42 U.S.C. § 1397kk: Phase-out of coverage for…

Summary

After February 4, 2009, the federal government will not approve new uses of CHIP money that pay for health coverage for adults who are not pregnant and have no children, or for parents of low-income children. For adults without children who were covered under existing CHIP waivers in 2009, federal money can be used only through December 31, 2009. States could ask by September 30, 2009, to extend any waiver that would end earlier, but any such extension can only run until December 31, 2009. The higher federal matching rate that applied in 2009 (the “enhanced FMAP”) covers those adult costs from February 4, 2009, through December 31, 2009. States whose CHIP adult coverage ends can apply by September 30, 2009, for a Medicaid waiver to continue covering those adults; the federal government must accept or reject the application within 90 days, and if it does nothing by December 31, 2009, the application is treated as approved. Any Medicaid spending limits for 2010 and later years are tied to what the State received in 2009 and then adjusted by national health spending projections. For parents of targeted low-income children, the same ban on new CHIP uses starts February 4, 2009, but existing waivers can keep working through fiscal year 2011. If a waiver would end before October 1, 2011, a State can ask to extend it and the federal government will allow it only through September 30, 2011. The enhanced FMAP applies to the third and fourth quarters of fiscal year 2009 and to fiscal years 2010 and 2011 for parent coverage under existing waivers. For fiscal years 2012 and 2013, a State may choose to keep parent coverage paid from a special block grant. That grant equals the federal share of 110% of the State’s projected waiver costs (as certified by the State by August 31 before the year). Payments are made quarterly and use different federal matching rates: in 2012 a State gets the enhanced match only if it met certain outreach or child-coverage benchmarks for 2011, otherwise it gets the regular Medicaid match; in 2013 a State may get a “REMAP” rate if it had the enhanced match in 2012 and met coverage targets in 2012, otherwise it gets the regular match. The State cannot spend more federal money than the set-aside, and it cannot raise the income limit for parents above the level in place on February 4, 2009. An “applicable existing waiver” means a waiver in effect in fiscal year 2009 that used CHIP money to cover these adults or parents. “Parent” includes caretaker relatives and legal guardians.

Title 42, §1397kk

The Public Health and Welfare, Source: USLM XML via OLRC

(a)Termination of coverage for nonpregnant childless adults

(1)No new CHIP waivers; automatic extensions at State option through 2009

Notwithstanding section 1315 of this title or any other provision of this subchapter, except as provided in this subsection— (A)

(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

No funds shall be available under this subchapter for child health assistance or other health benefits coverage that is provided to a nonpregnant childless adult under an applicable existing waiver after December 31, 2009.

(B)Extension upon State request

If an applicable existing waiver described in subparagraph (A) would otherwise expire before January 1, 2010, notwithstanding the requirements of subsections (e) and (f) of section 1315 of this title, a State may submit, not later than September 30, 2009, a request to the Secretary for an extension of the waiver. The Secretary shall approve a request for an extension of an applicable existing waiver submitted pursuant to this subparagraph, but only through December 31, 2009.

(C)Application of enhanced FMAP

The enhanced FMAP determined under section 1397ee(b) of this title shall apply to expenditures under an applicable existing waiver for the provision of child health assistance or other health benefits coverage to a nonpregnant childless adult during the period beginning on February 4, 2009, and ending on December 31, 2009.

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

(A)In general

Each State for which coverage under an applicable existing waiver is terminated under paragraph (2)(A) may submit, not later than September 30, 2009, an application to the Secretary for a waiver under section 1315 of this title of the State plan under subchapter XIX to provide medical assistance to a nonpregnant childless adult whose coverage is so terminated (in this subsection referred to as a “Medicaid nonpregnant childless adults waiver”).

(B)Deadline for approval

The Secretary shall make a decision to approve or deny an application for a Medicaid nonpregnant childless adults waiver submitted under subparagraph (A) within 90 days of the date of the submission of the application. If no decision has been made by the Secretary as of December 31, 2009, on the application of a State for a Medicaid nonpregnant childless adults waiver that was submitted to the Secretary by September 30, 2009, the application shall be deemed approved.

(C)Standard for budget neutrality

The budget neutrality requirement applicable with respect to expenditures for medical assistance under a Medicaid nonpregnant childless adults 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 waivers

Notwithstanding section 1315 of this title or any other provision of this subchapter, except as provided in this subsection— (i)

(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

If an applicable existing waiver described in subparagraph (A) would otherwise expire before October 1, 2011, and the State requests an extension of such waiver, the Secretary shall grant such an extension, but only, subject to paragraph (2)(A), through September 30, 2011.

