effective date.....................................104
A§3. General effective date; exception for state legislation;
contingent effective date; reliance on law..................104
County Medicaid health insuring organizations ....................106
H§805. County Medicaid health insuring organizations..........106
A§614. County Medicaid health insuring organizations; GAO
report on Medicaid managed care payment rates............106
Clarification of treatment of regional medical center ................107
H§816. Clarification treatment of regional medical center........107
A§618. Clarification treatment of regional medical center.........107
Diabetes grants .............................................109
H§822. Diabetes grants....................................109
S§613. Demonstration projects relating to diabetes prevention.....109
A§505. Demonstration projects relating to diabetes prevention....109
S§501. Child health quality improvement activities for children
enrolled in Medicaid and CHIP.........................110
Collection of data used in providing CHIP funds ...................110



A§602. Improving data collection. ..........................110
S§105. Incentive bonuses for states..........................112
Technical correction .........................................112
H§823. Technical correction................................112
S§605. Deficit Reduction Act technical corrections..............112
A611(b). Deficit Reduction Act technical corrections — Correction
of reference to children in foster care receiving child welfare
services. ...........................................112
S§605. Deficit Reduction Act technical corrections.............113
A§611(c). Transparency...................................113
Technical corrections regarding current state authority under Medicaid
......................................................114
S§601. Technical corrections regarding current state authority under
Medicaid. ..........................................114
Elimination of counting of Medicaid child presumptive eligibility costs
against CHIP allotments ..................................115
S§603. Elimination of counting Medicaid child presumptive
eligibility costs against title XXI allotment................115
A§113. Elimination of counting Medicaid child presumptive
eligibility costs against title XXI allotment................115
Outreach to small businesses...................................116
S§614. Outreach regarding health insurance options available to
children. ...........................................116
A§623. Outreach regarding health insurance options available to
children. ...........................................116
List of Tables
Table 1. Medicaid and SCHIP Provisions...............................8



Medicaid and SCHIP Provisions in
H.R. 3162, S. 1893/H.R. 976,
and Agreement
Background
Medicaid, authorized under Title XIX of the Social Security Act, is a federal-
state program providing medical assistance for low-income individuals who are
aged, blind, disabled, members of families with dependent children, or who have
one of a few specified medical conditions.
The Balanced Budget Act of 1997 (BBA 1997) established SCHIP under a
new Title XXI of the Social Security Act. SCHIP builds on Medicaid by
providing health insurance to uninsured children in families with incomes above
applicable Medicaid income standards. States provide SCHIP children with
health insurance that meets specific standards for benefits and cost-sharing, or
through their Medicaid programs, or through a combination of both.
SCHIP has federal appropriations through FY2007, but none are slated for
FY2008 (which begins on October 1, 2007) and beyond.1
Recent Legislative Activity
The 110th Congress has considered legislation that would make important
changes to Medicaid and SCHIP. On August 1, 2007, the House passed H.R.
3162, the Children’s Health and Medicare Protection (CHAMP) Act of 2007. The
bill would reauthorize and increase funding levels and state grant distributions for
the State Children’s Health Insurance Program (SCHIP) and make changes to the
Medicare and Medicaid programs.
An August 1 estimate from the Congressional Budget Office (CBO) indicates
that the SCHIP title of H.R. 3162 would increase outlays by $47.4 billion over 5
years and by $128.7 billion over 10 years, and that the Medicaid title of the bill
would increase outlays by $4.4 billion over 5 years and by $4.6 billion over 10
years. Including Medicare and miscellaneous provisions, the CBO estimates that
the entire bill would increase outlays by $25.6 billion over 5 years and by $58.0
billion over 10 years. These costs would be offset by an increase in the federal


1 Although no SCHIP appropriations are currently slated for FY2008 forward, both OMB
and CBO assume through the new calendar year that the program continues at the FY2007
appropriation level of $5.04 billion.

tobacco tax and other changes, which the CBO estimates would increase revenue
by $28.1 billion over 5 years and by $58.1 billion over 10 years.2
On July 19, 2007, the Senate Finance Committee marked up the Children’s
Health Insurance Program Reauthorization Act of 2007 (S. 1893/H.R. 976). The
Senate struck the language in an unrelated House-passed tax measure (H.R. 976)
and replaced it with the language contained in S. 1893, as approved by the Senate
Finance Committee. A total of 92 amendments were offered, with 9 adopted.
The bill passed the Senate on August 2, 2007.
The Senate bill contains eight titles, six dealing with SCHIP and Medicaid.
An August 24 estimate from CBO and JCT3 indicates that the Senate bill would
increase SCHIP outlays by $28.1 billion over the five-year period of FY2008-
FY2012. Additional outlay increases would occur as a result of effects on
Medicaid (e.g., changes in citizenship documentation). In sum, the CBO and JTC
estimate indicates that the Senate bill would increase net outlays by $35.2 billion
over 5 years and by $71.0 billion over 10 years.4 These costs would be offset by
an increase in the federal tobacco tax and other changes, which CBO and JCT
estimate would increase net revenue by $36.1 billion over 5 years and by $72.8
billion over 10 years.
A bicameral agreement on SCHIP reauthorization passed the House as an
amendment to H.R. 976 on September 25, and also passed the Senate on
September 27. President Bush vetoed the legislation on October 3, 2007. The
House sustained the President’s veto with a vote of 273 to 156 on October 18,
2007 — a vote that failed to achieve the two-thirds majority of voting members
required for an override. A continuing resolution that contains short-term funding
for SCHIP (H.J.Res. 52) was passed by the House on September 26, and the
Senate on September 27, and signed into law on September 29, 2007, as P.L. 110-

92.


2 CBO, Estimated Effect on Direct Spending and Revenues of H.R. 3162, the Children’s
Health and Medicare Protection Act, for the Rules Committee (August 1, 2007), available
at [http://www.cbo.gov/ftpdocs/85xx/doc8519/HR3162.pdf].
3 CBO, letter to the Honorable Max Baucus (August 24, 2007), available at
[ h t t p : / / www.cbo.gov/ f t pdocs/ 85xx/ doc8584/ 08-28-CHIP.pdf ] .
4 As described above, the Senate bill would specify national allotment funding for five years.
In FY2012, this funding would consist of two semi-annual allotments of $1.75 billion each
plus a one-time appropriation of $12.5 billion to accompany the first semi-annual allotment.
For years beyond FY2012, CBO is required to assume that national allotment funding
continues at the level prescribed by existing law, which appears to be $3.5 billion under the
Senate bill. In contrast, the SCHIP baseline under current law assumes an appropriation of
$5.04 billion for years beyond FY2007. As a result of this difference, CBO’s cost estimate
for national allotments in the Senate bill shows savings in years beyond FY2012. For more
information on budget baselines and scorekeeping, see CRS Report 98-560, Baselines and
Scorekeeping in the Federal Budget Process, by Bill Heniff Jr.

A September 24 estimate from CBO and JCT5 indicates that the SCHIP
agreement would increase net outlays by $34.9 billion over 5 years and by $71.5
billion over 10 years.6 These costs would be offset by an increase in the federal
tobacco tax and other changes, which CBO and JCT estimate would increase net
revenue by $36.3 billion over 5 years and by $72.8 billion over 10 years.
Medicaid and SCHIP Provisions in H.R. 3162,
S. 1893/H.R. 976, and the Bicameral Agreement
Table 1 provides a brief description of current law and a side-by-side
comparison of the changes that would be made to Medicaid and SCHIP under
H.R. 3162, S. 1893/H.R. 976, and the bicameral agreement.7 Medicare provisions
in Titles II through VII of H.R. 3162, provisions related to support to injured
service members, military family job protection, and the Sense of the Senate
regarding health care access are not described in this report. A comparison of
some of the key provisions across all three bills is described below.
Funding/Financing. Allotments. Under current law, the SCHIP
appropriation for FY2007 (the last year for which there is an appropriation) was
just over $5 billion, with states’ allotments available for three years. Under the
House bill, allotments from FY2008 onward would be available for only two
years. Appropriations for FY2008 onward would be provided without a national
amount specified. The annual appropriation would be determined automatically
as the sum total of the allotments calculated for all the states and territories. For
FY2009 onward, states’ allotments would be based on either prior-year allotments
or prior-year spending. States would not be limited in the amount of prior-year
balances they could carry forward.
Under the Senate legislation, allotments from FY2007 onward would be
available for only two years. The FY2008 appropriation would be $9.125 billion,
rising to $16.0 billion in FY2012, with no appropriations provided thereafter. As
long as those amounts were adequate, states would be allotted in FY2009-FY2011
what they project to spend for the year in federal SCHIP expenditures plus 10%,
with the funds not used for states’ allotments going into a bonus pool. States
would be limited in the amount of prior-year balances they could carry forward.
The agreement uses the national appropriations and the FY2008 allotment
formula specified in the Senate legislation. For FY2009 to FY2012, the allotment
formula would be structured according to the House bill, in which the FY2009
and FY2011 allotments are based on the prior year’s allotment, and the FY2010
and FY2012 allotments are based on the prior year’s federal SCHIP spending. As
in the House legislation, the agreement would reduce SCHIP allotments’ period of


5 CBO, letter to the Honorable Max Baucus (September 25, 2007), available at
[ h t t p : / / www.cbo.gov/ f t pdocs/ 86xx/ doc8655/ hr 976.pdf ] .
6 For an explanation of why CBO’s cost estimate for national allotments in the agreement
shows savings in years beyond FY2012, see earlier footnote on the Senate bill.
7 Medicare provisions in Titles II through VII of H.R. 3162 are not described here.

availability to two years, beginning with the FY2008 allotment. Also like the
House bill, there is no limit in the amount of prior-year balances states could carry
forward.
The House legislation calls for bonus payments to states that (1) increase
their enrollment of children in Medicaid or SCHIP above certain levels and (2)
implement certain activities to encourage enrollment and retention among
Medicaid- and SCHIP-eligible children. Qualifying states would receive cash
payments as a percentage of the state share of their Medicaid/SCHIP expenditures,
though setting a higher bar and paying a lower percentage in SCHIP as compared
to Medicaid. The Senate bill would also provide bonus payments, but the
payments would be for increasing child enrollment in Medicaid, not in SCHIP. In
addition, the Senate bill does not require the implementation of the specific
enrollment and retention efforts. The payments would be based on fixed-dollar
amounts specified in the legislation. The bonus payments in the agreement are
structured after the House bill, except altered to yield smaller payments than under
the House bill.8
Limitations on SCHIP Matching Rate. Under current law, states can
set their upper income eligibility level for SCHIP at the higher of 200% of the
federal poverty level (FPL) or 50 percentage points above their income eligibility
level for Medicaid children prior to SCHIP’s enactment. However, by using
existing flexibility to define what “counts” as income, any state can raise its
effective SCHIP income eligibility level above 200% FPL through the use of
income disregards. The House, Senate, and agreement bills would not affect
states’ ability to use income disregards. However, the Senate and agreement bills
would reduce the federal reimbursement rate for costs associated with SCHIP
enrollees whose income would exceed 300% FPL without the use of certain
disregards. An exception would be provided for states that, on the date of
enactment, have federal approval or have enacted a state law to cover SCHIP
enrollees above 300% FPL.
Eligibility. With respect to eligibility, the House bill would allow states to
cover individuals up to age 21 (rather than age 19) in their SCHIP programs. This
provision is not in the agreement. Although some differences apply, both the
House and Senate bills would allow broader coverage of pregnant women under
SCHIP, in terms of eligibility and benefits, when certain conditions are met. The
agreement follows the Senate bill with some modifications based on the House
bill. The House bill would allow states to cover certain legal immigrants who
meet applicable categorical and financial eligibility requirements (i.e., pregnant
women and/or children under age 21) before such persons have been in the United
States for a minimum of five years as required under current law. The Senate bill
and the agreement do not include a comparable provision.


8 Over the five-year period of FY2008 to FY2012, CBO estimated the cost of the bonus
payments at $2.7 billion in the Senate bill, $10.8 billion in the House bill, and $2.6 billion
in the agreement.

Section 1115 of the Social Security Act allows the Secretary of HHS to
waive certain statutory requirements to modify virtually all aspects of Medicaid
and SCHIP as long as such changes further the goals of Titles XIX (Medicaid)
and/or XXI (SCHIP). States and the federal government have used the Section
1115 waiver authority to cover non-Medicaid and SCHIP services, limit benefit
packages for certain groups, cap program enrollment, cover groups such as non-
pregnant childless adults that are not otherwise eligible, among other purposes.
With respect to SCHIP coverage of adult populations (e.g., nonpregnant
childless adults and parents of Medicaid and SCHIP-eligible children), the House
bill would allow for such coverage as long as states ensure that they have not
instituted a waiting list for their SCHIP program, and that they have an outreach
program to reach all targeted low-income children in families with annual
incomes less than 200% FPL. By contrast, the Senate and the agreement bills
phase out SCHIP coverage of non-pregnant childless adults after two years, and in
FY2009, federal reimbursement for such coverage would be reduced to the
Medicaid federal medical assistance percentage (FMAP) rate. Coverage of
parents would still be allowed, but beginning in FY2010, allowable spending
under the waivers would be subject to a set aside amount from a separate
allotment and would be matched at the state’s regular Medicaid FMAP rate unless
the state is able to prove that it met certain coverage benchmarks (related to
performance in providing coverage to children). Finally, in FY2011 and FY2012,
the federal matching rate for costs associated with such parent coverage would be
reduced to a rate between the Medicaid and SCHIP rates for states that meet
certain coverage benchmarks, and to the state’s regular Medicaid FMAP for all
other states.
Enrollment/Access. Each of the bills include provisions to facilitate
access and enrollment in Medicaid and SCHIP. Among the major provisions, the
House and the agreement bills would create a state option to rely on a finding
from specified agencies to determine whether a child under age 19 (or an age
specified by the state not to exceed 21 years of age) has met one or more of the
eligibility requirements (e.g., income, assets or resources, citizenship, or other
criteria) necessary to determine an individual’s initial eligibility, eligibility
redetermination, or renewal of eligibility for medical assistance under Medicaid or
SCHIP. The Senate bill, by contrast, would allow up to 10 states to use Express9
Lane eligibility determinations for Medicaid and SCHIP enrollment and renewal
through a three-year demonstration program. Like the House and agreement bills,
the Senate bill does not relieve states of their obligation to determine eligibility
for Medicaid, and would require the state to inform families that they may qualify
for lower premium payments or more comprehensive health coverage under
Medicaid if the family’s income were directly evaluated by the state Medicaid
agency. All three bills would drop the requirement for signatures on a Medicaid
application form under penalty of perjury.


9 Express Lane eligibility refers to specified agencies that would be permitted to a streamline
the Medicaid and SCHIP eligibility determination and intake process to make it easier for
individuals to qualify for coverage.

Current law and regulations require that SCHIP plans include procedures to
ensure that SCHIP coverage does not substitute for coverage provided in group
health plans, also known as crowd-out. In mid-August, the Administration issued
a guidance letter explaining how CMS would apply existing requirements in
reviewing state requests to extend SCHIP eligibility to children with income
levels exceeding 250% FPL, including specified crowd-out strategies states would
be required to implement within one year. The agreement also includes a new
crowd-out provision. It would require states already covering children with
income exceeding 300% FPL (and beginning in 2010, new states that propose to
do so) to describe how they will address crowd-out and implement “best
practices” to avoid crowd-out (to be developed by the Secretary in consultation
with the states). Beginning in 2010, these higher income states cannot have a rate
of public and private coverage for low-income children that is less than the target
rate of coverage for low-income children (a measure to be calculated by the
Secretary representing the average rate of private and public coverage among the
10 states and DC with the highest percentage of such coverage.) States failing to
meet this requirement in a given fiscal year would not receive any federal SCHIP
payments for higher income children until they come into compliance with this
rule. States would develop corrective action plans and the Secretary would not be
permitted to deny payments if there is a reasonable likelihood that such plans
would bring affected states into compliance. Both the GAO and the IOM (with a
$2 million appropriation) would conduct related crowd-out analyses on best
practices and measurement accuracy, respectively. This provision supersedes the
August guidance letter.
Citizenship Documentation Rules. The House, Senate, and agreement
bills would make some similar modifications of existing Medicaid citizenship
documentation rules (e.g., by requiring additional documentation options for
federally recognized Indian tribes and specifying the reasonable opportunity
period for individuals who are required to present documentation). However, the
Senate and agreement bills would allow states to meet Medicaid citizenship
documentation requirements through name and Social Security number validation,
make citizenship documentation a requirement for SCHIP, provide an enhanced
match for certain administrative costs, and require separate identification numbers
for children born to women on emergency Medicaid. In contrast, the House bill
would make Medicaid citizenship documentation for children under age 21 a state
option, allow “Express Lane” agencies to determine eligibility without citizenship
documentation, and require eligibility audits to ensure that federal funds are not
spent on individuals who are not legal residents.
Premium Assistance/Employer Buy-In. The House bill would allow
the Secretary of Health and Human Services to establish a five-year demonstration
project under which up to 10 states would be permitted to provide SCHIP child
health assistance to children (and their families) to individuals who are
beneficiaries under a group health plan. The Senate and the agreement bills
would allow states to offer a premium assistance subsidy for qualified employer
sponsored coverage to all targeted low-income children who are eligible for child
health assistance and have access to such coverage, or to parents of targeted low-
income children. The agreement bill would also allow states to offer a premium
assistance subsidy for qualified employer sponsored coverage (ESI) to Medicaid-



eligible children and/or parents of Medicaid-eligible children where the family
has access to ESI coverage. In addition, the agreement specifies that family
participation in premium assistance programs would be optional.
Benefits. Both the House and Senate bills would make other changes to
covered benefits under SCHIP. With respect to dental care, the agreement
includes selected provisions from both the House and Senate bills, as well as new
provisions. States would have the option to provide “benchmark dental benefit
packages” meeting certain requirements and would be available through FEHBP,
state employee coverage, and commercial HMOs. The House bill would also
require the Secretary of HHS to implement a program to educate new parents
about the importance of oral health care for infants, and would require states to
report data on the receipt of dental services for SCHIP children, both of which are
included in the agreement. In the Senate bill, a new grant would be authorized to
improve the availability of dental services and strengthen dental coverage for
children under SCHIP. The agreement includes a provision in the Senate bill to
make available to the public information on dental providers and covered dental
benefits. GAO would be required to evaluate access to dental care under both the
House and Senate bills, and in the agreement. In addition, the Senate bill and the
agreement include a new mental health parity provision for SCHIP, while the
House bill would broaden the scope of coverage for mental health services under
certain SCHIP benefit plans. Provisions to reduce diabetes in children are
included in both the House and Senate bills. The House bill would extend
funding for existing diabetes programs authorized under the Public Health
Services Act, while the Senate bill would create a new demonstration project to
promote screening and improvements in diet and physical activity. The agreement
follows the Senate bill. Finally, for the benchmark package option under
Medicaid, established in the Deficit Reduction Act of 2005 (P.L. 109-171), both
the House and Senate bills, and the agreement, would require coverage of the
Early and Periodic Screening, Diagnostic and Treatment (EPSDT), benefit for
individuals under 21 (rather than under age 19).
Monitoring Quality. There are other new initiatives to improve access and
quality of care for children under Medicaid and SCHIP, including a new federal
commission (House bill only), child health care quality measurement programs
(both the House and Senate bills, and the agreement), and a second federal SCHIP
evaluation (House bill and the agreement).
Payments. With respect to payment policies, both the House and Senate
bills would require that payments for Federally Qualified Health Care Centers
(FQHCs) and Rural Health Centers (RHCs) under SCHIP follow the prospective
payment system for such services under Medicaid. The House bill would prohibit
the Secretary of HHS from taking actions to further restrict Medicaid coverage or
payments for rehabilitation services or for certain school-based services beyond
policies in effect as of July 1, 2007. This prohibition would continue for one year
after the date of enactment of this provision. However, in mid-August and early
September, the Administration issued proposed rules for such payments. The
agreement is the same as the House bill except that the Secretary would be
prohibited from taking any action prior to May 28, 2008. Finally, the federal and
state governments are required to monitor and take actions to reduce erroneous



payments under both Medicaid and SCHIP. The two systems for conducting these
evaluations are the Medicaid Eligibility Quality Control (MEQC) program and the
newer Payment Error Rate Measurement (PERM) program. In mid-August, the
Administration issued a final rule for PERM. The Senate bill and the agreement
stipulate several requirements for a final rule on PERM and require the Secretary
of HHS to coordinate these two systems and reduce redundancies.



CRS-9
Table 1. Medicaid and SCHIP Provisions
rity Act; references; table of contents.
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
References to Title XXI; Elimination of Confusing Program References
ision in P.L. 106-113 directed theH§155. References to Title XXI. TheS§606. Elimination of confusingA§1. Short Title; Amendments to
tary of HHS or any other federalprovision would repeal this section ofprogram references. Same as HouseSocial Security Act; References;
ployee, with respect toP.L. 106-113. Thus, for officialbill.Table of Contents. The provision
ram under Titlepublication and communicationwould apply the following short title to
iki/CRS-RL34129I, in any publication or officialpurposes, the provision would reinstatethe bill, “Children’s Health Insurance
g/wmunication to use the term“CHIP” and “children’s healthProgram Reauthorization Act of 2007;”
s.orHIP” instead of “CHIP” and to useinsurance program,” as applicable, whenspecify that amendments made by this
leakerm “State children’s healthreferencing Title XXI.bill would be made to the Social
://wikiurance program” instead ofram.”Security Act; and, like the House bill,would reinstate “CHIP” and “children’s
httphealth insurance program,” as
applicable, when referencing Title XXI.
A§612. References to Title XXI.
Same as the House bill.



