---
kind: "section"
citation: "42 U.S.C. § 1397kk"
title: "42"
title_heading: "The Public Health and Welfare"
number: "1397kk"
heading: "Phase-out of coverage for nonpregnant childless adults; conditions for coverage of parents"
release: "119-102"
date: "2026-07-12"
url: "https://uscodex.org/usc/42/1397kk"
units:
  - "Chapter 7 — Social Security"
  - "Subchapter XXI — State Children’s Health Insurance Program"
---

# §1397kk. Phase-out of coverage for nonpregnant childless adults; conditions for coverage of parents

- (a) **Termination of coverage for nonpregnant childless adults—**
  - (1) **No new CHIP waivers; automatic extensions at State option through 2009—** Notwithstanding [section 1315 of this title](/usc/42/1315.md) or any other provision of this subchapter, except as provided in this subsection—
    - (A) the [Secretary](/usc/42/1301.md?p=a-6) shall not on or after February 4, 2009, approve or renew a waiver, experimental, pilot, or demonstration [project](/usc/42/13641.md?p=2) that would allow funds made available under this subchapter to be used to provide [child health assistance](/usc/42/1397jj.md?p=a) or other health benefits coverage to a nonpregnant childless [adult](/usc/42/619.md?p=1); and
    - (B) notwithstanding the terms and conditions of an applicable existing waiver, the provisions of [paragraph (2)](#a-2) shall apply for purposes of any period beginning on or after January 1, 2010, in determining the period to which the waiver applies, the individuals eligible to be covered by the waiver, and the amount of the Federal payment under this subchapter.
  - (2) **Termination of CHIP coverage under applicable existing waivers at the end of 2009—**
    - (A) **In general—** No funds shall be available under this subchapter for [child health assistance](/usc/42/1397jj.md?p=a) or other health benefits coverage that is provided to a nonpregnant childless [adult](/usc/42/619.md?p=1) under an applicable existing waiver after December 31, 2009.
    - (B) **Extension upon State request—** If an applicable existing waiver described in [subparagraph (A)](#a-2-A) would otherwise expire before January 1, 2010, notwithstanding the requirements of subsections (e) and (f) of [section 1315 of this title](/usc/42/1315.md), a [State](/usc/42/619.md?p=5) may submit, not later than September 30, 2009, a request to the [Secretary](/usc/42/1301.md?p=a-6) for an extension of the waiver. The [Secretary](/usc/42/1301.md?p=a-6) shall approve a request for an extension of an applicable existing waiver submitted pursuant to this subparagraph, but only through December 31, 2009.
    - (C) **Application of enhanced FMAP—** The enhanced FMAP determined under [section 1397ee(b) of this title](/usc/42/1397ee.md?p=b) shall apply to expenditures under an applicable existing waiver for the provision of [child health assistance](/usc/42/1397jj.md?p=a) or other health benefits coverage to a nonpregnant childless [adult](/usc/42/619.md?p=1) during the period beginning on February 4, 2009, and ending on December 31, 2009.
  - (3) **State option to apply for Medicaid waiver to continue coverage for nonpregnant childless adults—**
    - (A) **In general—** Each [State](/usc/42/619.md?p=5) for which coverage under an applicable existing waiver is terminated under [paragraph (2)(A)](#a-2-A) may submit, not later than September 30, 2009, an application to the [Secretary](/usc/42/1301.md?p=a-6) for a waiver under [section 1315 of this title](/usc/42/1315.md) of the [State](/usc/42/619.md?p=5) plan under subchapter XIX to provide medical assistance to a nonpregnant childless [adult](/usc/42/619.md?p=1) whose coverage is so terminated (in this subsection referred to as a “Medicaid nonpregnant childless [adults](/usc/42/619.md?p=1) waiver”).
