S 1977 — Improving Coverage and Care for Mothers Act

(a) Contents A State plan for medical assistance must— (1) provide that it shall be in effect in all political subdivisions of the State, and, if administered by them, be mandatory upon them; (2) provide for financial participation by the State equal to not less than 40 per centum of the non-Federal share of the expenditures under the plan with respect to which payments under section 1396b of this title are authorized by this subchapter; and, effective July 1, 1969, provide for financial participation by the State equal to all of such non-Federal share or provide for distribution of funds from Federal or State sources, for carrying out the State plan, on an equalization or other basis which will assure that the lack of adequate funds from local sources will not result in lowering the amount, duration, scope, or quality of care and services available under the plan; (3) provide for granting an opportunity for a fair hearing before the State agency to any individual whose claim for medical assistance under the plan is denied or is not acted upon with reasonable promptness; (4) provide (A) such methods of administration (including methods relating to the establishment and maintenance of personnel standards on a merit basis, except that the Secretary shall exercise no authority with respect to the selection, tenure of office, and compensation of any individual employed in accordance with such methods, including provision for utilization of professional medical personnel in the administration and, where administered locally, supervision of administration of the plan, and, subject to section 1396b(i) of this title, including a specification that the single State agency described in paragraph (5) will ensure necessary transportation for beneficiaries under the State plan to and from providers and a description of the methods that such agency will use to ensure such transportation) as are found by the Secretary to be necessary for the proper and efficient operation of the plan, (B) for the training and effective use of paid subprofessional staff, with particular emphasis on the full-time or part-time employment of recipients and other persons of low income, as community service aides, in the administration of the plan and for the use of nonpaid or partially paid volunteers in a social service volunteer program in providing services to applicants and recipients and in assisting any advisory committees established by the State agency, (C) that each State or local officer, employee, or independent contractor who is responsible for the expenditure of substantial amounts of funds under the State plan, each individual who formerly was such an officer, employee, or contractor, and each partner of such an officer, employee, or contractor shall be prohibited from committing any act, in relation to any activity under the plan, the commission of which, in connection with any activity concerning the United States Government, by an officer or employee of the United States Government, an individual who was such an officer or employee, or a partner of such an officer or employee is prohibited by section 207 or 208 of title 18, and (D) that each State or local officer, employee, or independent contractor who is responsible for selecting, awarding, or otherwise obtaining items and services under the State plan shall be subject to safeguards against conflicts of interest that are at least as stringent as the safeguards that apply under chapter 21 of title 41 to persons described in section 2102(a)(3) of title 41; (5) either provide for the establishment or designation of a single State agency to administer or to supervise the administration of the plan; or provide for the establishment or designation of a single State agency to administer or to supervise the administration of the plan, except that the determination of eligibility for medical assistance under the plan shall be made by the State or local agency administering the State plan approved un...

