STATE OF MAINE
118TH LEGISLATURE
FIRST REGULAR AND FIRST SPECIAL SESSION





Final Report
of the

MAINE COMMISSION
ON
CHILDREN'S HEALTH CARE

January 28, 1998










Members:

Rep. Randall L. Berry, chair
Sen. Susan W. Longley
Sen. Michael H. Michaud
Sen. S. Peter Mills
Rep. Joseph Bruno
Rep. Glenys Lovett
Rep. J. Elizabeth Mitchell
Christine Hastedt
David Howes, M.D.
Vicki Kelley
Patricia Riley
Neil Rolde
Lee Urban
John Wipfler
Comm. S. Catherine Longley
Comm. Kevin W. Concannon


Staff:
Jane Orbeton, Legislative Analyst
Office of Policy & Legal Analysis
Rooms 101/107/135, 13 State House Sta.
Augusta, Maine 04333
(207)287-1670


Table of Contents




Executive Summary

I. Introduction to the Maine Commission on Children’s Health Care

II. The Commission process

III. The federal Balanced Budget Act of 1997

IV. Insured and uninsured children in Maine


V. Recommendations of the Maine Commission on Children’s Health Care


Appendices
A. Authorizing legislation, Public Law 1997, Chapter 560
B. Maine Commission on Children’s Health Care membership
C. Public Law 105-33 (1997), the Balanced Budget Act of 1997, the State Children’s Health Insurance Program, Part J
D. Public Law 105-100 (1997), amending the Balanced Budget Act of 1997
E. Maine Children’s Health Insurance Survey Instrument
F. Maine Children’s Health Insurance Preliminary Results
G. Maine Commission on Children’s Health Care, Medicaid Expansion and Cub Care Program
H. Proposed legislation



Executive Summary


The Maine Commission on Children’s Health Care was established by Public Law 1997, chapter 560, Part B to consider the problem of uninsured children in Maine and options to increase the number who are insured. The commission worked through the fall and winter and is pleased to present this report to Governor King and the 118th Legislature with the recommendations of the commission. The commission endorses the submission of a plan to the federal Department of Health and Human Services that is a combination approach to reducing the number of uninsured children - an expanded Medicaid program and a separate state children’s health coverage program.

The commission recommends a comprehensive approach to reducing the number of uninsured children, an approach that is two-fold:

· Expand the popular and effective Medicaid program. Currently children ages birth through 12 months are eligible for Medicaid if their family incomes are below 185% of the federal poverty level. Children ages 1 through 5 years old are eligible for the Medicaid program if their family incomes are below 133% of the federal poverty level. Children ages 6 through 18 are eligible up to 125% of the federal poverty level. The commission recommends simplifying the eligibility criteria by imposing one higher figure, 150% of the federal poverty level, for all children ages 1 to 18. This would make the comprehensive health benefit coverage of the Medicaid program available to children in families of 3 with incomes up to approximately $20,000.

· Create a new program, paid for in part by premium contributions, for children in families between 150% and 185% of the federal poverty level. This would make health insurance with comprehensive benefits available to families of 3 earning between $20,000 and $24,700. The commission proposes naming the new program the Cub Care program.


The commission recommends that the State of Maine provide health insurance to children through the following approaches:

· Submitting a plan to the Department of Health and Human Services that is a Title XXI combined expanded Medicaid program and a separate state children’s health insurance program.

· Continuing to cover children ages birth through 12 months of age in families with incomes below 185% of the federal poverty level.

· Increasing the eligibility level for Medicaid to cover children 1 through 18 years of age in families with incomes below 150% of the federal poverty level.

· Establishing the Cub Care program to provide health insurance coverage to children 1 to 18 years of age in families with income from 150% to 185% of the federal poverty level. The income eligibility level will fluctuate depending on program expenditures, expanding upward if program expenditures are low in order to maximize the number of children covered and contracting downward if program expenditures are high in order to maintain expenses within the program budget.

· Allowing the purchase of Cub Care coverage for Cub Care enrollees and children on the Medicaid program whose family incomes rise above their program eligibility levels, at premium levels that cover the costs of providing coverage plus contributions for administrative costs.

· Granting continuous eligibility for 6-month enrollment periods in the Cub Care program.

· Imposing premiums, based on family income and the number of children covered, on all families in the Cub Care program.

· Spending up to 2% of program funds for outreach. After 6 months of operation if the program budget allows, spending an additional 3% on initiatives to increase access to health care, including the purchase of dental chairs for health clinics to improve access to dental services.
· Addressing crowd-out in the private insurance market through a number of provisions:

(1) excluding children with group health coverage or who had employer-based coverage within the 3 months prior to application for which the employer paid at least 50% of premium cost, with exceptions for high cost coverage and when coverage is lost through change of employment, termination under COBRA or for a reason not in the control of the employee; and

(2) charging premiums on a scale dependent on income for families above 150% of the federal poverty level.

· Adding at least one full-time position equivalent for health policy administration within the Bureau of Medical Services, adding 30 full-time positions within the Bureau of Family Independence, reauthorizing the Maine Commission on Children’s Health Care for 1 year and requiring a quarterly determination by the Commissioner of Human Services of the fiscal status of the program and a report to the commission and the Appropriations and Financial Affairs and Health and Human Services Committees.





I. Introduction

Public Law 1997, chapter 560, Part B established the Maine Commission on Children’s Health Care to study and report to the Governor and the Legislature on the following issues:

* Assess the best and latest available data regarding children’s health insurance in the State, including the number of children under 18 years of age who lack health insurance;
* Examine the costs and benefits of Medicaid expansion with pending federal changes;
* Examine the benefits and detriments of accepting a block grant that would expand children’s health access; and
* Examine the advantages and disadvantages of alternative health services and financing mechanisms of children’s health services.


The report of the commission may include necessary implementing legislation. The Joint Standing Committee on Health and Human Services may report out legislation based on the report of the commission. A copy of Part B of Public Law 1997 chapter 560 is included in Appendix A. The membership of the Maine Commission on Children’s Health Care is included as Appendix B.

A companion portion of the law, Public Law 1997, chapter 560, Part C established the Children’s Health Reserve Account, a dedicated fund to receive income as specified in the law from the General Fund, the Abandoned Property Fund and Title IV-A funds available through the Department of Human Services. The funds in the Children’s Health Reserve Account are dedicated to use as matching funds to match available state and federal funds for the purpose of meeting the recommendations of the commission. In addition the law requires the Governor to submit a request to the Joint Standing Committee on Appropriations and Financial Affairs for the additional funding required to fulfill the recommendations of the commission. The commission was informed that the Children’s Health Reserve Account contained a balance of over $8,000,000 during December, 1997. Part C of Public Law 1997 chapter 560 is included in Appendix A.

While the 118th Legislature was in summer recess and appointments to the commission were pending, the United States Congress passed the Balanced Budget Act of 1997, Public Law 105-33 (1997). This law, in Subtitle J, establishes in Title XXI of the Social Security Act, 42 U.S. Code section 2101 et seq. (1997), the State Children’s Health Insurance Program (CHIP). The State Children’s Health Insurance Program enables each state to initiate and expand health care for low-income children through expanding the state Medicaid program, establishing a separate state sponsored health insurance program under Title XXI, or utilizing the two programs. Part J of the Balanced Budget Act of 1997 is included as Appendix C. Appendix D contains an amendment to the Balanced Budget Act of 1997 which was enacted in November, 1997.

The Balanced Budget Act of 1997 allocates $20,000,000,000 over five federal fiscal years for state children’s health insurance programs. The State of Maine has been informed that Maine’s share of the federal funding is as follows:


* For federal fiscal year 1997-98 $12,724,728
* For federal fiscal year 1998-99 $12,724,728
* For federal fiscal year 1999-2000 $12,724,728
* For federal fiscal year 2000-2001 $13,233,956
* For federal fiscal year 2001-2002 $10,126,638
___________________________________________

* Total for all 5 federal fiscal years $61,534,777

The passage of the Balanced Budget Act of 1997 caused the focus of the work of the Maine Commission on Children’s Health Care to change even before the commission had met. The federal law requires that a state match be appropriated, increases the federal matching rate for Medicaid funds for the Title XXI program 30% over the usual matching rate applicable to the state, allows the state to carry forward unexpended balances for 2 federal fiscal years and distributes any remaining federal surplus among states that have fully spent their federal funds.


II. The Commission Process

The Commission began its work on October 14, 1997 and completed its meetings on January 19, 1998. During the course of its work the Commission heard testimony and received information from school-based children’s health programs, community and Indian health centers, the Maine Center for Economic Policy, the Maine Children’s Alliance, the Department of Human Services, the Department of Mental Health, Mental Retardation and Substance Abuse Services, the Bureau of Insurance, the State Employees’ Health Insurance Program, the Maine Medical Association, the Office of Fiscal and Program Review, Blue Cross Blue Shield of Maine, and other members of the public. Materials provided to the states by the Health Care Financing Administration of the federal Department of Health and Human Services assisted the commission in its work.

The Maine Department of Human Services contracted with the Muskie School of Public Service to conduct a survey of children’s health insurance coverage in Maine. A preliminary report on the survey was provided to the commission. The report estimates the number of uninsured children in the state and their family income levels. From these estimates and the cost per child information provided by the Department of Human Services, the commission estimated program costs and considered the options for coverage presented to the commission.

Currently children in Maine are eligible for the Medicaid program at different income levels depending on the children’s ages. Children birth to 12 months of age are eligible with family incomes up to 185% of the federal poverty level. Children ages 1 through 5 years are eligible with family incomes up to 133% of the federal poverty level. Children ages 6 through 18 years are eligible with family incomes up to 125% of the federal poverty level. The federal poverty levels applicable in 1997-98 are as follows:

Federal Poverty Levels, 1997-98

Size of family

100%

125%

133%

150%

185%

1

$7,890

$9,863

$10,494

$11,835

$14,597

2

10,610

13,263

14,111

15,915

19,629

3

13,330

16,663

17,729

19,995

24,661

4

16,050

20,063

21,347

24,075

29,693

5

18,770

23,463

24,964

28,155

34,725

6

21,490

26,863

28,582

32,235

39,757

7

24,210

30,263

32,199

36,315

44,789

8

26,930

33,663

35,817

40,395

49,821




III. Federal Balanced Budget Act of 1997

The State Children’s Health Insurance Program provisions of the Balanced Budget Act of 1997 were enacted to enable states to initiate and expand health insurance coverage for uninsured children. Funding under Title XXI of the Social Security Act is provided to states submitting approved Title XXI plans to the Department of Health and Human Services. The total amount of federal funding available to the states for federal fiscal year 1997-98 is $4,275,000,000. The share for the State of Maine for that federal fiscal year is $12,724,728. To qualify for this amount the state must submit an approvable plan by July 1, 1998. Federal funds for each fiscal year may be carried forward from the year in which they are allocated for 2 succeeding years. Federal funds not spent by a state within the year of the allocation or the following 2 years will be pooled and redivided among the states that spent their entire allocations for the year of the initial allocation.

The Balanced Budget Act of 1997 contains a number of options and requirements for the states. Title XXI funding may be used to expand Medicaid beyond the eligibility levels in effect on April 15, 1997. Under this option Medicaid rules would apply to children acquiring coverage under the Title XXI expansion. The funding may be used to create or expand a separate state children’s health insurance program to run in conjunction with the Medicaid program, which is required to cover all children who are Medicaid eligible. Because Maine does not have a separate children’s health insurance program, this would mean establishing such a program. The third option is for the state to use Title XXI funding to expand the Medicaid program and create a separate children’s health insurance program.

State Children’s Health Insurance Program federal funding is available to the states at an enhanced federal matching rate that is equal to the current federal matching rate plus 30% of the difference between the state’s regular match rate and 100%, subject to a limit of 85%. For Maine the enhanced match rate will provide $3.20 in federal funds for each $1.00 in state funds spent. Title XXI funding at the enhanced match rate is capped at the maximum amount allocated to the state under the State Children’s Health Insurance Program. Once the cap is reached federal matching funds are available at the regular Medicaid match rate for an expanded Medicaid program, which provides $1.90 for each $1.00 in state funds spent.

The Balanced Budget Act of 1997 requires states implementing a children’s health insurance program to apply Medicaid rules if using a Medicaid expansion. If a non-Medicaid program is chosen, coverage must include benefits that are the same as a benchmark package calculated according to the law, an actuarial equivalent to the benchmark package or a package approved by the Department of Health and Human Services. Cost-sharing may be required only of families above 150% of the federal poverty level but not for well-baby and well-child care or immunizations. Above 150% of the federal poverty level premiums may not exceed 5% of annual family income.

