Healthy Kids One Stop Act - Amends titles XIX (Medicaid) and XXI (State Children's Health Insurance) (SCHIP) of the Social Security Act to give states the option to rely on findings from a public Express Lane agency to conduct simplified eligibility determinations.
Amends SSA title XIX to authorize a federal or state agency or private entity in possession of the sources of data directly relevant for Medicaid eligibility determination (including eligibility files maintained by an Express Lane agency) to convey such information to the state Medicaid agency, if such conveyance meets specified requirements. Prescribes civil and criminal penalties for improper disclosure of such information.
[Congressional Bills 111th Congress]
[From the U.S. Government Printing Office]
[H.R. 542 Introduced in House (IH)]
111th CONGRESS
1st Session
H. R. 542
To amend titles XIX and XXI of the Social Security Act to permit States
to rely on findings from an express plan agency to conduct simplified
eligibility determinations under Medicaid and the State Children's
Health Insurance Program.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
January 14, 2009
Mr. Putnam introduced the following bill; which was referred to the
Committee on Energy and Commerce
_______________________________________________________________________
A BILL
To amend titles XIX and XXI of the Social Security Act to permit States
to rely on findings from an express plan agency to conduct simplified
eligibility determinations under Medicaid and the State Children's
Health Insurance Program.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Healthy Kids One Stop Act''.
SEC. 2. STATE OPTION TO RELY ON FINDINGS FROM AN EXPRESS LANE AGENCY TO
CONDUCT SIMPLIFIED ELIGIBILITY DETERMINATIONS UNDER
MEDICAID AND SCHIP.
(a) Application Under Medicaid and SCHIP.--
(1) Medicaid.--Section 1902(e) of the Social Security Act
(42 U.S.C. 1396a(e)) is amended by adding at the end the
following:
``(13) Express lane option.--
``(A) In general.--
``(i) Option to use a finding from an
express lane agency.--At the option of the
State, the State plan may provide that in
determining eligibility under this title for a
child (as defined in subparagraph (G)), the
State may rely on a finding made within a
reasonable period (as determined by the State)
from an Express Lane agency (as defined in
subparagraph (F)) when it determines whether a
child satisfies one or more components of
eligibility for medical assistance under this
title. The State may rely on a finding from an
Express Lane agency notwithstanding any
differences in budget unit, disregard, deeming,
or other methodology, if the following
requirements are met:
``(I) Prohibition on determining
children ineligible for coverage.--If a
finding from an Express Lane agency
would result in a determination that a
child does not satisfy an eligibility
requirement for medical assistance
under this title and for child health
assistance under title XXI, the State
shall determine eligibility for
assistance using its regular
procedures.
``(II) Notice requirement.--For any
child who is found eligible for medical
assistance under the State plan under
this title or child health assistance
under title XXI and who is subject to
premiums based on an Express Lane
agency's finding of such child's income
level, the State shall provide notice
that the child may qualify for lower
premium payments if evaluated by the
State using its regular policies and of
the procedures for requesting such an
evaluation.
``(III) Compliance with screen and
enroll requirement.--The State shall
satisfy the requirements under
subparagraphs (A) and (B) of section
2102(b)(3) (relating to screen and
enroll) before enrolling a child in
child health assistance under title
XXI. At its option, the State may
fulfill such requirements in accordance
with either option provided under
subparagraph (C) of this paragraph.
``(IV) Coding.--The State meets the
requirements of subparagraph (E).
``(ii) Option to apply to renewals and
redeterminations.--The State may apply the
provisions of this paragraph when conducting
initial determinations of eligibility,
redeterminations of eligibility, or both, as
described in the State plan.
``(B) Rules of construction.--Nothing in this
paragraph shall be construed--
``(i) to limit or prohibit a State from
taking any actions otherwise permitted under
this title or title XXI in determining
eligibility for or enrolling children into
medical assistance under this title or child
health assistance under title XXI;
``(ii) to modify the limitations in section
1902(a)(5) concerning the agencies that may
make a determination of eligibility for medical
assistance under this title; or
``(iii) to modify the application of
sections 1137(d), 1902(a)(46), 1903(i)(22), or
1903(x).
``(C) Options for satisfying the screen and enroll
requirement.--
``(i) In general.--With respect to a child
whose eligibility for medical assistance under
this title or for child health assistance under
title XXI has been evaluated by a State agency
using an income finding from an Express Lane
agency, a State may carry out its duties under
subparagraphs (A) and (B) of section 2102(b)(3)
(relating to screen and enroll) in accordance
with either clause (ii) or clause (iii).