CRS-10
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
F undi ng/ F i nanci ng
cial SecurityH§101. Establishment of new baseS§101. Extension of CHIP. TheA§101. Extension of CHIP. Same as
t specifies the following SCHIPCHIP allotments. Appropriations forfollowing national appropriationSenate bill.
ation amounts (of which theFY2008 onward would be providedamounts would be specified for CHIP in
eive 0.25%): $4.3 billionwithout a national amount specified.§2104(a): $9.125 billion in FY2008;
FY1998 to FY2001;The annual appropriation would be$10.675 billion in FY2009; $11.85
llion annually from FY2002 todetermined automatically as the sumbillion in FY2010; $13.75 billion in
iki/CRS-RL341292004; $4.05 billion in FY2005 and2006; and $5.0 billion in FY2007.total of the allotments calculated for allthe states and territories. No end yearFY2011; and two semiannualinstallments of $1.75 billion each in
g/w amounts are specified for FY2008would be specified; the program couldFY2012.
s.orreceive annual appropriations in
leakperpetuity.S§103. One-time appropriation. AA§108. One-time appropriation.
separate appropriation of $12.5 billionSame as Senate bill.
://wikiwould be provided for CHIP allotments
httpin the first half of FY2012.
CHIP funds to states
e national SCHIP amount available toH§101. Establishment of new baseS§102. Allotments for the 50 statesA§102. Allotments for states and
is allotted primarily on the basisCHIP allotments. FY2008. Generally,and the District of Columbia.territories. FY2008. Same as Senate
ates of each state’s number ofa state’s FY2008 allotment would be theFY2008. For FY2008, a state’sbill.


dren who are low income (that is,greater of (1) its own projection ofallotment would be calculated as 110%
h family income below 200% of thefederal CHIP expenditures in FY2008,of the greatest of the following four
eral poverty threshold) and thebased on the state’s May 2007amounts: (1) the state’s FY2007 federal
ber of such children who aresubmission to CMS, and (2) the state’sCHIP spending multiplied by the annual

CRS-11
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
he source of data is theFY2007 CHIP allotment multiplied byadjustment (described below); (2) the
e of the number of such childrenthe allotment increase factor (describedstate’s FY2007 federal CHIP allotment
d on the three most recent Annualbelow). If the state enacted legislationmultiplied by the annual adjustment; (3)
cial and Economic (ASEC)during 2007 that would expandfor states that receive federal CHIP
ents (formerly known as theeligibility or improve benefits, the statefunds in FY2007 because of their
rch supplements) to the Censusmay use its August 2007 submission ofshortfalls, or states that were projected
eyexpenditure projections instead.to be in shortfall based on their
fore the beginning of theNovember 2006 submission of projected
endar year in which the applicableexpenditures, the state’s FY2007
cal year begins. The estimates areprojected federal spending as of
iki/CRS-RL34129usted to account for geographicNovember 2006 (or as of May 2006, for
g/win health costs (calculated asa state whose May 2006 projection was
s.orch state’s variation from the$95 million to $96 million higher than
leakerage in its average wages inits November 2006 projection, a
://wiki health services industry). A ceilingprovision that affects only North
httpe to ensure that a state’srtion of the total availableCarolina) multiplied by the annualadjustment; and (4) the state’s FY 2008
federal CHIP projected spending as of
share of funds in FY1999. InAugust 2007 and certified by the state
there are three floors to ensurenot later than September 30, 2007.
below
els.
Adjustment for cost and childAdjustment for cost and childAdjustment for cost and child
population growth. The allotmentpopulation growth. The annualpopulation growth. Same as House bill.


increase factor would be the product ofadjustment for health care cost growth
(1) the per capita health care growthand child population growth is the

CRS-12
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
factor, and (2) the child populationproduct of (1) 1 plus the percentage
growth factor. The per capita healthincrease (if any) in the nominal
care growth factor would be 1 plus theprojected per capita spending in
percentage increase in the projected perNational Health Expenditures for the
capita amount of National Healthyear over the prior year, and (2) 1.01
Expenditures over the prior year’s. Theplus the percentage change in the child
child population growth factor would bepopulation (under age 19) in each state,
1.01 plus the percentage increase (ifbased on the most timely and accurate
any) in the population of children underpublished estimates from the Census

19 years of age in the state, based on theBureau.


iki/CRS-RL34129most recent published estimates from
g/wthe Census Bureau.
s.or
leakFY2009 onward. For FY2009 and everyFY2009 to FY2012. For FY2009 toFY2009 to FY2012. Similar to House
future odd-numbered fiscal year, aFY2011, a state’s allotment would bebill. The FY2009 allotment and the
://wikistate’s federal CHIP allotment would becalculated as 110% of its projectedFY2011 allotment would be the state’s
httpequal to the prior year’s allotmentspending for that year. prior-year allotment, plus amounts
(including “performance-based shortfallreceived by the state in the prior year
adjustment” described below)from the contingency fund (similar to
multiplied by the allotment increasethe House bill’s shortfall adjustment)
factor. multiplied by the allotment increase
factor.
For FY2010 and every futureThe regular CHIP appropriationsFor FY2010, similar to House bill: A
even-numbered fiscal year, a state’savailable to states in FY2012 (that is,state’s federal CHIP allotment would be
federal CHIP allotment would bethe $1.75 billion provided semi-“rebased.” The state’s allotment would
“rebased.” In these years, the state’sannually reduced by payments to thebe the FY2009 federal CHIP
allotment would be the prior year’sterritories) would be calculated usingexpenditures (from the state’s available



CRS-13
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
federal CHIP expenditures multiplied bystates’ projected federal CHIP spendingallotments, contingency funds, and
the allotment increase factor.allocable to each semi-annual period.redistribution funds) multiplied by the
The one-time appropriation of $12.5allotment increase factor.
billion in §103 of the legislation is to beFor FY2012, although the national
treated in the same manner as the $1.75appropriation is the same as the Senate
billion appropriation for the first semi-bill, the funds would be allotted to states
annual allotment. If the availablebased on the House bill’s rebasing to
national allotment for a semi-annualFY2011 federal CHIP expenditures
period in FY2012 exceeds the amount to(though accommodating the semi-
be allotted in that period based onannual nature of the national
iki/CRS-RL34129states’ projected CHIP expenditures, theappropriation). Specifically, the full-
g/wremaining amount would be allottedyear allotment amount for FY2012
s.orproportionally based on each state’swould be calculated as the state’s
leakshare of the allotment calculated for thatFY2011 federal CHIP expenditures
://wikiFY2012 period.(from the state’s available allotments,
httpcontingency funds, and redistributionfunds) multiplied by the allotment
increase factor. Approximately 89% of
this amount would be allotted on
October 1, 2011, and the remainder
would be allotted on April 1, 2012.
Increase in allotment to account for
approved program expansions. For
determining allotments in FY2009 to
FY2011, if a state has an approved State
Plan Amendment (SPA) or waiver to



CRS-14
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
expand CHIP eligibility or benefits and
if the state requests an expansion
allotment adjustment that specifies (i)
the additional expenditures attributable
to the expansion by not later than
August 31 before the beginning of the
fiscal year and (ii) the extent to which
the additional expenditures are projected
to exceed the allotment, the amount of
the state’s allotment would be increased
iki/CRS-RL34129by the amount in (i).
g/w
s.orIf national appropriation is inadequate.If national appropriation is inadequate.
leakFor FY2008, if the state allotments asFor FY2008 to FY2012, if the state
calculated exceed the available nationalallotments as calculated exceed the
://wikiallotment, states’ allotments would beavailable national allotment, states’
httpreduced proportionally.allotments would be reduced
For FY2009 to FY2012, if the stateproportionally.


allotments as calculated exceed the
available national allotment, then the
available national allotment would be
distributed among states using a
different formula. It would calculate
each state’s share (percentage) of the
available national allotment primarily
based on states’ own projected CHIP
expenditures for that fiscal year.

CRS-15
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
Increases in states’ projected spending.
If a state’s projected CHIP expenditures
for FY2009 to FY2012 are at least 10%
more than the allotment calculated for
the preceding fiscal year (regardless of
the computation used if the national
appropriation was inadequate) and,
during the preceding fiscal year, the
state did not receive approval for a
CHIP state plan amendment or waiver
iki/CRS-RL34129to expand CHIP coverage or did not
g/wreceive a CHIP Contingency Fund
s.orpayment, then the state would be
leakrequired to submit to the Secretary by
://wikiAugust 31 of the preceding fiscal year
httpinformation relating to the factors thatcontributed to the increase as well as
any additional information requested by
the Secretary. The Secretary would be
required to review the information and
provide a response in writing within 60
days as to whether the states’
projections of CHIP expenditures are
approved or disapproved (and if
disapproved, reasons for disapproval),
or specified additional information. If
disapproved or requested to provide



CRS-16
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
additional information, the state would
be provided with reasonable opportunity
to submit additional information. If the
Secretary has not determined by
September 30 whether the state has
demonstrated the need for the increase
in the succeeding fiscal year’s
allotment, a provisional allotment would
be provided based on 110% of the
allotment calculated for the preceding
iki/CRS-RL34129fiscal year (regardless of the
g/wcomputation used if the national
s.orappropriation was inadequate) and may
leakadjust the allotment by not later than
://wikiNovember 30.
httpDeadline and data for determiningDeadline and data for determining
FY2008 allotments. For calculating theFY2008 allotments. Same as Senate
FY2008 allotments to states andbill.


territories, the Secretary would be
required to use the most recent data
available before the start of the fiscal
year but may adjust the allotments as
necessary on the basis of actual
expenditure data for FY2007 submitted
no later than November 30, 2007. The
Secretary could make no adjustments

CRS-17
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
for FY2008 after December 31, 2007.
IP funds to territories
ing 0.25% of theH§101. Establishment of new baseS§104. Improving funding for theA§102. Allotments for states and
ional SCHIP appropriation in SectionCHIP allotments. There would be noterritories under CHIP and Medicaid.territories. As in both the House and
urity Act, theseparate CHIP appropriation for the There would be no separate CHIPSenate bills, there would be no separate
lowing SCHIP appropriation amountsterritories. Beginning with FY2008, theappropriation for the territories.CHIP appropriation for the territories;
re specified for the territories: Theallotment to a territory orFY2008. Each territory’s allotmentas with the states, the territories’
followingcommonwealth would be equal to itswould be its highest annual federalallotments would come entirely from
iki/CRS-RL34129propriation amounts in): $32 million in FY1999;prior year federal CHIP expendituresmultiplied by the per capita health careCHIP spending between FY1998 andFY2007, plus the annual adjustment forthe national appropriation. FY2008.Same as Senate bill. FY2009 to
g/w million in FY2000 and FY2001;growth factor (described above) and byhealth care cost growth and nationalFY2012. Territories would be treated
s.orillion in FY2002 to FY2004;1.01 plus the percentage increase (ifchild population growth describedlike states (that is, allotments in FY2009
leak4 million in FY2005 and FY2006;any) in the population of children underabove. FY2009 to FY2012. Eachand FY2011 based on prior-year
://wikiillion in FY2007. The19 years of age in the United States.territory’s allotment would be the priorallotment, and allotments in FY2010
httpounts set aside for the territories areyear’s allotment, plus the annualand FY2012 based on prior-year
to the percentagesadjustment for health care cost growthspending).


ico,and national child population growth. In
Guam, 3.5%; the Virgin Islands,FY2012, 89% of the amount to be
%; American Samoa, 1.2%; and theallotted to the territories would be
slands, 1.1%. allotted in the first half of the fiscal
year, with the remaining 11% allotted in
the second half of the fiscal year.

CRS-18
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
riod of availability of CHIP allotments
HIP allotments are available for threeH§102. 2-year initial availability ofS§109. Two-year availability ofA§105. 2-year initial availability of
CHIP allotments. Beginning with theallotments; expenditures countedCHIP allotments. Same as House bill.
FY2008 allotment, CHIP allotmentsagainst oldest allotments. Beginning
would be available for two years.with the FY2007 allotment, CHIP
allotments would be available for two
years. Notwithstanding the period of
availability, states would forgo from
their unspent FY2006 and FY2007
iki/CRS-RL34129allotments the amount by which those
g/wallotments not expended by September
s.or30, 2007, exceeded 50% of the FY2008
leakallotment. On October 1 of fiscal years
2009 to 2012, states would also forgo
://wikithe amount by which the unspent funds
httpfrom the prior year’s allotment
exceeded a particular percentage of that
allotment (that is, 20% in FY2009, and

10% in FY2010, FY2011, and FY2012).


ents unspent after three years areH§102. 2-year initial availability ofS§105. Incentive bonuses for states.A§106. Redistribution of unused
states thatCHIP allotments. H§103.Redistribution of unspent FY2005allotments to address state funding
entRedistribution of unused allotmentsallotments. FY2005 allotments unspentshortfalls. Redistribution of unspent
the end of the three-year period ofto address state funding shortfalls.after their three-year period ofFY2005 allotments. Same as Senate
ilability. The HHS SecretaryRedistribution of unspent FY2005availability would be redistributed onlybill, except that it would not apply if the



CRS-19
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ines how the funds areallotments and subsequent allotments.to states that met the third criteria usedredistribution of FY2005 funds had
n the pastOnly a shortfall state (that is, a state thatin calculating the base allotment foralready occurred by the bill’s date of
ple of years, redistributed funds havethe Secretary estimates will have federalFY2008 (that is, states that receivedenactment. Redistribution of
exclusively to shortfall states (i.e.,CHIP expenditures that exceed itsfederal CHIP funds in FY2007 becausesubsequent allotments. Same as House
ere projected to exhaust allavailable prior-year allotment balances,of their shortfalls, states that werebill.


available SCHIP allotments duringits performance-based shortfallprojected to be in shortfall in FY2007
ear) and sometimes the territories.adjustment, and its allotment for thebased on their November 2006
fiscal year) would be eligible to receivesubmission of projected expenditures, or
redistributed funds. If the fundsstates whose May 2006 projection was
redistributed to a state based on its$95 million to $96 million higher than
iki/CRS-RL34129projected shortfall are not spent by theits November 2006 projection). For
g/wend of the fiscal year, they would bethese states, the unspent FY2005 funds
s.oravailable for redistribution to otherwould be redistributed in proportion to
leakstates in the next fiscal year. If the totaltheir FY2007 allotment. Redistribution
://wikiamount available for redistributionof subsequent allotments. None
httpexceeds the projected shortfalls, theremaining amounts would be availableprovided. Unspent funds fromsubsequent allotments used for bonus
for redistribution in the next fiscal year.payments, discussed below.
If the total amount available for
redistribution is less than the projected
shortfalls, the amounts provided to
shortfall states would be reduced
proportionally. The Secretary could
adjust the amounts redistributed based
on actual expenditure data as submitted
not later than November 30 of the
succeeding fiscal year.

CRS-20
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
H§101. Establishment of new baseS§108. CHIP contingency fund.A§103. Child enrollment contingency
CHIP allotments. Source of funds.Source of funds. A CHIP Contingencyfund. Source of funds. Similar to the
Performance-based shortfall adjustmentFund would be established in the U.S.Senate bill, a Child Enrollment
would be calculated as part of a state’sTreasury. The Contingency Fund wouldContingency Fund would be established
allotment, which is not subject to a cap.receive deposits through a separatein the U.S. Treasury. The Contingency
appropriation. For FY2009, itsFund would receive deposits through a
appropriation would be 12.5% of theseparate appropriation. For FY2008, its
CHIP available national allotment. Forappropriation would be 20% of the
FY2010 through FY2012, theCHIP available national allotment. For
appropriation would be such sums as areFY2010 through FY2012, the
iki/CRS-RL34129necessary for making payments toappropriation would be such sums as are
g/weligible states for the fiscal year, as longnecessary for making payments to
s.oras the annual payments did not exceedeligible states for the fiscal year, as long
leak12.5% of that fiscal year’s CHIPas the annual payments did not exceed
://wikiavailable national allotment. Balances20% of that fiscal year’s CHIP available
httpthat are not immediately required forpayments from the Fund would benational allotment. Balances that are notimmediately required for payments
invested in U.S. securities that providefrom the Fund would be invested in U.S.
additional income to the Fund. Amountssecurities that provide additional
in excess of the 12.5% limit shall beincome to the Fund. Amounts in excess
deposited into the Incentive Pool. Forof the 20% limit shall be deposited into
purposes of the CHIP Contingencythe Incentive Pool.


Fund, amounts set aside for block grant
payments for transitional coverage of
childless adults shall not count as part of
the available national allotment.
Payments from the Fund are to be used

CRS-21
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
only to eliminate any eligible state’s
shortfall (that is, the amount by which a
state’s available federal CHIP
allotments are not adequate to cover the
state’s federal CHIP expenditures).
Payments. A payment would be madePayments. The Secretary wouldPayments. Same as House bill except
to a state if (1) its federal CHIPseparately compute the shortfallsfor the following: If funds balances are
expenditures in a fiscal year (beginningattributable to children and pregnantnot enough to make payments, then
with FY2008) exceeds the amount ofwomen, to childless adults, and topayments would be reduced
iki/CRS-RL34129federal CHIP allotments available to theparents of low-income children. Noproportionally; the Comptroller General
g/wstate (not including any available CHIPpayment from the Contingency Fundwould not be required to audit the data
s.orfunds redistributed from other states),shall be made for nonpregnant childlessused in determining contingency fund
leakand (2) its average monthly enrollmentadults. Any payments for shortfallspayments; payments based on a fiscal
of children in CHIP exceeded the targetattributable to parents shall be madeyear’s data would occur in that fiscal
://wikienrollment number for the year. Forfrom the Fund at the relevant matchingyear, with reconciliation committed
httpFY2008, the target number is therate. Eligible states for any month inbased on the submission of actual
average monthly CHIP enrollment inFY2009 to FY2012 are those that meetexpenditures.


