42 U.S.C. § 1397kk — Phase-out of coverage for nonpregnant

Page 4505 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1397kk quarter that begins on or after the date that is 24 months after Dec. 29, 2022, see section 5121(d) of Pub. L. 117–328, set out as a note under section 1396a of this title. Amendment by section 5122(b) of Pub. L. 117–328 effec- tive on the first day of the first calendar quarter that begins after the date that is 24 months after Dec. 29, 2022 and applicable to items and services furnished for periods beginning on or after such date, see section 5122(c) of Pub. L. 117–328, set out as a note under section 1396a of this title. EFFECTIVE DATE OF 2018 AMENDMENT Amendment by Pub. L. 115–271 effective with respect to child health assistance provided on or after the date that is 1 year after Oct. 24, 2018, with exception if State legislation required, see section 5022(e) of Pub. L. 115–271, set out as a note under section 1397bb of this title. EFFECTIVE DATE OF 2015 AMENDMENT Amendment by Pub. L. 114–95 effective Dec. 10, 2015, except with respect to certain noncompetitive pro- grams and competitive programs, see section 5 of Pub. L. 114–95, set out as a note under section 6301 of Title 20, Education. EFFECTIVE DATE OF 2010 AMENDMENT Pub. L. 111–148, title II, § 2102(a), Mar. 23, 2010, 124 Stat. 288, provided that the amendment made by sec- tion 2102(a)(7) of Pub. L. 111–148 is effective as if in- cluded in the enactment of the Children’s Health Insur- ance Program Reauthorization Act of 2009 (Pub. L. 111–3). EFFECTIVE DATE OF 2009 AMENDMENT Amendment by Pub. L. 111–3 effective Apr. 1, 2009, and applicable to child health assistance and medical as- sistance provided on or after that date, with certain ex- ceptions, see section 3 of Pub. L. 111–3, set out as an Ef- fective Date note under section 1396 of this title. EFFECTIVE DATE OF 2000 AMENDMENT Amendment by Pub. L. 106–554 effective as if included in the enactment of section 4901 of Pub. L. 105–33, see section 1(a)(6) [title VIII, § 802(f)] of Pub. L. 106–554, set out as a note under section 1396d of this title. EFFECTIVE DATE OF 1997 AMENDMENT Pub. L. 105–100, title I, § 162, Nov. 19, 1997, 111 Stat. 2188, provided in part that the amendment made by that section is effective as if included in the enactment of subtitle J (§§ 4901–4923) of title IV of the Balanced Budget Act of 1997, Pub. L. 105–33. CHIP ELIGIBILITY FOR CHILDREN INELIGIBLE FOR MED- ICAID AS A RESULT OF ELIMINATION OF DISREGARDS Pub. L. 111–148, title II, § 2101(f), Mar. 23, 2010, 124 Stat. 287, provided that: ‘‘Notwithstanding any other provision of law, a State shall treat any child who is determined to be ineligible for medical assistance under the State Medicaid plan or under a waiver of the plan as a result of the elimination of the application of an income disregard based on expense or type of in- come, as required under section 1902(e)(14) of the Social Security Act [42 U.S.C. 1396a(e)(14)] (as added by this Act), as a targeted low-income child under section 2110(b) [42 U.S.C. 1397jj(b)] (unless the child is excluded under paragraph (2) of that section) and shall provide child health assistance to the child under the State child health plan (whether implemented under title XIX or XXI, or both, of the Social Security Act [42 U.S.C. 1396 et seq., 1397aa et seq.]).’’ § 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 exten- sions at State option through 2009 Notwithstanding section 1315 of this title or any other provision of this subchapter, except as provided in this subsection— (A) the Secretary shall not on or after Feb- ruary 4, 2009, approve or renew a waiver, ex- perimental, pilot, or demonstration project that would allow funds made available under this subchapter to be used to provide child health assistance or other health benefits coverage to a nonpregnant childless adult; and (B) notwithstanding the terms and condi- tions of an applicable existing waiver, the provisions of paragraph (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 eli- gible to be covered by the waiver, and the amount of the Federal payment under this subchapter. (2) Termination of CHIP coverage under appli- cable existing waivers at the end of 2009 (A) In general No funds shall be available under this sub- chapter for child health assistance or other health benefits coverage that is provided to a nonpregnant childless adult under an ap- plicable existing waiver after December 31, 2009. (B) Extension upon State request If an applicable existing waiver described in subparagraph (A) would otherwise expire before January 1, 2010, notwithstanding the requirements of subsections (e) and (f) of section 1315 of this title, a State may sub- mit, not later than September 30, 2009, a re- quest to the Secretary for an extension of the waiver. The Secretary shall approve a request for an extension of an applicable ex- isting 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 shall apply to expenditures under an applicable existing waiver for the provision of child health as- sistance or other health benefits coverage to a nonpregnant childless adult during the pe- riod beginning on February 4, 2009, and end- ing on December 31, 2009. (3) State option to apply for Medicaid waiver to continue coverage for nonpregnant childless adults (A) In general Each State for which coverage under an applicable existing waiver is terminated under paragraph (2)(A) may submit, not later than September 30, 2009, an application Page 4506 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1397kk to the Secretary for a waiver