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Title II — Eligibility and Enrollment

S. 2461 · 113th Congress · Jun 11, 2014 · Lineage

II Eligibility and Enrollment

A Coverage Continuity

Sec. 201 State option to increase upper age limit for children with special health care needs

Section 2110(c)(1) (42 U.S.C. 2110(c)(1)) is amended—
(1)
by striking “The term” and inserting the following:

“(A) In general—Subject to subparagraph (B), the term”

(2)
by adding at the end the following:

“(B) Children with special health care needs—At State option, such term includes an individual under 26 years of age who has or is at an increased risk of a chronic physical, developmental, behavioral, or emotional condition and who also requires health and related services of a type or amount beyond that required by children typically.”

Sec. 202 Improving coverage transitions from Medicaid or CHIP to coverage under a qualified health plan

(a)
State coordination requirement— Section 2105(d)(3)(B) (42 U.S.C. 1397ee(d)(3)(B)) is amended—
(1)
in the subparagraph heading, by striking “shortfalls” and inserting “shortfalls; coordination requirements for transitioning to or from Exchange coverage”;
(2)
in the first sentence, by striking “In the event” and inserting the following:

“(i) Exchange coverage as a result of funding shortfalls—In the event”

(3)
by adding at the end the following:

“(ii) Coordination requirements for transitioning to or from Exchange coverage—The State shall establish procedures to eliminate gaps in coverage and to assist a child's and pregnant woman's transition from coverage under the State plan under title XIX or the State child health plan under this title (whether implemented under this title, title XIX, or both) to coverage under a qualified health plan that has been certified by the Secretary under subparagraph (C) and is offered through an Exchange and from coverage under a qualified health plan to coverage under the State plan under title XIX or the State child health plan under this title. Such procedures—

“(I) shall provide for coverage for the child's or pregnant woman's medical home, regardless of whether the medical home providers are participating providers under the State plan under title XIX or the State child health plan under this title, for a transitional time to be determined under regulations promulgated by the Secretary;

“(II) in the case of a child or pregnant woman with a chronic or complex condition, shall provide that the State plan under title XIX, or the State child health plan under this title (as applicable) shall permit the child or pregnant woman to continue to receive treatment from a non-network provider for a transitional period as determined under regulations promulgated by the Secretary;

“(III) shall require that if the benefits available and cost-sharing imposed under a qualified health plan available to the child or pregnant woman (as applicable) are not comparable to the benefits and coverage available to the child or pregnant woman under the State plan under title XIX or the State child health plan under this title (as applicable) the child or pregnant woman shall remain enrolled in the State plan under title XIX or the State child health plan under this title for so long as the child or pregnant woman is otherwise eligible for coverage under the title XIX or XXI State plans; and

“(IV) shall establish a system under which the State shall record all transitions of children and pregnant women from coverage under the State plan under title XIX or the State child health plan under this title to coverage under a qualified health plan and from coverage under a qualified health plan to coverage under the State plan under title XIX or the State child health plan under this title and submit a report to the Secretary each fiscal quarter that includes data on the number of children and pregnant women who made such transitions in the preceding fiscal quarter.”

(b)
Certification requirement— Section 2105(d)(3)(C) (42 U.S.C. 1397ee(d)(3)(C)) is amended—
(1)
in the subparagraph heading, by striking “Pediatric”;
(2)
by striking “With respect to” and inserting the following:

“(i) In general—With respect to”

(3)
by inserting “and pregnant women” after “children” each place it appears;
(4)
by striking “are at least comparable to the benefits offered and cost-sharing protections provided under the State child health plan” and inserting “meet the comparability standards described in clause (ii) and the continuous coverage requirements described in clause (iii)”; and
(5)
by adding at the end the following new clauses:

“(ii) Comparability standards—The Secretary shall develop, in consultation with non-government stakeholder entities (including not less than 1 national non-profit organization focused on children's advocacy), comparability standards for qualified health plans seeking certification under clause (i). Such standards must include standards for the following areas:

“(I) Affordability—The plan must be comparable to the State child health plan in terms of affordability, including premiums, deductibles, co-payments, co-insurance, medical home maintenance costs, and the cost of purchasing supplementary coverage for health benefits and services that are covered under the State child health plan but are not covered under the qualified health plan.

“(II) Benefits—The plan must be comparable to the State child health plan in terms of pediatric and pregnancy-related benefits.

“(III) Network adequacy—The plan must be comparable to the State child health plan in terms of access to appropriate providers of pediatric and pregnancy-related services, and must provide flexibility for children with special health care needs to remain in their medical home or seek appropriate pediatric sub-specialists.

