H.R. 3921 — what changed

“(21) for fiscal year 2018, $21,500,000,000;

“(22) for fiscal year 2019, $22,600,000,000;

“(23) for fiscal year 2020, $23,700,000,000;

“(24) for fiscal year 2021, $24,800,000,000; and

“(25) for fiscal year 2022, for purposes of making 2 semi-annual allotments—

“(A) $2,850,000,000 for the period beginning on October 1, 2021, and ending on March 31, 2022; and

“(B) $2,850,000,000 for the period beginning on April 1, 2022, and ending on September 30, 2022.”

“(10) For fiscal year 2022

“(A) First half—Subject to paragraphs (5) and (7), from the amount made available under subparagraph (A) of paragraph (25) of subsection (a) for the semi-annual period described in such subparagraph, increased by the amount of the appropriation for such period under section 101(b)(3) of the HEALTHY KIDS Act, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for such semi-annual period in an amount equal to the first half ratio (described in subparagraph (D)) of the amount described in subparagraph (C).

“(B) Second half—Subject to paragraphs (5) and (7), from the amount made available under subparagraph (B) of paragraph (25) of subsection (a) for the semi-annual period described in such subparagraph, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for such semi-annual period in an amount equal to the amount made available under such subparagraph, multiplied by the ratio of—

“(i) the amount of the allotment to such State under subparagraph (A); to

“(ii) the total of the amount of all of the allotments made available under such subparagraph.

“(C) Full year amount based on growth factor updated amount—The amount described in this subparagraph for a State is equal to the sum of—

“(i) the amount of the State allotment for fiscal year 2021 determined under paragraph (2)(B)(i); and

“(ii) the amount of any payments made to the State under subsection (n) for fiscal year 2021,

“(D) First half ratio—The first half ratio described in this subparagraph is the ratio of—

“(i) the sum of—

“(I) the amount made available under subsection (a)(25)(A); and

“(II) the amount of the appropriation for such period under section 101(b)(3) of the HEALTHY KIDS Act; to

“(ii) the sum of—

“(I) the amount described in clause (i); and

“(II) the amount made available under subsection (a)(25)(B).”

“(g) Use of blended risk pools

“(1) In general—Nothing in this title (or any other provision of Federal law) shall be construed as preventing a State from considering children enrolled in a qualified CHIP look-alike program and children enrolled in a State child health plan under this title (or a waiver of such plan) as members of a single risk pool.

“(2) Qualified CHIP look-alike program—In this subsection, the term qualified CHIP look-alike program means a State program—

changed “(A) under which children who are under the age of 18 19 and are not eligible to receive medical assistance under title XIX or child health assistance under this title may purchase coverage through the State that provides benefits that are at least identical to the benefits provided under the State child health plan under this title (or a waiver of such plan); and

“(B) that is funded exclusively through non-Federal funds, including funds received by the State in the form of premiums for the purchase of such coverage.”

“(1) In general—Out of any”

“(A) for each”

“(B) for the period”

“(C) for the period of fiscal years 2018 through 2022, $75,000,000 for the purpose of carrying out this section (other than subsections (e), (f), and (g)).

“(2) Availability—Funds appropriated under this subsection shall remain available until expended.”

removed Section 2113 of the Social Security Act (42 U.S.C. 1397mm) is amended—

added “(H) Parent mentors.”

added “(5) Parent mentor—The term “parent mentor” means an individual who—

added “(A) is a parent or guardian of at least one child who is an eligible child under this title or title XIX; and

added “(B) is trained to assist families with children who have no health insurance coverage with respect to improving the social determinants of the health of such children, including by providing—

added “(i) education about health insurance coverage, including, with respect to obtaining such coverage, eligibility criteria and application and renewal processes;

added “(ii) assistance with completing and submitting applications for health insurance coverage;

added “(iii) a liaison between families and representatives of State plans under title XIX or State child health plans under this title;

added “(iv) guidance on identifying medical and dental homes and community pharmacies for children; and

added “(v) assistance and referrals to successfully address social determinants of children’s health, including poverty, food insufficiency, and housing.”

“(C) The amount of the increase otherwise provided under subparagraph (A) for Puerto Rico shall be further increased by $880,000,000.

“(D)

“(i) For the period beginning October 1, 2017, and ending December 31, 2019, the amount of the increase otherwise provided under subparagraph (A) for Puerto Rico shall be further increased by $120,000,000 if the Financial Oversight and Management Board for Puerto Rico established under section 101 of the Puerto Rico Oversight, Management, and Economic Stability Act (48 U.S.C. 2121) certifies by a majority vote that Puerto Rico has taken reasonable and appropriate steps during such period to—

“(I) reduce fraud, waste, and abuse under the program under title XIX;

“(II) implement strategies to reduce unnecessary, inefficient, or excessive spending under title XIX;

“(III) improve the use and availability of Medicaid data for program operation and oversight; and

“(IV) improve the quality of care and patient experience for individuals enrolled under the program under title XIX.

