Sec. 300 Short title
This division may be cited as the “Helping Ensure Access for Little Ones, Toddlers, and Hopeful Youth by Keeping Insurance Delivery Stable Act of 2017” or the “HEALTHY KIDS Act”.
Division B — HEALTHY KIDS Act
B HEALTHY KIDS Act
I CHIP Extension and Other Medicaid and CHIP Provisions
Sec. 301 Five-year funding extension of the Children’s Health Insurance Program
Appropriation; total allotment— Section 2104(a) of the Social Security Act (42 U.S.C. 1397dd(a)) is amended—
in paragraph (19), by striking “and”;
in paragraph (20), by striking the period at the end and inserting a semicolon; and
by adding at the end the following new paragraphs:
“(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 two 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.”
Allotments—
in paragraph (2)—
in the heading, by striking “through 2016” and inserting “through 2022”; and
in subparagraph (B)—
in the matter preceding clause (i), by striking “(19)” and inserting “(24)”;
in clause (ii), in the matter preceding subclause (I), by inserting “(other than fiscal year 2022)” after “even-numbered fiscal year”; and
in clause (ii)(I), by inserting “(or, in the case of fiscal year 2018, under paragraph (4))” after “clause (i)”;
in paragraph (5)—
by striking “or (4)” and inserting “(4), or (10)”; and
by striking “or 2017” and inserting “, 2017, or 2022”;
in paragraph (7)—
in subparagraph (A), by striking “2017” and inserting “2022”;
in subparagraph (B), in the matter preceding clause (i), by inserting “(or, in the case of fiscal year 2018, by not later than the date that is 60 days after the date of the enactment of the HEALTHY KIDS Act)” after “before the August 31 preceding the beginning of the fiscal year”; and
in the matter following subparagraph (B), by striking “or fiscal year 2016” and inserting “fiscal year 2016, fiscal year 2018, fiscal year 2020, or fiscal year 2022”;
in paragraph (9)—
in the heading, by striking “fiscal years 2015 and 2017” and inserting “certain fiscal years”;
by striking “or (4)” and inserting “, (4), or (10)”; and
by striking “or fiscal year 2017” and inserting “, 2017, or 2022”; and
by adding at the end the following new paragraph:
“(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 301(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 301(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).”
Technical amendment— Section 2104(m)(2)(A) of such Act (42 U.S.C. 1397dd(m)(2)(A)) is amended by striking “the allotment increase factor under paragraph (5)” each place it appears and inserting “the allotment increase factor under paragraph (6)”.
One-time appropriation for fiscal year 2022— There is appropriated to the Secretary of Health and Human Services, out of any money in the Treasury not otherwise appropriated, $20,200,000,000 to accompany the allotment made for the period beginning on October 1, 2021, and ending on March 31, 2022, under paragraph (25)(A) of section 2104(a) of the Social Security Act (42 U.S.C. 1397dd(a)) (as added by subsection (a)(3)), to remain available until expended. Such amount shall be used to provide allotments to States under paragraph (10) of section 2104(m) of such Act (as added by subsection (b)(1)(E)) for the first 6 months of fiscal year 2022 in the same manner as allotments are provided under subsection (a)(25)(A) of such section 2104 and subject to the same terms and conditions as apply to the allotments provided from such subsection (a)(25)(A).
Extension of the Child Enrollment Contingency Fund— Section 2104(n) of the Social Security Act (42 U.S.C. 1397dd(n)) is amended—
in paragraph (2)—
in subparagraph (A)(ii)—
by striking “2010, 2011, 2012, 2013, 2014, and 2016” and inserting “2010 through 2014, 2016, and 2018 through 2021”; and
by striking “fiscal year 2015 and fiscal year 2017” and inserting “fiscal years 2015, 2017, and 2022”; and
in subparagraph (B)—
by striking “2010, 2011, 2012, 2013, 2014, and 2016” and inserting “2010 through 2014, 2016, and 2018 through 2021”; and
by striking “fiscal year 2015 and fiscal year 2017” and inserting “fiscal years 2015, 2017, and 2022”; and
in paragraph (3)(A), in the matter preceding clause (i), by striking “or a semi-annual allotment period for fiscal year 2015 or 2017” and inserting “or in any of fiscal years 2018 through 2021 (or a semi-annual allotment period for fiscal year 2015, 2017, or 2022)”.
