42 USC 1397 - Phase-out of coverage for nonpregnant childless adults; conditions for coverage of parents

Collapse to view only § 1397kk. Phase-out of coverage for nonpregnant childless adults; conditions for coverage of parents

§ 1397aa. Purpose; State child health plans
§ 1397bb. General contents of State child health plan; eligibility; outreach
§ 1397cc. Coverage requirements for children’s health insurance
§ 1397dd. Allotments
§ 1397ee. Payments to States
§ 1397ff. Process for submission, approval, and amendment of State child health plans
§ 1397gg. Strategic objectives and performance goals; plan administration
§ 1397hh. Annual reports; evaluations
§ 1397ii. Miscellaneous provisions
§ 1397jj. Definitions
§ 1397kk. Phase-out of coverage for nonpregnant childless adults; conditions for coverage of parents
§ 1397ll. Optional coverage of targeted low-income pregnant women through a State plan amendment
§ 1397mm. Grants to improve outreach and enrollment

§ 1397aa. Purpose; State child health plans

(a) Purpose

The purpose of this subchapter is to provide funds to States to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner that is coordinated with other sources of health benefits coverage for children. Such assistance shall be provided primarily for obtaining health benefits coverage through—

(1) obtaining coverage that meets the requirements of section 1397cc of this title, or

(2) providing benefits under the State’s medicaid plan under subchapter XIX,

or a combination of both.

(b) State child health plan required

A State is not eligible for payment under section 1397ee of this title unless the State has submitted to the Secretary under section 1397ff of this title a plan that—

(1) sets forth how the State intends to use the funds provided under this subchapter to provide child health assistance to needy children consistent with the provisions of this subchapter, and

(2) has been approved under section 1397ff of this title.

(d) Effective date

(Aug. 14, 1935, ch. 531, title XXI, § 2101, as added Pub. L. 105–33, title IV, § 4901(a), Aug. 5, 1997, 111 Stat. 552.)

§ 1397bb. General contents of State child health plan; eligibility; outreach

(a) General background and descriptionA State child health plan shall include a description, consistent with the requirements of this subchapter, of—

(1) the extent to which, and manner in which, children in the State, including targeted low-income children and other classes of children classified by income and other relevant factors, currently have creditable health coverage (as defined in section 1397jj(c)(2) of this title);

(2) current State efforts to provide or obtain creditable health coverage for uncovered children, including the steps the State is taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs and health insurance programs that involve public-private partnerships;

(3) how the plan is designed to be coordinated with such efforts to increase coverage of children under creditable health coverage;

(4) the child health assistance provided under the plan for targeted low-income children, including the proposed methods of delivery, and utilization control systems;

(5) eligibility standards consistent with subsection (b);

(6) outreach activities consistent with subsection (c); and

(7) methods (including monitoring) used—

(A) to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan;

(B) to assure access to covered services, including emergency services and services described in paragraphs (5) and (6) of section 1397cc(c) of this title; and

(C) to ensure that the State agency involved is in compliance with subparagraphs (A), (B), and (C) of section 1320a–7n(b)(2) of this title.

(b) General description of eligibility standards and methodology

(1) Eligibility standards

(A) In general

(B) Limitations on eligibility standardsSuch eligibility standards—

(i) shall, within any defined group of covered targeted low-income children, not cover such children with higher family income without covering children with a lower family income;

(ii) may not deny eligibility based on a child having a preexisting medical condition;

(iii) may not apply a waiting period (including a waiting period to carry out paragraph (3)(C)) in the case of a targeted low-income pregnant woman provided pregnancy-related assistance under section 1397ll of this title;

(iv) at State option, may not apply a waiting period in the case of a child provided dental-only supplemental coverage under section 1397jj(b)(5) of this title; and

(v) shall, beginning January 1, 2014, use modified adjusted gross income and household income (as defined in section 36B(d)(2) of the Internal Revenue Code of 1986) to determine eligibility for child health assistance under the State child health plan or under any waiver of such plan and for any other purpose applicable under the plan or waiver for which a determination of income is required, including with respect to the imposition of premiums and cost-sharing, consistent with section 1396a(e)(14) of this title.

(2) Methodology

(3) Eligibility screening; coordination with other health coverage programsThe plan shall include a description of procedures to be used to ensure—

(A) through both intake and followup screening, that only targeted low-income children are furnished child health assistance under the State child health plan;

(B) that children found through the screening to be eligible for medical assistance under the State medicaid plan under subchapter XIX are enrolled for such assistance under such plan;

(C) that the insurance provided under the State child health plan does not substitute for coverage under group health plans;

(D) the provision of child health assistance to targeted low-income children in the State who are Indians (as defined in section 1603(c) 1

1 See References in Text note below.

of title 25); and

(E) coordination with other public and private programs providing creditable coverage for low-income children.

(4) Reduction of administrative barriers to enrollment

(A) In general

(B) Deemed compliance if joint application and renewal process that permits application other than in person

(5) Nonentitlement

(c) Outreach and coordinationA State child health plan shall include a description of the procedures to be used by the State to accomplish the following:

(1) Outreach

(2) Coordination with other health insurance programs

(3) Premium assistance subsidies

(d) Treatment of children who are inmates of a public institution

(1) In generalThe State child health plan shall provide that—

(A) the State shall not terminate eligibility for child health or pregnancy-related assistance under the State child health plan for a targeted low-income child or targeted low-income pregnant woman because the child or pregnant woman is an inmate of a public institution, but may suspend coverage during the period the child or pregnant woman is such an inmate;

(B) in the case of a targeted low-income child who was determined eligible for child health assistance under the State child health plan (or waiver of such plan) immediately before becoming an inmate of a public institution, the State shall, prior to the child’s release from such public institution, conduct a redetermination of eligibility for such child with respect to such child health assistance (without requiring a new application from the child) and, if the State determines pursuant to such redetermination that the child continues to meet the eligibility requirements for such child health assistance, the State shall restore coverage for such child health assistance to such child upon the child’s release from such public institution; and

(C) in the case of a targeted low-income child who is determined eligible for child health assistance while an inmate of a public institution (subject to the exception to the exclusion of children who are inmates of a public institution described in section 1397jj(b)(7) of this title), the State shall process any application for child health assistance submitted by, or on behalf of, the child such that the State makes a determination of eligibility for the child with respect to child health assistance upon release of the child from the public institution.

(2) Required coverage of screenings, diagnostic services, referrals, and case management for certain inmates pre-release

(Aug. 14, 1935, ch. 531, title XXI, § 2102, as added Pub. L. 105–33, title IV, § 4901(a), Aug. 5, 1997, 111 Stat. 552; amended Pub. L. 111–3, title I, § 111(b)(2), title II, §§ 201(b)(2)(B)(i), 212, title III, § 302(a), title V, § 501(a)(2), (b)(2), Feb. 4, 2009, 123 Stat. 28, 39, 55, 63, 85, 86; Pub. L. 111–148, title II, § 2101(d)(1), Mar. 23, 2010, 124 Stat. 287; Pub. L. 111–152, title I, § 1004(b)(2)(A), Mar. 30, 2010, 124 Stat. 1034; Pub. L. 114–198, title VII, § 706(b)(2), July 22, 2016, 130 Stat. 754; Pub. L. 115–271, title V, § 5022(c), Oct. 24, 2018, 132 Stat. 3964; Pub. L. 117–328, div. FF, title V, § 5121(c)(1), Dec. 29, 2022, 136 Stat. 5942; Pub. L. 118–42, div. G, title I, § 205(b)(1), Mar. 9, 2024, 138 Stat. 406.)

§ 1397cc. Coverage requirements for children’s health insurance

(a) Required scope of health insurance coverageThe child health assistance provided to a targeted low-income child under the plan in the form described in paragraph (1) of section 1397aa(a) of this title shall consist, consistent with paragraphs (5), (6), (7), and (8) of subsection (c), of any of the following:

(1) Benchmark coverage

(2) Benchmark-equivalent coverageHealth benefits coverage that meets the following requirements:

(A) Inclusion of basic services

(B) Aggregate actuarial value equivalent to benchmark package

(3) Existing comprehensive State-based coverage

(4) Secretary-approved coverage

(b) Benchmark benefit packagesThe benchmark benefit packages are as follows:

(1) FEHBP-equivalent children’s health insurance coverage

(2) State employee coverage

(3) Coverage offered through HMOThe health insurance coverage plan that—

(A) is offered by a health maintenance organization (as defined in section 2791(b)(3) of the Public Health Service Act [42 U.S.C. 300gg–91(b)(3)]), and

(B) has the largest insured commercial, non-medicaid enrollment of covered lives of such coverage plans offered by such a health maintenance organization in the State involved.

(1) Categories of basic servicesFor purposes of this section, the categories of basic services described in this paragraph are as follows:

(A) Inpatient and outpatient hospital services.

(B) Physicians’ surgical and medical services.

(D) Well-baby and well-child care, including age-appropriate immunizations.

(E) Mental health and substance use disorder services (as defined in paragraph (5)).

(2) Categories of additional servicesFor purposes of this section, the categories of additional services described in this paragraph are as follows:

(A) Coverage of prescription drugs.

(B) Vision services.

(3) Treatment of other categories

(4) Determination of actuarial valueThe actuarial value of coverage of benchmark benefit packages, coverage offered under the State child health plan, and coverage of any categories of additional services under benchmark benefit packages and under coverage offered by such a plan, shall be set forth in an actuarial opinion in an actuarial report that has been prepared—

(A) by an individual who is a member of the American Academy of Actuaries;

(B) using generally accepted actuarial principles and methodologies;

(D) using a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan;

(E) applying the same principles and factors in comparing the value of different coverage (or categories of services);

(F) without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used; and

(G) taking into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage.

The actuary preparing the opinion shall select and specify in the memorandum the standardized set and population to be used under subparagraphs (C) and (D).

(5) Mental health and substance use disorder servicesRegardless of the type of coverage elected by a State under subsection (a), child health assistance provided under such coverage for targeted low-income children and, in the case that the State elects to provide pregnancy-related assistance under such coverage pursuant to section 1397ll of this title, such pregnancy-related assistance for targeted low-income pregnant women (as defined in section 1397ll(d) of this title) shall—

(A) include coverage of mental health services (including behavioral health treatment) necessary to prevent, diagnose, and treat a broad range of mental health symptoms and disorders, including substance use disorders; and

(B) be delivered in a culturally and linguistically appropriate manner.

(6) Dental benefits

(A) In general

(B) Permitting use of dental benchmark plans by certain States

(i) FEHBP children’s dental coverage

(ii) State employee dependent dental coverage

(iii) Coverage offered through commercial dental plan

(7) Mental health services parity

(A) In general

(B) Deemed compliance

(8) Construction on prohibited coverage

(9) Availability of coverage for items and services furnished through school-based health centers

(10) Certain in vitro diagnostic products for COVID–19 testing

(11) Required coverage of COVID–19 vaccines and treatmentRegardless of the type of coverage elected by a State under subsection (a), the child health assistance provided for a targeted low-income child, and, in the case of a State that elects to provide pregnancy-related assistance pursuant to section 1397ll of this title, the pregnancy-related assistance provided for a targeted low-income pregnant woman (as such terms are defined for purposes of such section), shall include coverage, during the period beginning on March 11, 2021, and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in section 1320b–5(g)(1)(B) of this title, of—

(A) a COVID–19 vaccine (and the administration of the vaccine); and

(B) testing and treatments for COVID–19, including specialized equipment and therapies (including preventive therapies), and, in the case of an individual who is diagnosed with or presumed to have COVID–19, during the period during which such individual has (or is presumed to have) COVID–19, the treatment of a condition that may seriously complicate the treatment of COVID–19, if otherwise covered under the State child health plan (or waiver of such plan).

(12) Required coverage of approved, recommended adult vaccines and their administration.

(d) Description of existing comprehensive State-based coverage

(1) In generalA program described in this paragraph is a child health coverage program that—

(A) includes coverage of a range of benefits;

(B) is administered or overseen by the State and receives funds from the State;

(D) was offered as of August 5, 1997.

(2) ModificationsA State may modify a program described in paragraph (1) from time to time so long as it continues to meet the requirement of subparagraph (A) and does not reduce the actuarial value of the coverage under the program below the lower of—

(A) the actuarial value of the coverage under the program as of August 5, 1997, or

(B) the actuarial value described in subsection (a)(2)(B),

evaluated as of the time of the modification.