States may adopt continuous eligibility for children in Medicaid and in a Title XXI separate state program. State Medicaid programs may adopt application procedures that provide for periods of up to 2 months of presumptive eligibility from the date of application.


IV. Insured and uninsured children in Maine

The Maine Department of Human Services contracted with the Institute for Health Policy at the Muskie School of Public Service, University of Southern Maine, to conduct a survey of children’s health insurance coverage in Maine. The survey was subcontracted to and conducted by the research organization Mathematica Policy Research, Inc. of Princeton, New Jersey. It was sponsored by Blue Cross Blue Shield of Maine, the Maine Children’s Alliance, the Maine Community Foundation and MaineHealth.

The preliminary report was a valuable resource for the Commission. It estimates the number of uninsured children in the state and their family income levels. From these estimates the commission estimated the number of children anticipated to enroll in a children’s health insurance program at different family income levels. Applying a per child per year cost based on the experience of the state in the Medicaid program and Maine Health Program, the commission estimated program costs, considered the options presented to it and chose an eligibility level designed to maximize coverage for children, avoid the forfeiture of federal funding for state children’s health insurance programs available to the state under the Balanced Budget Act of 1997 and maintain state spending within the program budget.

Between October 20 and November 30, 1997, Mathematica called 13,291 Maine households and completed interviews with 2,449 households with children. Preliminary findings of the survey are that 10.0% of Maine children lack health insurance, totaling 34,440 children. The income levels of these children, as shown in the following chart, are low. 10,366 of the 34,440 children without health insurance coverage live in families with incomes below 125% of the federal poverty level, making them eligible for the Medicaid program under current eligibility levels. Another 11,449 live in families with incomes between 125% and 185% of the federal poverty level, making some of them eligible for Medicaid currently and all of the reminder eligible for an expanded Medicaid program or the new Cub Care program. See Appendix E for a copy of the survey instrument and Appendix F for a copy of the preliminary report prepared by Beth Kilbreth, Senior Research Associate at the Institute for Health Policy at the Muskie School of Public Service.

Estimated Uninsured Children in Maine, 1997

Income levels, based on federal poverty levels Percent uninsured Number of children
Less than 125% fpl

12.7%

10,366

125% - 133% fpl

24.7%

2,871

133% - 185% fpl

21.3%

8,578

185% - 200% fpl

15.2%

2,264

200% - 250% fpl

8.3%

3,526

Above 250% fpl

2.3%

2,862

No income information

13.0%

3,974

In addition to the information on uninsured children, Mathematica obtained information about health insurance coverage for children in the state that was helpful to the commission. 63.2% of all Maine children have employer-sponsored health insurance coverage. An additional 5.8% have private insurance coverage. Medicaid provides coverage for 18.0%, while 2.7% more are covered by other government insurance.


V. Commission Recommendations

The commission makes the following recommendations to the Governor and the 118th Legislature. These recommendations are also listed in Appendix G and are contained in the proposed legislation included as Appendix H. A bill entitled “An Act to Implement the Recommendations of the Maine Commission on Children’s Health Care” will be printed and considered by the Joint Standing Committee on Health and Human Services. The commission recommends that the State of Maine provide health insurance to children by doing the following:

· Submitting a plan to the Department of Health and Human Services that is a Title XXI combined expanded Medicaid program and a separate state children’s health insurance program.

· Continuing to cover children ages birth through 12 months of age in families with incomes below 185% of the federal poverty level.

· Increasing the eligibility level for Medicaid for children to cover children 1 through 18 years of age in families with incomes below 150% of the federal poverty level.

· Establishing the Cub Care program to provide health insurance coverage to children 1 to 18 years of age in families with income from 150% to 185% of the federal poverty level. The income eligibility level will fluctuate depending on program expenditures, expanding upward if program expenditures are low in order to maximize the number of children covered and contracting downward if program expenditures are high in order to maintain expenses within the program budget.

· Allowing the purchase of Cub Care coverage for Cub Care enrollees and children on the Medicaid program whose family incomes rise above their program eligibility levels, at premium levels that cover the costs of providing coverage plus contributions for administrative costs.

· Granting continuous eligibility for 6-month enrollment periods in the Cub Care program.

· Imposing premiums, based on family income and the number of children covered, on all families in the Cub Care program.

· Spending up to 2% of program funds for outreach. After 6 months of operation if the program budget allows, spending an additional 3% on initiatives to increase access to health care, including the purchase of dental chairs for health clinics to improve access to dental services.

· Addressing crowd-out in the private insurance market through a number of provisions:
(1) excluding children with group health coverage or who had employer-based coverage within the 3 months prior to application for which the employer paid at least 50% of premium cost, with exceptions for high cost coverage and when coverage is lost through change of employment, termination under COBRA or for a reason not in the control of the employee; and
(2) charging premiums on a scale dependent on income for families above 150% of the federal poverty level.

· Adding at least one full-time position equivalent for health policy administration within the Bureau of Medical Services, adding 30 full-time positions within the Bureau of Family Independence, reauthorizing the Maine Commission on Children’s Health Care for 1 year and requiring a quarterly determination by the Commissioner of Human Services of the fiscal status of the program and a report to the commission and the Appropriations and Financial Affairs and Health and Human Services Committees.


APPENDIX A

Authorizing Legislation Public Law 1997, Chapter 560

CHAPTER 560

H.P. 1357 - L.D. 1904

An Act to Discourage Smoking, Provide Tax Relief and Improve
the Health of Maine Citizens



PART B

Sec. B-1. Maine Commission on Children's Health Care established. The Maine Commission on Children's Health Care, referred to in this Part as the "commission," is established.

Sec. B-2. Membership. The commission consists of 16 members as follows:

1. The following 2 commissioners:

A. The Commissioner of Human Services, or the commissioner's designee; and

B. The Commissioner of Professional and Financial Regulation, or the commissioner's designee;

2. Seven public members, 3 appointed by the Governor, 2 appointed by the President of the Senate and 2 appointed by the Speaker of the House of Representatives; and

3. Seven Legislators of whom 4 represent the majority party and 3 represent the minority party. Of the 7 Legislators, at least 2 may be members of the Joint Standing Committee on Health and Human Services, 2 may be members of the Joint Standing Committee on Banking and Insurance and 2 may be members of the Joint Standing Committee on Appropriations and Financial Affairs. The legislative members must be appointed jointly by the President of the Senate and the Speaker of the House of Representatives.

The chair of the commission must be selected jointly from among the members by the President of the Senate, the Speaker of the House of Representatives and the Governor.

Sec. B-3. Appointments. All appointments must be made no later than 15 days following the effective date of this Part. The appointing authorities shall notify the Executive Director of the Legislative Council upon making their appointments. When the appointment of all members is complete, the Executive Director of the Legislative Council shall call and convene the first meeting of the commission no later than October 10, 1997.

Sec. B-4. Duties. The commission shall assess the current health needs of the children of this State and develop a series of recommendations to maximize the fulfillment of those needs. The commission shall:

1. Assess the best and latest available data regarding children's health insurance in the State, including the number of children under 18 years of age who lack health insurance;

2. Examine the costs and benefits of Medicaid expansion with pending federal changes;

3. Examine the benefits and detriments of accepting a block grant that would expand children's health access; and

4. Examine the advantages and disadvantages of alternative health services and financing mechanisms of children's health services.

Sec. B-5. Staff assistance. The commission may request staffing and clerical assistance from the State Planning Office and the Legislative Council.

Sec. B-6. Compensation. Commission members who are Legislators are entitled to receive the legislative per diem, as defined in the Maine Revised Statutes, Title 3, section 2, and reimbursement for travel and other necessary expenses for each day's attendance at meetings of the commission. Other members of the commission are not entitled to compensation or reimbursement for expenses.

Sec. B-7. Report. The commission shall submit its recommendations, with any necessary implementing legislation, to the Governor and the Legislature by December 15, 1997. The Joint Standing Committee on Health and Human Services may report out legislation based on the report of the commission.

Sec. B-8. Appropriation. The following funds are appropriated from the General Fund to carry out the purposes of this Part.

1997-98

LEGISLATURE

Maine Commission on Children's
Health Care

Personal Services $1,540
All Other 1,900

Provides funds for the per diem and expenses of legislative members and miscellaneous costs, including printing of the Maine Commission on Children's Health Care.

LEGISLATURE
TOTAL $3,440



APPENDIX B

Maine Commission on Children's Health Care Membership


Appointments by the Governor:
Mr. Lee Urban, Esq.
75 Pearl Street, Suite 430
Portland, ME 04101

Mr. John Wipfler
93 Winding Way
Portland, ME 04102

Mr. David Howes, M.D.
287 Church Road
Brunswick, ME 04111

Joint Appointments by the President and Speaker


Senator Michael H. Michaud
111 Main Street
East Millinocket, ME 04430

Senator Susan W. Longley
RR1, Box 1108
Liberty, ME 04949

Senator S. Peter Mills
P.O. Box 9
Skowhegan, ME 04976

Representative J. Elizabeth Mitchell
28 Eastern Promenade #8
Portland, ME 04101

Representative Randall L. Berry
184 Robinson Road
Livermore, ME 04253

Representative Joseph Bruno
168 Egypt Road
Raymond, ME 04071

Representative Glenys Lovett
16 Cedarbrook Drive
Scarborough, ME 04074

Appointments by the Senate President

Mr. Neil Rolde
P.O. Box 304
York, ME 03909

Ms. Vicki Kelley
RR#4, Box 6225
Gardiner, ME 04345

Appointments by the Speaker of the House

Ms. Patricia Riley
National Academy for State Health Policy
50 Monument Square, Suite #502
Portland, ME 04101

Ms. Chris Hastedt
Maine Equal Justice Project
71 State Street
P.O. Box 5347
Augusta, ME 04332-5347

Ex Officio
Commissioner S. Catherine Longley
Department of Professional & Financial Regulation
35 State House Station
Augusta, ME 04333-0035

Commissioner Kevin W. Concannon
Department of Human Services
11 State House Station
Augusta, ME 04333-0011


Staff: Jane Orbeton, Office of Policy and Legal Analysis


APPENDIX C

Public Law 105-33 (1997)

The Balanced Budget Act of 1997,
The State Children's Health Insurance Program,

Part J

Subtitle J--State Children's Health Insurance Program

CHAPTER 1--STATE CHILDREN'S HEALTH INSURANCE PROGRAM

SEC. 4901. ESTABLISHMENT OF PROGRAM.

(a) ESTABLISHMENT- The Social Security Act is amended by adding at the end the
following new title:

`TITLE XXI--STATE CHILDREN'S HEALTH INSURANCE PROGRAM

`SEC. 2101. PURPOSE; STATE CHILD HEALTH PLANS.

`(a) PURPOSE- The purpose of this title is to provide funds to States to enable them to
initiate and expand the provision of child health assistance to uninsured, low-income children
in an effective and efficient manner that is coordinated with other sources of health benefits
coverage for children. Such assistance shall be provided primarily for obtaining health benefits
coverage through--

`(1) obtaining coverage that meets the requirements of section 2103, or

`(2) providing benefits under the State's medicaid plan under title XIX,

or a combination of both.

`(b) STATE CHILD HEALTH PLAN REQUIRED- A State is not eligible for payment
under section 2105 unless the State has submitted to the Secretary under section 2106 a plan
that--

`(1) sets forth how the State intends to use the funds provided under this title to
provide child health assistance to needy children consistent with the provisions of this
title, and

`(2) has been approved under section 2106.

`(c) STATE ENTITLEMENT- This title constitutes budget authority in advance of
appropriations Acts and represents the obligation of the Federal Government to provide for
the payment to States of amounts provided under section 2104.

`(d) EFFECTIVE DATE- No State is eligible for payments under section 2105 for child
health assistance for coverage provided for periods beginning before October 1, 1997.

`SEC. 2102. GENERAL CONTENTS OF STATE CHILD HEALTH PLAN;
ELIGIBILITY; OUTREACH.


`(a) GENERAL BACKGROUND AND DESCRIPTION- A State child health plan shall
include a description, consistent with the requirements of this title, of--

`(1) the extent to which, and manner in which, children in the State, including targeted
low-income children and other classes of children classified by income and other
relevant factors, currently have creditable health coverage (as defined in section
2110(c)(2));

`(2) current State efforts to provide or obtain creditable health coverage for uncovered
children, including the steps the State is taking to identify and enroll all uncovered
children who are eligible to participate in public health insurance programs and health
insurance programs that involve public-private partnerships;

`(3) how the plan is designed to be coordinated with such efforts to increase coverage
of children under creditable health coverage;

`(4) the child health assistance provided under the plan for targeted low-income
children, including the proposed methods of delivery, and utilization control systems;

`(5) eligibility standards consistent with subsection (b);

`(6) outreach activities consistent with subsection (c); and

`(7) methods (including monitoring) used--

`(A) to assure the quality and appropriateness of care, particularly with respect
to well-baby care, well-child care, and immunizations provided under the plan,
and

`(B) to assure access to covered services, including emergency services.