FY2007 increased by 1% and by theany of the following criteria: (1) The
state’s child population growth. Forstate’s available federal CHIP
subsequent fiscal years, the targetallotments are at least 95% but less than
number is the prior year’s target number100% of its projected federal CHIP
increased by 1% and by the state’s childexpenditures for the fiscal year (i.e., less
population growth. The adjustmentthan 5% shortfall in federal funds),
would be calculated as the product ofwithout regard to any payments
(1) the amount by which the actualprovided from the Incentive Pool; or
average monthly caseload exceeded the(2) The state’s available federal CHIP

CRS-22
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
target number of enrollees, and (2) theallotments are less than 95% of its
state’s projected per capita CHIPprojected federal CHIP expenditures for
expenditures (state and federal)the fiscal year (i.e., more than 5%
multiplied by the enhanced FMAP forshortfall in federal funds) and that such
the state for the fiscal year involved.shortfall is attributable to one or more of
The adjustment would only be availablethe following: (a) One or more parishes
in the fiscal year in which it wasor counties has been declared a major
provided and would not be available fordisaster and the President has
redistribution if unspent. Thedetermined individual and public
Comptroller General would be requiredassistance has been warranted from the
iki/CRS-RL34129to periodically audit the accuracy of thefederal government pursuant to the
g/wdata used for the allotment adjustmentStafford Act, or a public health
s.orand make recommendations to Congressemergency was declared by the
leakand the Secretary as the ComptrollerSecretary pursuant to the Public Health
://wikiGeneral deems appropriate.Service Act; (b) the state unemployment
httprate is at least 5.5% during anyconsecutive 13 week period during the
fiscal year and such rate is at least 120%
of the state unemployment rate for the
same period as averaged over the last
three fiscal years; (c) the state
experienced a recent event that resulted
in an increase in the percentage of
low-income children in the state without
health insurance that was outside the
control of the state and warrants
granting the state access to the Fund, as



CRS-23
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
determined by the Secretary.
Application to territories. TerritoriesApplication to territories. Territories
would not be eligible for contingencywould be eligible for contingency fund
fund payments.payments once the Secretary determines
there are satisfactory methods for
collecting and reporting the necessary
enrollment information reliably.
The Secretary shall make monthly
iki/CRS-RL34129payments from the Fund to all statesdetermined eligible for a month. If the
g/wsum of the payments from the Fund
s.orexceeds the amount available, the
leakSecretary shall reduce each payment
://wiki proportionally.
httptension of option for qualifying states
ing states, federal SCHIPH§104. Extension of option for S§111. Option for qualifying states toA§107. Option for qualifying states to
may be used to pay the differencequalifying states. In addition to thereceive the enhanced portion of thereceive the enhanced portion of the
en SCHIP’s enhanced Federalcurrent-law provisions, qualifying statesCHIP matching rate for MedicaidCHIP matching rate for Medicaid
l Assistance Percentage (FMAP)would also be able to use the entirety ofcoverage of certain children. coverage of certain children. Same as
P that the state isany allotment from FY2008 onward forQualifying states under §2105(g) maySenate bill.


receiving for children aboveCHIP spending under §2105(g).also use available balances from their
of poverty who are enrolled inCHIP allotments from FY2008 to
Qualifying statesFY2012 to pay the difference between
ited in the amount they can claimthe regular Medicaid FMAP and the
the lesser of(1) 20%CHIP enhanced FMAP for Medicaid

CRS-24
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
the state’s original SCHIP allotmentenrollees under age 19 (or age 20 or 21,
ounts (if available) fromif the state has so elected in its Medicaid
FY2001 and FY2004-FY2007;plan) whose family income exceeds
available balances of133% of poverty.
allotments. The statutory
ing states capture
st of those that had expanded their
income eligibility levels for
in their Medicaid programs to
erty prior to the enactment
iki/CRS-RL34129CHIP. Based on statutory
g/wstates were determined to
s.oring states: Connecticut,
leakland, Minnesota, New
://wikipshire, New Mexico, Rhode Island,
httpnnessee, Vermont, Washington and
enrollment of children
ision. H§111. CHIP performance bonusS§105. Incentive bonuses for states. A§104. CHIP performance bonus
payment to offset additionalA CHIP Incentive Bonuses Pool wouldpayment to offset additional
enrollment costs resulting frombe established in the U.S. Treasury, toenrollment costs resulting from
enrollment and retention efforts. be used for any purpose the stateenrollment and retention efforts.
From FY2009 to FY2013, performancedetermines is likely to reduce theLike the House bill, from FY2009 to
bonus payments would be paid to statespercentage of low-income children inFY2013, performance bonus payments
implementing specified enrollment andthe state without health insurance.would be paid to states implementing
retention efforts and enrolling eligiblespecified enrollment and retention



CRS-25
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
children above specified target levels.efforts and enrolling eligible children
above specified target levels.
Source of funds. No source ofSource of funds. The Incentive PoolSource of funds. Like the Senate bill,
appropriations specified.would receive deposits from an initialthe bonus pool would receive an initial
appropriation in FY2008 of $3 billion,deposit of $3 billion in FY2008, to be
along with transfers from six differentavailable until expended, along with
potential sources, with currentlytransfers from four different potential
available but not immediately requiredsources. The four additional sources for
funds invested in interest-bearing U.S.deposits would be as follows: (1) from
iki/CRS-RL34129securities that provide additional2008 to 2012, any of the national CHIP
g/wincome into the Incentive Pool. appropriation not allotted to the states;
s.orThe six additional sources for deposits(2) as of November 15 of fiscal years
leakwould be as follows: (1) On December2009 through 2012, the amount of
31, 2007, the amount by which states’unspent allotments available for
://wikiFY2006 and FY2007 allotments notredistribution that were not used for
httpexpended by September 30, 2007,redistribution to shortfall states or were
exceed 50% of the FY2008 allotment;not spent by those states; (3) on October
(2) from 2008 to 2012, any of the1 of FY2009 through FY2012, any
national CHIP appropriation not allottedamounts in the CHIP Contingency Fund
to the states; (3) on October 1 of fiscalin excess of the fund’s aggregate cap;
years 2009 to 2012, the amount byand (4) on October 1, 2009, any
which the unspent funds from the prioramounts set aside for transition off of
year’s allotment exceeds a particularCHIP coverage for childless adults that
percentage of that allotment (that is,are not expended by September 30,

20% in FY2009, and 10% in FY2010,2009.


FY2011, and FY2012); (4) any original

CRS-26
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
allotment amounts not expended by the
end of their second year of availability
(beginning with the FY2007 allotment);
(5) on October 1, 2009, any amounts set
aside for transition off of CHIP
coverage for childless adults that are not
expended by September 30, 2009; and
(6) on October 1 of FY2009 through
FY2012, any amounts in the CHIP
Contingency Fund in excess of the
iki/CRS-RL34129fund’s aggregate cap, as well as any
g/wContingency Fund payments provided
s.orto a state that are unspent at the end of
leakthe fiscal year following the one in
://wikiwhich the funds were provided.
httpQualifying for bonus payments. StatesQualifying for bonus payments. Funds
that implement at least 4 out of 7from the Incentive Pool would be
specified enrollment and retentionpayable in FY2009 to FY2012 to states
efforts (that is, continuous eligibility,that have increased their average
liberalization of asset requirements,monthly Medicaid enrollment among
elimination of in-person interviewlow-income children (with children
requirement, use of joint application fordefined as those under age 19 — or
Medicaid and CHIP, automatic renewal,under age 20 or 21 if a state has so
presumptive eligibility for children, andelected in its Medicaid program) during
express lane) would be eligible toa coverage period above a baseline
receive a bonus payment not later thanmonthly average for the state.Qualifying



CRS-27
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
the last day of the first calendar quarterfor bonus payments. Same as House
of the following fiscal year. Thebill.
amount would be the sum of payments
calculated for the number of child
enrollees in each of two “tiers” in
Medicaid as well as in CHIP (reflecting
certain levels of enrollment growth)
multiplied by a percentage of the state’s
share of projected Medicaid and CHIP
per capita expenditures.
iki/CRS-RL34129
g/wBaseline enrollment. The baselineBaseline enrollment. The coverageBaseline enrollment. Same as House
s.ornumber of child enrollees for FY2008period for FY2009 would be the firstbill.


leakwould be equal to the monthly averagetwo quarters of FY2009. The baseline
number of child enrollees duringmonthly average would be the average
://wikiFY2007 increased by child populationmonthly enrollment of low-income
httpgrowth for the year ending on June 30,children in Medicaid in the first two
2006 (as estimated by the Censusquarters of FY2007 multiplied by the
Bureau) plus one percentage point. Forsum of 1.02 and percentage population
a subsequent fiscal year, the baselinegrowth among low-income children in
number would be equal to the priorthe state from FY2007 to FY2009.
year’s baseline number plus child
population growth in that state plus oneFor FY2010 to FY2012, the coverage
percentage point.period would consist of the last two
quarters of the preceding fiscal year and
For such calculations, projected perthe first two quarters of the fiscal year.
capita state expenditures would beFor FY2010 to FY2012, the baseline

CRS-28
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
defined as projected average per capitamonthly average would be the baseline
federal and state Medicaid and CHIPmonthly average for the preceding fiscal
expenditures for children for the mostyear multiplied by the sum of 1.01 and
recent fiscal year, increased by thepercentage population growth among
annual percentage increase in per capitalow-income children in the state over
amounts of National Healththe prior year.
Expenditures for the respective
subsequent fiscal year, and multiplied
by the state’s share of such expenditures
required for the fiscal year involved.
iki/CRS-RL34129
g/wQualifying children. Average monthlyQualifying children. Average monthlyQualifying children. Same as House
s.orenrollment and the baseline averagesenrollment and the baseline averagesbill.
leakwould consist only of Medicaid- andwould exclude Medicaid-enrolled
CHIP-enrolled children who wouldchildren who would not meet the
://wikimeet the eligibility criteria (includingincome eligibility criteria in effect on
httpincome, categorical eligibility, age andJuly 19, 2007.
immigration status criteria) in effect on
July 1, 2007.
Amount of bonus payments. The firstAmount of bonus payments. A stateAmount of bonus payments. Same as
tier of child enrollment would be theeligible for a bonus would receive in theHouse bill, except for the percentage of
amount by which the monthly averagelast quarter of FY2009 the followingthe state share of expenditures used to
of children enrolled during the fiscalamounts, depending on the “excess” ofcalculate bonus payments. For the first
year exceeded the baseline number, butthe state’s enrollment of children intier above baseline child Medicaid
by no more than 3% for Medicaid orMedicaid above the baseline monthlyenrollment, the state would receive 15%
7.5% for CHIP. For the first tier aboveaverage during the coverage period: (i)of the state share of those projected
baseline child Medicaid enrollment, theIf the excess does not exceed 2%, theexpenditures. For the first tier above



CRS-29
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
state would receive 35% of the stateproduct of $75 and the number ofbaseline child CHIP enrollment, the
share of those projected expenditures.individuals in such excess; (ii) if thestate would receive 10% of the state
For the first tier above baseline childexcess is more than 2% but less thanshare of those projected expenditures.
CHIP enrollment, the state would5%, the product of $300 and the number
receive 5% of the state share of thoseof individuals in such excess, less the
projected expenditures.amount in (i); and (iii) if the excess
exceeds 5%, the product of $625 and the
number of individuals in such excess,
less the sum of the amounts in (i) and
(ii).
iki/CRS-RL34129
g/wThe second tier of child enrollmentFor FY2010 onward, these dollarFor the second tier above baseline child
s.orwould be the amount by which theamounts would be increased by theMedicaid enrollment, the state would
leakmonthly average of children enrolledpercentage increase (if any) in thereceive 60% of the state share of those
during the fiscal year exceeded theprojected per capita spending in theprojected expenditures. For the second
://wikibaseline number by 3% for Medicaid orNational Health Expenditures for thetier above baseline child CHIP
http7.5% for CHIP. For the second tiercalendar year beginning on January 1 ofenrollment, the state would receive 40%
above baseline child Medicaidthe coverage period over that of theof the state share of those projected
enrollment, the state would receive 90%preceding coverage period.expenditures.
of the state share of those projected
expenditures. For the second tier above
baseline child CHIP enrollment, the
state would receive 75% of the state
share of those projected expenditures.
If the funds in the Incentive Pool wereSame as Senate bill.


inadequate to cover the amounts
calculated for all the eligible states, the

CRS-30
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
amount would be reduced
proportionally.
Application to territories. Territories
would be eligible for bonus payments
once the Secretary determines there are
satisfactory methods for collecting and
reporting the necessary enrollment
information reliably.
iki/CRS-RL34129The Government Accountability Office(GAO) would be required to submit a
g/wreport for Congress not later than
s.orJanuary 1, 2013, regarding the
leakeffectiveness of the performance bonus
://wikipayment program in enrolling and
httpretaining uninsured children in
Medicaid and CHIP.
federal funding for illegal aliens
Medicaid program,H§135. No federal funding for illegalNo provision.A§605. No federal funding for illegal
ed aliens who meet all otheraliens. The House bill would specifyaliens. Same as the House bill.


ram criteria are only eligible forthat nothing in the bill allows federal
ergency coverage. Under SCHIP,payment for individuals who are not
ay opt to cover unauthorizedlegal residents.
nant, but covered
ces must be related to the
nancy or to conditions that could

CRS-31
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
plicate the pregnancy or threaten
unborn child (who will
a U.S. citizen if he or she is born in
nited States).
rams in the territories areH§811. Payments for Puerto Rico andNo provision.No provision.
ect to spending caps. For FY1999territories. Would increase the territory
ears, these capsMedicaid caps by the following
iki/CRS-RL34129creased by the percentage changeedical care component of theamounts:
g/wer Price Index (CPI-U) for all
s.orers (as published by the
leakreau of Labor Statistics). The Deficit
://wikiuction Act of 2005 increased the
http
2006 and FY2007. For FY2007 the
For Puerto Rico, $250,400,000. For Puerto Rico, $250,000,000 for
FY2009; $350,000,000 for FY2010;
$500,000,000 for FY2011; and
$600,000,000 for FY2012.
For the Virgin Islands, $12,520,000. For the Virgin Islands, $5,000,000
for each of fiscal years 2009
through 2012.



CRS-32
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
For Guam, $12,270,000. For Guam, $5,000,000 for each of
fiscal years 2009 through 2012.
For the Northern Mariana Islands, For the Northern Mariana Islands,
$4,580,000. $4,000,000 for each of fiscal years

2009 through 2012.


For American Samoa $8,290,000. For American Samoa, $4,000,000
for each of fiscal years 2009
through 2012.
iki/CRS-RL34129r FY2008 and subsequent fiscal
g/wal annual cap on federal
s.or for the Medicaid programs in
leak
the FY2007 ceiling for
://wiki
http
data systems in the territories
e federal Medicaid matching rate,H§811. Payments for Puerto Rico andS§104. Improving funding for theA§109. Improving funding for the
ich determines the federal share ofterritories. Beginning with FY2008, ifterritories under CHIP and Medicaid.territories under CHIP and Medicaid.
st Medicaid expenditures, isa territory qualifies for the enhancedSame as the House bill, but would alsoSame as Senate bill.


set at 50 percent in thefederal match (90% or 75%) that isrequire a GAO study (due to Congress
atch is alsoavailable under Medicaid forno later than September 30, 2009)
inistrativeimprovements in data reporting systems,regarding federal funding under
herefore, the federalsuch reimbursement would not countMedicaid and CHIP in the territories.
vernment generally pays 50% of thetowards its Medicaid spending cap.
s and services in

CRS-33
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
caps.
dicaid FMAP
e federal medical assistanceH§813. Adjustment in computationNo provision.A§615. Adjustment in computation
e (FMAP) is the rate at whichof Medicaid FMAP to disregard anof Medicaid FMAP to disregard an
bursed for most Medicaidextraordinary employer pensionextraordinary employer pension
ice expenditures. It is based on acontribution. For purposes ofcontribution. For purposes of
ula that provides highercomputing Medicaid FMAPs beginningcomputing Medicaid FMAPs beginning
bursement to states with lower perwith FY2006, any significantlywith FY2006, any significantly
iki/CRS-RL34129es relative to the nationale (and vice versa). When statedisproportionate employer pensioncontribution would be disregarded indisproportionate employer pension orinsurance fund contribution would be
g/wAPs are calculated by HHS for thecomputing state per capita income, butdisregarded in computing state per
s.oring fiscal year, the state and U.S.not U.S. per capita income. Acapita income, but not U.S. per capita
leake amounts used in thesignificantly disproportionate employerincome.
://wikiula are equal to the average of thepension contribution would be defined
httpost recent calendar years of dataas an employer contribution towardsA significantly disproportionate
per capita personal income availablepensions that is allocated to a state for aemployer pension and insurance fund
the Department of Commerce’speriod if the aggregate amount socontribution would be defined as any
reau of Economic Analysis (BEA).allocated exceeds 25% of the totalidentifiable employer contribution
A revises its most recent estimates ofincrease in personal income in that statetowards pension or other employee
a personal income on anfor the period involved.insurance funds that is estimated to
ised andaccrue to residents of such state for a
y available source data oncalendar year (beginning with calendar
tion and income. It alsoyear 2003) if the increase in the amount
es a comprehensive dataso estimated exceeds 25% of the total
ision every few years that may resultincrease in personal income in that State
isions tofor the year involved.



CRS-34
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
of the component parts of personalFor estimating and adjusting an FMAP
e, one of which is employeralready calculated as of the date of
ployee pension andenactment for a state with a
n describing its 2003significantly disproportionate employer
prehensive revision, BEA reportedpension and insurance fund
isions to employercontribution, the Secretary shall use the
inningpersonal income data set originally used
the result ofin calculating such FMAP.
thodological improvements and more
plete source data.If in any calendar year the total personal
iki/CRS-RL34129income growth in a state is negative, an
g/wemployer pension and insurance fund
s.orcontribution for the purposes of
leakcalculating the state’s FMAP for a
://wikicalendar year shall not exceed 125% of
httpthe amount of such contribution for theprevious calendar year for the State.
No state would have its FMAP for a
fiscal year reduced as a result of the
application of this section. Not later
than May 15, 2008, 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



CRS-35
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
FMAP and for Medicaid and on
possible alternative methodologies to
mitigate such problems.
P E-FMAP
e federal medical assistanceNo provision.S§110. Limitation on matching rateA§114. Limitation on matching rate
e (FMAP) is the rate at whichfor states that propose to coverfor states that propose to cover
bursed for most Medicaidchildren with effective family incomechildren with effective family income
ice expenditures. It is based on athat exceeds 300 percent of thethat exceeds 300 percent of the
iki/CRS-RL34129ula that provides higherbursement to states with lower perpoverty line. For child healthassistance or health benefits coveragepoverty line. Same as the Senate bill,with an additional statement that
g/wes relative to the nationalfurnished in any fiscal year beginningnothing in the amendments made by the
s.ore (and vice versa); it has awith FY2008 to targeted low-incomesection shall be construed as: (1)
leaktutory minimum of 50% andchildren whose effective family incomechanging any income eligibility level
://wikiximum of 83%. The enhancedwould exceed 300% of the poverty linefor children under CHIP or (2) changing
httpAP (E-FMAP) for SCHIP equals abut for the application of a generalthe flexibility provided states under
P increased byexclusion of a block of income that isCHIP to establish the income eligibility
ber of percentage points that isnot determined by type of expense orlevel for targeted low-income children
to 30% of the difference betweentype of income, states would beunder a state child health plan and the
rreimbursed using the FMAP instead ofmethodologies used by the state to
ple, in states with an FMAP ofthe E-FMAP. An exception would bedetermine income or assets under such
FMAP equals the FMAPprovided for states that, on the date ofplan.


12 percentage points (60%enactment, have an approved state plan
ultiplied by 40 percentageamendment or waiver, or have enacted
72%). E-FMAPs can rangea state law to submit a state plan

65% to 85%.amendment to cover targeted low-


income children above 300% of the

CRS-36
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ere are two types of incomepoverty line.


ards used by states. The first type
udes particular dollar amounts or
e (or certain expenses,
care expenses). Nearly
state uses such disregards in
P. These disregards often mirror
disregards in states’ Medicaid
rams. Although an individual’s
family income may be above the
iki/CRS-RL34129e eligibility level for
g/wHIP, the person may qualify because
s.ornet family income (taking into
leakt the state’s disregards) falls
://wikime threshold. The
httpHIP statute provides flexibility forards. The
pe of income disregard
des an entire block of
of-poverty income. For
ple, New Jersey’s SCHIP program
ers children with gross family
e up to 350% FPL by excluding
ily income between 200% and
overty (thereby reducing net
ily income to 200% of poverty).

CRS-37
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
Eligibility
statutory provision specifies a graceH§123. Premium grace period. StatesNo provision.A§504. Premium grace period. Same
payment of SCHIPwould have to provide CHIP enrolleesas House bill.


iums. The congressionallywith a grace period of at least 30 days
ndated evaluation of SCHIP in 10from the beginning of a new coverage
not later than Decemberperiod to make premium payments
, 2001) was to include anbefore the individual’s coverage may be
iki/CRS-RL34129aluation of disenrollment or othere toterminated. Within seven days after thefirst day of the grace period, the state
g/w premiums ….”would have to provide the individual
s.orFederal regulations require states’with notice that failure to make a
leakP plans to describe thepremium payment within the grace
://wikiee orperiod will result in termination of
httplicant who does not pay requiredcoverage and that the individual has the
miums and the disenrollmentright to challenge the proposed
the state.termination pursuant to the applicable
to the federal regulations, thefederal regulations. This provision
ust include the following:would be effective for new coverage
he state must give enrolleesperiods beginning on or after January 1,

2009.


past due premiums prior to
ent; (2) the disenrollment
ust give the individual the
to show a decline in family
e that may qualify the individual

CRS-38
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
cost-sharing; and (3) the
ust provide the enrollee with an
for an impartial review to
dress disenrollment from the
ram, during which time the
idual will continue being enrolled.
nerally, eligibility for children underH§131. Optional coverage of childrenNo provision.No provision.
iki/CRS-RL34129is limited to persons under age (or in some cases, under age 18, 19,up to age 21 under CHIP. Wouldexpand the definition of child under
g/wP, children areCHIP to include persons under age 20 or
s.ore 19.21, at state option. The effective date
leakwould be January 1, 2008.
://wikilegal immigrants in Medicaid and CHIP
http
ay provide full MedicaidH§132. Optional coverage of legalNo provision. No provision.


erage to legal immigrants who meetimmigrants under the Medicaid
tegorical and financialprogram and CHIP. Would allow
ibility requirements after suchstates to cover legal immigrants who are
e been in the United Statespregnant women and/or children under
a minimum of five years. Sponsorsage 21 (or such higher age as the state
the costs of publichas elected) under Medicaid or CHIP
Medicaid and SCHIP)before the five-year bar is met effective
ided to legal immigrants.upon the date of enactment. Sponsors
would not be held liable for the costs
associated with providing benefits to

CRS-39
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
such legal immigrants, and the cost of
such assistance would not be considered
an unreimbursed cost.
egnant women under CHIP
SCHIP, states can cover pregnantH§133. State option to expand or addS§107. State option to cover low-A§111. State option to cover low-
en ages 19 and older throughcoverage of certain pregnant womenincome pregnant women under CHIPincome pregnant women under CHIP
er authority or by providingunder CHIP. The provision wouldthrough a state plan amendment.through a state plan amendment.
erage to unborn children asallow states to cover pregnant womenWould allow states to provide optionalSame as the Senate bill with
iki/CRS-RL34129mitted through regulation. In theerage includes prenatalunder CHIP through a state planamendment only if: (1) the Medicaidcoverage under CHIP to pregnantwomen when specific conditions aremodifications based on the House bill.With respect to minimum income
g/wery services only. income eligibility threshold for pregnantmet, including, for example (1) theeligibility levels, states may cover
s.orwomen is at least 185% FPL (but cannotupper income eligibility level for certainpregnant women under CHIP through a
leakbe lower than the percentage in effectpregnant women under traditionalstate plan amendment if the minimum
://wikifor certain groups of pregnant women asMedicaid must be at least 185% FPL,Medicaid income level for certain
httpof July 1, 2007), (2) the income(2) states must not apply anygroups of pregnant women is at least
eligibility threshold is at least 200%pre-existing condition or waiting period185% FPL (or such higher percentage as
FPL for children under CHIP orrestrictions under CHIP, and (3) statesthe state has in effect), but in no case
Medicaid, and (3) certain enrollmentmust provide the same cost-sharinglower than the percent in effect for such
limitations for CHIP children are notprotections applicable to CHIP children,groups as of July 1, 2007, as per the
imposed. For the new group of CHIPand all cost-sharing incurred byHouse bill. An additional condition
pregnant women, the lower income limitpregnant women must be capped at 5%would be added to coverage of pregnant
would exceed 185% FPL (or theof annual family income. No cost-women under CHIP as per the House
applicable Medicaid threshold, ifsharing would apply to pregnancy-bill — for children under age 19 in
higher) and the upper income limitrelated services. States choosing thisCHIP or Medicaid, the income
could be up to the level of coverage fornew option would also be allowed toeligibility threshold must be at least
CHIP children in the state. Othertemporarily enroll such women for up to200% FPL. Also from the House bill,