(e) Cost-sharing

(1) Description; general conditions

(A) Description

(B) Protection for lower income children

(2) No cost sharing on benefits for preventive services, COVID–19 testing, a COVID–19 vaccine, COVID–19 treatment, or pregnancy-related assistance

(3) Limitations on premiums and cost-sharing

(A) Children in families with income below 150 percent of poverty lineIn the case of a targeted low-income child whose family income is at or below 150 percent of the poverty line, the State child health plan may not impose—

(i) an enrollment fee, premium, or similar charge that exceeds the maximum monthly charge permitted consistent with standards established to carry out section 1396o(b)(1) of this title (with respect to individuals described in such section); and

(ii) a deductible, cost sharing, or similar charge that exceeds an amount that is nominal (as determined consistent with regulations referred to in section 1396o(a)(3) of this title, with such appropriate adjustment for inflation or other reasons as the Secretary determines to be reasonable).

(B) Other children

(i) shall afford individuals enrolled under the plan a grace period of at least 30 days from the beginning of a new coverage period to make premium payments before the individual’s coverage under the plan may be terminated; and

(ii) shall provide to such an individual, not later than 7 days after the first day of such grace period, notice—(I) that failure to make a premium payment within the grace period will result in termination of coverage under the State child health plan; and(II) of the individual’s right to challenge the proposed termination pursuant to the applicable Federal regulations.

For purposes of clause (i), the term “new coverage period” means the month immediately following the last month for which the premium has been paid.

(4) Relation to medicaid requirements

(f) Application of certain requirements

(1) Restriction on application of preexisting condition exclusions

(A) In general

(B) Group health plans and group health insurance coverage

(2) Compliance with other requirements

(3) Compliance with managed care requirements

(Aug. 14, 1935, ch. 531, title XXI, § 2103, as added Pub. L. 105–33, title IV, § 4901(a), Aug. 5, 1997, 111 Stat. 554; amended Pub. L. 111–3, title I, § 111(b)(1), title IV, § 403(a), title V, §§ 501(a)(1), 502, 504(a), 505(a), Feb. 4, 2009, 123 Stat. 28, 84, 89, 90; Pub. L. 115–271, title V, § 5022(a)–(b)(2)(A), (d), Oct. 24, 2018, 132 Stat. 3964, 3965; Pub. L. 116–127, div. F, § 6004(b)(1), (3), Mar. 18, 2020, 134 Stat. 206; Pub. L. 116–260, div. BB, title II, § 203(a)(4)(C), Dec. 27, 2020, 134 Stat. 2917; Pub. L. 117–2, title IX, § 9821(a), Mar. 11, 2021,

§ 1397dd. Allotments

(a) Appropriation; total allotmentFor the purpose of providing allotments to States under this section, subject to subsection (d), there is appropriated, out of any money in the Treasury not otherwise appropriated—

(1) for fiscal year 1998, $4,295,000,000;

(2) for fiscal year 1999, $4,275,000,000;

(3) for fiscal year 2000, $4,275,000,000;

(4) for fiscal year 2001, $4,275,000,000;

(5) for fiscal year 2002, $3,150,000,000;

(6) for fiscal year 2003, $3,150,000,000;

(7) for fiscal year 2004, $3,150,000,000;

(8) for fiscal year 2005, $4,050,000,000;

(9) for fiscal year 2006, $4,050,000,000;

(10) for fiscal year 2007, $5,000,000,000;

(11) for fiscal year 2008, $5,000,000,000.1

1 So in original. The period probably should be a semicolon.

(12) for fiscal year 2009, $10,562,000,000;

(13) for fiscal year 2010, $12,520,000,000;

(14) for fiscal year 2011, $13,459,000,000;

(15) for fiscal year 2012, $14,982,000,000;

(16) for fiscal year 2013, $17,406,000,000;

(17) for fiscal year 2014, $19,147,000,000;

(18) for fiscal year 2015, for purposes of making 2 semi-annual allotments—

(A) $2,850,000,000 for the period beginning on October 1, 2014, and ending on March 31, 2015, and

(B) $2,850,000,000 for the period beginning on April 1, 2015, and ending on September 30, 2015;

(19) for fiscal year 2016, $19,300,000,000;

(20) for fiscal year 2017, for purposes of making 2 semi-annual allotments—

(A) $2,850,000,000 for the period beginning on October 1, 2016, and ending on March 31, 2017; and

(B) $2,850,000,000 for the period beginning on April 1, 2017, and ending on September 30, 2017;

(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;

(25) for fiscal year 2022, $25,900,000,000;

(26) for fiscal year 2023, for purposes of making two semi-annual allotments—

(A) $2,850,000,000 for the period beginning on October 1, 2022, and ending on March 31, 2023; and

(B) $2,850,000,000 for the period beginning on April 1, 2023, and ending on September 30, 2023;

(27) for each of fiscal years 2024 through 2028, such sums as are necessary to fund allotments to States under subsections (c) and (m); and

(28) for fiscal year 2029, for purposes of making two semi-annual allotments—

(A) $7,650,000,000 for the period beginning on October 1, 2028, and ending on March 31, 2029; and

(B) $7,650,000,000 for the period beginning on April 1, 2029, and ending on September 30, 2029.

(b) Allotments to 50 States and District of Columbia

(1) In generalSubject to paragraph (4) and subsections (d) and (m), of the amount available for allotment under subsection (a) for a fiscal year, reduced by the amount of allotments made under subsection (c) (determined without regard to paragraph (4) thereof) for the fiscal year, the Secretary shall allot to each State (other than a State described in such subsection) with a State child health plan approved under this subchapter the same proportion as the ratio of—

(A) the product of (i) the number of children described in paragraph (2) for the State for the fiscal year and (ii) the State cost factor for that State (established under paragraph (3)); to

(B) the sum of the products computed under subparagraph (A).

(2) Number of children

(A) In generalThe number of children described in this paragraph for a State for—

(i) each of fiscal years 1998 and 1999 is equal to the number of low-income children in the State with no health insurance coverage for the fiscal year;

(ii) fiscal year 2000 is equal to—(I) 75 percent of the number of low-income children in the State for the fiscal year with no health insurance coverage, plus(II) 25 percent of the number of low-income children in the State for the fiscal year; and

(iii) each succeeding fiscal year is equal to—(I) 50 percent of the number of low-income children in the State for the fiscal year with no health insurance coverage, plus(II) 50 percent of the number of low-income children in the State for the fiscal year.

(B) Determination of number of children

(3) Adjustment for geographic variations in health costs

(A) In generalFor purposes of paragraph (1)(A)(ii), the “State cost factor” for a State for a fiscal year equal to the sum of—

(i) 0.15, and

(ii) 0.85 multiplied by the ratio of—(I) the annual average wages per employee for the State for such year (as determined under subparagraph (B)), to(II) the annual average wages per employee for the 50 States and the District of Columbia.

(B) Annual average wages per employee

(4) Floors and ceilings in State allotments

(A) In generalThe proportion of the allotment under this subsection for a subsection (b) State (as defined in subparagraph (D)) for fiscal year 2000 and each fiscal year thereafter shall be subject to the following floors and ceilings:

(i) Floor of $2,000,000

(ii) Annual floor of 10 percent below preceding fiscal year’s proportion

(iii) Cumulative floor of 30 percent below the FY 1999 proportion

(iv) Cumulative ceiling of 45 percent above FY 1999 proportion

(B) Reconciliation

(i) Elimination of any deficit by establishing a percentage increase ceiling for States with highest annual percentage increases

(ii) Allocation of surplus through pro rata increase

(D) DefinitionsIn this paragraph:

(i) Proportion of allotment

(ii) Subsection (b) State

(1) In general

(2) PercentageThe percentage specified in this paragraph for—

(A) Puerto Rico is 91.6 percent,

(B) Guam is 3.5 percent,

(D) American Samoa is 1.2 percent, and

(E) the Northern Mariana Islands is 1.1 percent.

(3) Commonwealths and territoriesA commonwealth or territory described in this paragraph is any of the following if it has a State child health plan approved under this subchapter:

(A) Puerto Rico.

(B) Guam.

(D) American Samoa.

(E) The Northern Mariana Islands.

(4) Additional allotment

(A) In general

(B) Appropriations

(d) Additional allotments to eliminate funding shortfalls

(1) Appropriation; allotment authority

(2) Shortfall States describedFor purposes of paragraph (1), a shortfall State described in this paragraph is a State with a State child health plan approved under this subchapter for which the Secretary estimates, on the basis of the most recent data available to the Secretary as of December 16, 2005, that the projected expenditures under such plan for such State for fiscal year 2006 will exceed the sum of—

(A) the amount of the State’s allotments for each of fiscal years 2004 and 2005 that will not be expended by the end of fiscal year 2005;

(B) the amount, if any, that is to be redistributed to the State during fiscal year 2006 in accordance with subsection (f); and

(3) AllotmentsIn addition to the allotments provided under subsections (b) and (c), subject to paragraph (4), of the amount available for the additional allotments under paragraph (1) for fiscal year 2006, the Secretary shall allot—

(A) to each shortfall State described in paragraph (2) such amount as the Secretary determines will eliminate the estimated shortfall described in such paragraph for the State; and

(B) to each commonwealth or territory described in subsection (c)(3), the same proportion as the proportion of the commonwealth’s or territory’s allotment under subsection (c) (determined without regard to subsection (f)) to 1.05 percent of the amount appropriated under paragraph (1).

(4) Use of additional allotment

(5) 1-year availability; no redistribution of unexpended additional allotments

(e) Availability of amounts allotted

(1) In generalExcept as provided in paragraph (2), amounts allotted to a State pursuant to this section—

(A) for each of fiscal years 1998 through 2008, shall remain available for expenditure by the State through the end of the second succeeding fiscal year; and

(B) for fiscal year 2009 and each fiscal year thereafter, shall remain available for expenditure by the State through the end of the succeeding fiscal year.

(2) Availability of amounts redistributed

(f) Procedure for redistribution of unused allotments

(1) In general

(2) Shortfall States described

(A) In generalFor purposes of paragraph (1), with respect to a fiscal year, a shortfall State described in this subparagraph is a State with a State child health plan approved under this subchapter for which the Secretary estimates on the basis of the most recent data available to the Secretary, that the projected expenditures under such plan for the State for the fiscal year will exceed the sum of—

(i) the amount of the State’s allotments for any preceding fiscal years that remains available for expenditure and that will not be expended by the end of the immediately preceding fiscal year;

(ii) the amount (if any) of the child enrollment contingency fund 2

2 So in original. Probably should be “Child Enrollment Contingency Fund”.

payment under subsection (n); and

(iii) the amount of the State’s allotment for the fiscal year.

(B) Determination of redistributed amounts if insufficient amounts available

(i) Proration rule

(ii) Special rule for first half of fiscal year 2018(I) In general(II) Emergency shortfall State defined(III) Funds redistributed in the order in which States realize funding shortfalls(IV) Proration rule(V) Unobligated redistributed funds(VI) Application of qualifying State optionDuring the period described in subclause (I), section 1397ee(g)(4) of this title, as in effect on the day before January 22, 2018, shall apply to a qualifying State (as defined in section 1397ee(g)(2) of this title) as if under section 1397ee(g)(4) of this title, as so in effect—(aa) the reference to “2017” were a reference to “2018”; and(bb) the reference to “under subsections (e) and (m) of such section” were a reference to “under subsections (e), (f), and (m) of such section”.

(D) Rule of construction

(g) Rule for redistribution and extended availability of fiscal years 1998, 1999, 2000, and 2001 allotments

(1) Amount redistributed

(A) In generalIn the case of a State that expends all of its allotment under subsection (b) or (c) for fiscal year 1998 by the end of fiscal year 2000, or for fiscal year 1999 by the end of fiscal year 2001, or for fiscal year 2000 by the end of fiscal year 2002, or for fiscal year 2001 by the end of fiscal year 2003, the Secretary shall redistribute to the State under subsection (f) (from the fiscal year 1998, 1999, 2000, or 2001 allotments of other States, respectively, as determined by the application of paragraphs (2) and (3) with respect to the respective fiscal year) the following amount:

(i) StateIn the case of one of the 50 States or the District of Columbia, with respect to—(I) the fiscal year 1998 allotment, the amount by which the State’s expenditures under this subchapter in fiscal years 1998, 1999, and 2000 exceed the State’s allotment for fiscal year 1998 under subsection (b);(II) the fiscal year 1999 allotment, the amount by which the State’s expenditures under this subchapter in fiscal years 1999, 2000, and 2001 exceed the State’s allotment for fiscal year 1999 under subsection (b);(III) the fiscal year 2000 allotment, the amount specified in subparagraph (C)(i) (less the total of the amounts under clause (ii) for such fiscal year), multiplied by the ratio of the amount specified in subparagraph (C)(ii) for the State to the amount specified in subparagraph (C)(iii); or(IV) the fiscal year 2001 allotment, the amount specified in subparagraph (D)(i) (less the total of the amounts under clause (ii) for such fiscal year), multiplied by the ratio of the amount specified in subparagraph (D)(ii) for the State to the amount specified in subparagraph (D)(iii).