For purposes of this subchapter— (a) Medical assistance The term “medical assistance” means payment of part or all of the cost of the following care and services or the care and services themselves, or both (if provided in or after the third month before the month in which the recipient makes application for assistance or, in the case of medicare cost-sharing with respect to a qualified medicare beneficiary described in subsection (p)(1), if provided after the month in which the individual becomes such a beneficiary) for individuals, and, with respect to physicians’ or dentists’ services, at the option of the State, to individuals (other than individuals with respect to whom there is being paid, or who are eligible, or would be eligible if they were not in a medical institution, to have paid with respect to them a State supplementary payment and are eligible for medical assistance equal in amount, duration, and scope to the medical assistance made available to individuals described in section 1396a(a)(10)(A) of this title) not receiving aid or assistance under any plan of the State approved under subchapter I, X, XIV, or XVI, or part A of subchapter IV, and with respect to whom supplemental security income benefits are not being paid under subchapter XVI, who are— (i) under the age of 21, or, at the option of the State, under the age of 20, 19, or 18 as the State may choose, (ii) relatives specified in section 606(b)(1) 1 of this title with whom a child is living if such child is (or would, if needy, be) a dependent child under part A of subchapter IV, (iii) 65 years of age or older, (iv) blind, with respect to States eligible to participate in the State plan program established under subchapter XVI, (v) 18 years of age or older and permanently and totally disabled, with respect to States eligible to participate in the State plan program established under subchapter XVI, (vi) persons essential (as described in the second sentence of this subsection) to individuals receiving aid or assistance under State plans approved under subchapter I, X, XIV, or XVI, (vii) blind or disabled as defined in section 1382c of this title, with respect to States not eligible to participate in the State plan program established under subchapter XVI, (viii) pregnant women, (ix) individuals provided extended benefits under section 1396r–6 of this title, (x) individuals described in section 1396a(u)(1) of this title, (xi) individuals described in section 1396a(z)(1) of this title, (xii) employed individuals with a medically improved disability (as defined in subsection (v)), (xiii) individuals described in section 1396a(aa) of this title, (xiv) individuals described in section 1396a(a)(10)(A)(i)(VIII) or 1396a(a)(10)(A)(i)(IX) of this title, (xv) individuals described in section 1396a(a)(10)(A)(ii)(XX) of this title, (xvi) individuals described in section 1396a(ii) of this title, (xvii) individuals who are eligible for home and community-based services under needs-based criteria established under paragraph (1)(A) of section 1396n(i) of this title, or who are eligible for home and community-based services under paragraph (6) of such section, and who will receive home and community-based services pursuant to a State plan amendment under such subsection, or (xviii) individuals who, but for earnings in excess of the limit established under subsection (q)(2)(B), would be considered to be receiving supplemental security income, and who are at least 16 years of age, but whose income and resources are insufficient to meet all of such cost— (1) inpatient hospital services (other than services in an institution for mental diseases); (2) (A) outpatient hospital services, (B) consistent with State law permitting such services, rural health clinic services (as defined in subsection (l)(1)) and any other ambulatory services which are offered by a rural health clinic (as defined in subsection (l)(1)) and which are otherwise included in the plan, and (C) Federally...

(a) Authority (1) In general Notwithstanding any other provision of this subchapter, the Secretary shall establish a demonstration program under which States may provide under their State plans under this subchapter (including such a plan operating under a statewide waiver under section 1315 of this title) in accordance with this section for the provision of alternative benefits consistent with subsection (c) for eligible population groups in one or more geographic areas of the State specified by the State. An amendment under the previous sentence is referred to in this section as a “State demonstration program”. (2) Initial demonstration (A) In general The demonstration program under this section shall begin on January 1, 2007. During the first 5 years of such program, the Secretary shall not approve more than 10 States to conduct demonstration programs under this section, with each State demonstration program covering 1 or more geographic areas specified by the State. After such 5-year period— (i) unless the Secretary finds, taking into account cost-effectiveness, quality of care, and other criteria that the Secretary specifies, that a State demonstration program previously implemented has been unsuccessful, such a demonstration program may be extended or made permanent in the State; and (ii) unless the Secretary finds, taking into account cost-effectiveness, quality of care, and other criteria that the Secretary specifies, that all State demonstration programs previously implemented were unsuccessful, other States may implement State demonstration programs. (B) GAO report (i) In general Not later than 3 months after the end of the 5-year period described in subparagraph (A), the Comptroller General of the United States shall submit a report to Congress evaluating the demonstration programs conducted under this section during such period. (ii) Appropriation Out of any funds in the Treasury not otherwise appropriated, there is appropriated to the Comptroller General of the United States, $550,000 for the period of fiscal years 2007 through 2010 to carry out clause (i). (3) Approval The Secretary shall not approve a State demonstration program under paragraph (1) unless the program includes the following: (A) Creating patient awareness of the high cost of medical care. (B) Providing incentives to patients to seek preventive care services. (C) Reducing inappropriate use of health care services. (D) Enabling patients to take responsibility for health outcomes. (E) Providing enrollment counselors and ongoing education activities. (F) Providing transactions involving health opportunity accounts to be conducted electronically and without cash. (G) Providing access to negotiated provider payment rates consistent with this section. Nothing in this section shall be construed as preventing a State demonstration program from providing incentives for patients obtaining appropriate preventive care (as defined for purposes of section 223(c)(2)(C) of the Internal Revenue Code of 1986), such as additional account contributions for an individual demonstrating healthy prevention practices. (4) No requirement for statewideness Nothing in this section or any other provision of law shall be construed to require that a State must provide for the implementation of a State demonstration program on a Statewide 1 basis. (b) Eligible population groups (1) In general A State demonstration program under this section shall specify the eligible population groups consistent with paragraphs (2) and (3). (2) Eligibility limitations during initial demonstration period During the initial 5 years of the demonstration program under this section, a State demonstration program shall not apply to any of the following individuals: (A) Individuals who are 65 years of age or older. (B) Individuals who are disabled, regardless of whether or not their eligibility for medical assistance under this subchapter is based on such disability. (C) Individuals who are eligible...