`(b) GENERAL DESCRIPTION OF ELIGIBILITY STANDARDS AND
METHODOLOGY-

`(1) ELIGIBILITY STANDARDS-

`(A) IN GENERAL- The plan shall include a description of the standards used
to determine the eligibility of targeted low-income children for child health
assistance under the plan. Such standards may include (to the extent consistent
with this title) those relating to the geographic areas to be served by the plan,
age, income and resources (including any standards relating to spenddowns and
disposition of resources), residency, disability status (so long as any standard
relating to such status does not restrict eligibility), access to or coverage under
other health coverage, and duration of eligibility. Such standards may not
discriminate on the basis of diagnosis.


`(B) LIMITATIONS ON ELIGIBILITY STANDARDS- Such eligibility
standards--

`(i) shall, within any defined group of covered targeted low-income
children, not cover such children with higher family income without
covering children with a lower family income, and

`(ii) may not deny eligibility based on a child having a preexisting medical
condition.

`(2) METHODOLOGY- The plan shall include a description of methods of
establishing and continuing eligibility and enrollment.

`(3) ELIGIBILITY SCREENING; COORDINATION WITH OTHER HEALTH
COVERAGE PROGRAMS- The plan shall include a description of procedures to be
used to ensure--

`(A) through both intake and followup screening, that only targeted low-income
children are furnished child health assistance under the State child health plan;

`(B) that children found through the screening to be eligible for medical
assistance under the State medicaid plan under title XIX are enrolled for such
assistance under such plan;

`(C) that the insurance provided under the State child health plan does not
substitute for coverage under group health plans;

`(D) the provision of child health assistance to targeted low-income children in
the State who are Indians (as defined in section 4(c) of the Indian Health Care
Improvement Act, 25 U.S.C. 1603(c)); and

`(E) coordination with other public and private programs providing creditable
coverage for low-income children.

`(4) NONENTITLEMENT- Nothing in this title shall be construed as providing an
individual with an entitlement to child health assistance under a State child health plan.

`(c) OUTREACH AND COORDINATION- A State child health plan shall include a
description of the procedures to be used by the State to accomplish the following:

`(1) OUTREACH- Outreach to families of children likely to be eligible for child health
assistance under the plan or under other public or private health coverage programs to
inform these families of the availability of, and to assist them in enrolling their children in,
such a program.

`(2) COORDINATION WITH OTHER HEALTH INSURANCE PROGRAMS-
Coordination of the administration of the State program under this title with other public
and private health insurance programs.

`SEC. 2103. COVERAGE REQUIREMENTS FOR CHILDREN'S HEALTH
INSURANCE.


`(a) REQUIRED SCOPE OF HEALTH INSURANCE COVERAGE- The child health
assistance provided to a targeted low-income child under the plan in the form described in
paragraph (1) of section 2101(a) shall consist, consistent with subsection (c)(5), of any of the
following:

`(1) BENCHMARK COVERAGE- Health benefits coverage that is equivalent to the
benefits coverage in a benchmark benefit package described in subsection (b).

`(2) BENCHMARK-EQUIVALENT COVERAGE- Health benefits coverage that
meets the following requirements:

`(A) INCLUSION OF BASIC SERVICES- The coverage includes benefits for
items and services within each of the categories of basic services described in
subsection (c)(1).

`(B) AGGREGATE ACTUARIAL VALUE EQUIVALENT TO
BENCHMARK PACKAGE- The coverage has an aggregate actuarial value
that is at least actuarially equivalent to one of the benchmark benefit packages.

`(C) SUBSTANTIAL ACTUARIAL VALUE FOR ADDITIONAL
SERVICES INCLUDED IN BENCHMARK PACKAGE- With respect to
each of the categories of additional services described in subsection (c)(2) for
which coverage is provided under the benchmark benefit package used under
subparagraph (B), the coverage has an actuarial value that is equal to at least 75
percent of the actuarial value of the coverage of that category of services in such
package.

`(3) EXISTING COMPREHENSIVE STATE-BASED COVERAGE- Health
benefits coverage under an existing comprehensive State-based program, described in
subsection (d)(1).

`(4) SECRETARY-APPROVED COVERAGE- Any other health benefits coverage
that the Secretary determines, upon application by a State, provides appropriate
coverage for the population of targeted low-income children proposed to be provided
such coverage.

`(b) BENCHMARK BENEFIT PACKAGES- The benchmark benefit packages are as
follows:

`(1) FEHBP-EQUIVALENT CHILDREN'S HEALTH INSURANCE
COVERAGE- The standard Blue Cross/Blue Shield preferred provider option service
benefit plan, described in and offered under section 8903(1) of title 5, United States
Code.

`(2) STATE EMPLOYEE COVERAGE- A health benefits coverage plan that is
offered and generally available to State employees in the State involved.

`(3) COVERAGE OFFERED THROUGH HMO- The health insurance coverage plan
that--

`(A) is offered by a health maintenance organization (as defined in section
2791(b)(3) of the Public Health Service Act), and

`(B) has the largest insured commercial, non-medicaid enrollment of covered
lives of such coverage plans offered by such a health maintenance organization in
the State involved.

`(c) CATEGORIES OF SERVICES; DETERMINATION OF ACTUARIAL VALUE OF
COVERAGE-

`(1) CATEGORIES OF BASIC SERVICES- For purposes of this section, the
categories of basic services described in this paragraph are as follows:

`(A) Inpatient and outpatient hospital services.

`(B) Physicians' surgical and medical services.

`(C) Laboratory and x-ray services.

`(D) Well-baby and well-child care, including age-appropriate immunizations.

`(2) CATEGORIES OF ADDITIONAL SERVICES- For purposes of this section,
the categories of additional services described in this paragraph are as follows:

`(A) Coverage of prescription drugs.

`(B) Mental health services.

`(C) Vision services.

`(D) Hearing services.

`(3) TREATMENT OF OTHER CATEGORIES- Nothing in this subsection shall be
construed as preventing a State child health plan from providing coverage of benefits
that are not within a category of services described in paragraph (1) or (2).

(4) DETERMINATION OF ACTUARIAL VALUE- The actuarial value of coverage
of benchmark benefit packages, coverage offered under the State child health plan, and
coverage of any categories of additional services under benchmark benefit packages
and under coverage offered by such a plan, shall be set forth in an actuarial opinion in
an actuarial report that has been prepared--

`(A) by an individual who is a member of the American Academy of Actuaries;

`(B) using generally accepted actuarial principles and methodologies;

`(C) using a standardized set of utilization and price factors;

`(D) using a standardized population that is representative of privately insured
children of the age of children who are expected to be covered under the State
child health plan;

`(E) applying the same principles and factors in comparing the value of different
coverage (or categories of services);

`(F) without taking into account any differences in coverage based on the
method of delivery or means of cost control or utilization used; and

`(G) taking into account the ability of a State to reduce benefits by taking into
account the increase in actuarial value of benefits coverage offered under the
State child health plan that results from the limitations on cost sharing under such
coverage.

The actuary preparing the opinion shall select and specify in the memorandum the
standardized set and population to be used under subparagraphs (C) and (D).

`(5) CONSTRUCTION ON PROHIBITED COVERAGE- Nothing in this section
shall be construed as requiring any health benefits coverage offered under the plan to
provide coverage for items or services for which payment is prohibited under this title,
notwithstanding that any benchmark benefit package includes coverage for such an item
or service.

`(d) DESCRIPTION OF EXISTING COMPREHENSIVE STATE-BASED
COVERAGE-

`(1) IN GENERAL- A program described in this paragraph is a child health coverage
program that--

`(A) includes coverage of a range of benefits;

`(B) is administered or overseen by the State and receives funds from the State;

`(C) is offered in New York, Florida, or Pennsylvania; and

`(D) was offered as of the date of the enactment of this title.

`(2) MODIFICATIONS- A State may modify a program described in paragraph (1)
from time to time so long as it continues to meet the requirement of subparagraph (A)
and does not reduce the actuarial value of the coverage under the program below the
lower of--

`(A) the actuarial value of the coverage under the program as of the date of the
enactment of this title, or

`(B) the actuarial value described in subsection (a)(2)(B),

evaluated as of the time of the modification.

`(e) COST-SHARING-

`(1) DESCRIPTION; GENERAL CONDITIONS-

`(A) DESCRIPTION- A State child health plan shall include a description,
consistent with this subsection, of the amount (if any) of premiums, deductibles,
coinsurance, and other cost sharing imposed. Any such charges shall be imposed
pursuant to a public schedule.

`(B) PROTECTION FOR LOWER INCOME CHILDREN- The State child
health plan may only vary premiums, deductibles, coinsurance, and other cost
sharing based on the family income of targeted low-income children in a manner
that does not favor children from families with higher income over children from
families with lower income.

`(2) NO COST SHARING ON BENEFITS FOR PREVENTIVE SERVICES- The
State child health plan may not impose deductibles, coinsurance, or other cost sharing
with respect to benefits for services within the category of services described in
subsection (c)(1)(D).

(3) LIMITATIONS ON PREMIUMS AND COST-SHARING-

`(A) CHILDREN IN FAMILIES WITH INCOME BELOW 150 PERCENT
OF POVERTY LINE- In the case of a targeted low-income child whose family
income is at or below 150 percent of the poverty line, the State child health plan
may not impose--

`(i) an enrollment fee, premium, or similar charge that exceeds the
maximum monthly charge permitted consistent with standards established
to carry out section 1916(b)(1) (with respect to individuals described in
such section); and

`(ii) a deductible, cost sharing, or similar charge that exceeds an amount
that is nominal (as determined consistent with regulations referred to in
section 1916(a)(3), with such appropriate adjustment for inflation or other
reasons as the Secretary determines to be reasonable).

`(B) OTHER CHILDREN- For children not described in subparagraph (A),
subject to paragraphs (1)(B) and (2), any premiums, deductibles, cost sharing or
similar charges imposed under the State child health plan may be imposed on a
sliding scale related to income, except that the total annual aggregate
cost-sharing with respect to all targeted low-income children in a family under
this title may not exceed 5 percent of such family's income for the year involved.

`(4) RELATION TO MEDICAID REQUIREMENTS- Nothing in this subsection
shall be construed as affecting the rules relating to the use of enrollment fees, premiums,
deductions, cost sharing, and similar charges in the case of targeted low-income
children who are provided child health assistance in the form of coverage under a
medicaid program under section 2101(a)(2).

`(f) APPLICATION OF CERTAIN REQUIREMENTS-

`(1) RESTRICTION ON APPLICATION OF PREEXISTING CONDITION
EXCLUSIONS-

`(A) IN GENERAL- Subject to subparagraph (B), the State child health plan
shall not permit the imposition of any preexisting condition exclusion for covered
benefits under the plan.

`(B) GROUP HEALTH PLANS AND GROUP HEALTH INSURANCE
COVERAGE- If the State child health plan provides for benefits through
payment for, or a contract with, a group health plan or group health insurance
coverage, the plan may permit the imposition of a preexisting condition exclusion
but only insofar as it is permitted under the applicable provisions of part 7 of
subtitle B of title I of the Employee Retirement Income Security Act of 1974 and
title XXVII of the Public Health Service Act.

`(2) COMPLIANCE WITH OTHER REQUIREMENTS- Coverage offered under
this section shall comply with the requirements of subpart 2 of part A of title XXVII of
the Public Health Service Act insofar as such requirements apply with respect to a
health insurance issuer that offers group health insurance coverage.


SEC. 2104. ALLOTMENTS.

`(a) APPROPRIATION; TOTAL ALLOTMENT- For the purpose of providing allotments
to States under this section, there is appropriated, out of any money in the Treasury not
otherwise appropriated--

`(1) for fiscal year 1998, $4,275,000,000;

`(2) for fiscal year 1999, $4,275,000,000;

`(3) for fiscal year 2000, $4,275,000,000;

`(4) for fiscal year 2001, $4,275,000,000;

`(5) for fiscal year 2002, $3,150,000,000;

`(6) for fiscal year 2003, $3,150,000,000;

`(7) for fiscal year 2004, $3,150,000,000;

`(8) for fiscal year 2005, $4,050,000,000;

`(9) for fiscal year 2006, $4,050,000,000; and

`(10) for fiscal year 2007, $5,000,000,000.