(ii) Territory

(B) Expenditure rulesAn amount redistributed to a State under this paragraph—

(i) shall not be included in the determination of the State’s allotment for any fiscal year under this section;

(ii) notwithstanding subsection (e), with respect to fiscal year 1998, 1999, or 2000, shall remain available for expenditure by the State through the end of fiscal year 2004;

(iii) notwithstanding subsection (e), with respect to fiscal year 2001, shall remain available for expenditure by the State through the end of fiscal year 2005; and

(iv) shall be counted as being expended with respect to a fiscal year allotment in accordance with applicable regulations of the Secretary.

(i) the amount specified in this clause is the amount specified in paragraph (2)(B)(i)(I) for fiscal year 2000, less the total amount remaining available pursuant to paragraph (2)(A)(iii);

(ii) the amount specified in this clause for a State is the amount by which the State’s expenditures under this subchapter in fiscal years 2000, 2001, and 2002 exceed the State’s allotment for fiscal year 2000 under subsection (b); and

(iii) the amount specified in this clause is the sum, for all States entitled to a redistribution under subparagraph (A) from the allotments for fiscal year 2000, of the amounts specified in clause (ii).

(D) Amounts used in computing redistributions for fiscal year 2001For purposes of subparagraph (A)(i)(IV)—

(i) the amount specified in this clause is the amount specified in paragraph (2)(B)(i)(I) for fiscal year 2001, less the total amount remaining available pursuant to paragraph (2)(A)(iv);

(ii) the amount specified in this clause for a State is the amount by which the State’s expenditures under this subchapter in fiscal years 2001, 2002, and 2003 exceed the State’s allotment for fiscal year 2001 under subsection (b); and

(iii) the amount specified in this clause is the sum, for all States entitled to a redistribution under subparagraph (A) from the allotments for fiscal year 2001, of the amounts specified in clause (ii).

(2) Extension of availability of portion of unexpended fiscal years 1998 through 2001 allotments

(A) In generalNotwithstanding subsection (e):

(i) Fiscal year 1998 allotment

(ii) Fiscal year 1999 allotment

(iii) Fiscal year 2000 allotment

(iv) Fiscal year 2001 allotment

(B) Amount remaining available for expenditureThe amount specified in this subparagraph for a State for a fiscal year is equal to—

(i) the amount by which (I) the total amount available for redistribution under subsection (f) from the allotments for that fiscal year, exceeds (II) the total amounts redistributed under paragraph (1) for that fiscal year; multiplied by

(ii) the ratio of the amount of such State’s unexpended allotment for that fiscal year to the total amount described in clause (i)(I) for that fiscal year.

(3) Determination of amounts

(h) Special rules to address fiscal year 2007 shortfalls

(1) Redistribution of unused fiscal year 2004 allotments

(A) In general

(B) Shortfall State describedFor purposes of this paragraph, a shortfall State described in this subparagraph is a State with a State child health plan approved under this subchapter for which the Secretary estimates, on a monthly basis using the most recent data available to the Secretary as of such month, that the projected expenditures under such plan for such State for fiscal year 2007 will exceed the sum of—

(i) the amount of the State’s allotments for each of fiscal years 2005 and 2006 that was not expended by the end of fiscal year 2006; and

(ii) the amount of the State’s allotment for fiscal year 2007.

(D) Proration rule

(2) Funding part of shortfall for fiscal year 2007 through redistribution of certain unused fiscal year 2005 allotments

(A) In general

(B) Shortfall State describedFor purposes of this paragraph, a shortfall State described in this subparagraph is a State with a State child health plan approved under this subchapter for which the Secretary estimates, on a monthly basis using the most recent data available to the Secretary as of March 31, 2007, that the projected expenditures under such plan for such State for fiscal year 2007 will exceed the sum of—

(i) the amount of the State’s allotments for each of fiscal years 2005 and 2006 that was not expended by the end of fiscal year 2006;

(ii) the amount, if any, that is to be redistributed to the State in accordance with paragraph (1); and

(iii) the amount of the State’s allotment for fiscal year 2007.

(D) Proration rule

(3) Treatment of certain States with fiscal year 2005 allotments unexpended at the end of the first half of fiscal year 2007

(A) Identification of StatesThe Secretary, on the basis of the most recent data available to the Secretary as of March 31, 2007—

(i) shall identify those States that received an allotment for fiscal year 2005 under subsection (b) which have not expended all of such allotment by March 31, 2007; and

(ii) for each such State shall estimate—(I) the portion of such allotment that was not so expended by such date; and(II) whether the State is described in subparagraph (B).

(B) States with funds in excess of 200 percent of need

(i) In general

(ii) Applicable amountFor purposes of clause (i), the applicable amount described in this clause is the lesser of—(I) 50 percent of the amount described in subparagraph (A)(ii)(I); or(II) $20,000,000.

(4) Additional amounts to eliminate remainder of fiscal year 2007 funding shortfalls

(A) In general

(B) Remaining shortfall State describedFor purposes of subparagraph (A), a remaining shortfall State is a State with a State child health plan approved under this subchapter for which the Secretary estimates, on the basis of the most recent data available to the Secretary as of May 25, 2007, that the projected Federal expenditures under such plan for the State for fiscal year 2007 will exceed the sum of—

(i) the amount of the State’s allotments for each of fiscal years 2005 and 2006 that will not be expended by the end of fiscal year 2006;

(ii) the amount of the State’s allotment for fiscal year 2007; and

(iii) the amounts, if any, that are to be redistributed to the State during fiscal year 2007 in accordance with paragraphs (1) and (2).

(5) Retrospective adjustment

(A) In general

(B) Funding of any retrospective adjustments only from unexpended 2005 allotments

(i) authorizing the Secretary to use the allotments for fiscal year 2006 or 2007 under subsection (b) of States described in paragraph (3)(B) to provide additional amounts to States described in paragraph (2)(B) for purposes of eliminating the funding shortfall for such States for fiscal year 2007; or

(ii) limiting the authority of the Secretary to redistribute the allotments for fiscal year 2005 under subsection (b) that remain unexpended through the end of fiscal year 2007 and are available for redistribution under subsection (f) after the application of subparagraph (B).

(6) 1-year availability; no further redistribution

(7) Definition of State

(i) Redistribution of unused fiscal year 2005 allotments to States with estimated funding shortfalls for fiscal year 2008

(1) In general

(2) Fiscal year 2008 shortfall State describedA fiscal year 2008 shortfall State described in this paragraph is a State with a State child health plan approved under this subchapter for which the Secretary estimates, on a monthly basis using the most recent data available to the Secretary as of such month, that the projected expenditures under such plan for such State for fiscal year 2008 will exceed the sum of—

(A) the amount of the State’s allotments for each of fiscal years 2006 and 2007 that was not expended by the end of fiscal year 2007; and

(B) the amount of the State’s allotment for fiscal year 2008.

(3) Funds redistributed in the order in which States realize funding shortfalls

(4) Proration rule

(5) Retrospective adjustment

(6) 1–year availability; no further redistribution

(j) Additional allotments to eliminate funding shortfalls for fiscal year 2008

(1) Appropriation; allotment authority

(2) Shortfall States describedFor purposes of paragraph (3), a shortfall State described in this paragraph is a State with a State child health plan approved under this subchapter for which the Secretary estimates, on the basis of the most recent data available to the Secretary as of November 30, 2007, that the Federal share amount of the projected expenditures under such plan for such State for fiscal year 2008 will exceed the sum of—

(A) the amount of the State’s allotments for each of fiscal years 2006 and 2007 that will not be expended by the end of fiscal year 2007;

(B) the amount, if any, that is to be redistributed to the State during fiscal year 2008 in accordance with subsection (i); and

(A) to each shortfall State described in paragraph (2) not described in subparagraph (B), such amount as the Secretary determines will eliminate the estimated shortfall described in such paragraph for the State; and

(B) to each commonwealth or territory described in subsection (c)(3), an amount equal to the percentage specified in subsection (c)(2) for the commonwealth or territory multiplied by 1.05 percent of the sum of the amounts determined for each shortfall State under subparagraph (A).

(4) Proration rule

(5) Retrospective adjustment

(6) One-year availability; no redistribution of unexpended additional allotments

(k) Redistribution of unused fiscal year 2006 allotments to States with estimated funding shortfalls during fiscal year 2009

(1) In general

(2) Fiscal year 2009 shortfall State describedA fiscal year 2009 shortfall State described in this paragraph is a State with a State child health plan approved under this subchapter for which the Secretary estimates, on a monthly basis using the most recent data available to the Secretary as of such month, that the Federal share amount of the projected expenditures under such plan for such State for the first 2 quarters of fiscal year 2009 will exceed the sum of—

(A) the amount of the State’s allotments for each of fiscal years 2007 and 2008 that was not expended by the end of fiscal year 2008; and

(B) the amount of the State’s allotment for fiscal year 2009.

(3) Funds redistributed in the order in which States realize funding shortfalls

(4) Proration rule

(5) Retrospective adjustment

(6) Availability; no further redistribution

(l) Additional allotments to eliminate funding shortfalls for the first 2 quarters of fiscal year 2009

(1) Appropriation; allotment authority

(2) Shortfall States describedFor purposes of paragraph (3), a shortfall State described in this paragraph is a State with a State child health plan approved under this subchapter for which the Secretary estimates, on the basis of the most recent data available to the Secretary, that the Federal share amount of the projected expenditures under such plan for such State for the first 2 quarters of fiscal year 2009 will exceed the sum of—

(A) the amount of the State’s allotments for each of fiscal years 2007 and 2008 that will not be expended by the end of fiscal year 2008;

(B) the amount, if any, that is to be redistributed to the State during fiscal year 2009 in accordance with subsection (k); and

(A) to each shortfall State described in paragraph (2) not described in subparagraph (B) such amount as the Secretary determines will eliminate the estimated shortfall described in such paragraph for the State; and

(4) Proration rule

(5) Retrospective adjustment

(6) Availability; no redistribution of unexpended additional allotments

(m) Allotments for fiscal years 2009 and thereafter

(1) For fiscal year 2009

(A) For the 50 States and the District of ColumbiaSubject to the succeeding provisions of this paragraph and paragraph (5), the Secretary shall allot for fiscal year 2009 from the amount made available under subsection (a)(12), to each of the 50 States and the District of Columbia 110 percent of the highest of the following amounts for such State or District:

(i) The total Federal payments to the State under this subchapter for fiscal year 2008, multiplied by the allotment increase factor determined under paragraph (6) for fiscal year 2009.

(ii) The amount allotted to the State for fiscal year 2008 under subsection (b), multiplied by the allotment increase factor determined under paragraph (6) for fiscal year 2009.

(iii) The projected total Federal payments to the State under this subchapter for fiscal year 2009, as determined on the basis of the February 2009 projections certified by the State to the Secretary by not later than March 31, 2009.

(B) For the commonwealths and territories

(2) For fiscal years beginning with fiscal year 2010

(A) In generalSubject to paragraphs (4) and (6),5

5 See References in Text note below.

from the amount made available under paragraphs (13) through (15) of subsection (a) for each of fiscal years 2010 through 2012, respectively, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for each such fiscal year as follows:

(i) Growth factor update for fiscal year 2010For fiscal year 2010, the allotment of the State is equal to the sum of—(I) the amount of the State allotment under paragraph (1) for fiscal year 2009; and(II) the amount of any payments made to the State under subsection (k), (l), or (n) for fiscal year 2009,

multiplied by the allotment increase factor under paragraph (6) for fiscal year 2010.

(ii) Rebasing in fiscal year 2011

(iii) Growth factor update for fiscal year 2012For fiscal year 2012, the allotment of the State is equal to the sum of—(I) the amount of the State allotment under clause (ii) for fiscal year 2011; and(II) the amount of any payments made to the State under subsection (n) for fiscal year 2011,

multiplied by the allotment increase factor under paragraph (6) for fiscal year 2012.