(C)Application of enhanced FMAP

The enhanced FMAP determined under section 1397ee(b) of this title shall apply to expenditures under an applicable existing waiver for the provision of child health assistance or other health benefits coverage to a parent of a targeted low-income child during the third and fourth quarters of fiscal year 2009 and during fiscal years 2010 and 2011.

(2)Rules for fiscal years 2012 through 2013

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

Any State that provides child health assistance or health benefits coverage under an applicable existing waiver for a parent of a targeted low-income child may elect to continue to provide such assistance or coverage through fiscal year 2012 or 2013, subject to the same terms and conditions that applied under the applicable existing waiver, unless otherwise modified in subparagraph (B).

(B)Terms and conditions

(i)Block grant set aside from State allotment

If the State makes an election under subparagraph (A), the Secretary shall set aside for the State for each such fiscal year an amount equal to the Federal share of 110 percent of the State’s projected expenditures under the applicable existing waiver for providing child health assistance or health benefits coverage to all parents of targeted low-income children enrolled under such waiver for the fiscal year (as certified by the State and submitted to the Secretary by not later than August 31 of the preceding fiscal year). In the case of fiscal year 2013, the set aside for any State shall be computed separately for each period described in subparagraphs (A) and (B) of section 1397dd(a)(16) of this title and any reduction in the allotment for either such period under section 1397dd(m)(5) of this title shall be allocated on a pro rata basis to such set aside.

(ii)Payments from block grant

The Secretary shall pay the State from the amount set aside under clause (i) for the fiscal year, an amount for each quarter of such fiscal year equal to the applicable percentage determined under clause (iii) or (iv) for expenditures in the quarter for providing child health assistance or other health benefits coverage to a parent of a targeted low-income child.

(iii)Enhanced FMAP only in fiscal year 2012 for States with significant child outreach or that achieve child coverage benchmarks; FMAP for any other States

For purposes of clause (ii), the applicable percentage for any quarter of fiscal year 2012 is equal to—

(I)the enhanced FMAP determined under section 1397ee(b) of this title in the case of a State that meets the outreach or coverage benchmarks described in any of subparagraph (A), (B), or (C) of 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 2013

For purposes of clause (ii), the applicable percentage for any quarter of fiscal year 2013 is equal to—

(I)the REMAP percentage if—

(aa)the applicable percentage for the State under clause (iii) was the 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

No payments shall be made to a State for expenditures described in clause (ii) after the total amount set aside under clause (i) for a fiscal year has been paid to the State.

(vi)No increase in income eligibility level for parents

No payments shall be made to a State from the amount set aside under clause (i) for a fiscal year for expenditures for providing child health assistance or health benefits coverage to a parent of a targeted low-income child whose family income exceeds the income eligibility level applied under the applicable existing waiver to parents of targeted low-income children on February 4, 2009.

(3)Outreach or coverage benchmarks

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

(A)Significant child outreach campaign

The State—

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

(ii)implemented 1 or more of the 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

The State, on the basis of the most timely and accurate published estimates of the Bureau of the Census, ranks in the lowest ⅓ of States in terms of the State’s percentage of low-income children without health insurance.

(C)State increasing enrollment of low-income children

The State qualified for a performance bonus payment under section 1397ee(a)(3)(B) of this title for the most recent fiscal year applicable under such section.

(4)Rules of construction

Nothing in this subsection shall be construed as prohibiting a State from submitting an application to the Secretary for a waiver under section 1315 of this title of the State plan under subchapter XIX to provide medical assistance to a parent of a targeted low-income child that was provided child health assistance or health benefits coverage under an applicable existing waiver.

(c)Applicable existing waiver

For purposes of this section

(1) In general

(2)Definitions

(A)Parent

The term “parent” includes a caretaker relative (as such term is used in carrying out section 1396u–1 of this title) and a legal guardian.

(B)Nonpregnant childless adult

The term “nonpregnant childless adult” has the meaning given such term by section 1397gg(f) of this title.

Notes & Related Subsidiaries

Editorial Notes

References in Text

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

Amendments

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

Statutory Notes and Related Subsidiaries

Effective Date

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

§1397kk Phase-out of Coverage for Nonpregnant Childless Adults; Conditions for Coverage of Parents