    - (B) **Deadline for approval—** The [Secretary](/usc/42/1301.md?p=a-6) shall make a decision to approve or deny an application for a Medicaid nonpregnant childless [adults](/usc/42/619.md?p=1) waiver submitted under [subparagraph (A)](#a-3-A) within 90 days of the date of the submission of the application. If no decision has been made by the [Secretary](/usc/42/1301.md?p=a-6) as of December 31, 2009, on the application of a [State](/usc/42/619.md?p=5) for a Medicaid nonpregnant childless [adults](/usc/42/619.md?p=1) waiver that was submitted to the [Secretary](/usc/42/1301.md?p=a-6) by September 30, 2009, the application shall be deemed approved.
    - (C) **Standard for budget neutrality—** The budget neutrality requirement applicable with respect to expenditures for medical assistance under a Medicaid nonpregnant childless [adults](/usc/42/619.md?p=1) waiver shall—
      - (i) in the case of [fiscal year](/usc/42/619.md?p=3) 2010, allow expenditures for medical assistance under subchapter XIX for all such [adults](/usc/42/619.md?p=1) to not exceed the total amount of payments made to the [State](/usc/42/619.md?p=5) under [paragraph (2)(B)](#a-2-B) for [fiscal year](/usc/42/619.md?p=3) 2009, increased by the percentage increase (if any) in the projected nominal per capita amount of National Health Expenditures for 2010 over 2009, as most recently published by the [Secretary](/usc/42/1301.md?p=a-6); and
      - (ii) in the case of any succeeding [fiscal year](/usc/42/619.md?p=3), allow such expenditures to not exceed the amount in effect under this subparagraph for the preceding [fiscal year](/usc/42/619.md?p=3), increased by the percentage increase (if any) in the projected nominal per capita amount of National Health Expenditures for the calendar year that begins during the year involved over the preceding calendar year, as most recently published by the [Secretary](/usc/42/1301.md?p=a-6).
- (b) **Rules and conditions for coverage of parents of targeted low-income children—**
  - (1) **Two-year period; automatic extension at State option through fiscal year 2011—**
    - (A) **No new CHIP waivers—** Notwithstanding [section 1315 of this title](/usc/42/1315.md) or any other provision of this subchapter, except as provided in this subsection—
      - (i) the [Secretary](/usc/42/1301.md?p=a-6) shall not on or after February 4, 2009, approve or renew a waiver, experimental, pilot, or demonstration [project](/usc/42/13641.md?p=2) that would allow funds made available under this subchapter to be used to provide [child health assistance](/usc/42/1397jj.md?p=a) or other health benefits coverage to a parent of a [targeted low-income child](/usc/42/1397jj.md?p=b-1); and
      - (ii) notwithstanding the terms and conditions of an applicable existing waiver, the provisions of paragraphs [(2)](#b-2) and [(3)](#b-3) shall apply for purposes of any [fiscal year](/usc/42/619.md?p=3) beginning on or after October 1, 2011, in determining the period to which the waiver applies, the individuals eligible to be covered by the waiver, and the amount of the Federal payment under this subchapter.
    - (B) **Extension upon State request—** If an applicable existing waiver described in [subparagraph (A)](#b-1-A) would otherwise expire before October 1, 2011, and the [State](/usc/42/619.md?p=5) requests an extension of such waiver, the [Secretary](/usc/42/1301.md?p=a-6) shall [grant](/usc/42/1397j.md?p=10) such an extension, but only, subject to [paragraph (2)(A)](#b-2-A), through September 30, 2011.
    - (C) **Application of enhanced FMAP—** The enhanced FMAP determined under [section 1397ee(b) of this title](/usc/42/1397ee.md?p=b) shall apply to expenditures under an applicable existing waiver for the provision of [child health assistance](/usc/42/1397jj.md?p=a) or other health benefits coverage to a parent of a [targeted low-income child](/usc/42/1397jj.md?p=b-1) during the third and fourth quarters of [fiscal year](/usc/42/619.md?p=3) 2009 and during [fiscal years](/usc/42/619.md?p=3) 2010 and 2011.
  - (2) **Rules for fiscal years 2012 through 2013—**