``(ii) Establishing a screening
threshold.--
``(I) In general.--Under this
clause, the State establishes a
screening threshold set as a percentage
of the Federal poverty level that
exceeds the highest income threshold
applicable under this title to the
child by a minimum of 30 percentage
points or, at State option, a higher
number of percentage points that
reflects the value (as determined by
the State and described in the State
plan) of any differences between income
methodologies used by the program
administered by the Express Lane agency
and the methodologies used by the State
in determining eligibility for medical
assistance under this title.
``(II) Children with income not
above threshold.--If the income of a
child does not exceed the screening
threshold, the child is deemed to
satisfy the income eligibility criteria
for medical assistance under this title
regardless of whether such child would
otherwise satisfy such criteria.
``(III) Children with income above
threshold.--If the income of a child
exceeds the screening threshold, the
child shall be considered to have an
income above the Medicaid applicable
income level described in section
2110(b)(4) and to satisfy the
requirement under section 2110(b)(1)(C)
(relating to the requirement that CHIP
matching funds be used only for
children not eligible for Medicaid). If
such a child is enrolled in child
health assistance under title XXI, the
State shall provide the parent,
guardian, or custodial relative with
the following:
``(aa) Notice that the
child may be eligible to
receive medical assistance
under the State plan under this
title if evaluated for such
assistance under the State's
regular procedures and notice
of the process through which a
parent, guardian, or custodial
relative can request that the
State evaluate the child's
eligibility for medical
assistance under this title
using such regular procedures.
``(bb) A description of
differences between the medical
assistance provided under this
title and child health
assistance under title XXI,
including differences in cost-
sharing requirements and
covered benefits.
``(iii) Temporary enrollment in chip
pending screen and enroll.--
``(I) In general.--Under this
clause, a State enrolls a child in
child health assistance under title XXI
for a temporary period if the child
appears eligible for such assistance
based on an income finding by an
Express Lane agency.
``(II) Determination of
eligibility.--During such temporary
enrollment period, the State shall
determine the child's eligibility for
child health assistance under title XXI
or for medical assistance under this
title in accordance with this clause.
``(III) Prompt follow up.--In
making such a determination, the State
shall take prompt action to determine
whether the child should be enrolled in
medical assistance under this title or
child health assistance under title XXI
pursuant to subparagraphs (A) and (B)
of section 2102(b)(3) (relating to
screen and enroll).
``(IV) Requirement for simplified
determination.--In making such a
determination, the State shall use
procedures that, to the maximum
feasible extent, reduce the burden
imposed on the individual of such
determination. Such procedures may not
require the child's parent, guardian,
or custodial relative to provide or
verify information that already has
been provided to the State agency by an
Express Lane agency or another source
of information unless the State agency
has reason to believe the information
is erroneous.
``(V) Availability of chip matching
funds during temporary enrollment
period.--Medical assistance for items
and services that are provided to a
child enrolled in title XXI during a
temporary enrollment period under this
clause shall be treated as child health
assistance under such title.
``(D) Option for automatic enrollment.--
``(i) In general.--The State may initiate
and determine eligibility for medical
assistance under the State Medicaid plan or for
child health assistance under the State CHIP
plan without a program application from, or on
behalf of, the child based on data obtained
from sources other than the child (or the
child's family), but a child can only be
automatically enrolled in the State Medicaid
plan or the State CHIP plan if the child or the
family affirmatively consents to being enrolled
through affirmation and signature on an Express
Lane agency application, if the requirement of
clause (ii) is met.
``(ii) Information requirement.--The
requirement of this clause is that the State
informs the parent, guardian, or custodial
relative of the child of the services that will
be covered, appropriate methods for using such
services, premium or other cost sharing charges
(if any) that apply, medical support
obligations (under section 1912(a)) created by
enrollment (if applicable), and the actions the
parent, guardian, or relative must take to
maintain enrollment and renew coverage.