(B) Fiscal year 2013 and each succeeding fiscal yearSubject to paragraphs (5), (7), and (12), from the amount made available under paragraphs (16) through (27) of subsection (a) for fiscal year 2013 and each succeeding fiscal year, respectively, the Secretary shall compute a State allotment for each State (including the District of Columbia and each commonwealth and territory) for each such fiscal year as follows:

(i) Rebasing in fiscal year 2013 and each succeeding odd-numbered fiscal year

(ii) Growth factor update for fiscal year 2014 and each succeeding even-numbered fiscal yearExcept as provided in clauses (iii) and (iv), for fiscal year 2014 and each succeeding even-numbered fiscal year, the allotment of the State is equal to the sum of—(I) the amount of the State allotment under clause (i) (or, in the case of fiscal year 2018 or 2024, under paragraph (4) or (10), respectively) for the preceding fiscal year; and(II) the amount of any payments made to the State under subsection (n) for such preceding fiscal year,

multiplied by the allotment increase factor under paragraph (6) for such even-numbered fiscal year.

(iii) Special rule for 2016

(iv) Reduction in 2018

(3) For fiscal year 2015

(A) First half

(B) Second halfSubject to paragraphs (5) and (7), from the amount made available under subparagraph (B) of paragraph (18) of subsection (a) for the semi-annual period described in such paragraph, 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.

(D) First half ratioThe first half ratio described in this subparagraph is the ratio of—

(i) the sum of—(I) the amount made available under subsection (a)(18)(A); and(II) the amount of the appropriation for such period under section 108 of the Children’s Health Insurance Program Reauthorization Act of 2009; to

(ii) the sum of the 3 —(I) amount described in clause (i); and(II) the 3 amount made available under subsection (a)(18)(B).

(4) For fiscal year 2017

(A) First half

(B) Second halfSubject to paragraphs (5) and (7), from the amount made available under subparagraph (B) of paragraph (20) of subsection (a) for the semi-annual period described in such paragraph, 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.

(D) First half ratioThe first half ratio described in this subparagraph is the ratio of—

(i) the sum of—(I) the amount made available under subsection (a)(20)(A); and(II) the amount of the appropriation for such period under section 301(b)(3) of the Medicare Access and CHIP Reauthorization Act of 2015; to

(ii) the sum of the 3 —(I) amount described in clause (i); and(II) the 3 amount made available under subsection (a)(20)(B).

(5) Proration rule

(6) Allotment increase factorThe allotment increase factor under this paragraph for a fiscal year is equal to the product of the following:

(A) Per capita health care growth factor

(B) Child population growth factor

(7) Increase in allotment to account for approved program expansionsIn the case of one of the 50 States or the District of Columbia that—

(A) has submitted to the Secretary, and has approved by the Secretary, a State plan amendment or waiver request relating to an expansion of eligibility for children or benefits under this subchapter that becomes effective for a fiscal year (beginning with fiscal year 2010 and ending with fiscal year 2029); and

(B) has submitted to the Secretary, before the August 31 preceding the beginning of the fiscal year (or, in the case of fiscal year 2018, by not later than the date that is 60 days after January 22, 2018), a request for an expansion allotment adjustment under this paragraph for such fiscal year that specifies—

(i) the additional expenditures that are attributable to the eligibility or benefit expansion provided under the amendment or waiver described in subparagraph (A), as certified by the State and submitted to the Secretary by not later than August 31 preceding the beginning of the fiscal year; and

(ii) the extent to which such additional expenditures are projected to exceed the allotment of the State or District for the year,

subject to paragraph (5), the amount of the allotment of the State or District under this subsection for such fiscal year shall be increased by the excess amount described in subparagraph (B)(i). A State or District may only obtain an increase under this paragraph for an allotment for fiscal year 2010, fiscal year 2012, fiscal year 2014, fiscal year 2016, fiscal year 2018, fiscal year 2020, fiscal year 2022, fiscal year 2024, fiscal year 2026, or fiscal year 2028.

(8) Adjustment of fiscal year 2010 allotments to account for changes in projected spending for certain previously approved expansion programs

(9) Availability of amounts for semi-annual periods in certain fiscal years

(10) For fiscal year 2023

(A) First half

(B) Second half.—Subject to paragraphs (5) and (7), from the amount made available under subparagraph (B) of paragraph (26) 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.

(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)(26)(A); and(II) the amount of the appropriation for such period under section 3002(b)(2) 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)(26)(B).

(11) For fiscal year 2029

(A) First half

(B) Second halfSubject to paragraphs (5) and (7), from the amount made available under subparagraph (B) of paragraph (28) 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.

(D) First half ratioThe first half ratio described in this subparagraph is the ratio of—

(i) the sum of—(I) the amount made available under subsection (a)(28)(A); and(II) the amount of the appropriation for such period under section 50101(b)(2) of the Advancing Chronic Care, Extenders, and Social Services Act; to

(ii) the sum of—(I) the amount described in clause (i); and(II) the amount made available under subsection (a)(28)(B).

(12) Adjusting allotments to account for increased Federal payments for coverage and administration of COVID–19 vaccinesIf a State, commonwealth, or territory receives payment for a fiscal year (beginning with fiscal year 2021) under subsection (a) of section 1397ee of this title for expenditures that are subject to the enhanced FMAP specified under subsection (c)(12) of such section, the amount of the allotment determined for the State, commonwealth, or territory under this subsection—

(A) for such fiscal year shall be increased by the projected expenditures for such year by the State, commonwealth, or territory under the State child health plan (or a waiver of such plan) for vaccines described in section 1396d(a)(4)(E) of this title (and the administration of such vaccines); and

(B) once actual expenditures are available in the subsequent fiscal year, the fiscal year allotment that was adjusted by the amount described in subparagraph (A) shall be adjusted on the basis of the difference between—

(i) such projected amount of expenditures described in subparagraph (A) for such fiscal year described in such subparagraph by the State, commonwealth, or territory; and

(ii) the actual amount of expenditures for such fiscal year described in subparagraph (A) by the State, commonwealth, or territory under the State child health plan (or waiver of such plan) for vaccines described in section 1396d(a)(4)(E) of this title (and the administration of such vaccines).

(n) Child Enrollment Contingency Fund

(1) Establishment

(2) Deposits into Fund

(A) Initial and subsequent appropriationsSubject to subparagraphs (B) and (D), out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated to the Fund—

(i) for fiscal year 2009, an amount equal to 20 percent of the amount made available under paragraph (12) of subsection (a) for the fiscal year; and

(ii) for each of fiscal years 2010 through 2014, 2016, 2018 through 2022, and 2024 through 2028 (and for each of the semi-annual allotment periods for fiscal years 2015, 2017, 2023, and 2029), such sums as are necessary for making payments to eligible States for such fiscal year or period, but not in excess of the aggregate cap described in subparagraph (B).

(B) Aggregate cap

(D) Availability of excess funds for performance bonuses

(3) Child Enrollment Contingency Fund payments

(A) In generalIf a State’s expenditures under this subchapter in any of fiscal years 2009 through 2014, fiscal year 2016, fiscal years 2018 through 2022, or fiscal years 2024 through 2028 (or a semi-annual allotment period for fiscal year 2015, 2017, 2023, or 2027), exceed the total amount of allotments available under this section to the State in the fiscal year or period (determined without regard to any redistribution it receives under subsection (f) that is available for expenditure during such fiscal year or period, but including any carryover from a previous fiscal year) and if the average monthly unduplicated number of children enrolled under the State plan under this subchapter (including children receiving health care coverage through funds under this subchapter pursuant to a waiver under section 1315 of this title) during such fiscal year or period exceeds its target average number of such enrollees (as determined under subparagraph (B)) for that fiscal year or period, subject to subparagraph (D), the Secretary shall pay to the State from the Fund an amount equal to the product of—

(i) the amount by which such average monthly caseload exceeds such target number of enrollees; and

(ii) the projected per capita expenditures under the State child health plan (as determined under subparagraph (C) for the fiscal year), multiplied by the enhanced FMAP (as defined in section 1397ee(b) of this title) for the State and fiscal year involved (or in which the period occurs).

(B) Target average number of child enrolleesIn this paragraph, the target average number of child enrollees for a State—

(i) for fiscal year 2009 is equal to the monthly average unduplicated number of children enrolled in the State child health plan under this subchapter (including such children receiving health care coverage through funds under this subchapter pursuant to a waiver under section 1315 of this title) during fiscal year 2008 increased by the population growth for children in that State for the year ending on June 30, 2007 (as estimated by the Bureau of the Census) plus 1 percentage point; or

(ii) for a subsequent fiscal year (or semi-annual period occurring in a fiscal year) is equal to the target average number of child enrollees for the State for the previous fiscal year increased by the child population growth factor described in subsection (m)(6)(B) for the State for the prior fiscal year.

(C) Projected per capita expendituresFor purposes of subparagraph (A)(ii), the projected per capita expenditures under a State child health plan—

(i) for fiscal year 2009 is equal to the average per capita expenditures (including both State and Federal financial participation) under such plan for the targeted low-income children counted in the average monthly caseload for purposes of this paragraph during fiscal year 2008, increased by the annual percentage increase in the projected per capita amount of National Health Expenditures (as estimated by the Secretary) for 2009; or

(ii) for a subsequent fiscal year (or semi-annual period occurring in a fiscal year) is equal to the projected per capita expenditures under such plan for the previous fiscal year (as determined under clause (i) or this clause) increased by the annual percentage increase in the projected per capita amount of National Health Expenditures (as estimated by the Secretary) for the year in which such subsequent fiscal year ends.

(D) Proration rule

(E) Timely payment; reconciliation

(F) Continued reporting

(G) Application to commonwealths and territories

(Aug. 14, 1935, ch. 531, title XXI, § 2104, as added Pub. L. 105–33, title IV, § 4901(a), Aug. 5, 1997, 111 Stat. 558; amended Pub. L. 105–100, title I, § 162(6), (8), Nov. 19, 1997, 111 Stat. 2189, 2190; Pub. L. 105–277, div. A, § 101(f) [title VII, § 706], Oct. 21, 1998, 112 Stat. 2681–337, 2681–389; Pub. L. 106–113, div. B, § 1000(a)(6) [title VII, §§ 701(a), 702, 705(a)], Nov. 29, 1999, 113 Stat. 1536, 1501A–399, 1501A–400, 1501A–402; Pub. L. 106–554, § 1(a)(6) [title VIII, §§ 801(a), 802(b), (d)(3)], Dec. 21, 2000, 114 Stat. 2763, 2763A–578, 2763A–581; Pub. L. 108–74, § 1(a)(1)–(3), Aug. 15, 2003, 117 Stat. 892, 893; Pub. L. 108–173, title IX, § 900(e)(1)(M), Dec. 8, 2003, 117 Stat. 2372; Pub. L. 109–171, title VI, § 6101(a), (b), Feb. 8, 2006, 120 Stat. 130, 131; Pub. L. 109–482, title II, § 201(a), Jan. 15, 2007, 120 Stat. 3698; Pub. L. 110–28, title VII, § 7001, May 25, 2007, 121 Stat. 186; Pub. L. 110–92, § 136(c), Sept. 29, 2007, 121 Stat. 994; Pub. L. 110–173, title II, § 201(a)(1), (c)(1), Dec. 29, 2007, 121 Stat. 2509, 2510; Pub. L. 111–3, title I, §§ 101–103, 105, 106(a)(1), (b), Feb. 4, 2009, 123 Stat. 11, 15, 23, 24; Pub. L. 111–148, title II, § 2102(a)(1), title X, § 10203(d)(1)–(2)(B), Mar. 23, 2010, 124 Stat. 288, 928–930; Pub. L. 114–10, title III, § 301(a)–(b)(2)(C), (d)(1), Apr. 16, 2015, 129 Stat. 154–158; Pub. L. 115–90, div. B, § 201, Dec. 8, 2017, 131 Stat. 1280; Pub. L. 115–96, div. C, title II, § 3201(a)–(b)(2), (c)(1), Dec. 22, 2017, 131 Stat. 2050, 2051; Pub. L. 115–120, div. C, § 3002(a)(1), (b)(1), (c), (d)(2), Jan. 22, 2018, 132 Stat. 31–34; Pub. L. 115–123, div. E, title I, § 50101(a), (b)(1), (c), Feb. 9, 2018, 132 Stat. 172, 174; Pub. L. 117–2, title IX, § 9821(c), Mar. 11, 2021, 135 Stat. 220; Pub. L. 117–328, div. FF, title V, § 5111(a), (b)(1), (c)(5), Dec. 29, 2022, 136 Stat. 5938, 5939.)