Extension of qualifying states option— Section 2105(g)(4) of the Social Security Act (42 U.S.C. 1397ee(g)(4)) is amended—
in the heading, by striking “through 2017” and inserting “through 2022”; and
in subparagraph (A), by striking “2017” and inserting “2022”.
Extension of express lane eligibility option— Section 1902(e)(13)(I) of the Social Security Act (42 U.S.C. 1396a(e)(13)(I)) is amended by striking “2017” and inserting “2022”.
Assurance of affordability standard for children and families—
in the paragraph heading, by striking “until October 1, 2019” and inserting “through September 30, 2022”; and
in subparagraph (A), in the matter preceding clause (i)—
by striking “2019” and inserting “2022”; and
by striking “The preceding sentence shall not be construed as preventing a State during such period” and inserting “During the period that begins on October 1, 2019, and ends on September 30, 2022, the preceding sentence shall only apply with respect to children in families whose income does not exceed 300 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved. The preceding sentences shall not be construed as preventing a State during any such periods”.
Conforming amendments— Section 1902(gg)(2) of the Social Security Act (42 U.S.C. 1396a(gg)(2)) is amended—
in the paragraph heading, by striking “until October 1, 2019” and inserting “through September 30, 2022”; and
by striking “September 30, 2019,” and inserting “September 30, 2022 (but during the period that begins on October 1, 2019, and ends on September 30, 2022, only with respect to children in families whose income does not exceed 300 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved)”.
CHIP look-Alike plans—
Blending risk pools— Section 2107 of the Social Security Act (42 U.S.C. 1397gg) is amended by adding at the end the following:
“(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—
“(A) under which children who are under the age of 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.”
Coverage rule—
In general— Section 5000A(f)(1) of the Internal Revenue Code of 1986 is amended in subparagraph (A)(iii), by inserting “or under a qualified CHIP look-alike program (as defined in section 2107(g) of the Social Security Act)” before the comma at the end.
Effective date— The amendment made by subparagraph (A) shall apply with respect to taxable years beginning after December 31, 2017.
Sec. 302 Extension of certain programs and demonstration projects
Childhood obesity demonstration project— Section 1139A(e)(8) of the Social Security Act (42 U.S.C. 1320b–9a(e)(8)) is amended—
by striking “and $10,000,000” and inserting “, $10,000,000”; and
by inserting after “2017” the following: “, and $25,000,000 for the period of fiscal years 2018 through 2022”.
Pediatric quality measures program— Section 1139A(i) of the Social Security Act (42 U.S.C. 1320b–9a(i)) is amended—
by striking “Out of any” and inserting the following:
“(1) In general—Out of any”
by striking “there is appropriated for each” and inserting “there is appropriated—
“(A) for each”
by striking “, and there is appropriated for the period” and inserting “;
“(B) for the period”
by striking “. Funds appropriated under this subsection shall remain available until expended.” and inserting “; and”; and
by adding at the end the following:
“(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.”
Sec. 303 Extension of outreach and enrollment program
in subsection (a)(1), by striking “2017” and inserting “2022”; and
in subsection (g)—
by striking “and $40,000,000” and inserting “, $40,000,000”; and
by inserting after “2017” the following: “, and $100,000,000 for the period of fiscal years 2018 through 2022”.
Making organizations that use parent mentors eligible To receive grants— Section 2113(f) of the Social Security Act (42 U.S.C. 1397mm(f)) is amended—
in paragraph (1)(E), by striking “or community-based doula programs” and inserting “, community-based doula programs, or parent mentors”; and
by adding at the end the following new paragraph:
“(5) Parent mentor—The term “parent mentor” means an individual who—
“(A) is a parent or guardian of at least one child who is an eligible child under this title or title XIX; and
“(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—
“(i) education about health insurance coverage, including, with respect to obtaining such coverage, eligibility criteria and application and renewal processes;
“(ii) assistance with completing and submitting applications for health insurance coverage;
“(iii) a liaison between families and representatives of State plans under title XIX or State child health plans under this title;
“(iv) guidance on identifying medical and dental homes and community pharmacies for children; and
“(v) assistance and referrals to successfully address social determinants of children’s health, including poverty, food insufficiency, and housing.”