CRS-40
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
limitations on eligibility for CHIPtwo months until a formal determinationthe agreement adds another condition to
children would also apply. No pre-of eligibility is made. The upperthe option to cover pregnant women
existing condition exclusions or waitingincome limit for this new coverageunder CHIP — no waiting lists for
periods would be permitted. All cost-group would be the upper incomeenrollment of children under CHIP.
sharing would be capped at 5% ofstandard applicable to CHIP children in
annual income. States electing to coverthe state. Other eligibility restrictionsA§113. Elimination of counting
pregnant women would receive anfor children under CHIP would alsoMedicaid child presumptive eligibility
adjustment to their annual CHIPapply to this new group of pregnantcosts against title XXI allotment.
allotments to cover these additionalwomen (i.e., must be uninsured,Includes amendments to Medicaid that
costs. Pregnancy-related assistanceineligible for state employee coverage,are the same as the House bill (Sec.
iki/CRS-RL34129would include all services provided toetc.). Pregnancy-related assistance133) with respect to (1) continuous
g/wCHIP children in the state (excludingwould include all services coveredeligibility of newborns through age 1
s.orEPSDT), and the period of coverageunder CHIP for children in a state asregardless of their living arrangements
leakwould be during pregnancy through thewell as prenatal, delivery andand mothers’ eligibility, and (2)
://wikiend of the month in which the 60-daypostpartum care, including careallowing entities that make presumptive
httppostpartum period ends. Additionalprovisions would: (1) deem infants bornprovided to pregnant women under thestate’s Medicaid program. Alsoeligibility determinations for childrenunder Medicaid to make such
to CHIP pregnant women to be eligiblechildren born to these pregnant womendeterminations for pregnant women
for Medicaid or CHIP (as applicable) upwould be deemed eligible for Medicaidunder Medicaid.


to age one year (regardless of whetheror CHIP, as appropriate, and would be
the infant lives with the mother or thecovered up to age one year. States may
mother remains eligible), (2) allowcontinue to provide coverage to
presumptive eligibility for pregnantpregnant women through waivers and
women and children under CHIP, andthe unborn child regulation. States
(3) allow entities that make presumptivecovering pregnant women through the
eligibility determinations for childrenunborn child regulation would be
under Medicaid to make suchallowed to provide postpartum services

CRS-41
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
determinations for pregnant womento those women at state option.
under CHIP. The provision also
amendments Medicaid to (1) no longer
require that a newborn deemed eligible
for Medicaid at birth through age 1
remain in the mother’s household and
that the mother remain eligible for
Medicaid during this period in order for
such a newborn to remain eligible for
Medicaid, and (2) allow entities
iki/CRS-RL34129qualified to make presumptive
g/weligibility determinations for children
s.orunder Medicaid to also be allowed to
leakmake such determinations for pregnant
://wikiwomen under Medicaid.
http
current law, Section 1115 of theH§134. Limitation on waiverS§106. Phase-out coverage forA§112. Phase-Out of coverage for
Act gives the Secretaryauthority to cover adults. Thenonpregnant childless adults undernonpregnant childless adults under
alth and Human Services (HHS)provision would prohibit the SecretaryCHIP. Would prohibit the approval orCHIP; conditions for coverage of
to modify virtually allfrom allowing federal CHIP allotmentsrenewal of Section 1115 demonstrationparents. Same as Senate bill.


d SCHIPto be used to provide health carewaivers that allow federal CHIP funds
rams including expandingservices (under the Section 1115 waiverto be used to provide coverage to
ibility to populations who are notauthority) to individuals who are notnonpregnant childless adults. The six
ible for Medicaid ortargeted low-income children orstates with CMS approval for such
P (e.g., childless adults).pregnant women (e.g., non-pregnantwaivers would be permitted to use
ed SCHIP Section 1115 waiverschildless adults or parents of Medicaidfederal CHIP funds to continue such

CRS-42
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ed to be part of a state’s SCHIPor CHIP-eligible children) unless thecoverage through FY2008, but in
es of federalSecretary determines that no CHIP-FY2009, such states would receive an
bursement. Costs associated witheligible child in the state would beamount (as part of a separate allotment)
iver programs are subject to eachdenied CHIP coverage because of suchequal to the federal share of the State’s
FMAP. Under SCHIPeligibility. To meet this requirement,projected FY2008 waiver expenditures
1115 waivers, states must meetstates would have to assure that theyincreased by the annual adjustment for
lotment neutrality test” wherehave not instituted a waiting list forper capita health care growth, and such
bined federal expenditures for thetheir CHIP program, and that they havewaiver expenditures would be matched
ular SCHIP program and foran outreach program to reach allat the regular Medicaid FMAP rate.
HIP demonstrationtargeted low-income children in
iki/CRS-RL34129ram are capped at the state’sfamilies with annual income less than
g/widual SCHIP allotment. The200% FPL
s.oreduction Act of 2005
leakproval of new
://wikionstration projects that allow
httpP funds to be used toide coverage to nonpregnant
but allowed for the
g Medicaid
HIP waiver projects affecting
P funds that were approved

8, 2006.


States with nonpregnant childless adultSame as Senate bill.


CHIP waivers in effect during FY2007
would be permitted to seek approval for
a Medicaid nonpregnant childless adult

CRS-43
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
waiver, but allowable spending under
the Medicaid waiver would be limited to
waiver spending in the preceding fiscal
year, increased by the percentage
increase (if any) in the projected per
capita spending in the National Health
Expenditures for the calendar year that
begins during the fiscal year involved
over the prior calendar year.


iki/CRS-RL34129
g/w
s.or
leak
://wiki
http

CRS-44
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
e as above.Same as above.S§106. Conditions for coverage ofA§109. Phase-Out of coverage for
parents. Would prohibit the approvalnonpregnant childless adults under
or renewal of Section 1115CHIP; conditions for coverage of
demonstration waivers that allowparents. Same as Senate bill.


federal CHIP funds to be used to
provide coverage to parent(s) of
targeted low-income child(ren). The 11
states with CMS approval for such
iki/CRS-RL34129waivers would be permitted to use
g/wfederal CHIP funds to continue such
s.orcoverage during FY2008 and FY2009 as
leaklong as such funds are not used to cover
individuals with annual income that
://wikiexceeds the income eligibility in place
httpas of the date of enactment. Beginning
in FY2010, allowable spending under
the waivers would be subject to a set
aside amount from a separate allotment.

CRS-45
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
In FY2010 only, costs associated withSame as Senate bill.
such parent coverage would be subject
to each such state’s CHIP enhanced
FMAP for States that meet certain
coverage benchmarks (related to
performance in providing coverage to
children) in FY2009, or each such
state’s Medicaid FMAP rate for all other
states.
iki/CRS-RL34129For FY2011 or 2012, costs associatedSame as Senate bill.


g/wwith such parent coverage would be
s.orsubject to: (1) a state’s REMAP
leakpercentage (i.e., a percentage which
would be equal to the sum of (a) the
://wikistate’s FMAP percentage and (b) the
httpnumber of percentage points equal to
one-half of the difference between the
state’s FMAP rate and the state’s E-
FMAP rate) if the state meets certain
coverage benchmarks (related to
performance in providing coverage to
children) for the preceding fiscal year,
or (2) the state’s regular Medicaid
FMAP rate if the state failed to meet the
specified coverage benchmarks for the
preceding fiscal year.

CRS-46
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
Would require a GovernmentSame as Senate bill.
Accountability Office study regarding
effects of adult coverage on the increase
in child enrollment or quality of care.
are required to continue MedicaidH§801. Modernizing transitionalNo provision.No provision.


-income familiesMedicaid. The House bill would
lose coverageextend work-related TMA under section
iki/CRS-RL34129e of changes in their income.is continuation is called transitional1925 through September 30, 2011.States could opt to treat any reference to
g/wdical assistance (TMA). Federal lawa 6-month period (or 6 months) as a
s.oranently requires four months ofreference to a 12-month period (or 12
leak for families who lose Medicaidmonths) for purposes of the initial
://wikiibility due to increased child oreligibility period for work-related TMA,
httpollections, as well asin which case the additional 6-month
ho lose eligibility due to anextension would not apply. States could
e or hours ofopt to waive the requirement that a
ployment. Congress expandedfamily have received Medicaid in at
rk-related TMA under section 1925least three of the last six months in
Act in 1988,order to qualify. They would be
states to provide TMA torequired to collect and submit to the
ilies who lose Medicaid forSecretary of HHS (and make publicly
rk-related reasons for at least six, andavailable) information on average
to 12, months. Since 2001,monthly enrollment and participation
-related TMA requirements underrates for adults and children under
e been funded by awork-related TMA, and on the number

CRS-47
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
term extensions, mostand percentage of children who become
through September 30, 2007.ineligible for work-related TMA and
whose eligibility is continued under
another Medicaid eligibility category or
who are enrolled in CHIP. The
Secretary would submit annual reports
to Congress concerning these rates.
Except for the four-year extension of
work-related TMA, which would be
effective October 1, 2007, the provision
iki/CRS-RL34129would be effective upon enactment.
g/w
s.ore or resource eligibility for children
leakhave the ability under current lawNo provision.No provision.A§115. State Authority Under
://wikierage to childrenMedicaid. The provision clarifies that
httpilies with income below 133% ofnothing in the bill should be construed
age 6, or 7, or 8as limiting the flexibility of states to
increase the income or resource
r age 19. States also are able toeligibility levels for children under
ine income and resource countingMedicaid state plans or under Medicaid
thodologies. Part of this flexibilitywaivers. In addition, the provision
to disregard certainwould protect the ability of states to
ounts form income or resources forextend Medicaid coverage beyond the
ining MedicaidMedicaid applicable income level
ibility. A targeted low-income childeffectively allowing a shift of children
ing for enhanced federalfrom a targeted low-income eligibility
tching payments is one who is underpathway to a traditional Medicaid



CRS-48
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
e of 19 years without healtheligibility pathway.
not have been
ible for Medicaid under the rules in
e on March 31, 1997.
set the upper income level for
eted low-income children up to
% of the federal poverty level
L), or 50 percentage points above
SCHIP Medicaid
e level.
iki/CRS-RL34129
g/w
s.or grants states the option toH§804. State option to protectNo provision.No provision.


leak spousal impoverishment rules tocommunity spouses of individuals
://wiki of income and assets for awith disabilities. The provision would
httprried person who applies to Medicaidamend Medicaid law to allow states to
edically needy individual underapply spousal impoverishment rules to
) and (d) home andmedically needy applicants and their
munity-based (HCBS) waivers.spouses during the eligibility and
ay not, however, apply spousalpost-eligibility determination of income
poverishment rules when determiningprocess for applicants of HCBS waivers
ibility for medically needyauthorized under sections 1915(c), (d),
iduals under 1915(e) waivers. Inor (e) as well as section 1115 of the
ay not apply spousalSocial Security Act. It would also apply
poverishment rules to theto medically needy individuals who are
eligibility treatment of income forreceiving benefits under sections
dically needy persons enrolled in1915(I) and (j).

CRS-49
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ers. Neither
ibility nor post-eligibility spousal
poverishment rules are applied to
ing section 1915(I) or
) benefits unless these persons
for Medicaid through an
ibility group for which spousal
poverishment rules apply. Medicaid
spousal
poverishment eligibility and post-
iki/CRS-RL34129ibility rules to medically needy
g/widuals, subject to the Secretary’s
s.oral.
leak
://wiki
httpe Social Security AdministrationH§817. Extension of SSI web-basedNo provision.A§619. Extension of SSI web-based
a financial accountasset demonstration project to theasset demonstration project to the
stem (in field officesMedicaid program. Under the HouseMedicaid program. Same as the
ated in New York and New Jersey)bill, the Secretary of HHS would beHouse bill, except that the provision
asset verificationrequired to provide for application ofwould apply beginning on October 1,
to help confirm that individualsthe current law SSI pilot to assetFY2012.


for Supplemental Securityeligibility determinations under the
e (SSI) benefits are eligible. TheMedicaid program. This application
its automated paperlesswould only extend to states in which the
nsmission of asset verificationSSI pilot is operating and only for the
period in which the pilot is otherwise
titutions. Part of this pilotprovided. For purposes of applying the

CRS-50
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
lved a comprehensive study toSSI pilot to Medicaid, information
asure the value of such a system forobtained from a financial institution that
applicants as well as recipientsis used for purposes of SSI eligibility
eady on the payment rolls. Thisdeterminations could also be shared and
dy identified a small percentageused by states for purposes of Medicaid
out 5 percent) of applicants andeligibility determinations.
were overpaid based on
erification
. A bill (H.R. 3668) that would
the pilot to Medicaid beginning
iki/CRS-RL34129nding on
g/wber 30, 2012, was passed by the
s.orber 26.
leak
Enrollment/Access
://wiki
httpxpress lane” eligibility determinations
ulations containH§112. State option to rely on findingS§203. Demonstration project toA§203. State option to rely on finding
rements regarding determinationsfrom an express lane agency topermit States to rely on findings by anfrom an Express Lane agency to
ibility and applications forconduct simplified eligibilityExpress Lane agency to determineconduct simplified eligibility
n limited circumstancesdeterminations. Beginning in Januarycomponents of a child’s eligibility fordeterminations. Like the House bill,
ncies are permitted to2008, the bill would allow States to relyMedicaid or CHIP. Would create abeginning in January 2008, the
ine eligibility for Medicaid. Foron an eligibility determination findingthree-year demonstration program thatagreement would allow states to rely on
ple, when a joint TANF-Medicaidmade within a State-defined period fromwould allow up to ten states to usean eligibility determination finding
lication is used the state TANFan Express Lane Agency to determineExpress Lane eligibility determinationsmade within a State-defined period from
y may make the Medicaidwhether a child under age 19 (or up toat Medicaid and CHIP enrollment andan Express Lane Agency to determine
ibility determination. age 21 at state option) has met one orrenewal. The demonstration wouldwhether a child under age 19 (or up to



CRS-51
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
more of the eligibility requirementsauthorize and appropriate $44 millionage 21 at state option) has met one or
(e.g., income, assets or resources,for the period of FY2008 throughmore of the eligibility requirements
citizenship, or other criteria) necessaryFY2012 for systems upgrades and(e.g., income, assets or resources,
to determine an individual’s initialimplementation. Of this amount, $5citizenship, or other criteria) necessary
eligibility, eligibility redetermination, ormillion would be dedicated to anto determine an individual’s initial
renewal of eligibility for medicalindependent evaluation of theeligibility, eligibility redetermination, or
assistance under Medicaid or CHIP.demonstration for the Congress. Underrenewal of eligibility for medical
the demonstration, states would beassistance under Medicaid or CHIP.
permitted to rely on a finding made byUnder the agreement, however, states
an Express Lane Agency within thewould be required to verify citizenship
iki/CRS-RL34129preceding 12 months to determineor nationality status, and such eligibility
g/wwhether a child has met one or more ofdeterminations would not be permitted
s.orthe eligibility requirements (e.g.,after September 30, 2012.
leakincome, assets, citizenship or other
://wikicriteria) necessary to determine an
httpindividual’s eligibility for Medicaid orCHIP.
HIP defines a targeted low-incomeStates would be permitted to meet theCHIP screen and enroll requirements byLike the House provision the Senate’sprovision would establish criteria forSame as House bill.


under the age of 19using either or both of the followinghow a state would meet screen and
with no health insurance, and whorequirements: (1) establishing aenroll requirements, would not relieve
uld not have been eligible forthreshold percentage of the Federalstates of their obligation to determine
in effect in thepoverty level that exceeds the highesteligibility for Medicaid, and would
ibility for Medicaid andincome eligibility threshold applicableunder Medicaid for the child by arequire the state to inform families thatthey may qualify for lower premium
P be coordinated when Statesminimum of 30 percentage points (orpayments or more comprehensive health
plement separate SCHIP programs. In

CRS-52
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
stances, applications forsuch other higher number of percentagecoverage under Medicaid if the family’s
HIP coverage must first be screenedpoints) as the state determines reflectsincome were directly evaluated by the
ibility. the income methodologies of thestate Medicaid agency.
program administered by the Express
Lane Agency, or (2) with respect to any
individual within such population for
whom an Express Lane Agency finds
has income that does not exceed such
threshold percentage, such individual
would be eligible for Medicaid. If a
iki/CRS-RL34129finding from an Express Lane Agency
g/wresults in a child not being found
s.oreligible for Medicaid or CHIP, the
leakStates would be required to determine
://wikiMedicaid or CHIP eligibility using its
httpregular procedures and to inform thefamily that they may qualify for lower
premium payments if the family’s
income were directly evaluated for an
eligibility determination by the State
using its regular policies.
to initial application, StatesNo provision.Error rates associated with incorrectSame as Senate bill.


st request information from othereligibility determinations would be
encies, to verifymonitored.
ncome, resources,
enship status, and validity of Social

CRS-53
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
number (e.g., income from the
Administration (SSA),
e from the Internal
venue Service (IRS), unemployment
ation from the appropriate State
, qualified aliens must present
entation of their immigration
which States must then verify
mmigration and Naturalization
rvice, and the State must verify the
iki/CRS-RL34129N with the Social Security
g/wministration). States must also
s.oredicaid eligibility quality
leakogram designed to
://wikius expenditures by
http eligibility determinations.
Express Lane agencies would includeExpress Lane agencies would includeSame as Senate bill.


public agencies determined by the Statepublic agencies determined by the State
as capable of making eligibilityas capable of making eligibility
determinations including publicdeterminations and goes beyond list of
agencies that determine eligibility underagencies included in the House
the Food Stamp Act, the School Lunchprovisions to include additional public
Act, the Child Nutrition Act, or theagencies such as those that determine
Child Care Development Block Granteligibility under TANF, CHIP,
Act.Medicaid, Head Start, etc. Also included
are state specified governmental

CRS-54
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
agencies that have fiscal liability or
legal responsibility for the accuracy of
eligibility determination findings, and
public agencies that are subject to an
interagency agreement limiting the
disclosure and use of such information
for eligibility determination purposes.
The provision would explicitly exclude
programs run through title XX (Social
Services Block Grants) of the Social
iki/CRS-RL34129Security Act, and private for-profit
g/worganizations as agencies that would
s.orqualify as an Express Lane agency.
leak
ust attest to theSignatures under penalty of perjuryLike the House provision, the SenateSame as House bill, however, like the
://wiki of the information submittedwould not be required on a Medicaidbill would drop the requirement forSenate bill the agreement would
httpd signapplication form attesting to anysignatures under penalty of perjury.authorize entities in possession of
forms under penalty ofelement of the application for whichThe provision would permit signaturepotentially pertinent data relevant for
ury. eligibility is based on informationrequirements for a Medicaid applicationthe determination of eligibility under
received from an Express Lane Agencyto be satisfied through an electronicCHIP or Medicaid (e.g., the National
or from another public agency. Thesignature and would monitor error ratesDirectory of New Hires database) to
provision would authorize federal orassociated with incorrect eligibilityshare such information with the CHIP
State agencies or private entities indeterminations. Like the House bill, theor Medicaid agency.


possession of potentially pertinent dataprovision would authorize entities in
relevant for the determination ofpossession of potentially pertinent data
eligibility under Medicaid to share suchrelevant for the determination of
information with the Medicaid agencyeligibility under CHIP or Medicaid

CRS-55
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
for the purposes of child enrollment in(e.g., the National Directory of New
Medicaid, and would impose criminalHires database) to share such
penalties for entities who engage ininformation with the CHIP or Medicaid
unauthorized activities with such data.agency.
No provision. The Senate bill would authorize andLike the Senate bill, the agreement
appropriate $5 million in new federalwould authorize and appropriate $5
funds for fiscal years 2008 throughmillion in new federal funds for fiscal
FY2011 for the purpose of conductingyears 2008 through FY2011 for the
an evaluation of the effectiveness ofpurpose of conducting an evaluation of
iki/CRS-RL34129these demonstration programs. Thethe effectiveness of this state plan
g/wSecretary would be required to submit aoption, and the Secretary would be
s.orreport to Congress with regard to therequired to submit a report to Congress
leakevaluation findings no later thanwith regard to the evaluation findings no
September 30, 2011. later than September 30, 2011.
://wiki
httpt-stationed eligibility determinations
H§113. Application of MedicaidNo provision. No provision.