`(b) ALLOTMENTS TO 50 STATES AND DISTRICT OF COLUMBIA-

`(1) IN GENERAL- Subject to paragraph (4) and subsection (d), of the amount
available for allotment under subsection (a) for a fiscal year, reduced by the amount of
allotments made under subsection (c) for the fiscal year, the Secretary shall allot to
each State (other than a State described in such subsection) with a State child health
plan approved under this title the same proportion as the ratio of--

`(A) the product of (i) the number of children described in paragraph (2) for the
State for the fiscal year and (ii) the State cost factor for that State (established
under paragraph (3)); to

`(B) the sum of the products computed under subparagraph (A).

`(2) NUMBER OF CHILDREN-

`(A) IN GENERAL- The number of children described in this paragraph for a
State for--

`(i) each of fiscal years 1998 through 2000 is equal to the number of
low-income children in the State with no health insurance coverage for the
fiscal year;

`(ii) fiscal year 2001 is equal to--

`(I) 75 percent of the number of low-income children in the State
for the fiscal year with no health insurance coverage, plus

`(II) 25 percent of the number of low-income children in the State
for the fiscal year; and

(iii) each succeeding fiscal year is equal to--

`(I) 50 percent of the number of low-income children in the State
for the fiscal year with no health insurance coverage, plus

`(II) 50 percent of the number of low-income children in the State
for the fiscal year.

`(B) DETERMINATION OF NUMBER OF CHILDREN- For purposes of
subparagraph (A), a determination of the number of low-income children (and of
such children who have no health insurance coverage) for a State for a fiscal
year shall be made on the basis of the arithmetic average of the number of such
children, as reported and defined in the 3 most recent March supplements to the
Current Population Survey of the Bureau of the Census before the beginning of
the fiscal year.

`(3) ADJUSTMENT FOR GEOGRAPHIC VARIATIONS IN HEALTH COSTS-

`(A) IN GENERAL- For purposes of paragraph (1)(A)(ii), the `State cost
factor' for a State for a fiscal year equal to the sum of--

`(i) 0.15, and

`(ii) 0.85 multiplied by the ratio of--

`(I) the annual average wages per employee for the State for such
year (as determined under subparagraph (B)), to

`(II) the annual average wages per employee for the 50 States and
the District of Columbia.

`(B) ANNUAL AVERAGE WAGES PER EMPLOYEE- For purposes of
subparagraph (A), the `annual average wages per employee' for a State, or for
all the States. for a fiscal year is equal to the average of the annual wages per
employee for the State or for the 50 States and the District of Columbia for
employees in the health services industry (SIC code 8000), as reported by the
Bureau of Labor Statistics of the Department of Labor for each of the most
recent 3 years before the beginning of the fiscal year involved.

`(4) FLOOR FOR STATES- Subject to paragraph (5), in no case shall the amount of
the allotment under this subsection for one of the 50 States or the District of Columbia
for a year be less than $2,000,000. To the extent that the application of the previous
sentence results in an increase in the allotment to a State above the amount otherwise
provided, the allotments for the other States and the District of Columbia under this
subsection shall be reduced in a pro rata manner (but not below $2,000,000) so that
the total of such allotments in a fiscal year does not exceed the amount otherwise
provided for allotment under paragraph (1) for that fiscal year.

`(c) ALLOTMENTS TO TERRITORIES-

`(1) IN GENERAL- Of the amount available for allotment under subsection (a) for a
fiscal year, subject to subsection (d), the Secretary shall allot 0.25 percent among each
of the commonwealths and territories described in paragraph (3) in the same
proportion as the percentage specified in paragraph (2) for such commonwealth or
territory bears to the sum of such percentages for all such commonwealths or territories
so described.

`(2) PERCENTAGE- The percentage specified in this paragraph for--

`(A) Puerto Rico is 91.6 percent,

`(B) Guam is 3.5 percent,

`(C) Virgin Islands is 2.6 percent,

`(D) American Samoa is 1.2 percent, and

`(E) the Northern Mariana Islands is 1.1 percent.

`(3) COMMONWEALTHS AND TERRITORIES- A commonwealth or territory
described in this paragraph is any of the following if it has a State child health plan
approved under this title:

`(A) Puerto Rico.

B) Guam.

`(C) the Virgin Islands.

`(D) American Samoa.

`(E) the Northern Mariana Islands.

`(d) CERTAIN MEDICAID EXPENDITURES COUNTED AGAINST INDIVIDUAL
STATE ALLOTMENTS- The amount of the allotment otherwise provided to a State under
subsection (b) or (c) for a fiscal year shall be reduced by the sum of--

`(1) the amount (if any) of the payments made to that State under section 1903(a) for
calendar quarters during such fiscal year that is attributable to the provision of medical
assistance to a child during a presumptive eligibility period under section 1920A, and

`(2) the amount of payments under such section during such period that is attributable
to the provision of medical assistance to a child for which payment is made under
section 1903(a)(1) on the basis of an enhanced FMAP under section 1905(b).

`(e) 3-YEAR AVAILABILITY OF AMOUNTS ALLOTTED- Amounts allotted to a State
pursuant to this section for a fiscal year shall remain available for expenditure by the State
through the end of the second succeeding fiscal year; except that amounts reallotted to a State
under subsection (f) shall be available for expenditure by the State through the end of the fiscal
year in which they are reallotted.

`(f) PROCEDURE FOR REDISTRIBUTION OF UNUSED ALLOTMENTS- The
Secretary shall determine an appropriate procedure for redistribution of allotments from
States that were provided allotments under this section for a fiscal year but that do not expend
all of the amount of such allotments during the period in which such allotments are available for
expenditure under subsection (e), to States that have fully expended the amount of their
allotments under this section.

`SEC. 2105. PAYMENTS TO STATES.


`(a) IN GENERAL- Subject to the succeeding provisions of this section, the Secretary shall
pay to each State with a plan approved under this title, from its allotment under section 2104
(taking into account any adjustment under section 2104(d)), an amount for each quarter equal
to the enhanced FMAP of expenditures in the quarter--

`(1) for child health assistance under the plan for targeted low-income children in the
form of providing health benefits coverage that meets the requirements of section 2103;
and

`(2) only to the extent permitted consistent with subsection (c)--

`(A) for payment for other child health assistance for targeted low-income
children;

`(B) for expenditures for health services initiatives under the plan for improving
the health of children (including targeted low-income children and other
low-income children);

`(C) for expenditures for outreach activities as provided in section 2102(c)(1)
under the plan; and

`(D) for other reasonable costs incurred by the State to administer the plan.

`(b) ENHANCED FMAP- For purposes of subsection (a), the `enhanced FMAP', for a
State for a fiscal year, is equal to the Federal medical assistance percentage (as defined in the
first sentence of section 1905(b)) for the State increased by a number of percentage points
equal to 30 percent of the number of percentage points by which (1) such Federal medical
assistance percentage for the State, is less than (2) 100 percent; but in no case shall the
enhanced FMAP for a State exceed 85 percent.

`(c) LIMITATION ON CERTAIN PAYMENTS FOR CERTAIN EXPENDITURES-

`(1) GENERAL LIMITATIONS- Funds provided to a State under this title shall only
be used to carry out the purposes of this title (as described in section 2101), and any
health insurance coverage provided with such funds may include coverage of abortion
only if necessary to save the life of the mother or if the pregnancy is the result of an act
of rape or incest.

2) LIMITATION ON EXPENDITURES NOT USED FOR MEDICAID OR
HEALTH INSURANCE ASSISTANCE-

`(A) IN GENERAL- Except as provided in this paragraph, payment shall not be
made under subsection (a) for expenditures for items described in subsection (a)
(other than paragraph (1)) for a quarter in a fiscal year to the extent the total of
such expenditures exceeds 10 percent of the sum of--

`(i) the total Federal payments made under subsection (a) for such quarter
in the fiscal year, and

`(ii) the total Federal payments made under section 1903(a)(1) based on
an enhanced FMAP described in section 1905(u)(2) for such quarter.

`(B) WAIVER AUTHORIZED FOR COST-EFFECTIVE ALTERNATIVE-
The limitation under subparagraph (A) on expenditures for items described in
subsection (a)(2) shall not apply to the extent that a State establishes to the
satisfaction of the Secretary that--

`(i) coverage provided to targeted low-income children through such
expenditures meets the requirements of section 2103;

`(ii) the cost of such coverage is not greater, on an average per child
basis, than the cost of coverage that would otherwise be provided under
section 2103; and

`(iii) such coverage is provided through the use of a community-based
health delivery system, such as through contracts with health centers
receiving funds under section 330 of the Public Health Service Act or with
hospitals such as those that receive disproportionate share payment
adjustments under section 1886(d)(5)(F) or 1923.

`(3) WAIVER FOR PURCHASE OF FAMILY COVERAGE- Payment may be
made to a State under subsection (a)(1) for the purchase of family coverage under a
group health plan or health insurance coverage that includes coverage of targeted
low-income children only if the State establishes to the satisfaction of the Secretary
that--

`(A) purchase of such coverage is cost-effective relative to the amounts that the
State would have paid to obtain comparable coverage only of the targeted
low-income children involved, and

`(B) such coverage shall not be provided if it would otherwise substitute for
health insurance coverage that would be provided to such children but for the
purchase of family coverage.

`(4) USE OF NON-FEDERAL FUNDS FOR STATE MATCHING
REQUIREMENT- Amounts provided by the Federal Government, or services
assisted or subsidized to any significant extent by the Federal Government, may not be
included in determining the amount of non-Federal contributions required under
subsection (a).

`(5) OFFSET OF RECEIPTS ATTRIBUTABLE TO PREMIUMS AND OTHER
COST-SHARING- For purposes of subsection (a), the amount of the expenditures
under the plan shall be reduced by the amount of any premiums and other cost-sharing
received by the State.

`(6) PREVENTION OF DUPLICATIVE PAYMENTS-

`(A) OTHER HEALTH PLANS- No payment shall be made to a State under
this section for expenditures for child health assistance provided for a targeted
low-income child under its plan to the extent that a private insurer (as defined by
the Secretary by regulation and including a group health plan (as defined in
section 607(1) of the Employee Retirement Income Security Act of 1974), a
service benefit plan, and a health maintenance organization) would have been
obligated to provide such assistance but for a provision of its insurance contract
which has the effect of limiting or excluding such obligation because the individual
is eligible for or is provided child health assistance under the plan.

`(B) OTHER FEDERAL GOVERNMENTAL PROGRAMS- Except as
otherwise provided by law, no payment shall be made to a State under this
section for expenditures for child health assistance provided for a targeted
low-income child under its plan to the extent that payment has been made or can
reasonably be expected to be made promptly (as determined in accordance with
regulations) under any other federally operated or financed health care insurance
program, other than an insurance program operated or financed by the Indian
Health Service, as identified by the Secretary. For purposes of this paragraph,
rules similar to the rules for overpayments under section 1903(d)(2) shall apply.

`(7) LIMITATION ON PAYMENT FOR ABORTIONS-

`(A) IN GENERAL- Payment shall not be made to a State under this section for
any amount expended under the State plan to pay for any abortion or to assist in
the purchase, in whole or in part, of health benefit coverage that includes
coverage of abortion.

`(B) EXCEPTION- Subparagraph (A) shall not apply to an abortion only if
necessary to save the life of the mother or if the pregnancy is the result of an act
of rape or incest.

`(C) RULE OF CONSTRUCTION- Nothing in this section shall be construed
as affecting the expenditure by a State, locality, or private person or entity of
State, local, or private funds (other than funds expended under the State plan)
for any abortion or for health benefits coverage that includes coverage of
abortion.

`(d) MAINTENANCE OF EFFORT-

`(1) IN MEDICAID ELIGIBILITY STANDARDS- No payment may be made under
subsection (a) with respect to child health assistance provided under a State child
health plan if the State adopts income and resource standards and methodologies for
purposes of determining a child's eligibility for medical assistance under the State plan
under title XIX that are more restrictive than those applied as of June 1, 1997.

`(2) IN AMOUNTS OF PAYMENT EXPENDED FOR CERTAIN
STATE-FUNDED HEALTH INSURANCE PROGRAMS FOR CHILDREN-

`(A) IN GENERAL- The amount of the allotment for a State in a fiscal year
(beginning with fiscal year 1999) shall be reduced by the amount by which--

`(i) the total of the State children's health insurance expenditures in the
preceding fiscal year, is less than

`(ii) the total of such expenditures in fiscal year 1996.

`(B) STATE CHILDREN'S HEALTH INSURANCE EXPENDITURES- The
term `State children's health insurance expenditures' means the following:

`(i) The State share of expenditures under this title.

`(ii) The State share of expenditures under title XIX that are attributable
to an enhanced FMAP under section 1905(u).