Exclusion from modified adjusted gross income— Section 1902(e) of the Social Security Act (42 U.S.C. 1396a(e)) is amended—
in the first paragraph (14), relating to income determined using modified adjusted gross income, by adding at the end the following new subparagraph:
“(J) Exclusion of parent mentor compensation from income determination—Any nominal amount received by an individual as compensation, including a stipend, for participation as a parent mentor (as defined in paragraph (5) of section 2113(f)) in an activity or program funded through a grant under such section shall be disregarded for purposes of determining the income eligibility of such individual for medical assistance under the State plan or any waiver of such plan.”
by striking “(14) Exclusion” and inserting “(15) Exclusion”.
Sec. 304 Extension and reduction of additional Federal financial participation for CHIP
Section 2105(b) of the Social Security Act (42 U.S.C. 1397ee(b)) is amended in the second sentence by inserting “and during the period that begins on October 1, 2019, and ends on September 30, 2020, the enhanced FMAP determined for a State for a fiscal year (or for any portion of a fiscal year occurring during such period) shall be increased by 11.5 percentage points” after “23 percentage points,”.
Sec. 305 Modifying reductions in Medicaid DSH allotments
Section 1923(f)(7)(A) of the Social Security Act (42 U.S.C. 1396r–4(f)(7)(A)) is amended—
in clause (i), in the matter preceding subclause (I), by striking “2018” and inserting “2020”; and
in clause (ii), by striking subclauses (I) through (VIII) and inserting the following:
“(I) $4,000,000,000 for fiscal year 2020; and
“(II) $8,000,000,000 for each of fiscal years 2021 through 2025.”
Sec. 306 Puerto Rico and the Virgin Islands Medicaid payments
in paragraph (2)—
in subparagraph (A), by inserting “(or, with respect to fiscal years 2018 and 2019, increased by such percentage increase plus one percentage point)” after “beginning of the fiscal year”; and
in subparagraph (B), by inserting “(or, with respect to fiscal years 2018 and 2019, increased by such percentage increase plus one percentage point)” after “percentage increase referred to in subparagraph (A)”;
in paragraph (5)—
in subparagraph (A), by striking “subparagraph (B)” and inserting “subparagraphs (B), (C), (D), (E), and (F)”; and
by adding at the end the following new subparagraphs:
“(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).
“(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.
“(F)
“(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.
“(ii) For purposes of clause (i), the term “per capita equivalent” means the ratio of—
“(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
“(II) the population of Puerto Rico, as so determined.”
Federal match for medical personnel and fraud reduction— Section 1903(a) of the Social Security Act (42 U.S.C. 1396b(a)) is amended—
in paragraph (2)(A), by inserting “subject to paragraph (8),” before “an amount”;
in paragraph (6)—
in subparagraph (B), by inserting “subject to paragraph (8),” before “75 per centum”; and
by striking at the end “plus”;
in paragraph (7), by striking at the end the period and inserting “; plus” ; and
by adding at the end the following new paragraph:
“(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”.”
II Offsets
Sec. 401 Medicaid third party liability provisions
Medicaid third party liability—
Delay of Bipartisan Budget Act of 2013 third party liability provisions—
In general— Section 202(c) of the Bipartisan Budget Act of 2013 (Public Law 113–67; 127 Stat. 1177; 42 U.S.C. 1396a note), as amended by section 211 of the Protecting Access to Medicare Act of 2014 (Public Law 113–93; 128 Stat. 1047; 42 U.S.C. 1396a note) and section 220 of the Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114–10), is amended by striking “2017” and inserting “2019”.
Effective date; treatment— The amendment made by subparagraph (A) shall take effect on September 30, 2017, and shall apply with respect to any open claims, including claims generated or filed, after such date.
Clarification of definitions applicable to third party liability—
In general— Section 1902 of the Social Security Act (42 U.S.C. 1396a) is amended by adding at the end the following new subsection:
“(nn) Responsible Third Party and Health Insurer Definitions—For purposes of subsection (a)(25) and section 1903(d)(2)(B):
“(1) Responsible third party—The term “responsible third party” means a health insurer, a pharmacy benefit manager to the extent the pharmacy benefit manager provides information under this title for the purpose of coordinating benefits, an accountable care organization under section 1899, 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.