must provide for the receipt andoutreach procedures to all children
sing of applications forand pregnant women. Effective
dical assistance for low-incomeJanuary 1, 2008, the House bill would
nant women, infants, and childrenprovide for the receipt and initial
e 19 at outstation locationsprocessing of applications for medical
emporary Funding forassistance for children and pregnant
Assistance (TANF) offices suchwomen under any provision of this title,
hospitals, andand would allow for such application
-qualified health centers. Stateforms to vary across outstation

CRS-56
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ibility workers assigned tolocations.
rform initial
cessing of Medicaid applications
taking applications, assisting
cants in completing the application,
iding information and referrals,
taining required documentation to
plete processing of the application,
that the information contained
is complete, and
iki/CRS-RL34129 any necessary interviews.
g/w
s.or
leakcurrent law, title XXI specifiesH§114. Encouraging culturallyS§201. Grants for outreach andA§201. Grants and enhanced
://wikiP funds can be usedappropriate enrollment and retentionenrollment. The provision would setadministrative funding for outreach
http SCHIP health insurance coveragepractices. The provision would permitaside $100 million (during the period ofand enrollment. Same as Senate bill
ich meets certain requirements. Apartstates to receive Medicaid federalfiscal years 2008 through 2012) for awith the following changes: (1) the
m these benefit payments, SCHIPmatching payments for translation orgrant program under CHIP to financeagreement is silent as to whether grant
ments for four other specific healthinterpretation services in connectionoutreach and enrollment efforts thatfunds would be subject to current law
ities can be made, includingwith the enrollment and use of servicesincrease participation of Medicaid andrestrictions on expenditures for outreach
other child health assistance forby individuals for whom English is notCHIP-eligible children. Such amountsactivities, (2) in addition to the
eted low-income children; (2)their primary language. Payments forwould not be subject to current lawenhanced matching rate available for
ices initiatives to improve thethis activity would be matched at 75%restrictions on expenditures for outreachtranslation and interpretation services
of SCHIP children and other low-FMAP rate.activities. For such period, 10% of theunder CHIP, the agreement would also
e children; (3) outreach activities;funding would be dedicated to aprovide a 75% FMAP rate for
(4) other reasonable administrativenational enrollment campaign, and 10%translation and interpretation services
For a given fiscal year, paymentswould be set-side for grants for outreachunder Medicaid, and (3) the agreement



CRS-57
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
itiesto, and enrollment of, children who arewould allow for the use of Community
ceed 10% of the total amountIndians. Remaining funds would beHealth Workers for outreach activities.
expenditures for SCHIP benefits anddistributed to specified entities to
itiesconduct outreach campaigns that target
bined. The federal and stategeographic areas with high rates of
vernments share in the costs of botheligible but not enrolled children who
and SCHIP, based onreside in rural areas, or racial and ethnic
ulas defining the federalminorities and health disparity
law. The federalpopulations. Grant funds would also be
tch for administrative expenditurestargeted at proposals that address
iki/CRS-RL34129ary by state and is generallycultural and linguistic barriers to
g/wcertain administrativeenrollment. Finally, the bill would
s.ore a higher federalprovide the greater of 75%, or the sum
leaktching rate.of the enhanced FMAP for the state plus
://wikifive percentage points for translation
httpand interpretation services under CHIPby individuals for whom English is not
their primary language.
HIP
are required to redetermineH§115. Continuous eligibility underNo provision. No provision.


CHIP eligibility at leastCHIP. The House bill would require
12 months with respect toseparate CHIP programs (or CHIP
umstances that may change andprograms operating under the Section
eligibility. Continuous eligibility1115 waiver authority) to implement 12
s a child to remain enrolled for amonths of continuous eligibility for
period of time regardless of whethertargeted low-income children whose

CRS-58
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
child’s circumstances change (e.g.,annual family income is less than 200%
family’s income rises above theFPL.
ibility threshold), thus making it
enrolled. Not
tates offer it, but among those that
ontinuous eligibility
es from 6 months to 12 months.
iki/CRS-RL34129ith P.L. 92-263, in MayH§141. Children’s Access, PaymentNo provision.No provision.


g/w005, the Secretary of HHSand Equality Commission. Would
s.orMedicaid Commission, toestablish a new federal commission.
leakde advice on ways to modernizeAmong many tasks, this new
://wikiide highCommission would review (1) factors
http health care to its beneficiaries inaffecting expenditures for services in
financially sustainable way. Thedifferent sectors, payment
ommission includedmethodologies, and their relationship to
arding voting and non-votingaccess and quality of care for Medicaid
mbers, meetings, compensation,and CHIP beneficiaries, (2) the impact
ated costs, and two reports. Theof Medicaid and CHIP policies on the
mission terminated 30 days afteroverall financial stability of safety net
ission of its final report to theproviders (e.g., FQHCs, school-based
of HHS (dated December 29,clinics, disproportionate share
o ongoing Commission hashospitals), and (3) the extent to which
ram.the operation of Medicaid and CHIP
ensures access comparable to access

CRS-59
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
under employer-sponsored or other
private health insurance. Commission
recommendations would be required to
consider budget consequences, be voted
on by all members, and the voting
results would be included in
Commission reports. Certain MEDPAC
provisions would apply to this new
commission (i.e., relating to
membership with the addition of
iki/CRS-RL34129Medicaid and CHIP beneficiary
g/wrepresentatives, staff and consultants,
s.orand powers). The provision would
leakauthorize to be appropriated such sums
://wikias necessary to carry out the duties of
httpthe new Commission.
ent practices
ision.H§142. Model of interstateNo provision.A§213. Model of interstate
coordinated enrollment and coveragecoordinated enrollment and coverage
process. The House bill would requireprocess. Like the House bill, except the
the Comptroller General, in consultationagreement would require the Secretary
with State Medicaid, CHIP directors,of HHS, in consultation with State
and organizations representing programMedicaid, CHIP directors, and
beneficiaries to develop a model processorganizations representing program
(and report for Congress) for thebeneficiaries to develop a model process
coordination of enrollment, retention,(and report for Congress) for the



CRS-60
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
and coverage of children who frequentlycoordination of enrollment, retention,
change their residency due to migrationand coverage of children who frequently
of families, emergency evacuations,change their residency due to migration
educational needs, etc. of families, emergency evacuations,
educational needs, etc.
entation
rent law, noncitizens whoH§143. Medicaid citizenshipS§301. Verification of declaration ofA§211. Verification of declaration of
for full Medicaid benefits havedocumentation requirements. Thecitizenship or nationality for purposescitizenship or nationality for purposes
iki/CRS-RL34129equired since 1986 to presententation that indicates aHouse bill would make Medicaidcitizenship documentation for childrenof eligibility for Medicaid and CHIP.The Senate bill would provide a newof eligibility for Medicaid and CHIP.Same as the Senate bill regarding a new
g/w immigration status.” Dueunder age 21 a state option, usingoption for meeting citizenshipoption for meeting citizenship
s.orchanges, citizens and nationalscriteria that are no more stringent thandocumentation requirements. As part ofdocumentation requirements, except that
leakust present documentation thatthe existing documentation specified inits Medicaid state plan and with respectin the case of an individual whose name
://wikies citizenship and documentssection 1903(x)(3) of the Socialto individuals declaring to be U.S.or SSN is invalid, the state would have
httptity in order for states toSecurity Act. See H§136 (undercitizens or nationals for purposes ofto make a reasonable effort to identify
e federal Medicaid reimbursementMiscellaneous) for auditingestablishing Medicaid eligibility, a stateand address the causes of such invalid
ices provided to them. Thisrequirements. See H§112(a) for abilitywould be required to provide that itmatch (including through typographical
enship documentation requirementof “Express Lane” agencies tosatisfies existing Medicaid citizenshipor other clerical errors) by contacting
s included in the Deficit Reductiondetermine eligibility without citizenshipdocumentation rules under sectionthe individual to confirm the accuracy
t of 2005 (DRA, P.L. 109-171) anddocumentation.1903(x) of the Social Security Act orof the name or SSN submitted and
the Tax Relief and Healthnew rules under section 1902(dd).taking such additional actions as the
09-432).Under section 1902(dd), a state couldSecretary or the state may identify, and
fore the DRA, states could acceptmeet its Medicaid state plancontinue to provide the individual with
f-declaration of citizenship forrequirement for citizenshipmedical assistance while making such
h some chose todocumentation by: (1) submitting theeffort. If the name or SSN remains
evidence.name and Social Security number (SSN)invalid after such effort, the state would



CRS-61
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
e citizenship documentationof an individual to the Commissioner ofbe required to notify the individual,
ent is outlined under sectionSocial Security as part of a planprovide him or her with a period of 90
Act andestablished under specified rules and (2)days to either present evidence of
id eligibilityin the case of an individual whose namecitizenship as defined in section 1903(x)
inations and redeterminationsor SSN is invalid, notifying theor cure the invalid determination with
de on or after July 1, 2006. The lawindividual, providing him or her with athe Commissioner of Social Security
ents that are acceptableperiod of 90 days to either present(and continue to provide the individual
this purpose and exempts certainevidence of citizenship as defined inwith medical assistance during such 90-
rom the requirement. It doessection 1903(x) or cure the invalidday period), and disenroll the individual
t apply to SCHIP. However, sincedetermination with the Commissioner ofwithin 30 days after the end of the
iki/CRS-RL34129e states use the same enrollmentSocial Security, and disenrolling the90-day period if evidence is not
g/wfor all Medicaid and SCHIPindividual within 30 days after the endprovided or the invalid determination is
s.orsible that someof the 90-day period if evidence is notnot cured.
leakP enrollees would be asked toprovided.
://wikiidence of citizenship.
httpStates electing the name and SSNSame as the Senate bill, except that
validation option would be required tostates would only submit the name and
establish a program under which theSSN of newly enrolled individuals who
state submits each month to theare not exempt from the citizenship
Commissioner of Social Security fordocumentation requirement.


verification the name and SSN of each
individual enrolled in the State plan
under this title that month who has
attained the age of 1 before the date of
the enrollment.

CRS-62
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
In establishing the program, the stateIn establishing the program, the state
would be allowed to enter into anwould be allowed to enter into an
agreement with the Commissioner toagreement with the Commissioner: (1)
provide for the electronic submissionto provide for the electronic submission
and verification of the name and SSN ofand verification, through an on-line
an individual before the individual issystem or otherwise, of the name and
enrolled.SSN of an individual enrolled in the
State plan under this title; (2) to submit
to the Commissioner the names and
SSNs of such individuals on a batch
iki/CRS-RL34129basis, provided that such batches are
g/wsubmitted at least on a monthly basis; or
s.or(3) to provide for the verification of the
leaknames and SSNs of such individuals
://wikithrough such other method as agreed to
httpby the state and the Commissioner andapproved 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 (1) or (2).
The program would be required to
provide that, in the case of any
individual who is required to submit an
SSN to the state and who is unable to
provide the state with such number,



CRS-63
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
shall be provided with at least the same
reasonable opportunity to present
evidence that is provided under section
1137(d)(4)(A) of the Social Security
Act to noncitizens who are required to
present evidence of satisfactory
immigration status.
States would be required to provideStates would be required to provide
information to the Secretary on theinformation to the Secretary on the
iki/CRS-RL34129percentage of invalid names and SSNspercentage of invalid names and SSNs
g/wsubmitted each month, and could besubmitted each month, and could be
s.orsubject to a penalty if the averagesubject to a penalty if the average
leakmonthly percentage for any fiscal yearmonthly percentage for any fiscal year
is greater than 7%.is greater than 3%. A name or SSN
://wikiwould be treated as invalid and included
httpIf a state entered into an agreement within the determination of such percentage
the Commissioner of Social Security asonly if: (1) the name or SSN does not
described above, the invalid name andmatch Social Security Administration
SSN percentages and penaltiesrecords; (2) the inconsistency between
described here would not apply.the name or SSN could not be resolved
by the State; (3) the individual was
provided with a reasonable period of
time to resolve the inconsistency with
the Social Security Administration or
provide satisfactory documentation of
citizenship and did not successfully



CRS-64
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
resolve such inconsistency; and (4)
payment has been made for an item or
service furnished to the individual under
this title.
If a state entered into an agreement with
the Commissioner of Social Security as
described above, the invalid name and
SSN percentages and penalties
described here would not apply.
iki/CRS-RL34129
g/wStates would receive 90%Same as the Senate bill.
s.orreimbursement for costs attributable to
leakthe design, development, or installation
of such mechanized verification and
://wikiinformation retrieval systems as the
httpSecretary determines are necessary to
implement name and SSN validation,
and 75% for the operation of such
systems.
Groups that are exempt from theThe Senate provision would also clarifySame as the Senate bill, except that
citizenship documentation requirementrequirements under the existing sectionA§113(b)(1) would remove the
would remain the same as under current1903(x). It is similar to the Houserequirement that a newborn remain in
law, except for the inclusion of anprovision regarding the inclusion of anhis or her Medicaid-eligible mother’s
additional permanent exemption foradditional permanent exemption forhousehold in order to qualify for
children who are deemed eligible forchildren who are deemed eligible fordeemed eligibility.


Medicaid coverage by virtue of beingMedicaid coverage by virtue of being

CRS-65
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
born to a woman on Medicaid (note thatborn to a woman on Medicaid,
H§131(b)(1) is also relevant because itadditional documentation options for
would explicitly allow one year offederally recognized Indian tribes, and
deemed eligibility for all children bornthe reasonable opportunity to present
to women on Medicaid, includingevidence. However, the Senate
emergency Medicaid, by removing theprovision would not include additional
requirement that a newborn remain inlanguage to reiterate that states must not
his or her Medicaid-eligible mother’sdeny medical assistance on the basis of
household in order to qualify forfailure to provide documentation until
deemed eligibility under 1902(e)(4) ofan individual has had a reasonable
iki/CRS-RL34129the Social Security Act). The provisionopportunity. In addition, although the
g/wwould require additional documentationSenate provision would clarify that
s.oroptions for federally recognized Indiandeemed eligibility applies to children
leaktribes. It would also specify that statesborn to noncitizen women on
://wikimust provide citizens with the sameemergency Medicaid and would require
httpreasonable opportunity to presentevidence that is provided under sectionseparate identification numbers forchildren born to these women, the bill
1137(d)(4)(A) of the Social Securitywould not remove the requirement that
Act to noncitizens who are required toa newborn remain in his or her
present evidence of satisfactoryMedicaid-eligible mother’s household
immigration status and must not denyin order to qualify for deemed eligibility
medical assistance on the basis ofunder 1902(e)(4).


failure to provide such documentation
until the individual has had such an
opportunity.

CRS-66
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
The Senate provision would makeSame as the Senate bill.
citizenship documentation a
requirement for CHIP. In order to
receive reimbursement for an individual
who has, or is, declared to be a U.S.
citizen or national for purposes of
establishing CHIP eligibility, a state
would be required to meet the Medicaid
state plan requirement for citizenship
documentation described above. The
iki/CRS-RL3412990% and 75% reimbursement for name
g/wand SSN validation would be available
s.orunder CHIP, and would not count
leaktowards a state’s CHIP administrative
://wikiexpenditures cap.
httpThese changes would be effective as ifExcept for clarifications made to theSame as the Senate bill.


included in the Deficit Reduction Act ofexisting citizenship documentation
2005. States would be allowed torequirement, which would be
provide retroactive eligibility for certainretroactive, the provision would be
individuals who had been determinedeffective on October 1, 2008. States
ineligible under previous citizenshipwould be allowed to provide retroactive
documentation rules.eligibility for certain individuals who
had been determined ineligible under
previous citizenship documentation
rules.

CRS-67
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
Opportunity Accounts
e Deficit Reduction Act of 2005H§145. Prohibiting initiation of newNo provision.A§613. Prohibiting initiation of new
ed the Secretary of HHS tohealth opportunity accounthealth opportunity account
more then 10 demonstrationdemonstration programs. The Housedemonstration programs. Same as
rams within Medicaid for healthbill would prohibit the Secretary ofHouse bill.
tunity accounts (HOAs). HOAsHHS from approving any new Health
(via electronic fundsOpportunity Account demonstrations as
fers) health care expenses specifiedof the date of enactment of this Act.
the state. As of July 2007, South
iki/CRS-RL34129rolina was the only state to receive
g/wal for a Health Opportunity
s.oronstration.
leak
://wikiHIP plans must include aNo provision.S§202. Increased outreach andA§202. Increased outreach and
httpused to ensureenrollment of Indians. Wouldenrollment of Indians. Same as the
ision of child health assistanceencourage states to take steps to enrollSenate bill.


American Indian and Alaskan NativeIndians residing in or near reservations
Certain non-benefit paymentsin Medicaid and CHIP. These steps
P (e.g., for other child healthmay include outstationing of eligibility
ice initiatives,workers [at certain hospitals and
ogram administration)Federally Qualified Health Centers];
ceed 10% of the total amountentering into agreements with Indian
entities (i.e., the IHS, tribes, tribal
benefit payments combined. organizations) to provide outreach;
education regarding eligibility, benefits,

CRS-68
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
and enrollment; and translation services.
The Secretary would be required to
facilitate cooperation between states and
Indian entities in providing benefits to
Indians under Medicaid and CHIP. This
provision would also exclude costs for
outreach to potentially eligible Indian
children and families from the 10% cap
on non-benefit expenditures under
CHIP.
iki/CRS-RL34129
g/wation disclosure
s.or, each State must haveNo provision. S§204. Authorization of certainA§203. State option to rely on finding
leakome and eligibility verificationinformation disclosures to simplifyfrom an Express Lane agency to
://wiki under which (1) applicants forhealth coverage determinations. Theconduct simplified eligibility
httperal other specifiedSenate bill would authorize federal ordeterminations. Same as Senate bill,
vernment programs must furnish theirState agencies or private entities withbut included in the “Express Lane”
numbers to the state asdata sources that are directly relevanteligibility provision.


ibility, and (2) wagefor the determination of eligibility under
mation from various specifiedMedicaid to share such information with
vernment agencies is used to verifythe Medicaid agency if: (1) there is no
ibility and to determine the amountfamily objection to such disclosure, (2)
available benefits. Subsequent tothe data would be used solely for the
pplication, States must requestpurpose of determining Medicaid
ation from other federal and stateeligibility, and (3) there is an
to verify applicants’ income,interagency agreement in place to
enship status, andprevent the unauthorized use or

CRS-69
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
dity of Social Security number,disclosure of such information.
e, unemploymentIndividuals involved in such
ation, etc.unauthorized use would be subject to
criminal penalty. In addition, for the
purposes of the Express Lane
Demonstration states only, the provision
would allow the Medicaid and CHIP
programs to receive such data from (1)
the National New Hires Database, (2)
the National Income Data collected by
iki/CRS-RL34129the Commissioner of Social Security, or
g/w(3) data about enrollment in insurance
s.orthat may help to facilitate outreach and
leakenrollment under Medicaid, CHIP, and
://wikicertain other
http programs .
ducing administrative barriers to enrollment
ring the implementation of SCHIPNo provision. S§302. Reducing administrativeA§212. Reducing administrative
ariety of enrollmentbarriers to enrollment. The Senatebarriers to enrollment. Same as
gies tobill would require the State plan toSenate bill.


eligible children into Medicaiddescribe the procedures used to reduce
CHIP. As a result, substantialthe administrative barriers to the
ress was made at the state level toenrollment of children and pregnant
plify the application and enrollmentwomen in Medicaid and CHIP, and to
to find, enroll, and maintainensure that such procedures are revised
gibility among those eligible for theas often as the State determines is

CRS-70
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ram.appropriate to reduce newly identified
barriers to enrollment.
rowd-Out
regulations require thatNo provision.No provision.A§116. Preventing substitution of
HIP plans include procedures toCHIP coverage for private coverage.
that SCHIP coverage does not The agreement defines “CHIP crowd-
ute for coverage provided inout” as the substitution of CHIP
up health plans (also know ascoverage for health benefits coverage
iki/CRS-RL34129owd out”). State SCHIP plans mustde procedures for outreach andother than Medicaid or CHIP. Theagreement would require that states
g/wther public andalready covering children with income
s.orate health insurance programs. Onexceeding 300% FPL (and beginning in
leakust 17, 2007, the Bush2010, new states that propose to do so)
://wikiministration released a letter to stateto describe how they will address
httplth officials to explain how CMScrowd-out and implement “best
d apply these existing requirementspractices” to avoid crowd-out (to be
iewing state requests to extenddeveloped by the Secretary in
HIP eligibility to children in familiesconsultation with state). Beginning in
e exceeding 250% FPL.2010, these “higher income eligibility
ch states will now be required tostates” cannot have a rate of public and
plement specific crowd-outprivate coverage for low-income
ention strategies, including somechildren that is statistically significantly
adopted by many states (e.g.,less than the “target rate of coverage of
posing waiting periods, requiringlow-income children” (i.e., the average
sharing similar to policies forrate of both private and public health
vate coverage, verifying familybenefits coverage as of 1/1/10, among