“(ii) As a condition of any additional increase pursuant to clause (i), not later than October 1, 2018, Puerto Rico shall submit to the Financial Oversight and Management Board for Puerto Rico a report regarding steps taken to achieve each of the goals described in subclauses (I) through (IV) of clause (i).

changed “(E) Payments under section 1903(a)(8) for a quarter of a fiscal year shall not be taken into account in applying subsection (f) (as increased in accordance with this paragraph and paragraphs (1), (2), (3), and (4)) to Puerto Rico or the Virgin Islands for such fiscal year.”year.

added “(F)

added “(i) For the period beginning October 1, 2017, and ending December 31, 2019, the amount of the increase otherwise provided under subparagraph (A) for the Virgin Islands shall be further increased by an amount equal to the per capita equivalent of the total amount of the increase provided for Puerto Rico under subparagraphs (C) and (D) for such period.

added “(ii) For purposes of clause (i), the term “per capita equivalent” means the ratio of—

added “(I) the population of the Virgin Islands, as determined by the most recent census estimate released by the Bureau of the Census before September 4, 2017; to

added “(II) the population of Puerto Rico, as so determined.”

changed “(8) for quarters during the period beginning January 1, 2018, and ending December 31, 2019, paragraphs (2)(A) and (6) shall apply with respect to Puerto Rico and the Virgin Islands as if—

“(A) the reference to “75 per centum” in paragraph (2)(A) were a reference to “90 per centum”; and

“(B) the reference to “75 per centum” in paragraph (6)(B) were a reference to “90 per centum”.”

changed “(nn) For Responsible Third Party and Health Insurer Definitions—For purposes of subsection (a)(25) and section 1903(d)(2)(B):

changed “(1) The Responsible third party—The term “responsible third party” means a health insurer, an accountable care organization, or any other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service. Such term does not include a party if payment by such party has been made or can reasonably be expected to be made under a workmen’s compensation law or plan of the United States or a State, or under an automobile or liability insurance policy or plan (including a self-insured plan), or under no fault insurance.

changed “(2) The Health insurer—The term “health insurer” means a group health plan, as defined in section 607(1) of the Employee Retirement Income Security Act of 1974, a self-insured plan, a fully-insured plan, a service benefit plan, a medicaid managed care plan under section 1903(m) or 1932, a pharmacy benefit manager, and any other health plan determined appropriate by the Secretary.”

“(E) that, in the case of a State that provides medical assistance under this title through a contract with a health insurer, such contract shall specify whether the State is—

“(i) delegating to such insurer all or some of its right of recovery from a responsible third party for an item or service for which payment has been made under the State plan (or under a waiver of the plan); and

“(ii) transferring to such insurer all or some of the assignment to the State of any right of an individual or other entity to payment from a responsible third party for an item or service for which payment has been made under the State plan (or under a waiver of the plan);

“(F) that, in the case of a State that elects an option described in clause (i) or (ii) of subparagraph (E) with respect to a health insurer, the State shall provide assurances to the Secretary that the State laws referred to in subparagraph (I) confer to the health insurer the authority of the State with respect to the requirements specified in clauses (i) through (iv) of such subparagraph;”

“(ii) accept—

“(I) any State’s right of recovery and the assignment to any State of any right of an individual or other entity to payment from the party for an item or service for which payment has been made under the respective State’s plan (or under a waiver of the plan); and

“(II) as a valid authorization of the responsible third party for the furnishing of an item or service to an individual eligible to receive medical assistance under this title, an authorization made on behalf of such individual under the State plan (or under a waiver of such plan) for the furnishing of such item or service to such individual;”

“(n)

“(1) For any year beginning after 2020 (or a sooner year as provided in paragraph (2)), if a State fails to comply with the requirements of section 1902(a)(25) with respect to each calendar quarter in such year, the Secretary may reduce the Federal medical assistance percentage by 0.1 percentage point for calendar quarters in each subsequent year in which the State fails to so comply (and cumulatively for a failure to so comply for a period of consecutive years).

“(2) The Secretary may apply paragraph (1)—

“(A) for any year beginning after 2018, if a State fails to comply with the requirements of section 1902(a)(25) with respect to payment for items and services furnished to individuals described in subclause (VIII) of section 1902(a)(10)(A)(i) or non-expansion individuals; and

“(B) for any year beginning after 2019, if a State fails to comply with the requirements of section 1902(a)(25) with respect to payment for items and services furnished to individuals described in subdivision (i), (iii), or (iv) of section 1905(a).

“(3) For purposes of this subsection, the term “non-expansion individual” means, with respect to a State for a month, an individual who is—

“(A) eligible for medical assistance for items or services under this title and enrolled under the State plan (or a waiver of such plan) under this title for the month;

“(B) not under 19 years of age;

“(C) not 65 years of age or older; and

“(D) not eligible for medical assistance under this title on the basis of being blind or disabled.”

“(B) Section 1902(a)(25) (relating to third party liability).”

“(f) Third party liability training—With respect to education or training activities carried out pursuant to subsection (b)(4) with respect to the liability of responsible third parties (as defined in section 1902(nn) for payment for items and services furnished under State plans (or under waivers of such plans)) under this title, the Secretary shall—

“(1) publish (and update on an annual basis) on the public Internet website of the Centers for Medicare & Medicaid Services a dedicated Internet page containing best practices to be used in assessing such liability;

“(2) monitor efforts to assess such liability and analyze the challenges posed by that assessment;

“(3) distribute to State agencies administering the State plan under this title information related to such efforts and challenges; and

“(4) provide guidance to such State agencies with respect to State oversight of efforts under a medicaid managed care plan under section 1903(m) or 1932 to assess such liability.”