“(iii) Continuous coverage requirements—The Secretary shall require health plans seeking certification as qualified health plans for purposes of an American Health Benefits Exchange to ensure that—

“(I) with respect to a child or pregnant woman who is transitioning from coverage under a State child health plan or a State plan under title XIX—

“(aa) coverage under the qualified health plan shall be effective as of the 60-day period preceding the date on which the first premium payment is made for such coverage;

“(bb) coverage under the State child health plan or State plan under title XIX shall remain in effect during the 30-day period that precedes the 60-day period described in item (aa);

“(cc) the qualified health plan shall provide coverage for a child’s or a pregnant woman's medical home, regardless of whether the medical home provider is within the network of the plan, to allow the child or pregnant woman to finish a course of treatment for an acute illness or a treatment or surgery scheduled prior to the effective date for coverage under the plan under item (aa) or for a period of up to 90 days if, by the end of such period, the child or pregnant woman is enrolled with a medical home provider that is within the network of the plan; and

“(dd) in the case of a child or pregnant woman with a chronic or complex condition, the qualified health plan shall permit the child or pregnant woman to continue to receive treatment from a non-network provider for a transitional time that is not less than 90 days, or until the child or pregnant woman can be enrolled with an in-network provider;

“(II) similar requirements apply with respect to any child or pregnant woman who transitions from coverage under a qualified health plan to coverage under the State child health plan or the State plan under title XIX in accordance with subparagraph (B)(ii); and

“(III) a child or pregnant woman transitioning to or from coverage under the State child health plan or the State plan under title XIX and a qualified health plan is informed of the differences between the benefits available and cost-sharing imposed under the coverage the child or pregnant woman is transitioning from and into, and that the pregnant woman or the parent or guardian of the child has the option of electing to remain enrolled in whichever coverage is the most affordable or provides the best benefits for the child or pregnant woman for such period as the Secretary shall specify.”

(c)
Prohibition on transitioning CHIP-Eligible children— No child who is eligible for coverage under CHIP shall be transitioned from a State child health plan to a qualified health plan unless that plan is certified under section 2105(d)(3)(C) of the Social Security Act (42 U.S.C. 1397ee(d)(3)(C)) (as amended by subsection (b)).
(d)
Minimum essential coverage—
(1)
In general— Section 5000A(f) of the Internal Revenue Code of 1986 is amended by adding at the end the following:

“(6) Pregnancy-related assistance under CHIP—With respect to a targeted low-income pregnant woman (as defined in section 2112(d)(2) of the Social Security Act), notwithstanding paragraph (1)(A)(iii), the term minimum essential coverage, at the option of such a woman, shall not include pregnancy-related assistance (as defined in section 2112(d)(1) of the Social Security Act).”

(2)
Effective date— The amendment made by this subsection applies to taxable years beginning after December 31, 2014.

Sec. 203 Assuring coverage continuity for former foster care children

(a)
In general— Section 1902(a)(10)(A)(i)(IX) (42 U.S.C. 1396a(a)(10)(A)(i)(IX)) is amended—
(1)
in item (cc), by striking “responsibility of the State” and inserting “responsibility of a State”; and
(2)
in item (dd), by striking “the State plan under this title or under a waiver of the” and inserting “a State plan under this title or under a waiver of such a”.
(b)
Effective date— The amendments made by this section shall take effect on the date of enactment of this Act.

B Enrollment Simplification and Improvements

Sec. 211 Automatic enrollment for newborns under CHIP

(a)
In general— Section 2107(e)(1) (42 U.S.C. 1397gg(e)(1)) is amended—
(1)
by redesignating subparagraphs (E) through (O) as subparagraphs (F) through (P), respectively; and
(2)
by inserting after subparagraph (D) the following new subparagraph:

“(E) Section 1902(e)(4) (relating to automatic coverage for newborns through age 1).”

(b)
Effective date— The amendments made by this section shall take effect on the date of enactment of this Act.

Sec. 212 Express Lane Eligibility extension and application to pregnant women, foster children, and children with special health care needs

(a)
In general— Section 1902(e)(13) (42 U.S.C. 1396a(e)(13)) is amended—
(1)
in subparagraph (A), by adding at the end the following new clause:

“(iii) State option to extend express lane eligibility to pregnant women—At the option of the State, the State may apply the provisions of this paragraph with respect to determining eligibility under this title for a pregnant woman. In applying this paragraph in the case of a State electing such an option, any reference in this paragraph to a child with respect to this title (other than a reference to child health assistance) shall be deemed to be a reference to a pregnant woman.”

(2)
in subparagraph (G), by adding at the end the following new sentence: “Notwithstanding the age limit specified in the preceding sentence, such term includes an individual described in subsection (a)(10)(A)(i)(IX) and, at the option of the State, an individual described in section 2110(c)(1)(B).”; and
(3)
by striking subparagraph (I).
(b)
Effective date— The amendments made by this section shall take effect on the date of enactment of this Act.