CRS-71
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
Such states must alsothe 10 states and DC with the highest
ide certain assurances regardingpercentage of such coverage, to be
targeting the “core” low-incomecalculated by the Secretary). States that
., enrollment of atfail to meet this requirement in a given
95% of children below 200% FPLfiscal year would not receive any federal
P ) andCHIP payments for higher income
inimize crowd-children until they are able to establish
., monitoring changes in privatethat they are in compliance with this
erage for the targetrule. States would have an opportunity
pulation). While all states will beto submit and implement a corrective
iki/CRS-RL34129r adherence to theseaction plan prior to the start of the
g/wering children aboveaffected fiscal year. The Secretary
s.or to amend theirwould not be permitted to deny
leakHIP plans (and/or waivers aspayments before the beginning of such
://wikirdance with thisa fiscal year and must not deny
httpiew strategy within 12 months, oray pursue corrective action. payments if there is a reasonablelikelihood that the corrective action plan
would bring the state into compliance
with the target rate of coverage for low-
income children. Not later than 18
months after the date of enactment of
this Act, GAO would be required to
submit to the Congressional committees
with jurisdiction over CHIP and the
Secretary of HHS, a report describing
the best practices of states in addressing
CHIP crowd-out. Analyses must



CRS-72
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
address several issues, including (1) the
impact of different geographic areas
(urban versus rural) and different labor
markets on CHIP crowd-out, (2) the
impact of different strategies for
addressing CHIP crowd-out, (3) the
incidence of crowd-out at different
income levels, and (4) the relationship
between changes in the availability and
affordability of dependent coverage
iki/CRS-RL34129under employer-sponsored health
g/winsurance and CHIP crowd-out. In
s.oraddition, not later than 18 months after
leakthe date of enactment of this Act, the
://wikiIOM would be required to submit to the
httpCongressional committees withjurisdiction over CHIP and the
Secretary, a report on the most accurate,
reliable and timely way to measure (1)
state-specific rates of public and private
health benefits coverage among children
with income below 200% FPL, (2)
CHIP crowd-out, including for children
with income exceeding 200% FPL, and
(3) the least burdensome way to obtain
the necessary data to conduct these
measurements. The agreement



CRS-73
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
appropriates $2 million for this IOM
study for the period ending September

30, 2009.


e Child Support EnforcementNo provision.No provision.A§116(f). Treatment of medical
ram, within the Administration forsupport order. The agreement would
ildren and Families, providesspecify that nothing in title XXI of the
ce in obtaining support (bothSocial Security Act (CHIP) shall be
iki/CRS-RL34129medical) to childrenh locating parents, establishingconstrued to allow the Secretary torequire that a state deny CHIP eligibility
g/w and support obligations, andfor a targeted low-income child on the
s.or those obligations. The federalbasis of the existence of a valid medical
leakvernment has a major role insupport order being in effect. A state
://wikiining the main components ofcould elect to limit eligibility on the
httprams, funding, monitoring,basis of the existence of a valid medical
providing technical assistance, butsupport order, but only if the state does
responsibility of administeringnot deny eligibility in cases where the
Enforcement Programchild asserts that the order is not being
isions forcomplied with for specified reasons
lth insurance coverage, called(failure of the noncustodial parent to
dical support, are required to becomply with the order; failure of an
support orders and mayemployer, group health plan or health
ibility for SCHIP.insurance issuer to comply with such an
order; or the child resides in a
geographic area in which benefits under
the health benefits coverage are



CRS-74
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
generally unavailable), unless the state
demonstrates that none of the reasons
apply.
ate for Amendment Affecting Crowd-Out and Medical Child Support
isionNo provisionNo provisionThe amendments made by this section
shall take effect as if enacted August 16,
2007. The Secretary may not impose
(or continue in effect) any requirement
iki/CRS-RL34129on the basis of any policy orinterpretation relating to CHIP crowd-
g/wout or medical support order other than
s.oramendments made by this section.
leak
Premium Assistance/Employer Buy-In Programs
://wiki
http
-in program is aH§821. Demonstration project forNo provision.No provision.


ram under which the family of aemployer buy-in. The House bill would
for theallow the Secretary of Health and
P program (usually due to excessHuman Services to establish a five-year
e) can enroll their children intodemonstration project under which up to
P program by paying for most10 states would be permitted to provide
st of coverage. UnderCHIP child health assistance to children
, states may not receive(and their families) who would be
al matching funds for the servicestargeted low-income children except for
ided to these children, or for thethe fact that they have group health

CRS-75
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ts of administering the buy-incoverage as allowed under this
ram.provision. To qualify, states must have
a CHIP income eligibility that is at least

200% FPL. Under the demonstrations,


CHIP federal financial participation
would be permitted only for such costs
attributable to eligible children.
The House bill would require coverage
and benefits under a demonstration
iki/CRS-RL34129project to be the same as the coverage
g/wand benefits provided under the state’s
s.orCHIP plan for targeted low-income
leakchildren with the highest family income
level provided.
://wiki
httpFamilies would be responsible for
payments towards the premium for such
assistance in an amount specified by the
state as long as no cost sharing is
imposed on benefits for preventive
services, and CHIP rules related to
income-related limitations on cost
sharing are applied.
Qualifying providers would be
responsible for providing payment in an
amount that is equal to at least 50% of



CRS-76
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
the portion of the cost of the family
coverage that exceeds the amount of the
family’s cost sharing contribution.
Qualifying employers would be defined
as an employer with a majority of its
workforce that is composed of full time
workers (where two, part-time workers
are treated as a single full-time worker)
with family incomes reasonably
iki/CRS-RL34129estimated by the employer (based on
g/wwage information) at or below 200%
s.or FPL.
leak
://wikiid, states may pay aNo provision. S§401. Additional State option forA§301. Additional State option for
http’s share of costsproviding premium assistance. Theproviding premium assistance. Same
roup (employer-based) healthSenate bill would allow states to offer aas Senate bill, however, the agreement
erage for any Medicaid enrollee forpremium assistance subsidy forwould also allow states to offer a
coverage is available,qualified employer sponsored coveragepremium assistance subsidy for
prehensive, and cost-effective for(ESI) to all targeted low-incomequalified employer sponsored coverage
n individual’s enrollment inchildren who are eligible for CHIP, or(ESI) to Medicaid-eligible children
ployer plan is considered costparents of CHIP-eligible children whereand/or parents of Medicaid-eligible
e if paying the premiums,the family has access to ESI coverage.children where the family has access to
coinsurance and other cost-Qualified employer sponsored coverageESI coverage. In addition, the
obligations of the employer planwould be defined as a group health planagreement specifies that family
e than the state’sor health insurance coverage offeredparticipation in the premium assistance



CRS-77
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
cted cost of directly providingthrough an employer that (1) qualifies asprogram would be optional.
covered services. States werecredible health coverage as a group
ide coverage for thosehealth plan under the Public Health
ered services that are notService Act, (2) for which the employer
ate plans.contributes at least 40% toward the cost
of the premium, and (3) is
nondiscriminatory in a manner similar
to section 105(h)of the Internal Revenue
Code but would not allow employers to
exclude workers who had less than three
iki/CRS-RL34129years of service. The Bill explicitly
g/wexcludes (1) benefits provided under a
s.orhealth flexible spending arrangement,
leak(2) a high deductible health plan
://wikipurchased in conjunction with a health
httpsavings account as defined in theInternal Revenue Code of 1986 as
qualified coverage.
HIP, the Secretary has theThe Senate bill would establish a newThe agreement would make the
to approve funding for thecost effectiveness test for employerfollowing modifications to the cost
of “family coverage”under ansponsored insurance (ESI) programseffectiveness tests included in the
ployer-sponsored health insurancethat are approved after the date ofSenate bill: (1) with regard to the
e relative to theenactment of this Act. The state would“individual test,” administrative costs
ount paid to cover only the targetedbe required to establish that (1) the costwould be taken into account when
income children and does notof such coverage is less than statedetermining the cost-effectiveness of
or coverage under groupexpenditures to enroll the child or theextending ESI coverage to the child or



CRS-78
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
provided tofamily (as applicable) in CHIPfamily (as applicable); and (2) with
n addition, states using(individual test), or (2) the aggregateregard to the “aggregate test,” the
IP funds for employer-based planamount of State expenditures for theagreement specifies that federal
miums must ensure that SCHIPpurchase of all such coverage forspending would not be permitted to
nimum benefits are provided andtargeted low-income children underexceed the aggregate amount of
HIP cost-sharing ceilings are met.CHIP (including administrativeexpenditures that the State would have
e of these requirements,expenses) does not exceed the aggregatemade for providing CHIP coverage to
plementation of premium assistanceamount of expenditures that the Stateall such children or families (as
rams under Medicaid and SCHIPwould have made for providingapplicable).
idespread.coverage under the CHIP state plan for
iki/CRS-RL34129all such children (aggregate test).
g/w
s.order the Bush Administration’s HealthStates would be required to provideSame as Senate bill.


leaklexibility and Accountabilitysupplemental coverage for a targeted
IFA) Initiative, states werelow-income child enrolled in the ESI
://wikied to seek approval for Sectionplan consisting of items or services that
httper programs to direct unspentare not covered, or are only partially
P funds to extend coverage tocovered, and cost-sharing protections
consistent with the requirements of
e less than 200% FPL and to useCHIP. Plans that meet the CHIP benefit
and SCHIP funds to paycoverage requirements (i.e., as
ium costs for waiver enrollees whodetermined to be actuarially equivalent
e access to Employer Sponsoredto CHIP benchmark or benchmark-
ce (ESI). ESI programs approvedequivalent coverage) would not be
Section 1115 waiver authorityrequired to provide supplemental
ect to the same current lawcoverage for benefits and cost-sharing
under Medicaid’sprotections as required under CHIP.

CRS-79
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
nsurance Premium Payment
IPP) program or SCHIP’s family
e variance option (i.e., the
prehensiveness and cost-
eness tests).
States would be permitted to directlySame as Senate bill.
pay out-of-pocket expenditures for cost-
sharing imposed under the qualified ESI
coverage and collect all (or any) portion
iki/CRS-RL34129for cost-sharing imposed on the family.
g/wParents would be permitted to disenroll
s.ortheir child(ren) from ESI coverage and
leakenroll them in CHIP coverage effective
on the first day of any month for which
://wikithe child is eligible for such coverage.
http
States would be permitted to establishSame as Senate bill, except the
an employer-family premium assistanceagreement specifies that administrative
purchasing pool for employers with lesscosts associated with the start up or
than 250 employees who have at leastoperation of such purchasing pools
one employee who is a CHIP-eligiblewould only be permitted in so far as
pregnant woman or at least one memberthey meet the definition of allowable
of the family is a CHIP-eligible child.administrative expenditures under
Eligible families would have access toCHIP.


not less than 2 private health plans
where the health benefits coverage is
equivalent to the benefits coverage

CRS-80
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
available through a CHIP benchmark
benefit package or CHIP benchmark
equivalent coverage benefits package.
Finally the Senate bill would require theSame as Senate bill.
Government Accountability Office to
submit a report to Congress not later
than January 1, 2009 regarding cost and
coverage issues under State premium
assistance programs.
iki/CRS-RL34129in premium assistance programs
g/w
s.orHIP state plans are required toNo provision. S§402. Outreach, education, andA§302. Outreach, education, and
leakceduresenrollment assistance. The Senate billenrollment assistance. Same as the
ide outreach to childrenwould require states to include aSenate bill, but would limit expenditures
://wikiible for SCHIP child healthdescription of the procedures in place tofor such outreach activities to 1.25% of
httpstance, or other public or privateprovide outreach, education, andthe state’s limit on spending for
rams to (1) inform theseenrollment assistance for families ofadministrative costs associated with
ilies of the availability of public andchildren likely to be eligible fortheir CHIP program (i.e. 10% of the
ate health coverage and (2) to assistpremium assistance subsidies understate’s spending on benefit coverage in
in enrolling such children inCHIP or a waiver approved undera given fiscal year).


HIP. There is a limit on federal§1115. For employers likely to provide
for SCHIP administrativequalified employer-sponsored coverage,
a state’s spendingthe state is required to include the
benefit coverage in a given fiscalspecific resources the State intends to
Administrative expenses includeuse to educate employers about the
ities such as data collection andavailability of premium assistance

CRS-81
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
, as well as outreach andsubsidies under the CHIP state plan.
n addition, states areExpenditures for such outreach
to provide a description of theactivities would not be subject to the
ensure coordination10% limit on spending for
SCHIP and other healthadministrative costs associated with the
erage applies to StateCHIP program.
inistrative expenses.
iki/CRS-RL34129der the Internal Revenue Code, theployee Retirement Income SecurityNo provision.S§411. Special enrollment periodunder group health plans in case ofA§311. Special enrollment periodunder group health plans in case of
g/wt, and the Public Health Service Act,termination of Medicaid or CHIPtermination of Medicaid or CHIP
s.orroup health plan is required tocoverage or eligibility for assistancecoverage or eligibility for assistance
leakide special enrollment opportunitiesin purchase of employment-basedin purchase of employment-based
://wikified individuals. Suchcoverage; coordination of coverage.coverage; coordination of coverage.
httpiduals must have lost eligibility forThe bill would amend applicable federalSame as Senate bill.


roup coverage, or lost employerlaws to streamline coordination between
butions towards health coverage,public and private coverage, including
ent due to marriage,making the loss of Medicaid/CHIP
, or placement foreligibility a “qualifying event” for the
a grouppurpose of purchasing employer-
without having to wait untilsponsored coverage. Individuals may
ent opportunity or openrequest for such coverage up to 60 days
The individual still must meetafter the qualifying event. The bill
substantive eligibilitywould require health plan administrators
ents, such as being a full-timeto disclose to the state, upon request,
rker or satisfying a waiting period.information about their benefit packages

CRS-82
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ust give qualifiedso states can evaluate the need to
iduals at least 30 days after theprovide wraparound coverage. The bill
ing event (e.g., loss of eligibility)also would require employers to notify
ake a request for specialfamilies of their potential eligibility for
ent.premium assistance.
Benefits
P, states may provideH§121. Ensuring child-centeredS§608. Dental health grants. AsA§501. Dental benefits. The provision
iki/CRS-RL34129erage under their Medicaidcoverage. The provision would makeamended, would provide authority forregarding dental benefits under CHIP in
g/wrams, create a new separate SCHIPdental services a required benefit undernew dental health grants to improve thethe agreement includes selected
s.orram, or both. Under separateCHIP. States would also be required toavailability of dental services andprovisions in both the Senate and House
leakHIP programs, states may elect anyassure access to these services. Thestrengthen dental coverage for childrenbills, as well as new provisions. Under
three benefit options: (1) aeffective date would be October 1,under CHIP. To be awarded such athe agreement, dental services would be
://wikiark plan, (2) a benchmark-2008.grant, states would describe quality anda required benefit under CHIP and
httpalent plan, or (3) any other planoutcomes performance measures to bewould include services necessary to
of HHS deems wouldH§144. Access to dental care forused to evaluate the effectiveness ofprevent disease and promote oral health,
ide appropriate coverage for thechildren. The provision would requiregrant activities, and must assure thatrestore oral structures to health and
et population (called Secretary-the Secretary of HHS to develop andthey will cooperate with the collectionfunction, and treat emergency
ed coverage). Benchmark plansimplement a program to deliver oraland reporting of data to the Secretary ofconditions. States would have the
lude (1) the standard Bluehealth education materials that informHHS, among several requirements.option to provide dental services
ld preferred providernew parents about risks for, andGrantees would be required to maintainequivalent to “benchmark dental benefit
FEHBP, (2) the coverageprevention of, early childhood cariesstate funding of dental services underpackages.” These include (1) a dental
available to state employees,and the need for a dental visit within aCHIP at the level of expenditures in thebenefits plan under FEHBP that has
erage offered by thenewborn’s first year of life. Statesfiscal year preceding the first fiscal yearbeen selected most frequently by
est commercial HMO in the state.could not prevent an FQHC fromfor which the new grant is awarded.employees seeking dependent coverage,



CRS-83
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ark-equivalent plans must coverentering into contractual relationshipsSuch states would not be required toamong such plans that offer such
ic benefits (i.e., inpatient andwith private practice dental providersprovide any state matching funds for thecoverage, in either of the previous 2
al services, physicianunder both Medicaid and CHIPnew dental grant program. Theplan years, (2) a dental benefits plan
ices, lab/x-ray, and well-child care(effective January 1, 2008). The dataSecretary would be required to submitoffered and generally available to state
immunizations), and mustthat states submit to the federalto Congress an annual report on stateemployees that has been selected most
of the actuarialgovernment documenting receipt ofactivities and performances assessmentsfrequently by employees seeking
erage under the selectedEPSDT services each fiscal year wouldunder the new dental grant program.dependent coverage, among such plans
ark plan for specific additionalbe required to include parallelFor the period FY2008 through FY2012,that offer such coverage, in either of the
prescription drugs, mentalinformation on receipt of dental services$200 million would be appropriated forprevious 2 plan years, or (3) a dental
ices, vision care and hearingamong CHIP children. This reportingthis grant program, to remain availablebenefits plan that has the largest
iki/CRS-RL34129ices). Among other items, a staterequirement would also apply to annualuntil expended. The provision wouldcommercial, non-Medicaid enrollment
g/wP plan must include a descriptionstate CHIP reports. Such reportingalso require the Secretary of HHS toof dependent covered lives among such
s.orethods (including monitoring)would be required to includeinclude on the Insure Kids Now websiteplans offered in the state. As in the
leak andinformation on children enrolled inand hotline a current and accurate list ofHouse bill (Sec. 121), states would be
://wikimanaged care plans, other private healthall dentists and other dental providers inrequired to assure access to dental
httpell-baby care, well-and immunizations providedplans, and contracts with such plansunder CHIP (effective for annual stateeach state that provide such services toMedicaid and CHIP children, and mustservices under CHIP. The effective dateof these provisions would be October 1,
plan, and (2) assure access toCHIP reports submitted for yearsupdate this listing at least on a quarterly2008. The agreement also includes
ered services, including emergencybeginning after the date of enactment ofbasis. The Secretary would also beprovisions from the House bill (Sec.
ices. Under the Early and Periodicthis Act). In addition, GAO would berequired to work with states to include a144) for (1) dental education for parents
, Diagnostic and Treatmentrequired to conduct a study examiningdescription of covered dental servicesof newborns, (2) dental services through
) benefit under Medicaid, mostaccess to dental services by children infor children under both programsFederally Qualified Health Care Centers
age 21 receiveunder-served areas, and the feasibility(including under applicable waivers) for(FQHCs), and (3) reporting information
prehensive basic screening servicesand appropriateness of using qualifiedeach state, and must post thison dental services for children. The
child visits including age-mid-level dental providers to improveinformation on the Insure Kids Nowagreement includes the provision in the
ropriate immunizations) as well asaccess. A report on this GAO studywebsite. The provision would requireSenate bill (with some modifications)
ision and hearing services. Inwould be due not later than one yearGAO to conduct a study on children’sregarding information on dental



CRS-84
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
guarantees access toafter the date of enactment of this Act.access to oral health care, includingproviders and descriptions of covered
coverable servicespreventive and restorative servicesdental services under Medicaid and
ary to treat a problem orunder Medicaid and CHIP. The reportCHIP, to be made available to the public
ong eligible individuals.on this study must includevia the Insure Kids Now website and
e EPSDT provision in Medicaid lawrecommendations for such federal andhotline. The agreement would expand
o includes annual reportingstate legislative and administrativemeasurement of the availability of
ements for states. The tool usedchanges necessary to address barriers todental care to include dental treatment
re these EPSDT data is calledaccess to dental care under Medicaidand services to maintain dental health
416 form. Three separateand CHIP (and would be due not laterunder the child health quality
e unduplicatedthan two years after the date ofimprovement activities (Sec. 501 of the
iki/CRS-RL34129mber of EPSDT eligibles receivingenactment of this Act). Also theSenate bill). Finally, the GAO study of
g/w dental services, preventive dentalprovision would add an assessment ofdental services for children in the
s.orices and dental treatment services.the quality of dental care provided toagreement follows the Senate bill with
leakMedicaid and CHIP children to thesome additional provisions taken from
://wikiSecretary’s annual reports to Congressthe House bill (e.g., regarding the
httpunder the new child health qualityimprovement activities authorized in theavailability of mid-level dentalproviders). In addition, this GAO study
Senate-passed bill.would be due within 18 months of the
date of enactment of this Act, rather
than within 2 years as under the Senate
bill.
FQHCs) and rural health centers (RHCs) services
P statute, a number of coverableH§121. Ensuring child-centeredNo provision.No provision.


iccoverage. The provision would make
vices (including health centerthe services provided by FQHCs and
ices) and other ambulatory healthRHCs required benefits under CHIP.