    - (A) **Payments for coverage limited to block grant funded from State allotment—** Any [State](/usc/42/619.md?p=5) that provides [child health assistance](/usc/42/1397jj.md?p=a) or health benefits coverage under an applicable existing waiver for a parent of a [targeted low-income child](/usc/42/1397jj.md?p=b-1) may elect to continue to provide such assistance or coverage through [fiscal year](/usc/42/619.md?p=3) 2012 or 2013, subject to the same terms and conditions that applied under the applicable existing waiver, unless otherwise modified in [subparagraph (B)](#b-2-B).
    - (B) **Terms and conditions—**
      - (i) **Block grant set aside from State allotment—** If the [State](/usc/42/619.md?p=5) makes an election under [subparagraph (A)](#b-2-A), the [Secretary](/usc/42/1301.md?p=a-6) shall set aside for the [State](/usc/42/619.md?p=5) for each such [fiscal year](/usc/42/619.md?p=3) an amount equal to the Federal share of 110 percent of the [State](/usc/42/619.md?p=5)’s projected expenditures under the applicable existing waiver for providing [child health assistance](/usc/42/1397jj.md?p=a) or health benefits coverage to all parents of targeted low-income children enrolled under such waiver for the [fiscal year](/usc/42/619.md?p=3) (as certified by the [State](/usc/42/619.md?p=5) and submitted to the [Secretary](/usc/42/1301.md?p=a-6) by not later than August 31 of the preceding [fiscal year](/usc/42/619.md?p=3)). In the case of [fiscal year](/usc/42/619.md?p=3) 2013, the set aside for any [State](/usc/42/619.md?p=5) shall be computed separately for each period described in subparagraphs (A) and (B) of [section 1397dd(a)(16) of this title](/usc/42/1397dd.md?p=a-16) and any reduction in the allotment for either such period under [section 1397dd(m)(5) of this title](/usc/42/1397dd.md?p=m-5) shall be allocated on a pro rata basis to such set aside.
      - (ii) **Payments from block grant—** The [Secretary](/usc/42/1301.md?p=a-6) shall pay the [State](/usc/42/619.md?p=5) from the amount set aside under [clause (i)](#b-2-B-i) for the [fiscal year](/usc/42/619.md?p=3), an amount for each quarter of such [fiscal year](/usc/42/619.md?p=3) equal to the applicable percentage determined under clause [(iii)](#b-2-B-iii) or [(iv)](#b-2-B-iv) for expenditures in the quarter for providing [child health assistance](/usc/42/1397jj.md?p=a) or other health benefits coverage to a parent of a [targeted low-income child](/usc/42/1397jj.md?p=b-1).
      - (iii) **Enhanced FMAP only in fiscal year 2012 for States with significant child outreach or that achieve child coverage benchmarks; FMAP for any other States—** For purposes of [clause (ii)](#b-2-B-ii), the applicable percentage for any quarter of [fiscal year](/usc/42/619.md?p=3) 2012 is equal to—
        - (I) the enhanced FMAP determined under [section 1397ee(b) of this title](/usc/42/1397ee.md?p=b) in the case of a [State](/usc/42/619.md?p=5) that meets the outreach or coverage benchmarks described in any of subparagraph [(A)](#b-3-A), [(B)](#b-3-B), or [(C)](#b-3-C) of paragraph (3) for [fiscal year](/usc/42/619.md?p=3) 2011; or
        - (II) the Federal medical assistance percentage (as determined under [section 1396d(b) of this title](/usc/42/1396d.md?p=b) without regard to [clause (4)](/usc/42/1396d.md) of such section) in the case of any other [State](/usc/42/619.md?p=5).
      - (iv) **Amount of Federal matching payment in 2013—** For purposes of [clause (ii)](#b-2-B-ii), the applicable percentage for any quarter of [fiscal year](/usc/42/619.md?p=3) 2013 is equal to—
        - (I) the REMAP percentage if—
          - (aa) the applicable percentage for the [State](/usc/42/619.md?p=5) under [clause (iii)](#b-2-B-iii) was the enhanced FMAP for [fiscal year](/usc/42/619.md?p=3) 2012; and
          - (bb) the [State](/usc/42/619.md?p=5) met either of the coverage benchmarks described in subparagraph [(B)](#b-3-B) or [(C)](#b-3-C) of paragraph (3) for [fiscal year](/usc/42/619.md?p=3) 2012; or
        - (II) the Federal medical assistance percentage (as so determined) in the case of any [State](/usc/42/619.md?p=5) to which [subclause (I)](#b-2-B-iv-I) does not apply.