“(2) 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, and any other health plan determined appropriate by the Secretary.”
Conforming amendments— Section 1902(a)(25) of the Social Security Act (42 U.S.C. 1396a(a)(25)) is amended—
in subparagraph (A), in the matter preceding clause (i), by striking “third parties” and all that follows through “item or service)” and inserting “responsible third parties”;
in subparagraph (G), by striking “health insurer” and all that follows through “item or service)” and inserting “responsible third party”;
in subparagraph (I), in the matter preceding clause (i), by striking “health insurers” and all that follows through “item or service” and inserting “responsible third parties”; and
by inserting “responsible” before “third” each place it appears in subparagraphs (A)(i), (A)(ii), (C), (D), and (H).
Removal of special treatment of certain types of care and payments under Medicaid third party liability rules— Section 1902(a)(25) of the Social Security Act (42 U.S.C. 1396a(a)(25)), as amended by section 202(c) of the Bipartisan Budget Act of 2013 (after application of paragraph (1)), is amended—
in subparagraph (E)—
in the matter preceding clause (i), by striking “prenatal or preventive” and all that follows through “State plan” and inserting “items and services provided under the program required under the State plan pursuant to paragraph (62)”; and
in clause (i)—
by striking “such service” and inserting “such items and services”; and
by striking each place it appears “such services” and inserting “such items and services” each such place; and
by striking subparagraph (F).
Clarification of role of health insurers with respect to third party liability—
In general— Section 1902(a)(25) of the Social Security Act (42 U.S.C. 1396a(a)(25)), as amended by paragraph (3), is further amended by inserting after subparagraph (E) the following new subparagraph:
“(F) that—
“(i) in the case of a State that provides medical assistance under this title through a contract with a health insurer, such contract shall specify any responsibility of such health insurer (or other entity) with respect to recovery of payment from responsible third parties pursuant to the delegation or transfer by the State to such insurer (or other entity) of a right described in subparagraph (I)(ii); and
“(ii) in the case of a State that under a contract described in clause (i) delegates or transfers to a health insurer (or other entity) a right described in such clause, the State shall provide assurances to the Secretary that the State laws referred to in subparagraph (I), with respect to each responsibility of such health insurer (or other entity) specified under such clause, confer to such health insurer (or other entity) the authority of the State with respect to the requirements specified in clauses (i) through (iv) of such subparagraph (I);”
Treatment of collected amounts— Section 1903(d)(2)(B) of the Social Security Act (42 U.S.C. 1396b(d)(2)(B)) is amended by adding at the end the following: “For purposes of this subparagraph, reimbursements made by a responsible third party to health insurers (as defined in section 1902(nn)) pursuant to section 1902(a)(25)(F)(ii) shall be treated in the same manner as reimbursements made to a State under the previous sentence.”.
Increasing State flexibility with respect to third party liability— Section 1902(a)(25)(I) of the Social Security Act (42 U.S.C. 1396a(a)(25)(I)) is amended—
in clause (i), by striking “medical assistance under the State plan” and inserting “medical assistance under a State plan (or under a waiver of the plan)”;
by striking clause (ii) and inserting the following new clause:
“(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;”
in clause (iii)—
by striking “respond to” and inserting “not later than 60 days after receiving”; and
by striking “; and” at the end and inserting “, respond to such inquiry; and”; and
in clause (iv), by inserting “a failure to obtain a prior authorization,” after “claim form,”.
State incentive to pursue third party liability for newly eligibles— Section 1903(d)(2)(B) of the Social Security Act (42 U.S.C. 1396b(d)(2)(B)), as amended by paragraph (4)(B), is further amended by adding at the end the following: “In the case of expenditures for medical assistance provided during 2017 and subsequent years for individuals described in subclause (VIII) of section 1902(a)(10)(A)(i), in determining the amount, if any, of overpayment under this subparagraph with respect to such medical assistance, the Secretary shall apply the Federal medical assistance percentage for the State under section 1905(b), notwithstanding the application of section 1905(y).”.
Compliance with third party insurance reporting— Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended by adding at the end the following new subsection:
“(ee) Notwithstanding subsection (b), for any year beginning after 2019, 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.”