CRS-85
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ices.” Services provided byStates would also be required to assure
HCs and RHCs are a mandatoryaccess to these services. The effective
ost beneficiaries underdate would be October 1, 2008.
arkH§121. Ensuring child-centeredS§607. Mental health parity in CHIPA§502. Mental health parity in CHIP
erage options under SCHIP, see thecoverage. The provision wouldplans. The provision would ensure thatplans. Same as Senate bill.


description in the “dentalincrease the minimum actuarial valuethe financial requirements (e.g., such as
iki/CRS-RL34129ices” row above.for mental health services from 75% to100% for benchmark-equivalentannual and lifetime dollar limits) andtreatment limitations applicable to
g/walth Parity Actcoverage under CHIP. The effectivemental health or substance abuse
s.orPA), Medicaid and SCHIP plansdate would be October 1, 2008.benefits (when such benefits are
leaky define what constitutes mentalcovered) are no more restrictive than the
://wiki). The MHPAfinancial requirements and treatment
httphibits group plans from imposinglimitations applicable to substantially all
fetime dollar limits onmedical and surgical benefits covered
ntal health coverage that are moreunder the state CHIP plan. State CHIP
e than those applicable toplans that include coverage of EPSDT
dical and surgical coverage. Fullservices (as defined in Medicaid statute)
is not required, that is, groupwould be deemed to satisfy this mental
ay still impose more restrictivehealth parity requirement.
ent limits (e.g., with respect to
ber of outpatient visits or
s) or cost-sharing
ents on mental health coverage
pared to their medical and surgical

CRS-86
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ices.
and Treatment (EPSDT) Services
e Deficit Reduction Act of 2005H§121. Ensuring child-centeredS§605. Deficit Reduction ActA§611(a). Deficit Reduction Act
L. 109-171) gave states thecoverage. The provision would requiretechnical corrections. The provisiontechnical corrections - Clarification of
ide Medicaid tocoverage of the EPSDT benefit forwould require that EPSDT be coveredrequirement to provide EPSDT
e-specified groups throughindividuals under age 21, whether suchfor any individual under age 21 who isservices for all children in benchmark
rollment in benchmark andpersons are enrolled in benchmarkeligible for Medicaid through the statebenefit packages under Medicaid.
ark-equivalent coverage that isplans, benchmark-equivalent plans orMedicaid plan under one of the majorSame as the Senate bill with some
iki/CRS-RL34129 identical to plans available underHIP (described above in the “dentalotherwise under Medicaid. Theeffective date would be the same as themandatory and optional coveragegroups and is enrolled in benchmark ormodifications. The agreement identifiesspecific sections of current Medicaid
g/wices” row). For any child under ageoriginal DRA provision (i.e., March 31,benchmark-equivalent plans authorizedlaw (instead of all of Title XIX as
s.orajor mandatory and2006).under DRA. The provision would alsospecified in DRA) that would be
leakibility groups in Medicaid,give states flexibility in providingdisregarded in order to provide
://wikiaround benefits to the DRAcoverage of EPSDT services through thebenchmark benefit coverage. It also
httpark and benchmark-equivalentissuer of benchmark orincludes language from the House bill
verage includes EPSDT. Inbenchmark-equivalent coverage orthat specifies that an individual’s
Medicaid, EPSDT isotherwise. entitlement to EPSDT services remains
ost individuals under ageintact under the benchmark benefit
package option under Medicaid.
ber of coverable benefits areH§121. Ensuring child-centeredNo provision.A§506. Clarification of coverage of
CHIP statute, such ascoverage. The provision would add toservices provided through school-
ices (including health centerthe “clinic services” benefit category inbased health centers. The agreement
ices) and other ambulatory healthCHIP statute “school-based healthprovides that nothing in Title XXI shall
ices.”center services” for which coverage isbe construed as limiting a state’s ability



CRS-87
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
otherwise provided under this title.to provide CHIP for covered items and
Such providers must be authorized toservices furnished through school-based
cover such CHIP services under statehealth centers.
law. The effective date would be on or
after the date of enactment of this Act.
HIP, states may provideH§121. Ensuring child-centeredNo provision.


erage under their Medicaidcoverage. The provision would require
iki/CRS-RL34129rams, create a new separate SCHIPram, or both. Under separatethat benchmark coverage under CHIP beat least equivalent to the benchmark
g/wHIP programs, states may elect anybenefit packages specified in statute.
s.or (1) aThe effective date would be October 1,
leakark plan, (2) a benchmark-2008.
://wikialent plan, or (3) any other plan
http of HHS deems wouldH§122. Improving benchmark
ide appropriate coverage for thecoverage options. The provision would
et population (called Secretary-continue to allow Secretary-approved
ed coverage). Benchmark planscoverage under both CHIP and the DRA
standard Blueoption under Medicaid, but only if such
idercoverage is at least equivalent to a
eragebenchmark benefit package. The
available to state employees,provision would also more explicitly
(3) the coverage offered by thedefine state employees benchmark
est commercial HMO in the state.coverage for both CHIP and the DRA
ark-equivalent plans must coveroption for Medicaid to include the state
andemployee plan that has been selected the

CRS-88
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
patient hospital services, physicianmost frequently, by employees seeking
ices, lab/x-ray, and well-child caredependent coverage, among such plans
immunizations), and mustthat provide dependent coverage, in
ialeither of the previous two years. The
erage under the selectedeffective date would be October 1,
ark plan for specific additional2008.
(i.e., prescription drugs, mental
ices, vision care and hearing
ices). The DRA also allowed
ilar benchmark coverage options
iki/CRS-RL34129
g/w
s.oranning services and supplies
leakrams must offerH§802. Family planning services. TheNo provision. No provision.


://wikiily planning services and supplies toHouse bill would create a state option to
httporically needy individuals ofextend family planning services and
age, including minorssupplies (at the 90% federal Medicaid
active. Familymatch rate) to women who are not
services must be available topregnant and whose annual income does
ible pregnant women through thenot exceed the highest income eligibility
following the end of thelevel established under the Medicaid
nancy. Coverage of the medicallyState plan (or under title XXI) for
other than pregnant women maypregnant women. States would be
ily planning. States receivepermitted to include individuals eligible
atching rate forfor Medicaid §1115 family planning
attributable to the offering,waivers that were approved as of
ing, and furnishing of familyJanuary 1, 2007.

CRS-89
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
services and supplies.
Federal financial participation for
medical assistance made available to
such individuals would be limited to
family planning services and supplies
including medical diagnosis or
treatment services, and only for the
duration of the woman’s eligibility
under this state option or during a
iki/CRS-RL34129period of presumptive eligibility.
g/wFinally, the House bill would prohibit
s.orthe enrollment of such individuals in a
leakMedicaid benchmark and benchmark-
://wikiequivalent state plan option, unless such
httpcoverage includes medical assistance for
family planning services and supplies.
care programs provide healthH§803. Authority to continueNo provision.No provision.


social services in a group setting onproviding adult day health services
-time basis to certain frail olderapproved under a State Medicaid
with physical,plan. The provision would require the
otional, or mental impairments.Secretary to provide for federal
nerally, states that cover adult dayfinancial participation for adult day
o under homehealth care services, as defined under a
munity-based waivers, thestate Medicaid plan, approved during or

CRS-90
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ram for All-Inclusive Care for thebefore 1994. The provision would be
(PACE) or section 1115 waivereffective beginning November 3, 2005
. Some states cover adult dayand ending on March 1, 2009.
though Medicaid law does not list
care as a mandatory or
ional benefit. There have been
that CMS may not continue to
care to be offered under
an without the use
iki/CRS-RL34129a iver.
g/w
s.orMonitoring Quality
leake asurement
://wikie Centers for Medicare and MedicaidH§151. Pediatric health qualityS§501. Child health qualityA§401. Child health quality
httpices (CMS) and the Agency formeasurement program. The provisionimprovement activities for childrenimprovement activities for children
are Research and Qualitywould require the Secretary to establishenrolled in Medicaid or CHIP. Theenrolled in Medicaid or CHIP. Same
HRQ) are both actively involved ina child health care quality measurementprovision would direct the Secretary ofas the Senate bill. Adds a construction
and implementing an array ofprogram. The purpose would be toHHS to develop (1) child health qualityspecifying that nothing in this provision
improvement initiatives, thoughdevelop and implement pediatric qualitymeasures for children enrolled insupports restricting coverage under
AHRQ has engaged in activitiesmeasures, a system for reporting suchMedicaid and CHIP, and (2) aMedicaid and CHIP to only those
measures, and measures of overallstandardized format for reportingservices that are evidence-based.


program performance that may be usedinformation, and procedures that
e federal share of states’ Medicaidby public and private health careencourage states to voluntarily report on
aries by type of expenditure. Forpurchasers. By September 30, 2009, thethe quality of pediatric care in these
edical assistanceSecretary would be required to publishprograms. The Secretary would be

CRS-91
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
e (FMAP) is based on athe recommended measures for yearsrequired to disseminate information to
mula that provides higherbeginning with 2010. In developing andstates regarding best practices in
bursement to states with lower perimplementing this program, themeasuring and reporting such data. A
incomes (and vise versa); it has aSecretary would be required to consulttotal of $45 million would be
ry minimum of 50% and awith a number of entities. Theappropriated for these provisions, of
ximum of 83%. All states receive aSecretary could award grants andwhich specific amounts would be
atch for family planning services.contracts to develop, validate andearmarked for certain activities
atching rates fordisseminate these measures, and would(identified below). (The childhood
inistrative expenses does not varybe required to provide technicalobesity demonstration described below
state and is generally 50%, butassistance to states to establish suchwould have its own separate
iki/CRS-RL34129inistrative functions have areporting under Medicaid and CHIP.appropriation.) The Secretary would be
g/wher federal match. For example, aBy January 1, 2009, and annuallyrequired to award grants and contracts
s.oratch rate applies to the operationthereafter, the Secretary would beto develop, test and update (as needed)
leaked Medicaid managementrequired to make available in an on-lineevidence-based measures, and to
://wikiation system (MMIS) for claimsformat a complete list of all measures indisseminate such measures. Each state
httpation processing. Start-upSs are matched atuse by states to measure the quality ofmedical and dental services provided towould be required to report annually tothe Secretary on a variety of measures.
Medicaid and CHIP children. ByIn addition, the Secretary would be
January 1, 2010, and every two yearsrequired to award up to 10 grants to
thereafter, the Secretary would bestates and child health providers to
required to report to Congress on theconduct demonstrations to evaluate
quality of care for children enrolled inpromising ideas for improving the
CHIP and Medicaid, and patterns ofquality of children’s health care under
utilization by pediatric characteristics.Medicaid and CHIP, for which $20
million would be appropriated. The
Secretary would also be required to
conduct a demonstration to develop a



CRS-92
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
comprehensive and systematic model
for reducing childhood obesity through
grants to eligible entities (e.g., local
government agencies, Indian tribes,
community based organizations). This
demonstration would be authorized at
$25 million over five years ($5 per
year). The Secretary would be required
to submit a report to Congress on this
demonstration. The Secretary would
iki/CRS-RL34129also be required to establish a program
g/wto encourage the creation and
s.ordissemination of a model electronic
leakhealth record format for children
://wikienrolled in Medicaid and CHIP. A total
httpof $5 million would be appropriated forthis purpose. The Institute of Medicine
would be required to study and report to
Congress on the extent and quality of
efforts to measure child health status
and quality of care for children. Up to
$1 million would be appropriated for
this activity. Finally, the federal share
of costs incurred by states for the
development or modification of existing
claims processing and retrieval systems
as is necessary for the efficient



CRS-93
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
collection and reporting on child health
measures would be based on the FMAP
rate for benefits used under Medicaid.
, states submit reports to theNo provision.S§502. Improved informationA§402. Improved availability of
of HHS assessing theregarding access to coverage underpublic information regarding
of their SCHIP programs,CHIP. The provision would addenrollment of children in CHIP and
for example, progress made inseveral reporting requirements to states’Medicaid. Same as Senate bill. The
iki/CRS-RL34129 the number of uninsured low-e children, progress made inannual CHIP reports that are submittedto the Secretary of HHS. Examples ofagreement adds a requirement that theSecretary specify a standardized format
g/w other strategic objectives andthese new reporting requirementsfor states to use to report the new data
s.orance goals identified in the stateinclude (1) data on eligibility criteria,required by the bill within one year of
leak, effectiveness of discouragingenrollment and continuity of coverage,the date of enactment of this Act.
://wikistitution of public coverage for(2) use of self-declaration of income forApplicable states would be given up to
httpate coverage, identification ofapplications and renewals, and3 reporting periods to transition to the
enditures by type of beneficiarypresumptive eligibility, (3) data onreporting of these new data in
., children versus adults), anddenials of eligibility andaccordance with this standardized
e standards andredeterminations of eligibility, (4) dataformat. In addition, the agreement
thodologies. regarding access to primary andrequires the Secretary to improve the
specialty care, networks of care and caretimeliness of the data reported and
coordination, and (5) if the stateanalyzed from the Medicaid Statistical
provides premium assistance forInformation System (MSIS) with
employer-based insurance, datarespect to enrollment and eligibility for
regarding the extent to which suchchildren under Medicaid and CHIP, and
coverage is available to CHIP children,to provide guidance to states regarding
the range of monthly premium amounts,any new reporting requirements related



CRS-94
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
the number of children/familiesto such improvements. For this
receiving such assistance on a monthlypurpose, the agreement appropriates $5
basis, the income level of themillion to the Secretary in FY2008, to
children/families involved, the benefitsremain available until expended.
and cost-sharing protections for suchBeginning no later than October 1,
children/families, the strategies used to2008, MSIS data on enrollment of low-
reduce administrative barriers to suchincome children in Medicaid or CHIP
coverage, and the effects of suchwith respect to a fiscal year must be
premium assistance on preventingcollected and analyzed by the Secretary
substitution of CHIP coverage forwithin 6 months of submission.
iki/CRS-RL34129employer-based coverage. The
g/wprovision would also require GAO to
s.orconduct a study on access to primary
leakand speciality care under Medicaid and
://wikiCHIP, and report to Congress its
httpfindings and recommendations foraddressing existing barriers to
children’s access to care under these
programs.
deral evaluation
e Secretary was required to conductH§153. Updated federal evaluation ofNo provision.A§603. Updated federal evaluation of
aluation of 10 statesCHIP. The provision would require theCHIP. Same as House bill.


approved SCHIP plans, and toSecretary to conduct an independent
it a report on that study toevaluation of 10 states with approved
ngress by December 31, 2001. TenCHIP plans, directly or through
was appropriated for thiscontracts or interagency agreements, as

CRS-95
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ose in FY2000 and was availablebefore. The new evaluation would be
h FY2002. Thesubmitted to Congress by December 31,
states chosen for the evaluation were2010. Ten million dollars would be
utilized diverseappropriated for this purpose in FY2009
proaches to providing SCHIPand made available for expenditure
verage, represented variousthrough FY2011. The current-law
raphic areas (including a mix oflanguage for the types of states to be
ained achosen and the matters included in the
ificant portion of uninsuredevaluation would also apply to this new
ber of matters wereevaluation.


iki/CRS-RL34129aluation, including (1)
g/weys of the target populations, (2) an
s.ore and ineffective
leakand enrollment strategies, and
://wikient barriers, (3)
httphich coordinationP affected
ollment, (4) an assessment of the
ost-sharing on utilization,
ent and retention, and (5) an
ent or other

CRS-96
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
Payments
aceutical manufacturers that wishH§812. Medicaid Drug Rebate. TheNo provision.No provision.


e their products available toprovision would increase the rebate
id beneficiaries must enter intopercentage for the basic rebate for single
reements” under which theysource and innovator multiple source
provide state Medicaiddrugs to 22.1% of the AMP or the
rams with rebates for drugsdifference between the AMP and the
iki/CRS-RL34129ided to Medicaid beneficiaries.le source drugsbest price. The higher rebate percentagewould become effective after December
g/w, those still under patent) and31, 2007.
s.orator” multiple source drugs
leaks originally marketed under a
://wikiinal new drug application
http but for which generic
petition now exists) are calculated
reater of 15.1% of
erage manufacturer’s price (AMP)
between the AMP and
Additional rebates are
eighted average prices
iven manufacturer’s single
ator multiple source
s rise faster than inflation. For
innovator multiple source drugs,

CRS-97
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
President’s FY2008 Budget, someH§814. Moratorium on certainNo provision.A§616. Moratorium on certain
s affecting Medicaid andpayment restrictions. The provisionpayment restrictions. Same as the
HIP would be implementedwould prohibit the Secretary of HHSHouse bill, except that the Secretary
inistratively (e.g., via regulatoryfrom taking any action throughwould be prohibited from taking any
nge, issuance of program guidance,regulation, official guidance, use ofaction with respect to rehabilitation and
r possible methods) rather thanfederal payment audit procedures, orschool-based services prior to May 28,
h legislation. Two suchother administrative action, policy or2008 (rather than delaying such action
inistrative proposals were to phasepractice to restrict Medicaid coverage orfor one year after the date of enactment
iki/CRS-RL34129bursement for certainpayments for rehabilitation services, orof this Act).


g/wbased transportation andschool-based administration,
s.orinistrative claiming, and to clarifytransportation, or medical services if
leakh regulation the types of servicesuch actions are more restrictive in any
t may be claimed as Medicaidaspect than those applied to such
://wikiices. On August 13coverage or payment as of July 1, 2007.
httpSeptember 7, 2007, theThis prohibition would be in effect for
inistration issued proposed rulesone year after the date of enactment of
rehabilitation services and school-this Act.
inistration and transportation
ices, respectively, limiting the
umstances in which federal
bursements will be made for these
ices under Medicaid.

CRS-98
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
blishing hospital paymentH§ 815. Tennessee DSH. The provisionNo provision.A§617. Medicaid DSH allotments for
rams arewould set a DSH allotment for the stateTennessee and Hawaii. The provision
nize the situation ofof Tennessee for fiscal years beginningincludes the House bill language. In
ide a disproportionatewith 2008 to be equal to $30 million foraddition, it would set a DSH allotment
-income patientseach year. In addition, the provisionfor the state of Hawaii for FY2008 of
special needs. Suchwould allow the Secretary of HHS to$10 million. For FY2009 and
onate share (DSH)limit the total amount of payments madethereafter, DSH allotments for Hawaii
ments” are subject to statewideto hospitals under Tennessee’s researchwould be increased in the same manner
iki/CRS-RL34129ent caps. Allotments forand demonstration waiver authorizedas for all low DSH states. The provision
g/wnnessee and Hawaii have, in the past,under Section 1115 of the Socialalso prohibits the Secretary from
s.orzero. This is because thoseSecurity Act only to the extent that suchimposing a limit on payments made to
leake operated their Medicaidlimitation is necessary to ensure that ahospitals under Hawaii’s QUEST
rams under the provisions ofhospital does not receive a payment inSection 1115 demonstration project
://wikionstration waivers.excess of Tennessee’s annual state DSHexcept to the extent necessary to ensure
httpth states have had special DSHallotment or is necessary to ensure thatthat a hospital does not receive
isions established for them in thethe spending under the waiver remainspayments in excess of its hospital
For example, allowing for a DSHbudget neutral.specific cap, or that payments do not
ent for Tennessee in the event thatexceed the amount that the Secretary
er is discontinued, and andetermines is equal to the federal share
ent for Hawaii for FY2007.of DSH within the budget neutrality
provision of the QUEST demonstration
project.