``(E) Coding; application to enrollment error
rates.--
``(i) In general.--For purposes of
subparagraph (A)(iv), the requirement of this
subparagraph for a State is that the State
agrees to--
``(I) assign such codes as the
Secretary shall require to the children
who are enrolled in the State Medicaid
plan or the State CHIP plan through
reliance on a finding made by an
Express Lane agency for the duration of
the State's election under this
paragraph;
``(II) annually provide the
Secretary with a statistically valid
sample (that is approved by Secretary)
of the children enrolled in such plans
through reliance on such a finding by
conducting a full Medicaid eligibility
review of the children identified for
such sample for purposes of determining
an eligibility error rate (as described
in clause (iv)) with respect to the
enrollment of such children (and shall
not include such children in any data
or samples used for purposes of
complying with a Medicaid Eligibility
Quality Control (MEQC) review or a
payment error rate measurement (PERM)
requirement);
``(III) submit the error rate
determined under subclause (II) to the
Secretary;
``(IV) if such error rate exceeds 3
percent for either of the first 2
fiscal years in which the State elects
to apply this paragraph, demonstrate to
the satisfaction of the Secretary the
specific corrective actions implemented
by the State to improve upon such error
rate; and
``(V) if such error rate exceeds 3
percent for any fiscal year in which
the State elects to apply this
paragraph, a reduction in the amount
otherwise payable to the State under
section 1903(a) for quarters for that
fiscal year, equal to the total amount
of erroneous excess payments determined
for the fiscal year only with respect
to the children included in the sample
for the fiscal year that are in excess
of a 3 percent error rate with respect
to such children.
``(ii) No punitive action based on error
rate.--The Secretary shall not apply the error
rate derived from the sample under clause (i)
to the entire population of children enrolled
in the State Medicaid plan or the State CHIP
plan through reliance on a finding made by an
Express Lane agency, or to the population of
children enrolled in such plans on the basis of
the State's regular procedures for determining
eligibility, or penalize the State on the basis
of such error rate in any manner other than the
reduction of payments provided for under clause
(i)(V).
``(iii) Rule of construction.--Nothing in
this paragraph shall be construed as relieving
a State that elects to apply this paragraph
from being subject to a penalty under section
1903(u), for payments made under the State
Medicaid plan with respect to ineligible
individuals and families that are determined to
exceed the error rate permitted under that
section (as determined without regard to the
error rate determined under clause (i)(II)).
``(iv) Error rate defined.--In this
subparagraph, the term `error rate' means the
rate of erroneous excess payments for medical
assistance (as defined in section
1903(u)(1)(D)) for the period involved, except
that such payments shall be limited to
individuals for which eligibility
determinations are made under this paragraph
and except that in applying this paragraph
under title XXI, there shall be substituted for
references to provisions of this title
corresponding provisions within title XXI.
``(F) Express lane agency.--
``(i) In general.--In this paragraph, the
term `Express Lane agency' means a public
agency that--
``(I) is determined by the State
Medicaid agency or the State CHIP
agency (as applicable) to be capable of
making the determinations of one or
more eligibility requirements described
in subparagraph (A)(i);
``(II) is identified in the State
Medicaid plan or the State CHIP plan;
and
``(III) notifies the child's
family--
``(aa) of the information
which shall be disclosed in
accordance with this paragraph;
``(bb) that the information
disclosed will be used solely
for purposes of determining
eligibility for medical
assistance under the State
Medicaid plan or for child
health assistance under the
State CHIP plan; and
``(cc) that the family may
elect to not have the
information disclosed for such
purposes; and
``(IV) enters into, or is subject
to, an interagency agreement to limit
the disclosure and use of the
information disclosed.
``(ii) Inclusion of specific public
agencies.--Such term includes the following:
``(I) A public agency that
determines eligibility for assistance
under any of the following:
``(aa) The temporary
assistance for needy families
program funded under part A of
title IV.
``(bb) A State program
funded under part D of title
IV.
``(cc) The State Medicaid
plan.
``(dd) The State CHIP plan.
``(ee) The supplemental
nutrition assistance program
under the Food and Nutrition
Act of 2008 (7 U.S.C. 2011 et
seq.).
``(ff) The Head Start Act
(42 U.S.C. 9801 et seq.).
``(gg) The Richard B.
Russell National School Lunch
Act (42 U.S.C. 1751 et seq.).
``(hh) The Child Nutrition
Act of 1966 (42 U.S.C. 1771 et
seq.).
``(ii) The Child Care and
Development Block Grant Act of
1990 (42 U.S.C. 9858 et seq.).
``(jj) The Stewart B.
McKinney Homeless Assistance
Act (42 U.S.C. 11301 et seq.).
``(kk) The United States
Housing Act of 1937 (42 U.S.C.
1437 et seq.).
``(ll) The Native American
Housing Assistance and Self-
Determination Act of 1996 (25
U.S.C. 4101 et seq.).
``(II) A State-specified
governmental agency that has fiscal
liability or legal responsibility for
the accuracy of the eligibility
determination findings relied on by the
State.
``(III) A public agency that is
subject to an interagency agreement
limiting the disclosure and use of the
information disclosed for purposes of
determining eligibility under the State
Medicaid plan or the State CHIP plan.
``(iii) Exclusions.--Such term does not
include an agency that determines eligibility
for a program established under the Social
Services Block Grant established under title XX
or a private, for-profit organization.