`(iii) State expenditures under health benefits coverage under an existing
comprehensive State-based program, described section 2103(d).

`(e) ADVANCE PAYMENT; RETROSPECTIVE ADJUSTMENT- The Secretary may
make payments under this section for each quarter on the basis of advance estimates of
expenditures submitted by the State and such other investigation as the Secretary may find
necessary, and may reduce or increase the payments as necessary to adjust for any
overpayment or underpayment for prior quarters.

`SEC. 2106. PROCESS FOR SUBMISSION, APPROVAL, AND
AMENDMENT OF STATE CHILD HEALTH PLANS.

`(a) INITIAL PLAN-

`(1) IN GENERAL- As a condition of receiving payment under section 2105, a State
shall submit to the Secretary a State child health plan that meets the applicable
requirements of this title.

`(2) APPROVAL- Except as the Secretary may provide under subsection (e), a State
plan submitted under paragraph (1)--

`(A) shall be approved for purposes of this title, and

`(B) shall be effective beginning with a calendar quarter that is specified in the
plan, but in no case earlier than October 1, 1997.

`(b) PLAN AMENDMENTS-

`(1) IN GENERAL- A State may amend, in whole or in part, its State child health plan
at any time through transmittal of a plan amendment.

`(2) APPROVAL- Except as the Secretary may provide under subsection (e), an
amendment to a State plan submitted under paragraph (1)--

(A) shall be approved for purposes of this title, and

`(B) shall be effective as provided in paragraph (3).

`(3) EFFECTIVE DATES FOR AMENDMENTS-

`(A) IN GENERAL- Subject to the succeeding provisions of this paragraph, an
amendment to a State plan shall take effect on one or more effective dates
specified in the amendment.

`(B) AMENDMENTS RELATING TO ELIGIBILITY OR BENEFITS-

`(i) NOTICE REQUIREMENT- Any plan amendment that eliminates or
restricts eligibility or benefits under the plan may not take effect unless the
State certifies that it has provided prior public notice of the change, in a
form and manner provided under applicable State law.

`(ii) TIMELY TRANSMITTAL- Any plan amendment that eliminates or
restricts eligibility or benefits under the plan shall not be effective for
longer than a 60-day period unless the amendment has been transmitted
to the Secretary before the end of such period.

`(C) OTHER AMENDMENTS- Any plan amendment that is not described in
subparagraph (B) and that becomes effective in a State fiscal year may not
remain in effect after the end of such fiscal year (or, if later, the end of the
90-day period on which it becomes effective) unless the amendment has been
transmitted to the Secretary.

`(c) DISAPPROVAL OF PLANS AND PLAN AMENDMENTS-

`(1) PROMPT REVIEW OF PLAN SUBMITTALS- The Secretary shall promptly
review State plans and plan amendments submitted under this section to determine if
they substantially comply with the requirements of this title.

`(2) 90-DAY APPROVAL DEADLINES- A State plan or plan amendment is
considered approved unless the Secretary notifies the State in writing, within 90 days
after receipt of the plan or amendment, that the plan or amendment is disapproved (and
the reasons for disapproval) or that specified additional information is needed.

`(3) CORRECTION- In the case of a disapproval of a plan or plan amendment, the
Secretary shall provide a State with a reasonable opportunity for correction before
taking financial sanctions against the State on the basis of such disapproval.

`(d) PROGRAM OPERATION-

`(1) IN GENERAL- The State shall conduct the program in accordance with the plan
(and any amendments) approved under subsection (c) and with the requirements of this
title.

`(2) VIOLATIONS- The Secretary shall establish a process for enforcing
requirements under this title. Such process shall provide for the withholding of funds in
the case of substantial noncompliance with such requirements. In the case of an
enforcement action against a State under this paragraph, the Secretary shall provide a
State with a reasonable opportunity for correction before taking financial sanctions
against the State on the basis of such an action.

`(e) CONTINUED APPROVAL- An approved State child health plan shall continue in effect
unless and until the State amends the plan under subsection (b) or the Secretary finds, under
subsection (d), substantial noncompliance of the plan with the requirements of this title.

`SEC. 2107. STRATEGIC OBJECTIVES AND PERFORMANCE GOALS;
PLAN ADMINISTRATION.


`(a) STRATEGIC OBJECTIVES AND PERFORMANCE GOALS-

`(1) DESCRIPTION- A State child health plan shall include a description of--

`(A) the strategic objectives,

`(B) the performance goals, and

`(C) the performance measures,

the State has established for providing child health assistance to targeted low-income
children under the plan and otherwise for maximizing health benefits coverage for other
low-income children and children generally in the State.

(2) STRATEGIC OBJECTIVES- Such plan shall identify specific strategic objectives
relating to increasing the extent of creditable health coverage among targeted
low-income children and other low-income children.

`(3) PERFORMANCE GOALS- Such plan shall specify one or more performance
goals for each such strategic objective so identified.

`(4) PERFORMANCE MEASURES- Such plan shall describe how performance
under the plan will be--

`(A) measured through objective, independently verifiable means, and

`(B) compared against performance goals, in order to determine the State's
performance under this title.

`(b) RECORDS, REPORTS, AUDITS, AND EVALUATION-

`(1) DATA COLLECTION, RECORDS, AND REPORTS- A State child health plan
shall include an assurance that the State will collect the data, maintain the records, and
furnish the reports to the Secretary, at the times and in the standardized format the
Secretary may require in order to enable the Secretary to monitor State program
administration and compliance and to evaluate and compare the effectiveness of State
plans under this title.

`(2) STATE ASSESSMENT AND STUDY- A State child health plan shall include a
description of the State's plan for the annual assessments and reports under section
2108(a) and the evaluation required by section 2108(b).

`(3) AUDITS- A State child health plan shall include an assurance that the State will
afford the Secretary access to any records or information relating to the plan for the
purposes of review or audit.

`(c) PROGRAM DEVELOPMENT PROCESS- A State child health plan shall include a
description of the process used to involve the public in the design and implementation of the
plan and the method for ensuring ongoing public involvement.

`(d) PROGRAM BUDGET- A State child health plan shall include a description of the
budget for the plan. The description shall be updated periodically as necessary and shall
include details on the planned use of funds and the sources of the non-Federal share of plan
expenditures, including any requirements for cost-sharing by beneficiaries.

`(e) APPLICATION OF CERTAIN GENERAL PROVISIONS- The following sections of
this Act shall apply to States under this title in the same manner as they apply to a State under
title XIX:

`(1) TITLE XIX PROVISIONS-

`(A) Section 1902(a)(4)(C) (relating to conflict of interest standards).

`(B) Paragraphs (2), (16), and (17) of section 1903(i) (relating to limitations on
payment).

`(C) Section 1903(w) (relating to limitations on provider taxes and donations).

`(2) TITLE XI PROVISIONS-

`(A) Section 1115 (relating to waiver authority).

`(B) Section 1116 (relating to administrative and judicial review), but only
insofar as consistent with this title.

`(C) Section 1124 (relating to disclosure of ownership and related information).

`(D) Section 1126 (relating to disclosure of information about certain convicted
individuals).

`(E) Section 1128A (relating to civil monetary penalties).

`(F) Section 1128B(d) (relating to criminal penalties for certain additional
charges).

`(G) Section 1132 (relating to periods within which claims must be filed).

`SEC. 2108. ANNUAL REPORTS; EVALUATIONS.


`(a) ANNUAL REPORT- The State shall--

`(1) assess the operation of the State plan under this title in each fiscal year, including
the progress made in reducing the number of uncovered low-income children; and

(2) report to the Secretary, by January 1 following the end of the fiscal year, on the
result of the assessment.

`(b) STATE EVALUATIONS-

`(1) IN GENERAL- By March 31, 2000, each State that has a State child health plan
shall submit to the Secretary an evaluation that includes each of the following:

`(A) An assessment of the effectiveness of the State plan in increasing the
number of children with creditable health coverage.

`(B) A description and analysis of the effectiveness of elements of the State plan,
including--

`(i) the characteristics of the children and families assisted under the State
plan including age of the children, family income, and the assisted child's
access to or coverage by other health insurance prior to the State plan
and after eligibility for the State plan ends,

`(ii) the quality of health coverage provided including the types of benefits
provided,

`(iii) the amount and level (including payment of part or all of any
premium) of assistance provided by the State,

`(iv) the service area of the State plan,

`(v) the time limits for coverage of a child under the State plan,

`(vi) the State's choice of health benefits coverage and other methods
used for providing child health assistance, and

`(vii) the sources of non-Federal funding used in the State plan.

`(C) An assessment of the effectiveness of other public and private programs in
the State in increasing the availability of affordable quality individual and family
health insurance for children.

`(D) A review and assessment of State activities to coordinate the plan under
this title with other public and private programs providing health care and health
care financing, including medicaid and maternal and child health services.

`(E) An analysis of changes and trends in the State that affect the provision of
accessible, affordable, quality health insurance and health care to children.

`(F) A description of any plans the State has for improving the availability of
health insurance and health care for children.

`(G) Recommendations for improving the program under this title.

`(H) Any other matters the State and the Secretary consider appropriate.

`(2) REPORT OF THE SECRETARY- The Secretary shall submit to Congress and
make available to the public by December 31, 2001, a report based on the evaluations
submitted by States under paragraph (1), containing any conclusions and
recommendations the Secretary considers appropriate.

`SEC. 2109. MISCELLANEOUS PROVISIONS.


`(a) RELATION TO OTHER LAWS-

`(1) HIPAA- Health benefits coverage provided under section 2101(a)(1) (and
coverage provided under a waiver under section 2105(c)(2)(B)) shall be treated as
creditable coverage for purposes of part 7 of subtitle B of title II of the Employee
Retirement Income Security Act of 1974, title XXVII of the Public Health Service Act,
and subtitle K of the Internal Revenue Code of 1986.

`(2) ERISA- Nothing in this title shall be construed as affecting or modifying section
514 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1144) with
respect to a group health plan (as defined in section 2791(a)(1) of the Public Health
Service Act (42 U.S.C. 300gg-91(a)(1)).

`SEC. 2110. DEFINITIONS.


`(a) CHILD HEALTH ASSISTANCE- For purposes of this title, the term `child health
assistance' means payment for part or all of the cost of health benefits coverage for targeted
low-income children that includes any of the following (and includes, in the case described in
section 2105(a)(2)(A), payment for part or all of the cost of providing any of the following),
as specified under the State plan:



`(1) Inpatient hospital services.

`(2) Outpatient hospital services.

`(3) Physician services.

`(4) Surgical services.

`(5) Clinic services (including health center services) and other ambulatory health care
services.

`(6) Prescription drugs and biologicals and the administration of such drugs and
biologicals, only if such drugs and biologicals are not furnished for the purpose of
causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a
person.

`(7) Over-the-counter medications.

`(8) Laboratory and radiological services.

`(9) Prenatal care and prepregnancy family planning services and supplies.

`(10) Inpatient mental health services, other than services described in paragraph (18)
but including services furnished in a State-operated mental hospital and including
residential or other 24-hour therapeutically planned structured services.

`(11) Outpatient mental health services, other than services described in paragraph (19)
but including services furnished in a State-operated mental hospital and including
community-based services.

`(12) Durable medical equipment and other medically-related or remedial devices (such
as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive
devices).

`(13) Disposable medical supplies.

`(14) Home and community-based health care services and related supportive services
(such as home health nursing services, home health aide services, personal care,
assistance with activities of daily living, chore services, day care services, respite care
services, training for family members, and minor modifications to the home).

`(15) Nursing care services (such as nurse practitioner services, nurse midwife services,
advanced practice nurse services, private duty nursing care, pediatric nurse services,
and respiratory care services) in a home, school, or other setting.

`(16) Abortion only if necessary to save the life of the mother or if the pregnancy is the
result of an act of rape or incest.

`(17) Dental services.

`(18) Inpatient substance abuse treatment services and residential substance abuse
treatment services.

`(19) Outpatient substance abuse treatment services.

`(20) Case management services.

`(21) Care coordination services.

`(22) Physical therapy, occupational therapy, and services for individuals with speech,
hearing, and language disorders.

`(23) Hospice care.

`(24) Any other medical, diagnostic, screening, preventive, restorative, remedial,
therapeutic, or rehabilitative services (whether in a facility, home, school, or other
setting) if recognized by State law and only if the service is--

`(A) prescribed by or furnished by a physician or other licensed or registered
practitioner within the scope of practice as defined by State law,

`(B) performed under the general supervision or at the direction of a physician,
or

`(C) furnished by a health care facility that is operated by a State or local
government or is licensed under State law and operating within the scope of the
license.

`(25) Premiums for private health care insurance coverage.