§ 1397ee. Payments to States

(a) Payments

(1) In generalSubject to the succeeding provisions of this section, the Secretary shall pay to each State with a plan approved under this subchapter, from its allotment under section 1397dd of this title, an amount for each quarter equal to the enhanced FMAP (or, in the case of expenditures described in subparagraph (D)(iv), the higher of 75 percent or the sum of the enhanced FMAP plus 5 percentage points) of expenditures in the quarter—

(A) for child health assistance under the plan for targeted low-income children in the form of providing medical assistance for which payment is made on the basis of an enhanced FMAP under the fourth sentence of section 1396d(b) of this title;

(B)

(C) for child health assistance under the plan for targeted low-income children in the form of providing health benefits coverage that meets the requirements of section 1397cc of this title; and

(D) only to the extent permitted consistent with subsection (c)—

(i) for payment for other child health assistance for targeted low-income children;

(ii) for expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children);

(iii) for expenditures for outreach activities as provided in section 1397bb(c)(1) of this title under the plan;

(iv) for translation or interpretation services in connection with the enrollment of, retention of, and use of services under this subchapter by, individuals for whom English is not their primary language (as found necessary by the Secretary for the proper and efficient administration of the State plan); and

(v) for other reasonable costs incurred by the State to administer the plan.

(2) Order of paymentsPayments under paragraph (1) from a State’s allotment shall be made in the following order:

(A) First, for expenditures for items described in paragraph (1)(A).

(B) Second, for expenditures for items described in paragraph (1)(B).

(D) Fourth, for expenditures for items described in paragraph (1)(D).

(3) Performance bonus payment to offset additional Medicaid and CHIP child enrollment costs resulting from enrollment and retention efforts

(A) In general

(B) Amount for above baseline Medicaid child enrollment costsSubject to subparagraph (E), the amount described in this subparagraph for a State for a fiscal year is equal to the sum of the following amounts:

(i) First tier above baseline Medicaid enrollees

(ii) Second tier above baseline Medicaid enrollees

(C) Number of first and second tier above baseline child enrollees; baseline number of child enrolleesFor purposes of this paragraph:

(i) First tier above baseline child enrolleesThe number of first tier above baseline child enrollees for a State for a fiscal year under subchapter XIX is equal to the number (if any, as determined by the Secretary) by which—(I) the monthly average unduplicated number of qualifying children (as defined in subparagraph (F)) enrolled during the fiscal year under the State plan under subchapter XIX; exceeds(II) the baseline number of enrollees described in clause (iii) for the State and fiscal year under subchapter XIX;

but not to exceed 10 percent of the baseline number of enrollees described in subclause (II).

(ii) Second tier above baseline child enrolleesThe number of second tier above baseline child enrollees for a State for a fiscal year under subchapter XIX is equal to the number (if any, as determined by the Secretary) by which—(I) the monthly average unduplicated number of qualifying children (as defined in subparagraph (F)) enrolled during the fiscal year under subchapter XIX as described in clause (i)(I); exceeds(II) the sum of the baseline number of child enrollees described in clause (iii) for the State and fiscal year under subchapter XIX, as described in clause (i)(II), and the maximum number of first tier above baseline child enrollees for the State and fiscal year under subchapter XIX, as determined under clause (i).

(iii) Baseline number of child enrolleesSubject to subparagraph (H), the baseline number of child enrollees for a State under subchapter XIX—(I) for fiscal year 2009 is equal to the monthly average unduplicated number of qualifying children enrolled in the State plan under subchapter XIX during fiscal year 2007 increased by the population growth for children in that State from 2007 to 2008 (as estimated by the Bureau of the Census) plus 4 percentage points, and further increased by the population growth for children in that State from 2008 to 2009 (as estimated by the Bureau of the Census) plus 4 percentage points;(II) for each of fiscal years 2010, 2011, and 2012, is equal to the baseline number of child enrollees for the State for the previous fiscal year under subchapter XIX, increased by the population growth for children in that State from the calendar year in which the respective fiscal year begins to the succeeding calendar year (as estimated by the Bureau of the Census) plus 3.5 percentage points;(III) for each of fiscal years 2013, 2014, and 2015, is equal to the baseline number of child enrollees for the State for the previous fiscal year under subchapter XIX, increased by the population growth for children in that State from the calendar year in which the respective fiscal year begins to the succeeding calendar year (as estimated by the Bureau of the Census) plus 3 percentage points; and(IV) for a subsequent fiscal year is equal to the baseline number of child enrollees for the State for the previous fiscal year under subchapter XIX, increased by the population growth for children in that State from the calendar year in which the fiscal year involved begins to the succeeding calendar year (as estimated by the Bureau of the Census) plus 2 percentage points.

(D) Projected per capita State Medicaid expenditures

(E) Amounts available for payments

(i) Initial appropriation

(ii) TransfersNotwithstanding any other provision of this subchapter, the following amounts shall also be available, without fiscal year limitation, for making payments under this paragraph:(I) Unobligated national allotment(aa) Fiscal years 2009 through 2012(bb) First half of fiscal year 2013(cc) Second half of fiscal year 2013(II) Unexpended allotments not used for redistribution(III) Excess child enrollment contingency funds

(iii) Proportional reduction

(F) Qualifying children defined

(i) In general

(ii) Limitation

(iii) Exclusion

(G) Application to commonwealths and territories

(H) Application to States that implement a Medicaid expansion for children after fiscal year 2008In the case of a State that provides coverage under section 115 of the Children’s Health Insurance Program Reauthorization Act of 2009 for any fiscal year after fiscal year 2008—

(i) any child enrolled in the State plan under subchapter XIX through the application of such an election shall be disregarded from the determination for the State of the monthly average unduplicated number of qualifying children enrolled in such plan during the first 3 fiscal years in which such an election is in effect; and

(ii) in determining the baseline number of child enrollees for the State for any fiscal year subsequent to such first 3 fiscal years, the baseline number of child enrollees for the State under subchapter XIX for the third of such fiscal years shall be the monthly average unduplicated number of qualifying children enrolled in the State plan under subchapter XIX for such third fiscal year.

(4) Enrollment and retention provisions for childrenFor purposes of paragraph (3)(A), a State meets the condition of this paragraph for a fiscal year if it is implementing at least 5 of the following enrollment and retention provisions (treating each subparagraph as a separate enrollment and retention provision) throughout the entire fiscal year:

(A) Continuous eligibility

(B) Liberalization of asset requirementsThe State meets the requirement specified in either of the following clauses:

(i) Elimination of asset test

(ii) Administrative verification of assetsThe State—(I) permits a parent or caretaker relative who is applying on behalf of a child for medical assistance under subchapter XIX or child health assistance under this subchapter to declare and certify by signature under penalty of perjury information relating to family assets for purposes of determining and redetermining financial eligibility; and(II) takes steps to verify assets through means other than by requiring documentation from parents and applicants except in individual cases of discrepancies or where otherwise justified.

(D) Use of joint application for Medicaid and CHIP

(E) Automatic renewal (use of administrative renewal)

(i) In general

(ii) Satisfaction through demonstrated use of ex parte process

(F) Presumptive eligibility for children

(G) Express Lane

(H) Premium assistance subsidies

(b) Enhanced FMAP

(1) General limitations

(2) Limitation on expenditures not used for medicaid or health insurance assistance

(A) In general

(B) Waiver authorized for cost-effective alternativeThe limitation under subparagraph (A) on expenditures for items described in subsection (a)(1)(D) shall not apply to the extent that a State establishes to the satisfaction of the Secretary that—

(i) coverage provided to targeted low-income children through such expenditures meets the requirements of section 1397cc of this title;

(ii) the cost of such coverage is not greater, on an average per child basis, than the cost of coverage that would otherwise be provided under section 1397cc of this title; and

(iii) such coverage is provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 254b of this title or with hospitals such as those that receive disproportionate share payment adjustments under section 1395ww(d)(5)(F) or 1396r–4 of this title.

(C) Nonapplication to certain expendituresThe limitation under subparagraph (A) shall not apply with respect to the following expenditures:

(i) Expenditures to increase outreach to, and the enrollment of, Indian children under this subchapter and subchapter XIX

(ii) Expenditures to comply with citizenship or nationality verification requirements

(iii) Expenditures for outreach to increase the enrollment of children under this subchapter and subchapter XIX through premium assistance subsidies

(iv) Payment error rate measurement (PERM) expenditures

(3) Waiver for purchase of family coveragePayment may be made to a State under subsection (a)(1) for the purchase of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children only if the State establishes to the satisfaction of the Secretary that—

(A) purchase of such coverage is cost-effective relative to—

(i) the amount of expenditures under the State child health plan, including administrative expenditures, that the State would have made to provide comparable coverage of the targeted low-income child involved or the family involved (as applicable); or

(ii) the aggregate amount of expenditures that the State would have made under the State child health plan, including administrative expenditures, for providing coverage under such plan for all such children or families; and

(B) such coverage shall not be provided if it would otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage.

(4) Use of non-Federal funds for State matching requirement

(5) Offset of receipts attributable to premiums and other cost-sharing

(6) Prevention of duplicative payments

(A) Other health plans

(B) Other Federal governmental programs

(7) Limitation on payment for abortions

(A) In general

(B) Exception

(8) Limitation on matching rate for expenditures for child health assistance provided to children whose effective family income exceeds 300 percent of the poverty line

(A) FMAP applied to expenditures

(B) Exception

(9) Citizenship documentation requirements

(A) In general

(B) Enhanced payments

(10) State option to offer premium assistance

(A) In general

(B) Qualified employer-sponsored coverage

(i) In generalSubject to clause (ii), in this paragraph, the term “qualified employer-sponsored coverage” means a group health plan or health insurance coverage offered through an employer—(I) that qualifies as creditable coverage as a group health plan under section 2701(c)(1) of the Public Health Service Act; 3(II) for which the employer contribution toward any premium for such coverage is at least 40 percent; and(III) that is offered to all individuals in a manner that would be considered a nondiscriminatory eligibility classification for purposes of paragraph (3)(A)(ii) of section 105(h) of the Internal Revenue Code of 1986 (but determined without regard to clause (i) of subparagraph (B) of such paragraph).

(ii) ExceptionSuch term does not include coverage consisting of—(I) benefits provided under a health flexible spending arrangement (as defined in section 106(c)(2) of the Internal Revenue Code of 1986); or(II) a high deductible health plan (as defined in section 223(c)(2) of such Code), without regard to whether the plan is purchased in conjunction with a health savings account (as defined under section 223(d) of such Code).

(i) In general

(ii) State payment option

(iii) Employer opt-out

(iv) Treatment as child health assistance

(D) Application of secondary payor rules

(E) Requirement to provide supplemental coverage for benefits and cost-sharing protection provided under the State child health plan

(i) In generalNotwithstanding section 1397jj(b)(1)(C) of this title, the State shall provide for each targeted low-income child enrolled in qualified employer-sponsored coverage, supplemental coverage consisting of—(I) items or services that are not covered, or are only partially covered, under the qualified employer-sponsored coverage; and(II) cost-sharing protection consistent with section 1397cc(e) of this title.

(ii) Record keeping requirements

(F) Application of waiting period imposed under the State

(G) Opt-out permitted for any month

(H) Application to parentsIf a State provides child health assistance or health benefits coverage to parents of a targeted low-income child in accordance with section 1397kk(b) of this title, the State may elect to offer a premium assistance subsidy to a parent of a targeted low-income child who is eligible for such a subsidy under this paragraph in the same manner as the State offers such a subsidy for the enrollment of the child in qualified employer-sponsored coverage, except that—

(i) the amount of the premium assistance subsidy shall be increased to take into account the cost of the enrollment of the parent in the qualified employer-sponsored coverage or, at the option of the State if the State determines it cost-effective, the cost of the enrollment of the child’s family in such coverage; and

(ii) any reference in this paragraph to a child is deemed to include a reference to the parent or, if applicable under clause (i), the family of the child.

(I) Additional State option for providing premium assistance

(i) In general

(ii) Access to choice of coverage

(iii) Clarification of payment for administrative expenditures

(J) No effect on premium assistance waiver programs

(K) Notice of availabilityIf a State elects to provide premium assistance subsidies in accordance with this paragraph, the State shall—

(i) include on any application or enrollment form for child health assistance a notice of the availability of premium assistance subsidies for the enrollment of targeted low-income children in qualified employer-sponsored coverage;

(ii) provide, as part of the application and enrollment process under the State child health plan, information describing the availability of such subsidies and how to elect to obtain such a subsidy; and

(iii) establish such other procedures as the State determines necessary to ensure that parents are fully informed of the choices for receiving child health assistance under the State child health plan or through the receipt of premium assistance subsidies.