(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 subchapter. (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 subchapter. (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 1397hh(a) of this title and the evaluation required by section 1397hh(b) of this title. (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 chapter shall apply to States under this subchapter in the same manner as they apply to a State under subchapter XIX: (1) Subchapter XIX provisions (A) Section 1396a(a)(4)(C) of this title (relating to conflict of interest standards). (B) Section 1396a(a)(25) of this title (relating to third party liability). (C) Section 1396a(a)(39) of this title (relating to termination of participation of certain providers). (D) Section 1396a(a)(78) of this title (relating to enrollment of providers participating in State plans providing medical assistance on a fee-for-service basis). (E) Section 1396a(a)(72) of this title (relating to limiting FQHC contracting for provision of dental services). (F) Section 1396a(a)(73) of this title (relating to requiring certain States to seek advice from designees of Indian Health Programs and Urban Indian Organizations). (G) Subsections (a)(77) and (kk) of section 1396a of this title (relating to provider and supplier screening, oversight, and reporting requirements) and subsection (a)(83) of section 1396a of this title (relating to searchable directories of the providers described in subsection (mm) of such section). (H) Section 1396a(a)(88) of this title (relating to address information for enrollees and prevention of simultaneous enrollments). (I) Section 1396a(e)(13) of this title (relating to the State option to rely on findi...

(a) In general Subject to the succeeding provisions of this section, a State may elect through an amendment to its State child health plan under section 1397bb of this title to provide pregnancy-related assistance under such plan for targeted low-income pregnant women. (b) Conditions A State may only elect the option under subsection (a) if the following conditions are satisfied: (1) Minimum income eligibility levels for pregnant women and children The State has established an income eligibility level— (A) for pregnant women under subsection (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), or (l)(1)(A) of section 1396a of this title that is at least 185 percent (or such higher percent as the State has in effect with regard to pregnant women under this subchapter) of the poverty line applicable to a family of the size involved, but in no case lower than the percent in effect under any such subsection as of July 1, 2008; and (B) for children under 19 years of age under this subchapter (or subchapter XIX) that is at least 200 percent of the poverty line applicable to a family of the size involved. (2) No CHIP income eligibility level for pregnant women lower than the State’s Medicaid level The State does not apply an effective income level for pregnant women under the State plan amendment that is lower than the effective income level (expressed as a percent of the poverty line and considering applicable income disregards) specified under subsection (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), or (l)(1)(A) of section 1396a of this title, on February 4, 2009, to be eligible for medical assistance as a pregnant woman. (3) No coverage for higher income pregnant women without covering lower income pregnant women The State does not provide coverage for pregnant women with higher family income without covering pregnant women with a lower family income. (4) Application of requirements for coverage of targeted low-income children The State provides pregnancy-related assistance for targeted low-income pregnant women in the same manner, and subject to the same requirements under section 1397cc(c) of this title, as the State provides child health assistance for targeted low-income children under the State child health plan, and in addition to providing child health assistance for such women. (5) No preexisting condition exclusion or waiting period The State does not apply any exclusion of benefits for pregnancy-related assistance based on any preexisting condition or any waiting period (including any waiting period imposed to carry out section 1397bb(b)(3)(C) of this title) for receipt of such assistance. (6) Application of cost-sharing protection The State provides pregnancy-related assistance to a targeted low-income woman consistent with the cost-sharing protections under section 1397cc(e) of this title and applies the limitation on total annual aggregate cost sharing imposed under paragraph (3)(B) of such section to the family of such a woman. (7) No waiting list for children The State does not impose, with respect to the enrollment under the State child health plan of targeted low-income children during the quarter, any enrollment cap or other numerical limitation on enrollment, any waiting list, any procedures designed to delay the consideration of applications for enrollment, or similar limitation with respect to enrollment. (c) Option to provide presumptive eligibility A State that elects the option under subsection (a) and satisfies the conditions described in subsection (b) may elect to apply section 1396r–1 of this title (relating to presumptive eligibility for pregnant women) to the State child health plan in the same manner as such section applies to the State plan under subchapter XIX. (d) Definitions For purposes of this section: (1) Pregnancy-related assistance The term “pregnancy-related assistance” has the meaning given the term “child health assistance” in section 1397jj(a) of this title with respect to an individual during the period ...