`(26) Medical transportation.

`(27) Enabling services (such as transportation, translation, and outreach services) only
if designed to increase the accessibility of primary and preventive health care services
for eligible low-income individuals.

(28) Any other health care services or items specified by the Secretary and not
excluded under this section.

`(b) TARGETED LOW-INCOME CHILD DEFINED- For purposes of this title--

`(1) IN GENERAL- Subject to paragraph (2), the term `targeted low-income child'
means a child--

`(A) who has been determined eligible by the State for child health assistance
under the State plan;

`(B)(i) who is a low-income child, or

`(ii) is a child whose family income (as determined under the State child health
plan) exceeds the medicaid applicable income level (as defined in paragraph
(4)), but does not exceed 50 percentage points above the medicaid applicable
income level; and

`(C) who is not found to be eligible for medical assistance under title XIX or
covered under a group health plan or under health insurance coverage (as such
terms are defined in section 2791 of the Public Health Service Act).

`(2) CHILDREN EXCLUDED- Such term does not include--

`(A) a child who is an inmate of a public institution or a patient in an institution
for mental diseases; or

`(B) a child who is a member of a family that is eligible for health benefits
coverage under a State health benefits plan on the basis of a family member's
employment with a public agency in the State.

`(3) SPECIAL RULE- A child shall not be considered to be described in paragraph
(1)(C) notwithstanding that the child is covered under a health insurance coverage
program that has been in operation since before July 1, 1997, and that is offered by a
State which receives no Federal funds for the program's operation.

`(4) MEDICAID APPLICABLE INCOME LEVEL- The term `medicaid applicable
income level' means, with respect to a child, the effective income level (expressed as a
percent of the poverty line) that has been specified under the State plan under title XIX
(including under a waiver authorized by the Secretary or under section 1902(r)(2)), as
of June 1, 1997, for the child to be eligible for medical assistance under section
1902(l)(2) for the age of such child.

`(c) ADDITIONAL DEFINITIONS- For purposes of this title:

`(1) CHILD- The term `child' means an individual under 19 years of age.

`(2) CREDITABLE HEALTH COVERAGE- The term `creditable health coverage'
has the meaning given the term `creditable coverage' under section 2701(c) of the
Public Health Service Act (42 U.S.C. 300gg(c)) and includes coverage that meets the
requirements of section 2103 provided to a targeted low-income child under this title or
under a waiver approved under section 2105(c)(2)(B) (relating to a direct service
waiver).

`(3) GROUP HEALTH PLAN; HEALTH INSURANCE COVERAGE; ETC- The
terms `group health plan', `group health insurance coverage', and `health insurance
coverage' have the meanings given such terms in section 2191 of the Public Health
Service Act.

`(4) LOW-INCOME- The term `low-income child' means a child whose family
income is at or below 200 percent of the poverty line for a family of the size involved.

`(5) POVERTY LINE DEFINED- The term `poverty line' has the meaning given such
term in section 673(2) of the Community Services Block Grant Act (42 U.S.C.
9902(2)), including any revision required by such section.

`(6) PREEXISTING CONDITION EXCLUSION- The term `preexisting condition
exclusion' has the meaning given such term in section 2701(b)(1)(A) of the Public
Health Service Act (42 U.S.C. 300gg(b)(1)(A)).

`(7) STATE CHILD HEALTH PLAN; PLAN- Unless the context otherwise requires,
the terms `State child health plan' and `plan' mean a State child health plan approved
under section 2106.

(8) UNCOVERED CHILD- The term `uncovered child' means a child that does not
have creditable health coverage.'.

(b) CONFORMING AMENDMENTS-

(1) DEFINITION OF STATE- Section 1101(a)(1) is amended--

(A) by striking `and XIX' and inserting `XIX, and XXI', and

(B) by striking `title XIX' and inserting `titles XIX and XXI'.

(2) TREATMENT AS STATE HEALTH CARE PROGRAM- Section 1128(h) (42
U.S.C. 1320a-7(h)) is amended by--

(A) in paragraph (2), by striking `or' at the end;

(B) in paragraph (3), by striking the period and inserting `, or'; and

(C) by adding at the end the following:

`(4) a State child health plan approved under title XXI.'.

CHAPTER 2--EXPANDED COVERAGE OF CHILDREN
UNDER MEDICAID


SEC. 4911. OPTIONAL USE OF STATE CHILD HEALTH ASSISTANCE
FUNDS FOR ENHANCED MEDICAID MATCH FOR EXPANDED
MEDICAID ELIGIBILITY.

(a) INCREASED FMAP FOR MEDICAL ASSISTANCE FOR EXPANDED
COVERAGE OF TARGETED LOW-INCOME CHILDREN- Section 1905 of the Social
Security Act (42 U.S.C. 1396d), as amended by section 4702(a)(2), is amended--

(1) in subsection (b), by adding at the end the following new sentence:
`Notwithstanding the first sentence of this subsection, in the case of a State plan that
meets the condition described in subsection (u)(1), with respect to expenditures
described in subsection (u)(2)(A) or subsection (u)(3) the Federal medical assistance
percentage is equal to the enhanced FMAP described in section 2105(b).'; and

(2) by adding at the end the following new subsection:

`(u)(1) The conditions described in this paragraph for a State plan are as follows:

`(A) The State is complying with the requirement of section 2105(d)(1).

`(B) The plan provides for such reporting of information about expenditures and
payments attributable to the operation of this subsection as the Secretary deems
necessary in order to carry out paragraph (2) and section 2104(d).

`(2)(A) For purposes of subsection (b), the expenditures described in this subparagraph are
expenditures for medical assistance for optional targeted low-income children described in
subparagraph (C), but not in excess, for a State for a fiscal year, of the amount described in
subparagraph (B) for the State and fiscal year.

`(B) The amount described in this subparagraph, for a State for a fiscal year, is the amount of
the State's allotment under section 2104 (not taking into account reductions under section
2104(d)(2)) for the fiscal year reduced by the amount of any payments made under section
2105 to the State from such allotment for such fiscal year.

`(C) For purposes of this paragraph, the term `optional targeted low-income child' means a
targeted low-income child as defined in section 2110(b)(1) who would not qualify for medical
assistance under the State plan under this title based on such plan as in effect on April 15,
1997 (but taking into account the expansion of age of eligibility effected through the operation
of section 1902(l)(2)(D)).

`(3) For purposes of subsection (b), the expenditures described in this subparagraph are
expenditures for medical assistance for children who are born before October 1, 1983, and
who would be described in section 1902(l)(1)(D) if they had been born on or after such date,
and who are not eligible for such assistance under the State plan under this title based on such
State plan as in effect as of April 15, 1997.'.

(b) ESTABLISHMENT OF OPTIONAL ELIGIBILITY CATEGORY- Section
1902(a)(10)(A)(ii) (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by section 4733, is
amended--

(1) in subclause (XII), by striking `or' at the end;


2) in subclause (XIII), by adding `or' at the end; and

(3) by adding at the end the following:

`(XIV) who are optional targeted low-income children described in
section 1905(u)(2)(C);'.

(c) EFFECTIVE DATE- The amendments made by this section shall apply to medical
assistance for items and services furnished on or after October 1, 1997.

SEC. 4912. MEDICAID PRESUMPTIVE ELIGIBILITY FOR
LOW-INCOME CHILDREN.


(a) IN GENERAL- Title XIX of the Social Security Act is amended by inserting after section
1920 the following new section:

`PRESUMPTIVE ELIGIBILITY FOR CHILDREN

`SEC. 1920A. (a) A State plan approved under section 1902 may provide for making
medical assistance with respect to health care items and services covered under the State plan
available to a child during a presumptive eligibility period.

`(b) For purposes of this section:

`(1) The term `child' means an individual under 19 years of age.

`(2) The term `presumptive eligibility period' means, with respect to a child, the period
that--

`(A) begins with the date on which a qualified entity determines, on the basis of
preliminary information, that the family income of the child does not exceed the
applicable income level of eligibility under the State plan, and

`(B) ends with (and includes) the earlier of--

`(i) the day on which a determination is made with respect to the eligibility
of the child for medical assistance under the State plan, or

`(ii) in the case of a child on whose behalf an application is not filed by the
last day of the month following the month during which the entity makes
the determination referred to in subparagraph (A), such last day.

`(3)(A) Subject to subparagraph (B), the term `qualified entity' means any entity that--

`(i)(I) is eligible for payments under a State plan approved under this title and
provides items and services described in subsection (a) or (II) is authorized to
determine eligibility of a child to participate in a Head Start program under the
Head Start Act (42 U.S.C. 9821 et seq.), eligibility of a child to receive child
care services for which financial assistance is provided under the Child Care and
Development Block Grant Act of 1990 (42 U.S.C. 9858 et seq.), eligibility of
an infant or child to receive assistance under the special supplemental nutrition
program for women, infants, and children (WIC) under section 17 of the Child
Nutrition Act of 1966 (42 U.S.C. 1786); and

`(ii) is determined by the State agency to be capable of making determinations of
the type described in paragraph (1)(A).

`(B) The Secretary may issue regulations further limiting those entities that may become
qualified entities in order to prevent fraud and abuse and for other reasons.

`(C) Nothing in this section shall be construed as preventing a State from limiting the
classes of entities that may become qualified entities, consistent with any limitations
imposed under subparagraph (B).

`(c)(1) The State agency shall provide qualified entities with--

`(A) such forms as are necessary for an application to be made on behalf of a child for
medical assistance under the State plan, and

`(B) information on how to assist parents, guardians, and other persons in completing
and filing such forms.

`(2) A qualified entity that determines under subsection (b)(1)(A) that a child is presumptively
eligible for medical assistance under a State plan shall--

`(A) notify the State agency of the determination within 5 working days after the date
on which determination is made, and

(B) inform the parent or custodian of the child at the time the determination is made
that an application for medical assistance under the State plan is required to be made
by not later than the last day of the month following the month during which the
determination is made.

`(3) In the case of a child who is determined by a qualified entity to be presumptively eligible
for medical assistance under a State plan, the parent, guardian, or other person shall make
application on behalf of the child for medical assistance under such plan by not later than the
last day of the month following the month during which the determination is made, which
application may be the application used for the receipt of medical assistance by individuals
described in section 1902(l)(1).

`(d) Notwithstanding any other provision of this title, medical assistance for items and services
described in subsection (a) that--

`(1) are furnished to a child--

`(A) during a presumptive eligibility period,

`(B) by a entity that is eligible for payments under the State plan; and

`(2) are included in the care and services covered by a State plan;

shall be treated as medical assistance provided by such plan for purposes of section 1903.'.

(b) CONFORMING AMENDMENTS-

(1) Section 1902(a)(47) (42 U.S.C. 1396a(a)(47)) is amended by inserting before the
semicolon at the end the following: `and provide for making medical assistance for
items and services described in subsection (a) of section 1920A available to children
during a presumptive eligibility period in accordance with such section'.

(2) Section 1903(u)(1)(D)(v) (42 U.S.C. 1396b(u)(1)(D)(v)) is amended by inserting
before the period at the end the following: `or for items and services described in
subsection (a) of section 1920A provided to a child during a presumptive eligibility
period under such section'.

(c) EFFECTIVE DATE- The amendments made by this section shall take effect on the date
of the enactment of this Act.

SEC. 4913. CONTINUATION OF MEDICAID ELIGIBILITY FOR
DISABLED CHILDREN WHO LOSE SSI BENEFITS.


(a) IN GENERAL- Section 1902(a)(10)(A)(i)(II) (42 U.S.C. 1396a(a)(10)(A)(i)(II)) is
amended by inserting `(or were being paid as of the date of the enactment of section 211(a)
of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L.
104-193)) and would continue to be paid but for the enactment of that section' after `title
XVI'.

(b) EFFECTIVE DATE- The amendment made by subsection (a) applies to medical
assistance furnished on or after July 1, 1997.


APPENDIX D



Sec. 158. Notwithstanding any provision of any federally granted
charter or any other provision of law, the real property of the National
Education Association located in the District of Columbia shall be
subject to taxation by the District of Columbia in the same manner as
any similar organization.
Sec. 159. (a) Section 501(c)(4) of the District of Columbia Police
and Firemen's Act of 1958 (D.C. Code, sec. 4-416(c)(4)) is amended by
striking ``locality pay'' and inserting ``longevity pay''.
(b) <<NOTE: Effective date.>> The amendment made by subsection (a)
is effective on the date of enactment of Public Law 105-61.