CRS-99
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
encies are required toNo provision.S§602. Payment error rateA§601. Payment error rate
ually review programs that aremeasurement (“PERM”). Themeasurement (“PERM”). Follows the
nificant erroneousprovision would apply a federalSenate bill with some modifications.
ments, and to estimate the amount ofmatching rate of 90% to expendituresThe agreement specifies that the
proper payments, to report thoserelated to administration of PERMpayment error rate for a state must not
ates to Congress, and to submit arequirements applicable to CHIP. Thetake into account payment errors
on actions the agency is taking toprovision also would exclude from theresulting from the state’s verification of
ments. On August10% cap on CHIP administrative costsan applicant’s self-declaration or self-
iki/CRS-RL34129all expenditures related to thecertification of eligibility for, and the
g/wRM for Medicaid and SCHIPadministration of PERM requirementscorrect amount of, Medicaid or CHIP
s.ore October 1, 2007) whichapplicable to CHIP. The Secretary mustassistance, if the state process for
leakments received on anot calculate or publish national orverifying such information satisfies the
final rule, and includedstate-specific error rates based onrequirements for such a process
://wikie changes to that interim final rule.PERM for CHIP until six months afterapplicable under regulations issued by
httpents of payment error ratesthe date on which a final PERM rule isor otherwise approved by the Secretary.
s for both fee-for-servicein effect for all states. Calculations ofIn addition, the agreement deletes
anaged care services, as well asnational- or state-specific error rateslanguage that would have been
ibility determinations are made. Aafter such a final rule is in effect for allapplicable to states for which PERM
or to PERM, called thestates could only be inclusive of errors,requirements were in effect under
ligibility Quality Controlas defined in this rule or in guidanceinterim rules (now obsolete) for
stem, is operated by stateissued after the effective date thatFY2008. The agreement also gives
agencies for similar purposes.includes detailed instructions for thestates the option to substitute MEQC
specific methodology for errordata for Medicaid eligibility reviews for
determinations. The final PERM ruledata required for PERM purposes, but
would be required to include (1) clearlyonly if the state MEQC reviews are



CRS-100
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
defined criteria for errors for both statesbased on a broad, representative sample
and providers, (2) a clearly definedof Medicaid applicants or enrollees.


process for appealing error
determinations by review contractors,
and (3) clearly defined responsibilities
and deadlines for states in implementing
any corrective action plans. Special
provisions would apply to states for
which the PERM requirements were
first in effect under interim final rules
iki/CRS-RL34129for FY2007 or FY2008 and their
g/wapplication would depend on when the
s.orfinal PERM rule is in effect for all
leakstates. The Senate bill would also
://wikirequire the Secretary to review the
httpMedicaid Eligibility Quality Control(MEQC) requirements with the PERM
requirements and coordinate consistent
implementation of both sets of
requirements, while reducing
redundancies. For purposes of
determining the erroneous excess
payments ratio applicable to the state
under MEQC, a state may elect to
substitute data resulting from the
application of PERM after the final
PERM rule is in effect for all states, for

CRS-101
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
the data used for the MEQC
requirements. The Secretary would also
be required to establish state-specific
sample sizes for application of the
PERM requirements to CHIP for
FY2009 forward. In establishing such
sample sizes, the Secretary must
minimize the administrative cost burden
on states under Medicaid and CHIP, and
must maintain state flexibility to
iki/CRS-RL34129manage these programs.
g/w
s.ors and RHCs under CHIP
leakmentsH§121. Ensuring child-centeredS§609. Application of prospectiveA§503. Application of prospective
://wikie based on acoverage. The provision would requirepayment system for services providedpayment system for services provided
httpe payment system. Beginningthat payments for FQHC and RHCby Federally-qualified health centersby federally-qualified health centers
isit payments wereservices provided under CHIP followand rural health clinics. The provisionand rural health clinics. Same as
erage costs duringthe prospective payment system forwould require states that operateSenate bill.


usted for changes insuch services under Medicaid. Theseparate and/or combination CHIP
scope of services furnished.effective date would be October 1,programs to reimburse FQHCs and
applied to entities first2008.RHCs based on the Medicaid
For subsequentprospective payment system. This
isit payment for allprovision would apply to services
s and RHCs equals the amountsprovided on or after October 1, 2008.
fiscal year increasedFor FY2008, $5 million would be
the percentage increase in theappropriated (to remain available until
ic Index applicable toexpended) to states with separate CHIP

CRS-102
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
mary care services, and adjusted forprograms for expenditures related to
changes in the scope of servicestransitioning to a prospective payment
that fiscal year. Insystem for FQHCs/RHCs under CHIP.
naged care contracts, states areFinally, the Secretary would be required
to make supplementalto report to Congress on the effects (if
ments to the facility equal to theany) of the new prospective payment
ference between the contractedsystem on access to benefits, provider
ount and the cost-based amounts.payment rates or scope of benefits.
Miscellaneous
iki/CRS-RL34129rpose of Title XXI
g/w
s.orision.H§100. Purpose. The provision statesNo provision.A§2. Purpose. Same as the House bill,
leakthat the purpose of the CHIP title of theexcept that the purpose would refer to
House bill is to provide dependable andthe entire agreement.
://wikistable funding for children’s health
httpinsurance under Titles XXI (CHIP) and
XIX (Medicaid) of the Social Security
Act in order to enroll all six million
children who are eligible, but not
enrolled, for coverage today.
statuteH§136. Auditing requirement toSee S§301 (under Enrollment/Access)See A§201 (under Enrollment/Access)
ligibilityenforce citizenship restrictions onfor information on monitoring of invalidfor information on monitoring of invalid
ality Control (MEQC) regulationseligibility for Medicaid and CHIPnames and SSNs submitted fornames and SSNs submitted for
an allowable error rate (3%) forbenefits. Under the House bill, eachcitizenship documentation purposes.citizenship documentation purposes.



CRS-103
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
payments that are duestate would be required to audit a
eligibility errors, as well as astatistically based sample of individuals
thodology for determining a state’swhose Medicaid or CHIP eligibility is
ecause state error ratesdetermined under: (1) optional
ered through MEQC programscitizenship documentation rules for
istently below 3% as of thechildren (specified in H§143 of the bill)
d-1990s, CMS offered states theor (2) optional coverage rules for legal
o develop alternative ways toimmigrant pregnant women and
ntify and reduce erroneous payments.children (specified in H§132 of the bill)
mproper Paymentsto demonstrate to the satisfaction of the
iki/CRS-RL34129ation Act of 2002 (P.L. 107-300),Secretary that federal Medicaid and
g/wencies are also required toCHIP funds are not unlawfully spent on
s.or programs that are susceptible toindividuals who are not legal residents.
leaknificant improper payments, estimateIn conducting such audits, a state may
://wikiamount of overpayments, and reportrely on MEQC or PERM eligibility
http to Congress on those figurese steps being taken to reducereviews. States would be required toremit the federal share of any unlawful
yments. A new regulationexpenditures which are identified under
arding Payment Error Ratethe required audit.


asurement (PERM) for Medicaid and
P was effective on October 1,
th respect to these two
grams, the subset of states selected
iew in a given year are reviewed
a statistically valid random
ple of claims and eligibility
inations to determine error rates.

CRS-104
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ust submit a corrective action
sis,
ust return overpayments of federal
ber of sections of the SocialH§152. Application of certainS§503. Application of certainA§403. Application of certain
Act apply to states under Titlemanaged care quality safeguards tomanaged care quality safeguards tomanaged care quality safeguards to
(SCHIP) in the same manner asCHIP. The House bill would addCHIP. Same as the House bill, butCHIP. Same as the House bill.
iki/CRS-RL34129y apply to a state under Title XIXhese include sectionsubsections (a)(4), (a)(5), (b), (c), (d),and (e) of section 1932, which relate towith no effective date specified.
g/w to conflict ofrequirements for managed care, to the
s.orparagraphs (2), (16),list of Title XIX provisions that apply
leak(17) of section 1903(i) (relating tounder Title XXI. It would apply to
://wikiitations on payment); sectioncontract years for health plans
http to limitations onbeginning on or after July 1, 2008.
ider taxes and donations); and
n 1920A (relating to presumptive
ibility for children).
HIP
ery third fiscal year (beginning withH§154. Access to records for IG andNo provision.A§604. Access to records for IG and
), the Secretary (through theGAO audits. Under the House bill, forGAO audits. Same as the House bill,
General of the Department ofthe purpose of evaluating and auditingexcept that it would also apply for the
an Services) must auditthe CHIP program, the Secretary, thepurpose of evaluating and auditing the
ple from among the states with anOffice of Inspector General, and theMedicaid program.


oved SCHIP state plan that doesComptroller General would have access

CRS-105
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
such plan, provide healthto any books, accounts, records,
erage under Medicaid. Thecorrespondence, and other documents
mptroller General of the Unitedthat are related to the expenditure of
ust monitor these audits and,federal CHIP funds and that are in the
ch fiscalpossession, custody, or control of states,
after a fiscal year in which an auditpolitical subdivisions of states, or their
it a report tograntees or contractors.
ngress on the results of the audit
the prior fiscal year.
iki/CRS-RL34129
g/wision.H§156. Reliance on law; exceptionS§801. Effective date. The effectiveA§3. General effective date;
s.orfor state legislation. The House billdate of the Senate bill (unless otherwiseexception for state legislation;
leakdoes not specify an effective date for theprovided) would be October 1, 2007,contingent effective date; reliance on
://wikibill in its entirety, however it states thatwhether or not final regulations to carrylaw. Same as the Senate bill with
httpwith respect to amendments made byout provisions in the bill have beenrespect to the general effective date.
Title I (CHIP) or Title VIII (Medicaid)promulgated by that date.Same as the House bill with respect to
of the bill that become effective as of aamendments made by all but Title VII
date: (1) such amendments would be(revenue provisions) of the bill that
effective as of such date whether or notbecome effective as of a date: (1) such
regulations implementing suchamendments would be effective as of
amendments have been issued, and (2)such date whether or not regulations
federal financial participation forimplementing such amendments have
medical or child health assistancebeen issued, and (2) federal financial
furnished under Medicaid or CHIP on orparticipation for medical or child health
after such date by a state in good faithassistance furnished under Medicaid or
reliance on such amendments before theCHIP on or after such date by a state in



CRS-106
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
date of promulgation of final regulationsgood faith reliance on such amendments
(if any) to carry out such amendments,before the date of promulgation of final
or the date of guidance (if any)regulations (if any) to carry out such
regarding the implementation of suchamendments, or the date of guidance (if
amendments shall not be denied on theany) regarding the implementation of
basis of the state’s failure to complysuch amendments shall not be denied on
with such regulations or guidance.the basis of the state’s failure to comply
with such regulations or guidance..
In the case of CHIP and Medicaid stateSame as the House bill in the case of aSame as the Senate and House bills in
iki/CRS-RL34129plans, if the Secretary of HHSstate that requires legislation.the case of a state that requires
g/wdetermines that a state must pass newlegislation.


s.orstate legislation to implement the
leakrequirements of the CHIP and Medicaid
titles of the bill, the state plan, if
://wikiapplicable, would not be regarded as
httpfailing to comply solely on the basis of
its failure to meet such requirements
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 the House bill. In the case
of a state that has a two-year legislative
session, each year of such session would
be considered a separate regular session
of the state legislature.

CRS-107
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
The agreement would specify a
contingent effective date for CHIP
funding for FY2008. If funds are
appropriated under any law (other than
the agreement) to provide allotments to
states under CHIP for all (or any
portion) of FY2008: (1) any amounts
that are so appropriated that are not so
allotted and obligated before the date of
enactment of the agreement would be
iki/CRS-RL34129rescinded and (2) any amount provided
g/wfor CHIP allotments to a state under the
s.oragreement for such fiscal year would be
leakreduced by the amount of such
://wikiappropriations so allotted and obligated
httpbefore such date.
eneral, Medicaid managed careH§805. County Medicaid healthNo provision.A§614. County Medicaid health
anizations are subject to contractinginsuring organizations. The House billinsuring organizations; GAO report
ents described in sectionwould add an exemption for HIOson Medicaid managed care payment
)(2)(A) of the Social Securityoperated by Ventura County andrates. Same as the House bill, except
er, certain county-operatedMerced County, and would raise thefor the addition of a GAO report. Not
naged care plans in California thatallowable percentage of beneficiaries tolater than 18 months after the date of the
e Medicaid beneficiaries, which are16%. The provision would be effectiveenactment, the Comptroller General of
to as “county organized healthupon enactment.the United States would be required to
stems” or “health insuringsubmit a report to the Committee on



CRS-108
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
anizations” (HIOs), are exempt fromFinance of the Senate and the
requirements. TheCommittee on Energy and Commerce of
lidated Omnibus Budgetthe House of Representatives analyzing
t of 1985 (P.L.the extent to which state payment rates
272) grandfathered thefor Medicaid managed care

03(m)(2)(A) exemption for HIOsorganizations are actuarially sound.


before January 1, 1986. In
he Omnibus Budget
ct of 1990 (P.L.
508) provided an exemption for up
iki/CRS-RL34129nty-operated HIOs in
g/wlifornia that became operational on or
s.oranuary 1, 1986, provided that
leakents were met. For
://wikiple, the three entities could enroll
httpore than 10% of all Medicaidalifornia, later raised
the Medicare, Medicaid, and
P Benefits Improvement and
2000 (incorporated by

554).


ent of regional medical center
e states and federal government shareH§816. Clarification treatment ofNo provision.A§618. Clarification treatment of
dicaid program.regional medical center. The provisionregional medical center. Same as
etimes hospitals fund the state sharewould prohibit the Secretary fromHouse provision.


e of its own Medicaid payments,denying federal matching payments

CRS-109
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ensuring that federal matchingwhen the state share has been
will be available even if the statetransferred from certain publicly-owned
ot pay its share. Suchregional medical centers in other states
-governmental transfers” ofif the Secretary determines that the use
s made byof such funds is proper and in the
pes of health care providers tointerest of the Medicaid program..


federal share of states’
penditures are allowable but
under
rtain circumstances. Some of those
iki/CRS-RL34129stances are described in detailed
g/weral regulations. Other limitations are
s.or CMS administrative
leakFor example, CMS has recently
://wikifederal matching payments when
httpas comprised ofments transferred from out-of-state

CRS-110
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
e Public HealthH§822. Diabetes grants. The provisionS§613. Demonstration projectsA§505. Demonstration projects
ice Act specifies that the Secretary,would provide $150 million for FY2009relating to diabetes prevention. Therelating to diabetes prevention. Same
or through grants, must providefor each of these two diabetes grantSenate bill, as amended, would create aas Senate bill.


into the prevention and cureprograms under the Public Healthnew demonstration project to fund up to
ype I diabetes. Appropriations areService Act, as part of the appropriation10 states over three years to promote
illion per year during thefor CHIP under this bill.children’s receipt of screenings and
2004 through FY2008.improvements in healthy eating and
e Public Healthphysical activity to reduce the incidence
iki/CRS-RL34129ice Act specifies the Secretary mustof type 2 diabetes. Activities could
g/wke grants for providing services forinclude reductions in cost-sharing or
s.orention and treatment of diabetespremiums when children receive regular
leakong American Indian and Alaskascreenings and reach certain
es. Appropriations are set at $150benchmarks in healthy eating and
://wiki per year during the periodphysical activity. States would be
httph FY2008. permitted to provide (1) financial
bonuses for partnerships with entities
(e.g., schools) that increase education
and other activities to reduce the
incidence of type 2 diabetes, and (2)
incentives to providers serving
Medicaid and CHIP children to perform
screening and counseling regarding
healthy eating and exercise. The
Secretary of HHS would be required to
provide a report to Congress on the

CRS-111
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
degree to which funded activities
improve health outcomes related to type
2 diabetes among children in
participating states. The provision
would authorize to be appropriated a
total of $15 million during FY2008
through FY2012 to fund this
demonstration.
S§501. Child health quality
iki/CRS-RL34129improvement activities for children
g/wenrolled in Medicaid and CHIP.
s.orWould include a childhood obesity
leakdemonstration project that would also
include activities designed to improve
://wikihealth eating and physical activity
httpamong children.
in providing CHIP funds
e Secretary of Commerce wasNo provision.S§604. Improving data collection.A§602. Improving data collection.
ake appropriateBesides the $10 million providedSame as Senate bill.


ustments to the Current Populationannually for the CPS since FY2000, an
rvey (CPS), which is the primaryadditional $10 million (for a total of
law data source for determining$20 million additionally) would be
P allotments, (1) to produceappropriated from FY2008 onward. In
reliable annual state data onaddition to the current-law requirements
ber of low-income children whoof the appropriation, for data collection

CRS-112
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ve health insurance coverage,beginning in FY2008, in appropriate
es in the uninsuranceconsultation with the HHS Secretary,
es of children can reasonably bethe Secretary of Commerce would be
ata thatrequired to make adjustments to the
orizes such children by familyCPS to develop more accurate
e, age, and race or ethnicity; andstate-specific estimates of the number of
children enrolled in CHIP or Medicaid,
ple size used in the state samplingor who are without coverage and to
ber of samplingassess whether estimates from the
its in a state, and to include anAmerican Community Survey (ACS)
iki/CRS-RL34129erification element. Forproduce more reliable estimates than the
g/willion wasCPS for CHIP allotments and payments.
s.or, beginning inOn the basis of that assessment, the
leakCommerce Secretary would recommend
://wikito the HHS Secretary whether ACS
httpestimates should be used in lieu of, or insome combination with, CPS estimates
for CHIP purposes.
If the Commerce Secretary recommends
to the HHS Secretary that ACS
estimates should be used instead of, or
in combination with, CPS estimates for
CHIP purposes, the HHS Secretary may
provide a transition period for using
ACS estimates, provided that the
transition is implemented in a way that



CRS-113
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
avoids adverse impacts on states.
S§105. Incentive bonuses for states.
An appropriation of $5 million would be
provided to the Secretary for FY2008
for improving the timeliness of data
reported from the Medicaid Statistical
Information System (MSIS) and to
provide guidance to states with respect
to any new reporting requirements
iki/CRS-RL34129related to such improvements. Amounts
g/wappropriated are available until
s.orexpended. The resulting improvements
leakare to be designed and implemented so
that, no later than October 1, 2008,
://wikiMedicaid and CHIP enrollment data
httpcould be collected and analyzed by the
Secretary within six months of
submission.
171 gave states the option toH§823. Technical correction. TheS§605. Deficit Reduction ActA611(b). Deficit Reduction Act
ide Medicaid to state-specifiedprovision would make a correction totechnical corrections. Same as Housetechnical corrections — Correction of
h enrollment inthe reference to children in foster carebill.reference to children in foster care
ark and benchmark-equivalentreceiving child welfare services in P.L.receiving child welfare services. Same
erage which is nearly identical to109-171; this change would be effectiveas House and Senate bill.


ailable under CHIP. This lawas if included in this law (i.e., March 31,

CRS-114
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ber of groups as exempt2006).
m mandatory enrollment in
ark or benchmark equivalent
hese exempted groups may be
voluntary
ne such exempted group is
en in foster care receiving child
lfare services under Part B of title IV
ty Act and children
ing foster care or adoption
iki/CRS-RL34129
g/w
s.ore Deficit Reduction Act of 2005No provision.S§605. Deficit Reduction ActA§611(c). Transparency. The
leak171) gave states thetechnical corrections. The Secretaryagreement would require the Secretary
tion to provide Medicaid to state-would be required to publish in theto publish on the CMS internet website
://wikiroups through enrollment inFederal Register and on the internetonly the list of provisions in Title XIX
httpark and benchmark-equivalentwebsite of CMS, a list of the provisionsthat do not apply in order to enable a
erage that is nearly identical to plansin Title XIX that the Secretary hasstate to provide benchmark coverage
CHIP (described abovedetermined do not apply in order tounder Medicaid on the date that such
ices” row).enable a state to carry out a state planapproval is given (rather than within 30
amendment to provide benchmark ordays of such approval). It would also
benchmark-equivalent coverage underrequire the Secretary to publish these
Medicaid. In such publications, thesame findings in the Federal Register
Secretary must also provide the reasonwithin 30 days of the date of approval.
for each such determination. TheThe effective date would be the same as
effective date would be the same as thethe original DRA provision (i.e., March
original DRA provision (i.e., March 31,31, 2006)



CRS-115
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement

2006).


rrent state authority under Medicaid
e federal medical assistanceNo provision.S§601. Technical corrections
e (FMAP) is the rate at whichregarding current state authority
bursed for most Medicaidunder Medicaid. With respect to
ice expenditures. It is based on aMedicaid expenditures for FY2007 and
ula that provides higherFY2008 only, the provision would allow
bursement to states with lower perstates to elect (1) to cover optional,
iki/CRS-RL34129es relative to the nationale (and visa versa); it has apoverty-related children and, may applyless restrictive income methodologies to
g/w minimum of 50% andsuch individuals, for which the regular
s.orximum of 83%. The enhancedMedicaid matching rate, rather than the
leakFMAP) under SCHIP buildsenhanced matching rate under CHIP,
://wikif the regular FMAP forwould apply to determine the federal
http The E-FMAP can range fromshare of such expenditures, or (2) to
receive the regular Medicaid matching
rate, rather than the enhanced CHIP
matching rate, for CHIP children under
an expansion of the state’s Medicaid
program. This provision would be
repealed as of October 1, 2008 (i.e., the
beginning of FY2009). States electing
these options would be “held harmless”
for related expenditures in FY2007 and
FY2008, once this repeal takes effect.



CRS-116
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
ination of counting of Medicaid child presumptive eligibility costs against CHIP allotments
IP statute sets the federal share ofNo provision.S§603. Elimination of countingA§113. Elimination of counting
periods ofMedicaid child presumptive eligibilityMedicaid child presumptive eligibility
ptive eligibility for Medicaidcosts against title XXI allotment. Thecosts against title XXI allotment.
p to two months ofprovision would strike these current lawSame as Senate bill.


erage while a final determination ofprovisions.
ibility is made) at the Medicaid
tching rate. The law also allows
ment out of CHIP allotments for
iki/CRS-RL34129ed by Medicaid
g/wn during periods of presumptive
s.oribility.
leak
://wiki
http

CRS-117
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
treach to small businesses
ision.No provision.S§614. Outreach regarding healthA§623. Outreach regarding health
insurance options available toinsurance options available to
children. The Senate bill wouldchildren. Same as the Senate bill.


establish a task force, consisting of the
Administrator of the Small Business
Administration (SBA) and the
Secretaries of HHS, Labor, and the
Treasury, to conduct a nationwide
iki/CRS-RL34129campaign of education and outreach for
g/wsmall businesses regarding the
s.oravailability of coverage for children
leakthrough private insurance, Medicaid,
and CHIP. The campaign would
://wikiinclude information regarding options to
httpmake insurance more affordable,
including federal and state tax
deductions and credits and the federal
tax exclusion available under
employer-sponsored cafeteria plans; it
would also include efforts to educate
small businesses about the value of
health insurance coverage for children,
assistance available through public
programs, and the availability of the
hotline operated as part of the Insure

CRS-118
Current LawHouse: H.R. 3162Senate: H.R. 976Agreement
Kids Now program at HHS. The task
force would be allowed to use any
business partner of the SBA, enter into
a memorandum of understanding with a
chamber of commerce and a partnership
with any appropriate small business or
health advocacy group, and designate
outreach programs at HHS regional
offices to work with SBA district
offices. It would require the SBA
iki/CRS-RL34129website to prominently display links to
g/wstate eligibility and enrollment
s.orrequirements for Medicaid and CHIP,
leakand would require a report to Congress
://wikievery two years.


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