(L) Application to qualified employer-sponsored benchmark coverage

(M) Coordination with medicaid

(11) Enhanced payments

(12) Temporary enhanced payment for coverage and administration of COVID–19 vaccines

(d) Maintenance of effort

(1) In medicaid eligibility standards

(2) In amounts of payment expended for certain State-funded health insurance programs for children

(A) In generalThe amount of the allotment for a State in a fiscal year (beginning with fiscal year 1999) shall be reduced by the amount by which—

(i) the total of the State children’s health insurance expenditures in the preceding fiscal year, is less than

(ii) the total of such expenditures in fiscal year 1996.

(B) State children’s health insurance expendituresThe term “State children’s health insurance expenditures” means the following:

(i) The State share of expenditures under this subchapter.

(ii) The State share of expenditures under subchapter XIX that are attributable to an enhanced FMAP under the fourth sentence of section 1396d(b) of this title.

(iii) State expenditures under health benefits coverage under an existing comprehensive State-based program, described in section 1397cc(d) of this title.

(3) Continuation of eligibility standards for children through September 30, 2029

(A) In generalDuring the period that begins on March 23, 2010, and ends on September 30, 2029, as a condition of receiving payments under section 1396b(a) of this title, a State shall not have in effect eligibility standards, methodologies, or procedures under its State child health plan (including any waiver under such plan) for children (including children provided medical assistance for which payment is made under section 1397ee(a)(1)(A) of this title) that are more restrictive than the eligibility standards, methodologies, or procedures, respectively, under such plan (or waiver) as in effect on March 23, 2010. During the period that begins on October 1, 2019, and ends on September 30, 2029, 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 1397jj(c)(5) of this title) applicable to a family of the size involved. The preceding sentences shall not be construed as preventing a State during any such periods from—

(i) applying eligibility standards, methodologies, or procedures for children under the State child health plan or under any waiver of the plan that are less restrictive than the eligibility standards, methodologies, or procedures, respectively, for children under the plan or waiver that are in effect on March 23, 2010;

(ii) after September 30, 2015, enrolling children eligible to be targeted low-income children under the State child health plan in a qualified health plan that has been certified by the Secretary under subparagraph (C); or

(iii) imposing a limitation described in section 1397ll(b)(7) of this title for a fiscal year in order to limit expenditures under the State child health plan to those for which Federal financial participation is available under this section for the fiscal year.

(B) Assurance of exchange coverage for targeted low-income children unable to be provided child health assistance as a result of funding shortfalls

(e) Advance payment; retrospective adjustment

(f) Flexibility in submittal of claims

(g) Authority for qualifying States to use certain funds for medicaid expenditures

(1) State option

(A) In general

(B) Payments to States

(i) In general

(ii) Expenditures described

(iii) No impact on determination of budget neutrality for waivers

(2) Qualifying State

(3) Construction

(4) Option for allotments for fiscal years 2009 through 2029

(A) Payment of enhanced portion of matching rate for certain expenditures

(B) Expenditures described

(Aug. 14, 1935, ch. 531, title XXI, § 2105, as added Pub. L. 105–33, title IV, § 4901(a), Aug. 5, 1997, 111 Stat. 560; amended Pub. L. 105–100, title I, § 162(5), (7), Nov. 19, 1997, 111 Stat. 2189, 2190; Pub. L. 106–113, div. B, § 1000(a)(6) [title VII, § 705(b)], Nov. 29, 1999, 113 Stat. 1536, 1501A–402; Pub. L. 106–554, § 1(a)(6) [title VIII, § 802(a), (d)(4), (e)], Dec. 21, 2000, 114 Stat. 2763, 2763A–580 to 2763A–582; Pub. L. 108–74, § 1(b), Aug. 15, 2003, 117 Stat. 895; Pub. L. 108–127, § 1, Nov. 17, 2003, 117 Stat. 1354; Pub. L. 109–171, title VI, §§ 6102(b), 6103(a), Feb. 8, 2006, 120 Stat. 131, 132; Pub. L. 109–482, title II, § 201(b), Jan. 15, 2007, 120 Stat. 3701; Pub. L. 110–92, § 136(d), Sept. 29, 2007, 121 Stat. 995; Pub. L. 110–173, title II, § 201(b)(1), Dec. 29, 2007, 121 Stat. 2509; Pub. L. 111–3, title I, §§ 104, 107(a), 113(a), 114(a), title II, §§ 201(b)(1), 202(b), 211(c), title III, §§ 301(a)(1), (2)(A), 302(b), title VI, § 601(a), Feb. 4, 2009, 123 Stat. 17, 24, 34, 39, 40, 54, 57, 61, 63, 96; Pub. L. 111–148, title II, §§ 2101(a)–(c), 2102(a)(3)–(5), title X, §§ 10201(g), 10203(b)(3), (4), (c), (d)(2)(C), Mar. 23, 2010, 124 Stat. 286–288, 922, 927, 928, 930; Pub. L. 114–10, title III, § 301(c), Apr. 16, 2015, 129 Stat. 158; Pub. L. 115–120, div. C, §§ 3002(d)(1), (f)(1), 3005, Jan. 22, 2018, 132 Stat. 34, 37; Pub. L. 115–123, div. E, title I, § 50101(d), (f)(1), Feb. 9, 2018, 132 Stat. 174; Pub. L. 116–117, § 3(b)(3), Mar. 2, 2020, 134 Stat. 134; Pub. L. 117–2, title IX, § 9821(b), Mar. 11, 2021, 135 Stat. 219; Pub. L. 117–328, div. FF, title V, § 5111(c)(2), (3), Dec. 29, 2022, 136 Stat. 5939.)

§ 1397ff. Process for submission, approval, and amendment of State child health plans

(a) Initial plan

(1) In general

(2) Approval

Except as the Secretary may provide under subsection (e), a State plan submitted under paragraph (1)—

(A) shall be approved for purposes of this subchapter, and

(B) shall be effective beginning with a calendar quarter that is specified in the plan, but in no case earlier than October 1, 1997.

(b) Plan amendments

(1) In general

(2) Approval

Except as the Secretary may provide under subsection (e), an amendment to a State plan submitted under paragraph (1)—

(A) shall be approved for purposes of this subchapter, and

(B) shall be effective as provided in paragraph (3).

(3) Effective dates for amendments

(A) In general

(B) Amendments relating to eligibility or benefits

(i) Notice requirement

(ii) Timely transmittal

(1) Prompt review of plan submittals

(2) 90-day approval deadlines

(3) Correction

(d) Program operation

(1) In general

(2) Violations

(e) Continued approval

(Aug. 14, 1935, ch. 531, title XXI, § 2106, as added Pub. L. 105–33, title IV, § 4901(a), Aug. 5, 1997, 111 Stat. 563.)

§ 1397gg. Strategic objectives and performance goals; plan administration

(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

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

(3) Performance goals

(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

(2) State assessment and study

(3) Audits

(d) Program budget

(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).

(H)Section 1396a(e)(13) of this title (relating to the State option to rely on findings from an Express Lane agency to help evaluate a child’s eligibility for medical assistance).

(I)Section 1396a(e)(14) of this title (relating to income determined using modified adjusted gross income and household income).

(J) Paragraphs (5) and (16) of section 1396a(e) of this title (relating to the State option to provide medical assistance consisting of full benefits during pregnancy and throughout the 12-month postpartum period under subchapter XIX),1

1 So in original. There are two closing parentheses for the opening parenthesis preceding “relating”.

if the State provides child health assistance for targeted low-income children who are pregnant or to targeted low-income pregnant women and the State has elected to apply such paragraph (16) with respect to pregnant women under subchapter XIX, the provision of assistance under the State child health plan or waiver for targeted low-income children or targeted low-income pregnant women during pregnancy and the 12-month postpartum period shall be required and not at the option of the State and shall include coverage of all items or services provided to a targeted low-income child or targeted low-income pregnant woman (as applicable) under the State child health plan or waiver).1

(K)Section 1396a(e)(12) of this title (relating to 1 year of continuous eligibility for children), except that a targeted low-income child enrolled under the State child health plan or waiver may be transferred to the Medicaid program under subchapter XIX for the remaining duration of the 12-month continuous eligibility period, if the child becomes eligible for full benefits under subchapter XIX during such period.

(L)Section 1396a(bb) of this title (relating to payment for services provided by Federally-qualified health centers and rural health clinics).

(M)Section 1396a(ff) of this title (relating to disregard of certain property for purposes of making eligibility determinations).

(N) Paragraphs (2), (16), and (17) of section 1396b(i) of this title (relating to limitations on payment).

(O)Section 1396b(m)(3) of this title (relating to limitation on payment with respect to managed care).

(P) Paragraph (4) of section 1396b(v) of this title (relating to optional coverage of categories of lawfully residing immigrant children or pregnant women), but only if the State has elected to apply such paragraph with respect to such category of children or pregnant women under subchapter XIX.

(Q)Section 1396b(w) of this title (relating to limitations on provider taxes and donations).

(R)Section 1396r–1a of this title (relating to presumptive eligibility for children).

(S) Subsections (a)(2)(C) (relating to Indian enrollment), (d)(5) (relating to contract requirement for managed care entities), (d)(6) (relating to enrollment of providers participating with a managed care entity), and (h) (relating to special rules with respect to Indian enrollees, Indian health care providers, and Indian managed care entities) of section 1396u–2 of this title.

(T)Section 1396w–2 of this title (relating to authorization to receive data directly relevant to eligibility determinations).

(U)Section 1396w–3(b) of this title (relating to coordination with State Exchanges and the State Medicaid agency).

(2) Subchapter XI provisions

(A)Section 1315 of this title (relating to waiver authority).

(B)Section 1316 of this title (relating to administrative and judicial review), but only insofar as consistent with this subchapter.

(C)Section 1320a–3 of this title (relating to disclosure of ownership and related information).

(D)Section 1320a–5 of this title (relating to disclosure of information about certain convicted individuals).

(E)Section 1320a–7a of this title (relating to civil monetary penalties).

(F)Section 1320a–7b(d) of this title (relating to criminal penalties for certain additional charges).

(G)Section 1320b–2 of this title (relating to periods within which claims must be filed).

(f) Limitation of waiver authority

Notwithstanding subsection (e)(2)(A) and section 1315(a) of this title:

(1) The Secretary may not approve a waiver, experimental, 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 or a parent (as defined in section 1397kk(c)(2)(A) of this title), who is not pregnant, of a targeted low-income child.

(2) The Secretary may not approve, extend, renew, or amend a waiver, experimental, pilot, or demonstration project with respect to a State after February 4, 2009, that would waive or modify the requirements of section 1397kk of this title.

(g) Use of blended risk pools

(1) In general

(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 subchapter XIX or child health assistance under this subchapter 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 subchapter (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.

(Aug. 14, 1935, ch. 531, title XXI, § 2107, as added Pub. L. 105–33, title IV, § 4901(a), Aug. 5, 1997, 111 Stat. 565; amended Pub. L. 106–554, § 1(a)(6) [title VIII, § 803], Dec. 21, 2000, 114 Stat. 2763, 2763A–582; Pub. L. 109–171, title VI, § 6102(a), Feb. 8, 2006, 120 Stat. 131; Pub. L. 111–3, title I, § 112(a)(2)(A), title II, §§ 203(a)(2), (d)(2), 214(b), title V, §§ 501(d)(2), 503(a)(1), Feb. 4, 2009, 123 Stat. 33, 46, 49, 57, 87, 89; Pub. L. 111–5, div. B, title V, § 5006(b)(2), (d)(2), (e)(2)(B), Feb. 17, 2009, 123 Stat. 506, 510; Pub. L. 111–148, title II, § 2101(d)(2), (e), title VI, § 6401(c), Mar. 23, 2010, 124 Stat. 287, 753; Pub. L. 111–152, title I, § 1004(b)(2)(B), Mar. 30, 2010, 124 Stat. 1034; Pub. L. 111–309, title II, § 205(f)(2), Dec. 15, 2010, 124 Stat. 3291; Pub. L. 114–255, div. A, title V, § 5005(c)(1), Dec. 13, 2016, 130 Stat. 1194; Pub. L. 115–120, div. C, § 3002(g)(1), Jan. 22, 2018, 132 Stat. 35; Pub. L. 115–123, div. E, title XII, § 53102(d)(1), Feb. 9, 2018, 132 Stat. 299; Pub. L. 117–2, title IX, § 9822(a)(1), Mar. 11, 2021, 135 Stat. 220; Pub. L. 117–328, div. FF, title V, §§ 5112(b), 5123(c), Dec. 29, 2022, 136 Stat. 5940, 5946.)

§ 1397hh. Annual reports; evaluations

(a) Annual reportSubject to subsection (e), the State shall—

(1) assess the operation of the State plan under this subchapter in each fiscal year, including the progress made in reducing the number of uncovered low-income children; and

(2) report to the Secretary, by January 1 following the end of the fiscal year, on the result of the assessment.