``(iv) Rules of construction.--Nothing in
this paragraph shall be construed as--
``(I) exempting a State Medicaid
agency from complying with the
requirements of section 1902(a)(4)
relating to merit-based personnel
standards for employees of the State
Medicaid agency and safeguards against
conflicts of interest); or
``(II) authorizing a State Medicaid
agency that elects to use Express Lane
agencies under this subparagraph to use
the Express Lane option to avoid
complying with such requirements for
purposes of making eligibility
determinations under the State Medicaid
plan.
``(v) Additional definitions.--In this
paragraph:
``(I) State.--The term `State'
means 1 of the 50 States or the
District of Columbia.
``(II) State chip agency.--The term
`State CHIP agency' means the State
agency responsible for administering
the State CHIP plan.
``(III) State chip plan.--The term
`State CHIP plan' means the State child
health plan established under title XXI
and includes any waiver of such plan.
``(IV) State medicaid agency.--The
term `State Medicaid agency' means the
State agency responsible for
administering the State Medicaid plan.
``(V) State medicaid plan.--The
term `State Medicaid plan' means the
State plan established under title XIX
and includes any waiver of such plan.
``(G) Child defined.--For purposes of this
paragraph, the term `child' means an individual under
19 years of age, or, at the option of a State, such
higher age, not to exceed 21 years of age, as the State
may elect.
``(H) Application.--This paragraph shall not apply
to with respect to eligibility determinations made
after September 30, 2014.
``(I) Continued application.--''.
(2) CHIP.--Section 2107(e)(1) of such Act (42 U.S.C.
1397gg(e)(1)) is amended by redesignating subparagraphs (B),
(C), and (D) as subparagraphs (C), (D), and (E), respectively,
and by inserting after subparagraph (A) the following new
subparagraph:
``(B) Section 1902(e)(13) (relating to the State
option to rely on findings from an Express Lane agency
to help evaluate a child's eligibility for medical
assistance).''.
(b) Evaluation and Report.--
(1) Evaluation.--The Secretary shall conduct, by grant,
contract, or interagency agreement, a comprehensive,
independent evaluation of the option provided under the
amendments made by subsection (a). Such evaluation shall
include an analysis of the effectiveness of the option, and
shall include--
(A) obtaining a statistically valid sample of the
children who were enrolled in the State Medicaid plan
or the State CHIP plan through reliance on a finding
made by an Express Lane agency and determining the
percentage of children who were erroneously enrolled in
such plans;
(B) determining whether enrolling children in such
plans through reliance on a finding made by an Express
Lane agency improves the ability of a State to identify
and enroll low-income, uninsured children who are
eligible but not enrolled in such plans;
(C) evaluating the administrative costs or savings
related to identifying and enrolling children in such
plans through reliance on such findings, and the extent
to which such costs differ from the costs that the
State otherwise would have incurred to identify and
enroll low-income, uninsured children who are eligible
but not enrolled in such plans; and
(D) any recommendations for legislative or
administrative changes that would improve the
effectiveness of enrolling children in such plans
through reliance on such findings.
(2) Report to congress.--Not later than September 30, 2013,
the Secretary shall submit a report to Congress on the results
of the evaluation under paragraph (1).
(3) Funding.--
(A) In general.--Out of any funds in the Treasury
not otherwise appropriated, there is appropriated to
the Secretary to carry out the evaluation under this
subsection $5,000,000 for the period of fiscal years
2010 through 2013.
(B) Budget authority.--Subparagraph (A) constitutes
budget authority in advance of appropriations Act and
represents the obligation of the Federal Government to
provide for the payment of such amount to conduct the
evaluation under this subsection.
(c) Electronic Transmission of Information.--Section 1902 of such
Act (42 U.S.C. 1396a) is amended by adding at the end the following new
subsection:
``(dd) Electronic Transmission of Information.--If the State agency
determining eligibility for medical assistance under this title or
child health assistance under title XXI verifies an element of
eligibility based on information from an Express Lane Agency (as
defined in subsection (e)(13)(F)), or from another public agency, then
the applicant's signature under penalty of perjury shall not be
required as to such element. Any signature requirement for an
application for medical assistance may be satisfied through an
electronic signature, as defined in section 1710(1) of the Government
Paperwork Elimination Act (44 U.S.C. 3504 note). The requirements of
subparagraphs (A) and (B) of section 1137(d)(2) may be met through
evidence in digital or electronic form.''.
(d) Authorization of Information Disclosure.--
(1) In general.--Title XIX of the Social Security Act is
amended by adding at the end the following new section:
``SEC. 1942. AUTHORIZATION TO RECEIVE RELEVANT INFORMATION.