Application to CHIP—
by redesignating subparagraphs (B) through (R) as subparagraphs (C) through (S), respectively; and
by inserting after subparagraph (A) the following new subparagraph:
“(B) Section 1902(a)(25) (relating to third party liability).”
Mandatory reporting— Section 1902(a)(25)(I)(i) of the Social Security Act (42 U.S.C. 1396a(a)(25)(I)(i)), as amended by subsection (a)(5), is further amended—
by striking “(and, at State option, child” and inserting “and child”; and
by striking “title XXI)” and inserting “title XXI”.
Training on third party liability— Section 1936 of the Social Security Act (42 U.S.C. 1396u–6) is amended—
in subsection (b)(4), by striking “and quality of care” and inserting “, quality of care, and the liability of responsible third parties (as defined in section 1902(nn))”; and
by adding at the end the following new subsection:
“(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.”
Development of model uniform fields for States To report third party information— Not later than January 1, 2019, the Secretary of Health and Human Services shall, in consultation with the States, develop and make available to the States a model uniform reporting set of reporting fields and accompanying guidance documentation that States shall use for purposes of—
reporting information to the Secretary within the Transformed Medicaid Statistical Information System (T–MSIS) (or a successor system); and
collecting information that identifies responsible third parties (as defined in subsection (nn) of section 1902 of the Social Security Act (42 U.S.C. 1396a), as added by subsection (a)(2)(A)) and other relevant information for ascertaining the legal responsibility of such third parties to pay for care and services available under the State plan (or under a waiver of the plan) under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) or under the State child health plan under title XXI of such Act (42 U.S.C. 1397 et seq.).
Effective date—
In general— Except as provided in paragraph (2), this section and the amendments made by this section (other than as specified in the preceding provisions of this section) shall take effect on October 1, 2019, and shall apply to medical assistance or child health assistance provided on or after such date.
Exception if State legislation required— In the case of a State plan for medical assistance under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), or a State child health plan for child health assistance under title XXI of such Act (42 U.S.C. 1397aa et seq.), that the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirement imposed by the amendments made under this section, such plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature.
Sec. 402 Treatment of lottery winnings and other lump-sum income for purposes of income eligibility under Medicaid
in subsection (a)(17), by striking “(e)(14), (e)(14)” and inserting “(e)(14), (e)(15)”; and
in subsection (e)(14), as amended by section 303(c), by adding at the end the following new subparagraph:
“(K) Treatment of certain lottery winnings and income received as a lump sum
“(i) In general—In the case of an individual who is the recipient of qualified lottery winnings (pursuant to lotteries occurring on or after January 1, 2018) or qualified lump sum income (received on or after such date) and whose eligibility for medical assistance is determined based on the application of modified adjusted gross income under subparagraph (A), a State shall, in determining such eligibility, include such winnings or income (as applicable) as income received—
“(I) in the month in which such winnings or income (as applicable) is received if the amount of such winnings or income is less than $80,000;
“(II) over a period of 2 months if the amount of such winnings or income (as applicable) is greater than or equal to $80,000 but less than $90,000;
“(III) over a period of 3 months if the amount of such winnings or income (as applicable) is greater than or equal to $90,000 but less than $100,000; and
“(IV) over a period of 3 months plus 1 additional month for each increment of $10,000 of such winnings or income (as applicable) received, not to exceed a period of 120 months (for winnings or income of $1,260,000 or more), if the amount of such winnings or income is greater than or equal to $100,000.
“(ii) Counting in equal installments—For purposes of subclauses (II), (III), and (IV) of clause (i), winnings or income to which such subclause applies shall be counted in equal monthly installments over the period of months specified under such subclause.
“(iii) Hardship exemption—An individual whose income, by application of clause (i), exceeds the applicable eligibility threshold established by the State, shall continue to be eligible for medical assistance to the extent that the State determines, under procedures established by the State (in accordance with standards specified by the Secretary), that the denial of eligibility of the individual would cause an undue medical or financial hardship as determined on the basis of criteria established by the Secretary.