(b) State evaluations

(1) In generalBy March 31, 2000, each State that has a State child health plan shall submit to the Secretary an evaluation that includes each of the following:

(A) An assessment of the effectiveness of the State plan in increasing the number of children with creditable health coverage.

(B) A description and analysis of the effectiveness of elements of the State plan, including—

(i) the characteristics of the children and families assisted under the State plan including age of the children, family income, and the assisted child’s access to or coverage by other health insurance prior to the State plan and after eligibility for the State plan ends,

(ii) the quality of health coverage provided including the types of benefits provided,

(iii) the amount and level (including payment of part or all of any premium) of assistance provided by the State,

(iv) the service area of the State plan,

(v) the time limits for coverage of a child under the State plan,

(vi) the State’s choice of health benefits coverage and other methods used for providing child health assistance, and

(vii) the sources of non-Federal funding used in the State plan.

(C) An assessment of the effectiveness of other public and private programs in the State in increasing the availability of affordable quality individual and family health insurance for children.

(D) A review and assessment of State activities to coordinate the plan under this subchapter with other public and private programs providing health care and health care financing, including medicaid and maternal and child health services.

(E) An analysis of changes and trends in the State that affect the provision of accessible, affordable, quality health insurance and health care to children.

(F) A description of any plans the State has for improving the availability of health insurance and health care for children.

(G) Recommendations for improving the program under this subchapter.

(H) Any other matters the State and the Secretary consider appropriate.

(2) Report of the Secretary

(1) In general

(2) Selection of States

(3) Matters includedIn addition to the elements described in subsection (b)(1), the evaluation conducted under this subsection shall include each of the following:

(A) Surveys of the target population (enrollees, disenrollees, and individuals eligible for but not enrolled in the program under this subchapter).

(B) Evaluation of effective and ineffective outreach and enrollment practices with respect to children (for both the program under this subchapter and the medicaid program under subchapter XIX), and identification of enrollment barriers and key elements of effective outreach and enrollment practices, including practices (such as through community health workers and others) that have successfully enrolled hard-to-reach populations such as children who are eligible for medical assistance under subchapter XIX but have not been enrolled previously in the medicaid program under that subchapter.

(C) Evaluation of the extent to which State medicaid eligibility practices and procedures under the medicaid program under subchapter XIX are a barrier to the enrollment of children under that program, and the extent to which coordination (or lack of coordination) between that program and the program under this subchapter affects the enrollment of children under both programs.

(D) An assessment of the effect of cost-sharing on utilization, enrollment, and coverage retention.

(E) Evaluation of disenrollment or other retention issues, such as switching to private coverage, failure to pay premiums, or barriers in the recertification process.

(4) Submission to Congress

(5) Subsequent evaluation using updated information

(A) In general

(B) Selection of States and matters included

(C)

(D) Funding

(d) Access to records for IG and GAO audits and evaluations

(e)1

1 So in original. Two subsecs. (e) have been enacted.

Information required for inclusion in State annual reportThe State shall include the following information in the annual report required under subsection (a):

(1) Eligibility criteria, enrollment, and retention data (including data with respect to continuity of coverage or duration of benefits).

(2) Data regarding the extent to which the State uses process measures with respect to determining the eligibility of children under the State child health plan, including measures such as 12-month continuous eligibility, self-declaration of income for applications or renewals, or presumptive eligibility.

(3) Data regarding denials of eligibility and redeterminations of eligibility.

(4) Data regarding access to primary and specialty services, access to networks of care, and care coordination provided under the State child health plan, using quality care and consumer satisfaction measures included in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.

(5) If the State provides child health assistance in the form of premium assistance for the purchase of coverage under a group health plan, data regarding the provision of such assistance, including the extent to which employer-sponsored health insurance coverage is available for children eligible for child health assistance under the State child health plan, the range of the monthly amount of such assistance provided on behalf of a child or family, the number of children or families provided such assistance on a monthly basis, the income of the children or families provided such assistance, the benefits and cost-sharing protection provided under the State child health plan to supplement the coverage purchased with such premium assistance, the effective strategies the State engages in to reduce any administrative barriers to the provision of such assistance, and,2

2 So in original. The comma probably should not appear.

the effects, if any, of the provision of such assistance on preventing the coverage provided under the State child health plan from substituting for coverage provided under employer-sponsored health insurance offered in the State.

(6) To the extent applicable, a description of any State activities that are designed to reduce the number of uncovered children in the State, including through a State health insurance connector program or support for innovative private health coverage initiatives.

(7) Data collected and reported in accordance with section 300kk of this title, with respect to individuals enrolled in the State child health plan (and, in the case of enrollees under 19 years of age, their parents or legal guardians), including data regarding the primary language of such individuals, parents, and legal guardians.

(e)1 Information on dental care for children

(1) In generalEach annual report under subsection (a) shall include the following information with respect to care and services described in section 1396d(r)(3) of this title provided to targeted low-income children enrolled in the State child health plan under this subchapter at any time during the year involved:

(A) The number of enrolled children by age grouping used for reporting purposes under section 1396a(a)(43) of this title.

(B) For children within each such age grouping, information of the type contained in questions 12(a)–(c) of CMS Form 416 (that consists of the number of enrolled targeted low income children who receive any,2 preventive, or restorative dental care under the State plan).

(C) For the age grouping that includes children 8 years of age, the number of such children who have received a protective sealant on at least one permanent molar tooth.

(2) Inclusion of information on enrollees in managed care plans

(Aug. 14, 1935, ch. 531, title XXI, § 2108, as added Pub. L. 105–33, title IV, § 4901(a), Aug. 5, 1997, 111 Stat. 566; amended Pub. L. 106–113, div. B, § 1000(a)(6) [title VII, § 703(b), (c)], Nov. 29, 1999, 113 Stat. 1536, 1501A–401; Pub. L. 111–3, title II, § 201(b)(2)(B)(ii), title IV, § 402(a), title V, § 501(e)(2), title VI, §§ 603, 604, Feb. 4, 2009, 123 Stat. 39, 82, 87, 99; Pub. L. 111–8, div. G, title I, § 1301(e), Mar. 11, 2009, 123 Stat. 829; Pub. L. 111–148, title IV, § 4302(b)(1)(B), Mar. 23, 2010, 124 Stat. 581.)

§ 1397ii. Miscellaneous provisions

(a) Relation to other laws

(1) HIPAA

(2) ERISA

(b) Adjustment to Current Population Survey to include State-by-State data relating to children without health insurance coverage

(1) In general

(2) Additional requirements

In addition to making the adjustments required to produce the data described in paragraph (1), with respect to data collection occurring for fiscal years beginning with fiscal year 2009, in appropriate consultation with the Secretary of Health and Human Services, the Secretary of Commerce shall do the following:

(A) Make appropriate adjustments to the Current Population Survey to develop more accurate State-specific estimates of the number of children enrolled in health coverage under subchapter XIX or this subchapter.

(B) Make appropriate adjustments to the Current Population Survey to improve the survey estimates used to determine a high-performing State under section 1397kk(b)(3)(B) of this title and any other data necessary for carrying out this subchapter.

(D) Assess whether American Community Survey estimates, once such survey data are first available, produce more reliable estimates than the Current Population Survey with respect to the purposes described in subparagraph (B).

(E) On the basis of the assessment required under subparagraph (D), recommend to the Secretary of Health and Human Services whether American Community Survey estimates should be used in lieu of, or in some combination with, Current Population Survey estimates for the purposes described in subparagraph (B).

(F) Continue making the adjustments described in the last sentence of paragraph (1) with respect to expansion of the sample size used in State sampling units, the number of sampling units in a State, and using an appropriate verification element.

(3) Authority for the Secretary of Health and Human Services to transition to the use of all, or some combination of, ACS estimates upon recommendation of the Secretary of Commerce

(4) Appropriation

(Aug. 14, 1935, ch. 531, title XXI, § 2109, as added Pub. L. 105–33, title IV, § 4901(a), Aug. 5, 1997, 111 Stat. 567; amended Pub. L. 106–113, div. B, § 1000(a)(6) [title VII, §§ 703(a), 705(c)], Nov. 29, 1999, 113 Stat. 1536, 1501A–400, 1501A–403; Pub. L. 110–173, title II, § 205, Dec. 29, 2007, 121 Stat. 2514; Pub. L. 111–3, title VI, § 602, Feb. 4, 2009, 123 Stat. 98; Pub. L. 111–148, title II, § 2102(a)(6), Mar. 23, 2010, 124 Stat. 288.)

§ 1397jj. Definitions

(a) Child health assistanceFor purposes of this subchapter, the term “child health assistance” means payment for part or all of the cost of health benefits coverage for targeted low-income children that includes any of the following (and includes, in the case described in section 1397ee(a)(1)(D)(i) of this title, payment for part or all of the cost of providing any of the following), as specified under the State plan:

(1) Inpatient hospital services.

(2) Outpatient hospital services.

(3) Physician services.

(4) Surgical services.

(5) Clinic services (including health center services) and other ambulatory health care services.

(6) Prescription drugs and biologicals and the administration of such drugs and biologicals, only if such drugs and biologicals are not furnished for the purpose of causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a person.

(7) Over-the-counter medications.

(8) Laboratory and radiological services.

(9) Prenatal care and prepregnancy family planning services and supplies.

(10) Inpatient mental health services, other than services described in paragraph (18) but including services furnished in a State-operated mental hospital and including residential or other 24-hour therapeutically planned structured services.

(11) Outpatient mental health services, other than services described in paragraph (19) but including services furnished in a State-operated mental hospital and including community-based services.

(12) Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices).

(13) Disposable medical supplies.

(14) Home and community-based health care services and related supportive services (such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home).

(15) Nursing care services (such as nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services) in a home, school, or other setting.

(16) Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest.

(17) Dental services.

(18) Inpatient substance use treatment services and residential substance use treatment services.

(19) Outpatient substance use treatment services.

(20) Case management services.

(21) Care coordination services.

(22) Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders.

(23) Hospice care (concurrent, in the case of an individual who is a child, with care related to the treatment of the child’s condition with respect to which a diagnosis of terminal illness has been made.1

1 So in original. A closing parenthesis probably should precede the period.

(24) Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services (whether in a facility, home, school, or other setting) if recognized by State law and only if the service is—

(A) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as defined by State law,

(B) performed under the general supervision or at the direction of a physician, or

(C) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

(25) Premiums for private health care insurance coverage.

(26) Medical transportation.

(27) Enabling services (such as transportation, translation, and outreach services) only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

(28) Any other health care services or items specified by the Secretary and not excluded under this section.

(b) “Targeted low-income child” definedFor purposes of this subchapter—

(1) In generalSubject to paragraph (2), the term “targeted low-income child” means a child—

(A) who has been determined eligible by the State for child health assistance under the State plan;

(B)

(i) who is a low-income child, or

(ii) is a child—(I) whose family income (as determined under the State child health plan) exceeds the medicaid applicable income level (as defined in paragraph (4)), but does not exceed 50 percentage points above the medicaid applicable income level;(II) whose family income (as so determined) does not exceed the medicaid applicable income level (as defined in paragraph (4) but determined as if “June 1, 1997” were substituted for “March 31, 1997”); or(III) who resides in a State that does not have a medicaid applicable income level (as defined in paragraph (4)); and

(C) who is not found to be eligible for medical assistance under subchapter XIX or, subject to paragraph (5), covered under a group health plan or under health insurance coverage (as such terms are defined in section 300gg–91 of this title).

(2) Children excludedSuch term does not include—

(A) except as provided in paragraph (7), a child who is an inmate of a public institution or a patient in an institution for mental diseases; or

(B) except as provided in paragraph (6), a child who is a member of a family that is eligible for health benefits coverage under a State health benefits plan on the basis of a family member’s employment with a public agency in the State.

(3) Special rule

(4) Medicaid applicable income level

(5) Option for States with a separate CHIP program to provide dental-only supplemental coverage

(A) In generalSubject to subparagraphs (B) and (C), in the case of any child who is enrolled in a group health plan or health insurance coverage offered through an employer who would, but for the application of paragraph (1)(C), satisfy the requirements for being a targeted low-income child under a State child health plan that is implemented under this subchapter, a State may waive the application of such paragraph to the child in order to provide—

(i) dental coverage consistent with the requirements of subsection (c)(6) of section 1397cc of this title; or

(ii) cost-sharing protection for dental coverage consistent with such requirements and the requirements of subsection (e)(3)(B) of such section.