      For purposes of subclause (I), the REMAP percentage is the percentage which is the sum of such Federal medical assistance percentage and a number of percentage points equal to one-half of the difference between such Federal medical assistance percentage and such enhanced FMAP.

      - (v) **No Federal payments other than from block grant set aside—** No payments shall be made to a [State](/usc/42/619.md?p=5) for expenditures described in [clause (ii)](#b-2-B-ii) after the total amount set aside under [clause (i)](#b-2-B-i) for a [fiscal year](/usc/42/619.md?p=3) has been paid to the [State](/usc/42/619.md?p=5).
      - (vi) **No increase in income eligibility level for parents—** No payments shall be made to a [State](/usc/42/619.md?p=5) from the amount set aside under [clause (i)](#b-2-B-i) for a [fiscal year](/usc/42/619.md?p=3) for expenditures for providing [child health assistance](/usc/42/1397jj.md?p=a) or health benefits coverage to a parent of a [targeted low-income child](/usc/42/1397jj.md?p=b-1) whose family income exceeds the income eligibility level applied under the applicable existing waiver to parents of targeted low-income children on February 4, 2009.
  - (3) **Outreach or coverage benchmarks—** For purposes of [paragraph (2)](#b-2), the outreach or coverage benchmarks described in this paragraph are as follows:
    - (A) **Significant child outreach campaign—** The [State](/usc/42/619.md?p=5)—
      - (i) was awarded a [grant](/usc/42/1397j.md?p=10) under [section 1397mm of this title](/usc/42/1397mm.md) for [fiscal year](/usc/42/619.md?p=3) 2011;
      - (ii) implemented 1 or more of the enrollment and retention provisions described in [section 1397ee(a)(4) of this title](/usc/42/1397ee.md?p=a-4) for such [fiscal year](/usc/42/619.md?p=3); or
      - (iii) has submitted a specific plan for outreach for such [fiscal year](/usc/42/619.md?p=3).
    - (B) **High-performing State—** The [State](/usc/42/619.md?p=5), on the basis of the most timely and accurate published estimates of the Bureau of the Census, ranks in the lowest ⅓ of [States](/usc/42/619.md?p=5) in terms of the [State](/usc/42/619.md?p=5)’s percentage of low-income children without health insurance.
    - (C) **State increasing enrollment of low-income children—** The [State](/usc/42/619.md?p=5) qualified for a performance bonus payment under [section 1397ee(a)(3)(B) of this title](/usc/42/1397ee.md?p=a-3-B) for the most recent [fiscal year](/usc/42/619.md?p=3) applicable under such section.
  - (4) **Rules of construction—** Nothing in this subsection shall be construed as prohibiting a [State](/usc/42/619.md?p=5) from submitting an application to the [Secretary](/usc/42/1301.md?p=a-6) for a waiver under [section 1315 of this title](/usc/42/1315.md) of the [State](/usc/42/619.md?p=5) plan under subchapter XIX to provide medical assistance to a parent of a [targeted low-income child](/usc/42/1397jj.md?p=b-1) that was provided [child health assistance](/usc/42/1397jj.md?p=a) or health benefits coverage under an applicable existing waiver.
- (c) **Applicable existing waiver—** For purposes of this section—
  - (1) **In general—** The term “applicable existing waiver” means a waiver, experimental, pilot, or demonstration [project](/usc/42/13641.md?p=2) under [section 1315 of this title](/usc/42/1315.md), grandfathered under section 6102(c)(3) of the Deficit Reduction Act of 2005, or otherwise conducted under authority that—
    - (A) would allow funds made available under this subchapter to be used to provide [child health assistance](/usc/42/1397jj.md?p=a) or other health benefits coverage to—
      - (i) a parent of a [targeted low-income child](/usc/42/1397jj.md?p=b-1);
      - (ii) a nonpregnant childless [adult](/usc/42/619.md?p=1); or
      - (iii) individuals described in both clauses [(i)](#c-1-A-i) and [(ii)](#c-1-A-ii); and
    - (B) was in effect during [fiscal year](/usc/42/619.md?p=3) 2009.
  - (2) **Definitions—**
    - (A) **Parent—** The term “parent” [includes](/usc/42/1301.md?p=b) a caretaker relative (as such term is used in carrying out [section 1396u–1 of this title](/usc/42/1396u–1.md)) and a legal guardian.
    - (B) **Nonpregnant childless adult—** The term “nonpregnant childless [adult](/usc/42/619.md?p=1)” has the meaning given such term by [section 1397gg(f) of this title](/usc/42/1397gg.md?p=f).

## Source credit

(Aug. 14, 1935, ch. 531, title XXI, § 2111, as added Pub. L. 111–3, title I, § 112(a)(1), Feb. 4, 2009, 123 Stat. 29; amended Pub. L. 114–10, title III, § 301(b)(2)(D), Apr. 16, 2015, 129 Stat. 157.)

## Notes

### Editorial Notes

### References in Text

Section 6102(c)(3) of the Deficit Reduction Act of 2005, referred to in subsec. (c)(1), is section 6102(c)(3) of Pub. L. 109–171, which is set out as a note under section 1397gg of this title.

### Amendments

2015—Subsec. (b)(2)(B)(i). Pub. L. 114–10 substituted “section 1397dd(m)(5)” for “section 1397dd(m)(4)”.

### Statutory Notes and Related Subsidiaries

### Effective Date

Section effective Apr. 1, 2009, and applicable to child health assistance and medical assistance provided on or after that date, with certain exceptions, see section 3 of Pub. L. 111–3, set out as a note under section 1396 of this title.