“(iv) Notifications and assistance required in case of loss of eligibility—A State shall, with respect to an individual who loses eligibility for medical assistance under the State plan (or a waiver of such plan) by reason of clause (i)—
“(I) before the date on which the individual loses such eligibility, inform the individual—
“(aa) of the individual’s opportunity to enroll in a qualified health plan offered through an Exchange established under title I of the Patient Protection and Affordable Care Act during the special enrollment period specified in section 9801(f)(3) of the Internal Revenue Code of 1986 (relating to loss of Medicaid or CHIP coverage); and
“(bb) of the date on which the individual would no longer be considered ineligible by reason of clause (i) to receive medical assistance under the State plan or under any waiver of such plan and be eligible to reapply to receive such medical assistance; and
“(II) provide technical assistance to the individual seeking to enroll in such a qualified health plan.
“(v) Qualified lottery winnings defined—In this subparagraph, the term qualified lottery winnings means winnings from a sweepstakes, lottery, or pool described in paragraph (3) of section 4402 of the Internal Revenue Code of 1986 or a lottery operated by a multistate or multijurisdictional lottery association, including amounts awarded as a lump sum payment.
“(vi) Qualified lump sum income defined—In this subparagraph, the term qualified lump sum income means income that is received as a lump sum from one of the following sources:
“(I) Monetary winnings from gambling (as defined by the Secretary and including gambling activities described in section 1955(b)(4) of title 18, United States Code).
“(II) Damages received, whether by suit or agreement and whether as lump sums or as periodic payments (other than monthly payments), on account of causes of action other than causes of action arising from personal physical injuries or physical sickness.
“(III) Income received as liquid assets from the estate (as defined in section 1917(b)(4)) of a deceased individual.”
Rules of construction—
Interception of lottery winnings allowed— Nothing in the amendment made by subsection (a)(2) shall be construed as preventing a State from intercepting the State lottery winnings awarded to an individual in the State to recover amounts paid by the State under the State Medicaid plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) for medical assistance furnished to the individual.
Applicability limited to eligibility of recipient of lottery winnings or lump sum income— Nothing in the amendment made by subsection (a)(2) shall be construed, with respect to a determination of household income for purposes of a determination of eligibility for medical assistance under the State plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) (or a waiver of such plan) made by applying modified adjusted gross income under subparagraph (A) of section 1902(e)(14) of such Act (42 U.S.C. 1396a(e)(14)), as limiting the eligibility for such medical assistance of any individual that is a member of the household other than the individual who received qualified lottery winnings or qualified lump-sum income (as defined in subparagraph (K) of such section 1902(e)(14), as added by subsection (a)(2) of this section).
Sec. 403 Adjustments to Medicare part B and part D premium subsidies for higher income individuals
In general— Section 1839(i)(3)(C)(i)(II) of the Social Security Act (42 U.S.C. 1395r(i)(3)(C)(i)(II)) is amended, in the table, by striking the last row and inserting the following new rows:
Joint returns— Section 1839(i)(3)(C)(ii) of the Social Security Act (42 U.S.C. 1395r(i)(3)(C)(ii)) is amended by inserting before the period the following: “except, with respect to the dollar amounts applied in the last row of the table under subclause (II) of such clause (and the second dollar amount specified in the second to last row of such table), clause (i) shall be applied by substituting dollar amounts which are 175 percent of such dollar amounts for the calendar year”.
in paragraph (5)—
in subparagraph (A), by striking “In the case” and inserting “Subject to subparagraph (C), in the case”;
in subparagraph (B), by striking “subparagraph (A)” and inserting “subparagraph (A) or (C)”; and
by adding at the end the following new subparagraph:
“(C) Treatment of adjustments for certain higher income individuals
“(i) In general—Subparagraph (A) shall not apply with respect to each dollar amount in paragraph (3) of $500,000.
“(ii) Adjustment beginning 2027—In the case of any calendar year beginning after 2026, each dollar amount in paragraph (3) of $500,000 shall be increased by an amount equal to—
“(I) such dollar amount, multiplied by
“(II) the percentage (if any) by which the average of the Consumer Price Index for all urban consumers (United States city average) for the 12-month period ending with August of the preceding calendar year exceeds such average for the 12-month period ending with August 2025.”
in paragraph (6)(B), by inserting “(other than $500,000)” after “the dollar amounts”.