``(a) In General.--Notwithstanding any other provision of law, a
Federal or State agency or private entity in possession of the sources
of data directly relevant to eligibility determinations under this
title (including eligibility files maintained by Express Lane agencies
described in section 1902(e)(13)(F), information described in paragraph
(2) or (3) of section 1137(a), vital records information about births
in any State, and information described in sections 453(i) and
1902(a)(25)(I)) is authorized to convey such data or information to the
State agency administering the State plan under this title, to the
extent such conveyance meets the requirements of subsection (b).
``(b) Requirements for Conveyance.--Data or information may be
conveyed pursuant to subsection (a) only if the following requirements
are met:
``(1) The individual whose circumstances are described in
the data or information (or such individual's parent, guardian,
caretaker relative, or authorized representative) has either
provided advance consent to disclosure or has not objected to
disclosure after receiving advance notice of disclosure and a
reasonable opportunity to object.
``(2) Such data or information are used solely for the
purposes of--
``(A) identifying individuals who are eligible or
potentially eligible for medical assistance under this
title and enrolling or attempting to enroll such
individuals in the State plan; and
``(B) verifying the eligibility of individuals for
medical assistance under the State plan.
``(3) An interagency or other agreement, consistent with
standards developed by the Secretary--
``(A) prevents the unauthorized use, disclosure, or
modification of such data and otherwise meets
applicable Federal requirements safeguarding privacy
and data security; and
``(B) requires the State agency administering the
State plan to use the data and information obtained
under this section to seek to enroll individuals in the
plan.
``(c) Penalties for Improper Disclosure.--
``(1) Civil money penalty.--A private entity described in
the subsection (a) that publishes, discloses, or makes known in
any manner, or to any extent not authorized by Federal law, any
information obtained under this section is subject to a civil
money penalty in an amount equal to $10,000 for each such
unauthorized publication or disclosure. The provisions of
section 1128A (other than subsections (a) and (b) and the
second sentence of subsection (f)) shall apply to a civil money
penalty under this paragraph in the same manner as such
provisions apply to a penalty or proceeding under section
1128A(a).
``(2) Criminal penalty.--A private entity described in the
subsection (a) that willfully publishes, discloses, or makes
known in any manner, or to any extent not authorized by Federal
law, any information obtained under this section shall be fined
not more than $10,000 or imprisoned not more than 1 year, or
both, for each such unauthorized publication or disclosure.
``(d) Rule of Construction.--The limitations and requirements that
apply to disclosure pursuant to this section shall not be construed to
prohibit the conveyance or disclosure of data or information otherwise
permitted under Federal law (without regard to this section).''.
(2) Conforming amendment to title xxi.--Section 2107(e)(1)
of such Act (42 U.S.C. 1397gg(e)(1)), as amended by subsection
(a)(2), is amended by adding at the end the following new
subparagraph:
``(F) Section 1942 (relating to authorization to
receive data directly relevant to eligibility
determinations).''.
(3) Conforming amendment to provide access to data about
enrollment in insurance for purposes of evaluating applications
and for chip.--Section 1902(a)(25)(I)(i) of such Act (42 U.S.C.
1396a(a)(25)(I)(i)) is amended--
(A) by inserting ``(and, at State option,
individuals who apply or whose eligibility for medical
assistance is being evaluated in accordance with
section 1902(e)(13)(D))'' after ``with respect to
individuals who are eligible''; and
(B) by inserting ``under this title (and, at State
option, child health assistance under title XXI)''
after ``the State plan''.
(e) Authorization for States Electing Express Lane Option To
Receive Certain Data Directly Relevant to Determining Eligibility and
Correct Amount of Assistance.--The Secretary of Health and Human
Services shall enter into such agreements as are necessary to permit a
State that elects the Express Lane option under section 1902(e)(13) of
the Social Security Act to receive data directly relevant to
eligibility determinations and determining the correct amount of
benefits under a State child health plan under title XXI of the Social
Security Act or a State plan under title XIX of such Act from the
following:
(1) The National Directory of New Hires established under
section 453(i) of the Social Security Act (42 U.S.C. 653(i)).
(2) Data regarding enrollment in insurance that may help to
facilitate outreach and enrollment under the State Medicaid
plan, the State child health plan, and such other programs as
the Secretary may specify.
(f) Effective Date.--The amendments made by this section are
effective on January 1, 2010.
<all>
Introduced in House
Introduced in House
Referred to the House Committee on Energy and Commerce.
Referred to the Subcommittee on Health.
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