under section 1315 of this title of the State plan under sub- chapter XIX to provide medical assistance to a nonpregnant childless adult whose cov- erage is so terminated (in this subsection re- ferred to as a ‘‘Medicaid nonpregnant child- less adults waiver’’). (B) Deadline for approval The Secretary shall make a decision to ap- prove or deny an application for a Medicaid nonpregnant childless adults waiver sub- mitted under subparagraph (A) within 90 days of the date of the submission of the ap- plication. If no decision has been made by the Secretary as of December 31, 2009, on the application of a State for a Medicaid non- pregnant childless adults waiver that was submitted to the Secretary by September 30, 2009, the application shall be deemed ap- proved. (C) Standard for budget neutrality The budget neutrality requirement appli- cable with respect to expenditures for med- ical assistance under a Medicaid nonpreg- nant childless adults waiver shall— (i) in the case of fiscal year 2010, allow expenditures for medical assistance under subchapter XIX for all such adults to not exceed the total amount of payments made to the State under paragraph (2)(B) for fis- cal year 2009, increased by the percentage increase (if any) in the projected nominal per capita amount of National Health Ex- penditures for 2010 over 2009, as most re- cently published by the Secretary; and (ii) in the case of any succeeding fiscal year, allow such expenditures to not ex- ceed the amount in effect under this sub- paragraph for the preceding fiscal year, in- creased 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 cal- endar year, as most recently published by the Secretary. (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 or any other provision of this subchapter, except as provided in this subsection— (i) the Secretary shall not on or after February 4, 2009, approve or renew a waiv- er, experimental, pilot, or demonstration project that would allow funds made avail- able under this subchapter to be used to provide child health assistance or other health benefits coverage to a parent of a targeted low-income child; and (ii) notwithstanding the terms and con- ditions of an applicable existing waiver, the provisions of paragraphs (2) and (3) shall apply for purposes of any fiscal year beginning on or after October 1, 2011, in de- termining the period to which the waiver applies, the individuals eligible to be cov- ered 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) would otherwise expire before October 1, 2011, and the State requests an extension of such waiver, the Secretary shall grant such an extension, but only, sub- ject to paragraph (2)(A), through September 30, 2011. (C) Application of enhanced FMAP The enhanced FMAP determined under section 1397ee(b) of this title shall apply to expenditures under an applicable existing waiver for the provision of child health as- sistance or other health benefits coverage to a parent of a targeted low-income child dur- ing the third and fourth quarters of fiscal year 2009 and during fiscal years 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 that provides child health as- sistance or health benefits coverage under an applicable existing waiver for a parent of a targeted low-income child may elect to continue to provide such assistance or cov- erage through fiscal year 2012 or 2013, subject to the same terms and conditions that ap- plied under the applicable existing waiver, unless otherwise modified in subparagraph (B). (B) Terms and conditions (i) Block grant set aside from State allot- ment If the State makes an election under subparagraph (A), the Secretary shall set aside for the State for each such fiscal year an amount equal to the Federal share of 110 percent of the State’s projected ex- penditures under the applicable existing waiver for providing child health assist- ance or health benefits coverage to all par- ents of targeted low-income children en- rolled under such waiver for the fiscal year (as certified by the State and submitted to the Secretary by not later than August 31 of the preceding fiscal year). In the case of fiscal year 2013, the set aside for any State shall be computed separately for each pe- riod described in subparagraphs (A) and (B) of section 1397dd(a)(16) of this title and any reduction in the allotment for either such period under section 1397dd(m)(5) of this title shall be allocated on a pro rata basis to such set aside. (ii) Payments from block grant The Secretary shall pay the State from the amount set aside under clause (i) for the fiscal year, an amount for each quarter of such fiscal year equal to the applicable percentage determined under clause (iii) or (iv) for expenditures in the quarter for pro- viding child health assistance or other health benefits coverage to a parent of a targeted low-income child. Page 4507 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1397kk (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), the applicable percentage for any quarter of fiscal year 2012 is equal to— (I) the enhanced FMAP determined under section 1397ee(b) of this title in the case of a State that meets the outreach or coverage benchmarks described in any of subparagraph (A), (B), or (C) of para- graph (3) for fiscal year 2011; or (II) the Federal medical assistance per- centage (as determined under section 1396d(b) of this title without regard to clause (4) of such section) in the case of any other State. (iv) Amount of Federal matching payment in 2013 For purposes of clause (ii), the applicable percentage for any quarter of fiscal