(B) Limitation

(C) ConditionsA State may not offer dental-only supplemental coverage under this paragraph unless the State satisfies the following conditions:

(i) Income eligibilityThe State child health plan under this subchapter—(I) has the highest income eligibility standard permitted under this subchapter (or a waiver) as of January 1, 2009;(II) does not limit the acceptance of applications for children or impose any numerical limitation, waiting list, or similar limitation on the eligibility of such children for child health assistance under such State plan; and(III) provides benefits to all children in the State who apply for and meet eligibility standards.

(ii) No more favorable treatment

(6) Exceptions to exclusion of children of employees of a public agency in the State

(A) In generalA child shall not be considered to be described in paragraph (2)(B) if—

(i) the public agency that employs a member of the child’s family to which such paragraph applies satisfies subparagraph (B); or

(ii) subparagraph (C) applies to such child.

(B) Maintenance of effort with respect to agency contribution for family coverage

(7) Exception to exclusion of children who are inmates of a public institution

(1) Child

(2) Creditable health coverage

(3) Group health plan; health insurance coverage; etc.

(4) Low-income child

(5) Poverty line defined

(6) Preexisting condition exclusion

(7) State child health plan; plan

(8) Uncovered child

(9) School-based health center

(A) In generalThe term “school-based health center” means a health clinic that—

(i) is located in or near a school facility of a school district or board or of an Indian tribe or tribal organization;

(ii) is organized through school, community, and health provider relationships;

(iii) is administered by a sponsoring facility;

(iv) provides through health professionals primary health services to children in accordance with State and local law, including laws relating to licensure and certification; and

(v) satisfies such other requirements as a State may establish for the operation of such a clinic.

(B) Sponsoring facilityFor purposes of subparagraph (A)(iii), the term “sponsoring facility” includes any of the following:

(i) A hospital.

(ii) A public health department.

(iii) A community health center.

(iv) A nonprofit health care agency.

(v) A local educational agency (as defined under section 7801 of title 20.1

(vi) A program administered by the Indian Health Service or the Bureau of Indian Affairs or operated by an Indian tribe or a tribal organization.

(Aug. 14, 1935, ch. 531, title XXI, § 2110, as added Pub. L. 105–33, title IV, § 4901(a), Aug. 5, 1997, 111 Stat. 567; amended Pub. L. 105–100, title I, § 162(3), (9), Nov. 19, 1997, 111 Stat. 2189, 2190;

§ 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 2009Notwithstanding 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 February 4, 2009, approve or renew a waiver, experimental, 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 conditions 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 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

(B) Extension upon State request

(3) State option to apply for Medicaid waiver to continue coverage for nonpregnant childless adults

(A) In general

(B) Deadline for approval

(C) Standard for budget neutralityThe budget neutrality requirement applicable with respect to expenditures for medical assistance under a Medicaid nonpregnant 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 fiscal year 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; and

(ii) in the case of any succeeding fiscal year, allow such expenditures to not exceed the amount in effect under this subparagraph for the preceding fiscal year, 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.

(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 waiversNotwithstanding 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 waiver, experimental, 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 parent of a targeted low-income child; and

(ii) notwithstanding the terms and conditions 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 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

(2) Rules for fiscal years 2012 through 2013

(A) Payments for coverage limited to block grant funded from State allotment

(B) Terms and conditions

(i) Block grant set aside from State allotment

(ii) Payments from block grant

(iii)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 paragraph (3) for fiscal year 2011; or(II) the Federal medical assistance percentage (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 2013For 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 enhanced FMAP for fiscal year 2012; and(bb) the State met either of the coverage benchmarks described in subparagraph (B) or (C) of paragraph (3) for fiscal year 2012; or(II) the Federal medical assistance percentage (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

(vi) No increase in income eligibility level for parents

(3) Outreach or coverage benchmarksFor purposes of paragraph (2), the outreach or coverage benchmarks described in this paragraph are as follows:

(A) Significant child outreach campaignThe State—

(i) was awarded a grant under section 1397mm of this title for fiscal year 2011;

(ii) implemented 1 or more of the enrollment 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

(4) Rules of construction

(1) In generalThe term “applicable existing waiver” means a waiver, experimental, pilot, or demonstration 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 benefits 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

(B) Nonpregnant childless adult

(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.)

§ 1397ll. Optional coverage of targeted low-income pregnant women through a State plan amendment

(a) In general

(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

(3) No coverage for higher income pregnant women without covering lower income pregnant women

(4) Application of requirements for coverage of targeted low-income children

(5) No preexisting condition exclusion or waiting period

(6) Application of cost-sharing protection

(7) No waiting list for children

(d) Definitions

For purposes of this section:

(1) Pregnancy-related assistance

(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

1 So in original. The comma probably should not appear.

(beginning on the last day of her pregnancy) ends;

(B) whose family income exceeds 185 percent (or, if higher, the percent applied under subsection (b)(1)(A)) of the poverty line applicable to a family of the size involved, but does not exceed the income eligibility level established under the State child health plan under this subchapter for a targeted low-income child; and

(C) who satisfies the requirements of paragraphs (1)(A), (1)(C), (2), and (3) of section 1397jj(b) of this title in the same manner as a child applying for child health assistance would have to satisfy such requirements.

(e) Automatic enrollment for children born to women receiving pregnancy-related assistance

(f) States providing assistance through other options

(1) Continuation of other options for providing assistance

The option to provide assistance in accordance with the preceding subsections of this section shall not limit any other option for a State to provide—

(A) child health assistance through the application of sections 457.10, 457.350(b)(2), 457.622(c)(5), and 457.626(a)(3) of title 42, Code of Federal Regulations (as in effect after the final rule adopted by the Secretary and set forth at 67 Fed. Reg. 61956–61974 (October 2, 2002)), or

(B) pregnancy-related services through the application of any waiver authority (as in effect on June 1, 2008).

(2) Clarification of authority to provide postpartum services

(3) No inference

Nothing in this subsection shall be construed—

(A) to infer congressional intent regarding the legality or illegality of the span of the sections specified in paragraph (1)(A); or

(B) to modify the authority to provide pregnancy-related services under a waiver specified in paragraph (1)(B).

(Aug. 14, 1935, ch. 531, title XXI, § 2112, as added Pub. L. 111–3, title I, § 111(a), Feb. 4, 2009, 123 Stat. 26; amended Pub. L. 116–127, div. F, § 6004(b)(2), Mar. 18, 2020, 134 Stat. 206; Pub. L. 117–2, title IX, § 9822(a)(2), Mar. 11, 2021, 135 Stat. 221.)

§ 1397mm. Grants to improve outreach and enrollment

(a) Outreach and enrollment grants; national campaign

(1) In general

(2) Ten percent set aside for national enrollment campaign

(3) Ten percent set aside for evaluating and providing technical assistance to grantees

(b) Priority for award of grants

(1) In generalIn awarding grants under subsection (a), the Secretary shall give priority to eligible entities that—

(A) propose to target geographic areas with high rates of—

(i) eligible but unenrolled children, including such children who reside in rural areas; or

(ii) racial and ethnic minorities and health disparity populations, including those proposals that address cultural and linguistic barriers to enrollment; and

(B) submit the most demonstrable evidence required under paragraphs (1) and (2) of subsection (c).

(2) Ten percent set aside for outreach to Indian children

(c) ApplicationAn eligible entity that desires to receive a grant under subsection (a) shall submit an application to the Secretary in such form and manner, and containing such information, as the Secretary may decide. Such application shall include—

(1) evidence demonstrating that the entity includes members who have access to, and credibility with, ethnic or low-income populations in the communities in which activities funded under the grant are to be conducted;

(2) evidence demonstrating that the entity has the ability to address barriers to enrollment, such as lack of awareness of eligibility, stigma concerns and punitive fears associated with receipt of benefits, and other cultural barriers to applying for and receiving child health assistance or medical assistance;

(3) specific quality or outcomes performance measures to evaluate the effectiveness of activities funded by a grant awarded under this section; and

(4) an assurance that the eligible entity shall—

(A) conduct an assessment of the effectiveness of such activities against the performance measures;

(B) cooperate with the collection and reporting of enrollment data and other information in order for the Secretary to conduct such assessments; and

(C) in the case of an eligible entity that is not the State, provide the State with enrollment data and other information as necessary for the State to make necessary projections of eligible children and pregnant women.

(d) Dissemination of enrollment data and information determined from effectiveness assessments; annual reportThe Secretary shall—

(1) make publicly available the enrollment data and information collected and reported in accordance with subsection (c)(4)(B); and

(2) submit an annual report to Congress on the outreach and enrollment activities conducted with funds appropriated under this section.

(e) Maintenance of effort for States awarded grants; no match required for any eligible entity awarded a grant

(1) State maintenance of effort

(2) No matching requirement

(f) DefinitionsIn this section:

(1) Eligible entityThe term “eligible entity” means any of the following:

(A) A State with an approved child health plan under this subchapter.

(B) A local government.

(C) An Indian tribe or tribal consortium, a tribal organization, an urban Indian organization receiving funds under title V of the Indian Health Care Improvement Act (25 U.S.C. 1651 et seq.), or an Indian Health Service provider.

(D) A Federal health safety net organization.

(E) A national, State, local, or community-based public or nonprofit private organization, including organizations that use community health workers, community-based doula programs, or parent mentors.

(F) A faith-based organization or consortia, to the extent that a grant awarded to such an entity is consistent with the requirements of section 300x–65 of this title relating to a grant award to nongovernmental entities.

(G) An elementary or secondary school.

(2) Federal health safety net organizationThe term “Federal health safety net organization” means—

(A) a Federally-qualified health center (as defined in section 1396d(l)(2)(B) of this title);

(B) a hospital defined as a disproportionate share hospital for purposes of section 1396r–4 of this title;

(D) any other entity or consortium that serves children under a federally funded program, including the special supplemental nutrition program for women, infants, and children (WIC) established under section 1786 of this title, the Head Start and Early Head Start programs under the Head Start Act (42 U.S.C. 9801 et seq.),1

1 See References in Text note below.

the school lunch program established under the Richard B. Russell National School Lunch Act [42 U.S.C. 1751 et seq.], and an elementary or secondary school.

(3) Indians; Indian tribe; tribal organization; urban Indian organization

(4) Community health workerThe term “community health worker” means an individual who promotes health or nutrition within the community in which the individual resides—

(A) by serving as a liaison between communities and health care agencies;

(B) by providing guidance and social assistance to community residents;

(D) by providing culturally and linguistically appropriate health or nutrition education;

(E) by advocating for individual and community health or nutrition needs; and

(F) by providing referral and followup services.

(5) Parent mentorThe 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 subchapter or subchapter 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 subchapter XIX or State child health plans under this subchapter;

(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.

(g) Appropriation

(h) National enrollment campaignFrom the amounts made available under subsection (a)(2), the Secretary shall develop and implement a national enrollment campaign to improve the enrollment of underserved child populations in the programs established under this subchapter and subchapter XIX. Such campaign may include—

(1) the establishment of partnerships with the Secretary of Education and the Secretary of Agriculture to develop national campaigns to link the eligibility and enrollment systems for the assistance programs each Secretary administers that often serve the same children;

(2) the integration of information about the programs established under this subchapter and subchapter XIX in public health awareness campaigns administered by the Secretary;

(3) increased financial and technical support for enrollment hotlines maintained by the Secretary to ensure that all States participate in such hotlines;

(4) the establishment of joint public awareness outreach initiatives with the Secretary of Education and the Secretary of Labor regarding the importance of health insurance to building strong communities and the economy;

(5) the development of special outreach materials for Native Americans or for individuals with limited English proficiency;

(6) the development of materials and toolkits and the provision of technical assistance to States regarding enrollment and retention strategies for eligible children under this subchapter and subchapter XIX; and

(7) such other outreach initiatives as the Secretary determines would increase public awareness of the programs under this subchapter and subchapter XIX.

(Aug. 14, 1935, ch. 531, title XXI, § 2113, as added Pub. L. 111–3, title II, § 201(a), Feb. 4, 2009, 123 Stat. 35; amended Pub. L. 111–148, title X, § 10203(d)(2)(E), Mar. 23, 2010, 124 Stat. 931; Pub. L. 114–10, title III, § 303, Apr. 16, 2015, 129 Stat. 158; Pub. L. 115–120, div. C, § 3004(a), (b), Jan. 22, 2018, 132 Stat. 36; Pub. L. 115–123, div. E, title I, § 50103, Feb. 9, 2018, 132 Stat. 176; Pub. L. 117–328, div. FF, title V, § 5111(c)(4), Dec. 29, 2022, 136 Stat. 5939.)