Sec. 160. In addition to amounts appropriated or otherwise made
available, $3,000,000 is appropriated for the purpose of funding a
Medicare Coordinated Care Demonstration Project in the District of
Columbia as specified in section 4016(b)(2)(C) of the Balanced Budget
Act of 1997.
Sec. 161. Nothing in this Act shall be construed to authorize any
office, agency or entity to expend funds for programs or functions for
which a reorganization plan is required but has not been approved by the
District of Columbia Financial Responsibility and Management Assistance
Authority (hereafter in this section referred to as ``Authority'').
Appropriations made by this Act for such programs or functions are
conditioned only on the approval by the Authority of the required
reorganization plans.
Sec. 162. <<NOTE: Effective date.>> Effective as if included in the
enactment of subtitle J of title IV of the Balanced Budget Act of
1997 <<NOTE: 42 USC 1396b note.>> (Public Law 105-33) the Social
Security Act is amended as follows:
(1) The fourth sentence of section 1905(b) of such Act (42
U.S.C. 1396d(b)) is amended by inserting ``for the State for a
fiscal year, and that do not exceed the amount of the State's
allotment under section 2104 (not taking into account reductions
under section 2104(d)(2)) for the fiscal year reduced by the
amount of any payments made under section 2105 to the State from
such allotment for such fiscal year,'' after ``subsection
(u)(3)''.
(2) Section 1905(u) of such Act (42 U.S.C. 1396d(u)) is
amended--
(A) in paragraph (1)(B), by striking ``paragraph
(2)'' and inserting ``the fourth sentence of subsection
(b)'';
(B) in paragraph (2)(A), by striking ``(C), but not
in excess'' and all that follows up to the period at the
end and inserting ``(B)'';
(C) by striking subparagraphs (B) and (C) of
paragraph (2) and inserting the following:

``(B) For purposes of this paragraph, the term `optional targeted
low-income child' means a targeted low-income child as defined in
section 2110(b)(1) (determined without regard to that portion of
subparagraph (C) of such section concerning eligibility for medical
assistance under this title) who would not qualify for medical
assistance under the State plan under this title as in effect on March
31, 1997 (but taking into account the expansion of age of eligibility
effected through the operation of section 1902(l)(1)(D)).'';
(D) in paragraph (3)--
(i) by striking ``described in this
subparagraph'' and inserting ``described in this
paragraph''; and

[[Page 111 STAT. 2189]]

(ii) by striking ``April 15, 1997'' and
inserting ``March 31, 1997''; and
(E) by adding at the end the following:

``(4) The limitations on payment under subsections (f ) and (g) of
section 1108 shall not apply to Federal payments made under section
1903(a)(1) based on an enhanced FMAP described in section 2105(b).''.
(3) Section 2110(b) of such Act (42 U.S.C. 1397jj(b)) is
amended--
(A) in paragraph (1)(B)(ii) to read as follows:
``(ii) is a child--
``(I) whose family income (as determined under
the State child health plan) exceeds the medicaid
applicable income level (as defined in paragraph
(4)), but does not exceed 50 percentage points
above the medicaid applicable income level;
``(II) whose family income (as so determined)
does not exceed the medicaid applicable income
level (as defined in paragraph (4) but determined
as if `June 1, 1997' were substituted for `March
31, 1997'); or
``(III) who resides in a State that does not
have a medicaid applicable income level (as
defined in paragraph (4)); and''; and
(B) in paragraph (4)--
(i) by striking ``June 1, 1997'' and inserting
``March 31, 1997''; and
(ii) by inserting ``or 1905(n)(2) (as selected
by a State)'' after ``1902(l)(2)''.
(4) Section 1903(f )(4) of such Act (42 U.S.C. 1396b(f )(4))
is amended by striking ``or 1905(p)(1)'' and inserting
``1905(p)(1), or 1905(u)''.
(5) Section 2105(c)(2)(A) of such Act (42 U.S.C.
1397ee(c)(2)(A)) is amended to read as follows--
``(A) In general.--Except as provided in this
paragraph, payment shall not be made under subsection
(a) for expenditures for items described in subsection
(a) (other than paragraph (1)) for a fiscal year to the
extent the total of such expenditures (for which payment
is made under such subsection) exceeds 10 percent of the
sum of--
``(i) the total of such expenditures for such
fiscal year, and
``(ii) the total expenditures for medical
assistance by the State under title XIX for which
Federal payments made under section 1903(a)(1) are
based on an enhanced FMAP described in section
2105(b) for such fiscal year.''.
(6) Section 2104 of such Act (42 U.S.C. 1397dd) is amended--
(A) in subsection (d)(1), by striking ``for calendar
quarters'' and inserting ``for expenditures claimed by
the State''; and
(B) by striking subsection (d)(2) and inserting the
following:
``(2) the amount (if any) of the payments made to that State
under section 1903(a) for expenditures claimed by the State
during such fiscal year that is attributable to the provision of
medical assistance to a child for which payment is

[[Page 111 STAT. 2190]]

made under section 1903(a)(1) on the basis of an enhanced FMAP
under the fourth sentence of section 1905(b).''.
(7) Section 2105 of such Act (42 U.S.C. 1397ee) is amended
by adding at the end the following:

``(f ) Flexibility in Submittal of Claims.--Nothing in this section
or subsections (e) and (f ) of section 2104 shall be construed as
preventing a State from claiming as expenditures in the quarter
expenditures that were incurred in a previous quarter.''.
(8) Section 2104 of such Act (42 U.S.C. 1397dd) is amended--
(A) in subsection (a)(1), by striking
``$4,275,000,000'' and inserting ``$4,295,000,000'';
(B) in subsection (b)(4), by striking ``Subject to
paragraph (5), in'' and inserting ``In''; and
(C) in subsection (c)--
(i) in paragraph (2)(C), by inserting ``the''
before `` Virgin Islands'', and
(ii) in paragraphs (3)(C) and (3)(E), by
striking ``the'' and inserting `` The''.
(9) Section 2110(c)(3) of such Act (42 U.S.C. 1397jj(c)(3))
is amended by striking ``2191'' and inserting ``2791''.

Sec. 163. The Administrator of General Services is authorized to
amend the use restriction contained in the Administrator's 1956
conveyance of land to the City of Bonham, Texas, mandated by Public Law
586 of the 84th Congress. The amended use restriction will limit the
property to State veterans, nursing homes and public safety
communications purposes only.
Sec. 164. Notwithstanding any other provision of law, rule, or
regulation, the evaluation process and instruments for evaluating
District of Columbia public schools employees shall be a non-negotiable
item for collective bargaining purposes.
Sec. 165. There are appropriated from such funds of the District of
Columbia, as are deemed appropriate by the District of Columbia
Financial Responsibility and Management Assistance Authority,
$2,600,000, for the Fire and Emergency Medical Services Department for a
5 percent pay increase for uniformed firefighters.
Sec. 166. Notwithstanding any other provision of Federal or District
of Columbia law applicable to a reemployed annuitant's entitlement to
retirement or pension benefits, the Director of the Office of Personnel
Management may waive the provisions of section 8344 of title 5 of the
United States Code for any reemployed annuitants appointed heretofore or
hereafter as a Trustee under section 11202 or 11232 of the National
Capital Revitalization and Self-Government Improvement Act of 1997, or,
at the request of such a Trustee, for any employee of such Trustee.
Sec. 167. Section 2203(i)(2)(A) of the District of Columbia School
Reform Act of 1995 (Public Law 104-134; 110 Stat. 3009-504; D.C. Code
31-2853.13(i)(2)(A)) is amended to read as follows:


APPENDIX E

Maine Children's Health Insurance Survey Instrument


(Available in printed report only)



APPENDIX F

Maine Children's Health Insurance
Preliminary Results


(Available in printed report only)




APPENDIX G

Maine Commission on Children's Health Care
Medicaid Expansion and Cub Care Program


APPENDIX H

Proposed Legislation



Sponsor: Commission on Children's Health Care
Drafted by: Jane Orbeton
Date: 1/28/98

DRAFT


Title: An Act to Implement the Recommendations of
the Maine Commission on Children’s Health Care


Emergency preamble. Whereas, Acts of the Legislature do not become effective until 90 days after adjournment unless enacted as emergencies; and

Whereas, approximately 34,440 children in Maine are without health coverage and periodically require health care treatment for preventative, diagnostic, therapeutic, rehabilitative and acute care purposes; and

Whereas, the State is committed to finding a way to make health coverage available to uninsured Maine children and expressed that commitment by establishing the Maine Commission on Children’s Health Care in Public Law 1997, chapter 560, and setting aside approximately $8,000,000 to fund health coverage; and

Whereas, the federal government has made funding available to the State of approximately $61,500,000 over the next five years for a children’s health program under the Balanced Budget Act of 1997; and

Whereas, in the judgment of the Legislature, these facts create an emergency within the meaning of the Constitution of Maine and require the following legislation as immediately necessary for the preservation of the public peace, health and safety; now, therefore,

Be it enacted by the People of the State of Maine as follows:

PART A


Sec. A-1. 22 MRSA §3174-G, sub-§1
is amended to read:

1. Delivery of services. The department shall provide for the delivery of federally approved Medicaid services to qualified pregnant women up to 60 days following delivery and infants up to one year of age when the woman's or child's family income is below 185% of the nonfarm income official poverty line and children under 5 years of age and , qualified elderly and disabled persons , when the child's or person's family income is below 100% of the nonfarm income official poverty line and children ages 1 year old through 18 years old when the child’s family income is below 150% of the nonfarm income official poverty line. The official poverty line shall be that applicable to a family of the size involved, as defined by the Federal Office of Management and Budget and revised annually in accordance with the United States Omnibus Budget Reconciliation Act of 1981, Section 673, Subsection 2. These services shall be effective October 1, 1988.

Sec. A-2. 22 MRSA §3174-R is enacted to read:

§3174-R. Cub Care program
1. Program established. The Cub Care program is established to provide health coverage for low-income children who are ineligible for benefits under the Medicaid program and who meet the requirements of subsection 2. The purpose of the Cub Care program is to provide health coverage to as many children as possible within the fiscal constraints of the program budget and without forfeiting any federal funding that is available to the State for the State Children’s Health Insurance Program through the Balanced Budget Act of 1997, Public Law 105-100 (November 19, 1997), as amended, hereinafter referred to as the Balanced Budget Act of 1997.

2. Eligibility; enrollment. Health coverage under the Cub Care program is available to children ages 1 through 18 years old whose family income is above the eligibility level for Medicaid under section 3174-G and below the maximum eligibility level established under paragraphs A and B, who meet the requirements set forth in paragraph C and for whom premiums are paid under subsection 5.

A. The maximum eligibility level, subject to adjustment by the commissioner under paragraph B, is 185% of the nonfarm income official poverty line.

B. If the commissioner has determined the fiscal status of the Cub Care program under subsection 8 and has determined that an adjustment in the maximum eligibility level is required under this paragraph, the commissioner shall adjust the maximum eligibility level in accordance with the requirements of this paragraph.

(1) The adjustment must accomplish the purposes of the Cub Care program set forth in subsection 1.

(2) If program expenditures are reasonably anticipated to exceed the program budget, the commissioner shall adjust the maximum eligibility level set in paragraph A downward to the extent necessary to bring the program within the program budget.

(3) If program expenditures are reasonably anticipated to fall below the program budget, the commissioner shall adjust the maximum eligibility level set in paragraph A upward to the extent necessary to provide coverage to as many children as possible within the fiscal constraints of the program budget.

(4) The commissioner must give at least 30 days notice of the proposed change in maximum eligibility level to the joint standing committees having jurisdiction over appropriations and financial affairs and health and human services matters.

C. All children resident in the State are eligible except a child who:

(1) Is eligible for coverage under the Medicaid program;

(2) Is covered under a group health insurance plan or under health insurance, as defined in section 2791 of the federal Public Health Service Act;

(3) Is a member of a family that is eligible for health coverage under the State Employee Health Program under Title 5, section 285;

(4) Is an inmate in a public institution or a patient in an institution for mental diseases; or

(5) Within the 3 months prior to application for coverage under the Cub Care program, was insured or otherwise provided coverage under an employer-based health plan for which the employer paid 50% or more of the cost for the child’s coverage, except that this subparagraph does not apply if:


(i) The cost to the employee of coverage for the family exceeds 10% of the family’s income;

(ii) The parent lost coverage for the child because of a change in employment, termination of coverage under COBRA or termination for a reason not in the control of the employee; or

(iii) The department has determined that grounds exist for a good cause exception.