Sec. 213 Outreach to targeted populations

(a)
Outreach and enrollment grants— Section 2113 (42 U.S.C. 1397mm) is amended—
(1)
in subsection (a)(1), by striking “during the period of fiscal years 2009 through 2015 ”; and
(2)
in subsection (g), by inserting “and $40,000,000 for each fiscal year thereafter,” after “2015,”.
(b)
Outreach to non-English speakers and other populations—
(1)
National enrollment campaign requirements— Such section 2113 is amended—
(A)
in subsection (h), by striking “Such campaign” and inserting “In addition to the requirements described in subsection (i), such campaign”; and
(B)
by adding at the end the following subsection:

“(i) Required elements of national enrollment campaign—Beginning with fiscal year 2015, each of the following initiatives shall be part of the national enrollment campaign:

“(1) Initiative to increase enrollment among individuals with limited English proficiency—An initiative to increase enrollment in the State child health plan under this title or the State plan under title XIX of children from families that speak a primary language other than English that shall include—

“(A) language services, including oral interpreting and written translation services, for individuals with limited proficiency in English; and

“(B) other culturally appropriate efforts to increase enrollment of such children.

“(2) Initiative to increase enrollment of children in families with complex or multiple coverage sources—An initiative to identify and increase enrollment in the State child health plan under this title or the State plan under title XIX of children from families who have multiple coverage sources or other coverage complexities, including children in foster care and children subject to a medical child support order.”

(2)
Increased reimbursement for State spending on language services—
(A)
Medicaid— Section 1903(a)(2)(E) (42 U.S.C. 1396b(a)(2)(E)) is amended by striking “75 percent” and inserting “the higher of 90 percent or the sum of the enhanced FMAP (as defined in section 2105(b)) plus 5 percentage points (not to exceed 100 percent)”.
(B)
CHIP— Section 2105(a)(1) (42 U.S.C. 1397ee(a)(1)) is amended in the matter preceding paragraph (1), by striking “the higher of 75 percent or the sum of the enhanced FMAP plus 5 percentage points” and inserting “the higher of 90 percent or the sum of the enhanced FMAP plus 5 percentage points (not to exceed 100 percent)”.
(3)
Requirement that managed care organizations provide language services to enrollees— Section 1932(b) (42 U.S.C. 1396u–2(b)) is amended by adding at the end the following new paragraph:

“(9) Language services—Each contract with a medicaid managed care organization under section 1903(m) shall require the organization to provide (at no cost to the individual) language services, including oral interpreting and written translation services, to any individual who is eligible for medical assistance under the State plan under this title and is enrolled with the organization and to a parent or guardian of such individual if such individual, parent, or guardian is in need of such services when interacting with the organization or with any provider receiving payment from the organization.”

(4)
Translation of applications and other vital documents—
(A)
Medicaid— Section 1902(a) (42 U.S.C. 1396a(a)) is amended—
(i)
by striking “and” at the end of paragraph (80);
(ii)
by striking the period at the end of paragraph (81) and inserting “; and”; and
(iii)
by inserting after paragraph (81) the following new paragraph:

“(82) provide for the translation of all documents and materials necessary to make application for medical assistance under the plan, and such other documents and materials as the Secretary may specify, including any such documents and materials that are available via a website, into the primary language spoken by any limited English proficiency group in the State with a population of at least 1000 individuals or that constitutes 5 percent of the State population.”

(B)
CHIP— Section 2107(e)(1), as amended by section 221, is amended—
(i)
by redesignating subparagraphs (E) through (P) as subparagraphs (F) through (Q), respectively; and
(ii)
by inserting after subparagraph (D) the following subparagraph:

“(E) Section 1902(a)(82) (relating to the translation of documents and materials).”

(c)
Primary language data collection—
(1)
Data from eligible entities— Section 2113(c)(4)(B) (42 U.S.C. 1397mm(c)(4)(B)) is amended by inserting “under this title and title XIX, individual data on the primary language of enrollees under this title and title XIX (and for such enrollees who are minors or incapacitated, data on the primary language of their parents or guardians)” after “enrollment data”.
(2)
Annual report—
(A)
CHIP— Section 2108 (42 U.S.C. 1397hh) is amended—
(i)
by redesignating the subsection (e) added by section 501(e)(2) of Public Law 111–3 as subsection (f); and
(ii)
in paragraph (1) of the subsection (e) added by section 402 of Public Law 111–3, by inserting “and primary language” after “duration of benefits”.
(B)
Medicaid— Section 1946(c) (42 U.S.C. 1396w–5(c)) is amended by inserting “demographic” before “data on health care disparities”.
(d)
Effective date— The amendments made by this section shall take effect on the date of enactment of this Act.