year 2013 is equal to— (I) the REMAP percentage if— (aa) the applicable percentage for the State under clause (iii) was the en- hanced FMAP for fiscal year 2012; and (bb) the State met either of the cov- erage benchmarks described in sub- paragraph (B) or (C) of paragraph (3) for fiscal year 2012; or (II) the Federal medical assistance per- centage (as so determined) in the case of any State to which subclause (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 for expenditures described in clause (ii) after the total amount set aside under clause (i) for a fiscal year has been paid to the State. (vi) No increase in income eligibility level for parents No payments shall be made to a State from the amount set aside under clause (i) for a fiscal year for expenditures for pro- viding child health assistance or health benefits coverage to a parent of a targeted low-income child whose family income ex- ceeds 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), the outreach or coverage benchmarks described in this paragraph are as follows: (A) Significant child outreach campaign The State— (i) was awarded a grant under section 1397mm of this title for fiscal year 2011; (ii) implemented 1 or more of the enroll- ment and retention provisions described in section 1397ee(a)(4) of this title for such fiscal year; or (iii) has submitted a specific plan for outreach for such fiscal year. (B) High-performing State The State, on the basis of the most timely and accurate published estimates of the Bu- reau of the Census, ranks in the lowest 1⁄3 of States in terms of the State’s percentage of low-income children without health insur- ance. (C) State increasing enrollment of low-in- come children The State qualified for a performance bonus payment under section 1397ee(a)(3)(B) of this title for the most recent fiscal year applicable under such section. (4) Rules of construction Nothing in this subsection shall be con- strued as prohibiting a State from submitting an application to the Secretary for a waiver under section 1315 of this title of the State plan under subchapter XIX to provide medical assistance to a parent of a targeted low-in- come child that was provided child health as- sistance 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 dem- onstration project under section 1315 of this title, 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 or other health bene- fits coverage to— (i) a parent of a targeted low-income child; (ii) a nonpregnant childless adult; or (iii) individuals described in both clauses (i) and (ii); and (B) was in effect during fiscal year 2009. (2) Definitions (A) Parent The term ‘‘parent’’ includes a caretaker relative (as such term is used in carrying out section 1396u–1 of this title) and a legal guardian. (B) Nonpregnant childless adult The term ‘‘nonpregnant childless adult’’ has the meaning given such term by section 1397gg(f) of this title. (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.) Page 4508 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1397ll 1 So in original. The comma probably should not appear. 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. § 1397ll. Optional coverage of targeted low-in- come pregnant women through a State plan amendment (a) In general Subject to the succeeding provisions of this section, a State may elect through an amend- ment to its State child health plan under sec- tion 1397bb of this title to provide pregnancy-re- lated assistance under such plan for targeted low-income pregnant women. (b) Conditions A State may only elect the option under sub- section (a) if the following conditions are satis- fied: (1) Minimum income eligibility levels for preg- nant women and children The State has established an income eligi- bility 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 in- volved, 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 appli- cable to a family of the size involved. (2) No CHIP income eligibility level for preg- nant women lower than the State’s Med- icaid level The State does not apply an effective income level for pregnant women under the State plan amendment that is lower than the effective in- come level (expressed as a percent of the pov- erty 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 preg- nant 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 assist- ance 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 assist- ance 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 wait- ing 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 assist- ance to a targeted low-income woman con- sistent 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 nu- merical limitation on enrollment, any waiting list, any procedures designed to delay the con- sideration of applications for enrollment, or similar limitation with respect to enrollment. (c) Option to provide presumptive eligibility A State that elects the option under sub- section (a) and satisfies the conditions described in subsection (b) may elect to apply section 1396r–1 of this title (relating to presumptive eli- gibility 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 described in paragraph (2)(A). (2) Targeted low-income pregnant woman The term ‘‘targeted low-income pregnant woman’’ means an individual— (A) during pregnancy and through the end of the month in which the 60-day period, or, in the case that subparagraph (A) of section 1396a(e)(16) of this title applies to the State child health plan (or waiver of such plan), pursuant to section 1397gg(e)(1) of this title, the 12-month period,1 (beginning on the last day of her pregnancy) ends;