D. Coverage under the Cub Care program may be purchased for an additional period of 18 months as provided in this paragraph at a premium level that is revenue neutral and that covers the cost of the benefit and a contribution toward administrative costs no greater than the maximum level allowable under COBRA. The department shall adopt rules to implement this paragraph. The following children are eligible to enroll under this paragraph:

(1) Children who are enrolled under paragraph A or B and whose family income, at the end of the child’s 6-month enrollment term, exceeds the maximum allowable income set in that paragraph; and

(2) Children who are enrolled in the Medicaid program and whose family income exceeds the limits of that program. The department shall terminate Medicaid coverage for a child who enrolls in the Cub Care program under this subparagraph.


E. Notwithstanding changes in maximum eligibility level determined under paragraph B, the following requirements apply to enrollment and eligibility:

(1) Children must be enrolled for 6-month enrollment periods. Prior to the end of each 6-month enrollment period the department shall redetermine eligibility for continuing coverage; and

(2) Children of higher family income may not be covered unless children of lower family income are also covered. This subparagraph may not be applied to disqualify a child during the 6-month enrollment period. Children of higher income may be disqualified at the end of the 6-month enrollment period if the commissioner has adjusted the maximum eligibility level downward under subsection 2, paragraph B.



3. Program administration; benefit design.
With the exception of premium payments under subsection 5 and any other requirements imposed under this section, the Cub Care program must be integrated with the Medicaid program and administered with it in one administrative structure within the department, with the same enrollment and eligibility process, outreach and benefit package and in compliance with the same laws and policies as the Medicaid program, except when those laws and policies are inconsistent with this section and the Balanced Budget Act of 1997. The department shall adopt and promote a simplified eligibility form and eligibility process.

4. Benefit delivery. The Cub Care program must use, but is not limited to, the same benefit delivery system as the Medicaid program, providing benefits through the same health plans, contracting process and providers. Co-payments and deductibles may not be charged for benefits provided under the program.

5. Premium payments. Premiums must be paid in accordance with this subsection.

A. Premiums must be paid at the beginning of each month for coverage for that month according to the following scale:

(1) Families with incomes between 150% and 160% of the nonfarm income official poverty line must pay premiums of 5% of the benefit cost per child, not exceeding 5% of the cost for 2 children;

(2) Families with incomes between 160% and 170% of the nonfarm income official poverty line must pay premiums of 10% of the benefit cost per child, not exceeding 10% of the cost for 2 children; and

(3) Families with incomes between 170% and 185% of the nonfarm income official poverty line must pay premiums of 15% of the benefit cost per child, not exceeding 15% of the cost for 2 children.


B. When a premium is not paid at the beginning of the month, the department shall provide notice at the beginning of that month and month 6 of the 6-month enrollment period if the premium is unpaid at that time, an opportunity for a hearing and a grace period in which the premium may be paid and no penalty will apply for the late payment. If a premium is not paid by the end of the grace period, coverage must be terminated unless the department has determined that waiver of premium is appropriate under paragraph D. The grace period must be determined according to this paragraph.

(1) If non-payment is for month 1, 2, 3, 4, or 5 of the 6-month enrollment period, the grace period is equal to the remainder of the 6-month enrollment period.

(2) If non-payment is for month 6 of the 6-month enrollment period, the grace period is equal to 6 weeks.

C. A child whose coverage under the Cub Care program has been terminated for non-payment of premium and who has received coverage for a month or longer without premium payment may not re-enroll until after a waiting period that equals the number of months of coverage under the Cub Care program without premium payment, not to exceed 3 months.

D. The department shall adopt rules allowing waiver of premiums for good cause.

6. Incentives. In the contracting process for the Cub Care program and the Medicaid program the department shall create incentives to reward health plans that contract with school-based clinics, community health centers and other community-based programs.

7. Administrative costs. The department shall budget 2% of the costs of the Cub Care program for outreach activities. After the first 6 months of the program and to the extent that the program budget allows, the department may expend up to 3% of the program budget on activities to increase access to health care. Administrative costs must include the cost of staff with experience in health policy administration equal to one full-time equivalent position.

8. Quarterly determination of fiscal status; reports. On a quarterly basis the commissioner shall determine the fiscal status of the Cub Care program, determine whether an adjustment in maximum eligibility level is required under subsection 2, paragraph B and report to the joint standing committees having jurisdiction over appropriations and financial affairs and health and human services on the following matters:

A. Enrollment approvals, denials, terminations, re-enrollments, levels and projections. With regard to denials, the department shall gather data from a statistically significant sample and provide information on the income levels of children who are denied eligibility due to family income level;

B. Program expenditures, expenditure projections and fiscal status;

C. Proposals for increasing or decreasing enrollment consistent with subsection 2, paragraph B;

D. Proposals for enhancing the program;

E. Any information the department has from the program or from the Bureau of Insurance or the Department of Labor on employer health coverage and insurance coverage for low-income children;

F. The use of and experience with the purchase option under subsection 2, paragraph D; and

G. Program administrative costs.


9. Rulemaking. The department shall adopt rules in accordance with Title 5, chapter 375 as required to implement this section. Rules adopted pursuant to this subsection are routine technical rules as defined by Title 5, chapter 375, subchapter II-A.

Sec. 3. Reauthorization of the Maine Commission on Children’s Health Care.
The Maine Commission on Children’s Health Care, established in Public Law 1997, chapter 560, Part B, is reauthorized for 1998 for the purpose of overseeing the expansion of the Medicaid program under 22 MRSA section 3174-G and the establishment of the Cub Care program under 22 MRSA section 3174-R. The commission shall receive quarterly reports from the Commissioner of Human Services. The commission is authorized to meet up to 2 times during 1998 and shall submit a report and recommendations to the Joint Standing Committees on Appropriations and Financial Affairs and Health and Human Services of the 119th Legislature by December 15, 1998 on the operation of the Cub Care program.

Sec. A-4. Application clause. Section 3 of this Act applies retroactively to December 15, 1997.

Sec. A-5. Appropriation.
(To be written by the Office of Fiscal and Program Review)

Provide appropriations from the General Fund sufficient for 1 administratorFTE position in the Bureau of Medical Services and 30 full-time employees in
the Bureau of Family Independence.

Sec. A-6. Allocation.
(To be written by the Office of Fiscal and Program Review)

Provide allocations from federal funds sufficient for 1 administrator FTE position in the
Bureau of Medical Services and 30 full-time employees in the Bureau of Family Independence.

PART B


Sec. B-1. 24 MRSA §2332-A, sub-§2 is amended to read:

2. Medicaid and Cub Care programs. Nonprofit service organizations may not consider the availability or eligibility for medical assistance under 42 United States Code, Section 13969, referred to as “Medicaid,” or Title 22, section 3174-R, referred to as “the Cub Care program,” when considering coverage eligibility or benefit calculations for subscribers and covered family members.

A. To the extent that payment for coverage expenses has been made under the Medicaid or Cub Care program for health care items or services furnished to an individual, the State is considered to have acquired the rights of the covered subscriber or family member to payment by the nonprofit service organization for those health care items or services. Upon presentation of proof that the Medicaid or Cub Care program has paid for covered items or services, the nonprofit service organization shall make payment to the Medicaid or Cub Care program according to the coverage provided in the contract or certificate.

B. A nonprofit service organization may not impose requirements on a state agency that has been assigned the rights of an individual eligible for Medicaid or Cub Care coverage and covered by a subscriber contract that are different from requirements applicable to an agent or assignee of any other covered individual.


Sec. B-2. 24-A MRSA §2808-B, sub-§1, paragraph E is amended to read:

E. "Late enrollee" means an eligible employee or dependent who requests enrollment in a small group health plan following the initial minimum 30-day enrollment period provided under the terms of the plan, except that, an eligible employee or dependent is not considered a late enrollee if the eligible employee or dependent meets the requirements of section 2849-B, subsection 3, paragraph A B, C, C-1 or D.

Sec. B-3. 24-A MRSA §2844, sub-§2 is amended to read:

24A § 2844. Coordination of benefits


2. Medicaid and Cub Care programs. Insurers may not consider the availability or eligibility for medical assistance under 42 United States Code, Section 13969, referred to as "Medicaid," or Title 22, section 3174-R, referred to as the “Cub Care program,” when considering coverage eligibility or benefit calculations for insureds and covered family members.

A. To the extent that payment for coverage expenses has been made under the Medicaid or Cub Care program for health care items or services furnished to an individual, the State is considered to have acquired the rights of the insured or family member to payment by the insurer for those health care items or services. Upon presentation of proof that the Medicaid or Cub Care program has paid for covered items or services, the insurer shall make payment to the Medicaid or Cub Care program according to the coverage provided in the contract or certificate.

B. An insurer may not impose requirements on a state agency that has been assigned the rights of an individual eligible for Medicaid or Cub Care coverage and covered by a subscriber contract that are different from requirements applicable to an agent or assignee of any other covered individual.


Sec. B-4. 24-A MRSA §2848, sub§1-B, paragraph A is amended to read:

§1-B. Creditable coverage. "Creditable coverage" means:

A. Health benefits or coverage provided under any of the following:

(1) An employee welfare benefit plan as defined in Section 3(1) of the federal Employee Retirement Income Security Act of 1974, 29 United States Code, Section 1001, or a plan that would be an employee welfare benefit plan but for the "governmental plan" or "nonelecting church plan" exceptions, if the plan provides medical care as defined in subsection 2-A, and includes items and services paid for as medical care directly or through insurance, reimbursement or otherwise;

(2) Benefits consisting of medical care provided directly, through insurance or reimbursement and including items and services paid for as medical care under a policy, contract or certificate offered by a carrier; or

(3) Part A or Part B of Title XVIII of the Social Security Act, Medicare;

(4) Title XIX of the Social Security Act, Medicaid, other than coverage consisting solely of benefits under Section 1928 of the Social Security Act, or a state children’s health insurance program under Title XXI of the Social Security Act;

(5) The Civilian Health and Medical Program for the Uniformed Services, CHAMPUS, 10 United States Code, Chapter 55;

(6) A medical care program of the federal Indian Health Care Improvement Act, 25 United States Code, Section 1601 or of a tribal organization;

(7) A state health benefits risk pool;

(8) A health plan offered under the federal Employees Health Benefits Amendments Act, 5 United States Code, Chapter 89;

(9) A public health plan as defined in federal regulations authorized by the federal Public Health Service Act, Section 2701(c)(1)(I), as amended by Public Law 104-191; or

(10) A health benefit plan under Section 5(e) of the Peace Corps Act, 22 United States Code, Section 2504(e).


Sec. B-5. 24-A MRSA §2849-B, sub-§3 is amended to read:

3. Exception for late enrollees. Notwithstanding subsection 2, this section does not provide continuity of coverage for a late enrollee. A late enrollee may be excluded from coverage for not more than 12 months based on medical underwriting or preexisting conditions. For purposes of this section, a "late enrollee" is a person who requests enrollment in a group plan following the initial enrollment period provided under the terms of the plan, except that a person is not a late enrollee if:


A. The request for enrollment is made within 30 days after termination of coverage under a prior contract or policy and the individual did not request coverage initially under the succeeding contract or policy or terminated coverage under the succeeding contract because that individual was covered under a prior contract or policy and:

(1) Coverage under that contract or policy ceased because the individual became ineligible for reasons other than fraud or material misrepresentation, including, but not limited to, termination of employment, termination of the group policy or group contract under which the individual was covered, death of a spouse or divorce; or

(2) Employer contributions toward that coverage were terminated;

B. A court has ordered that coverage be provided for a spouse or minor child under a covered employee's plan and the request for coverage is made within 30 days after issuance of the court order;

C. That person was covered by the Maine High-Risk Insurance Organization on December 1, 1993 and the request for replacement coverage is made while coverage is in effect or within 30 days of the termination of coverage; or

C-1. That person was covered by the Cub Care program under Title 22, section 3174-R, and the request for replacement coverage is made while coverage is in effect or within 30 days after the termination of coverage; or

D. That person was previously ineligible for coverage and the request for enrollment is made within 30 days of the date the person becomes eligible.



Emergency clause. In view of the emergency cited in the preamble, this Act takes effect July 1, 1998.

SUMMARY


This bill contains the recommendations of the Maine Commission on Children’s Health Care. It does the following:

(1) Expands coverage under the Medicaid program for children 1 through 18 years of age whose family incomes are below 150% of the federal poverty level.

(2) Establishes the Cub Care program to provide health insurance coverage to children whose families are between 150% and 185% of the federal poverty level and who pay a monthly premium and for 18 months at premium levels that equal the benefit cost plus an administrative fee to children who are enrolled and who become ineligible because of increasing family income.

(3) Reauthorizes the Maine Commission on Children’s Health Care for a period of 1 year.

(4) Appropriates and allocates the necessary funding to support the expansion of the Medicaid program and the creation of the Cub Care program.

(5) Amends provisions in Titles 24 and 24-A related to insurance coordination of benefits, late enrollee status and continuity of coverage.

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