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F:\EGG\MEDICA\DAREP\MEDICAImmittee Print] Title II, Subtitle A
1
TITLE I-COMMITTEE ON
2
COMMERCE
3
Subtitle -Restructuring Medicaid
4
SEC. 2001. SHORT TITLE OF SUBTITLE.
5
This subtitle may be cited as the "Medicaid Restructuring
6
Act of 1996".
7
SEC. 2002. FINDING; GOALS FOR MEDICAID RESTRUC-
8
TURING.
9
(a) FINDING.-The Congress finds that the National Gov-
10
ernors' Association on February 6, 1996, adopted unanimously
11
and on a bipartisan basis goals to guide the restructuring of
12
the medicaid program.
13
(b) GOALS FOR RESTRUCTURING.-The following are the
14
4 primary goals so adopted:
15
(1) The basic health care needs of the nation's most
16
vulnerable populations must be guaranteed.
17
(2) The growth in health care expenditures must be
18
brought under control.
19
(3) States must have maximum flexibility in the design
20
and implementation of cost-effective systems of care.
21
(4) States must be protected from unanticipated pro-
22
gram costs resulting from economic fluctuations in the
23
business cycle. changing demographics, and natural disas-
24
ters.
25
SEC. 2003. RESTRUCTURING THE MEDICAID PROGRAM.
26
The Social Security Act is amended by inserting after title
27
XIV the following new title:
"TITLE AT-PROGRAM OF MEDICAL ASSISTANCE FOR LOW-
INCOME INDIVIDUALS AND FAMILIES
"TABLE OF CONTENTS OF TITLE
"See. 1500. Purpose: State plans.
"PART A-ELIGIBILITY AND BENEFITS
"Sec. 1501. Guaranteed eligibility and benefits.
"See. 1502. Other provisions relating to eligibility and benefits.
"Sec. 1503. Premiums and cost-sharing.
"See. 1504. Description of process for developing capitation payment rates.
"See. 1505. Preventing spousal impoverishment.
"See. 1506. Preventing family impoverishment.
"Sec. 1507. State flexibility.
June 11 1996
REP\MEDICAIDCmmittee Print] Title II, Subtitle A
2
"Sec. 1508. Private rights of action.
"PART B-PAYMENTS TO STATES
"Sec. 1511. Allotment of funds among States.
"Sec. 1512. Payments to States.
"Sec. 1513. Limitation on use of funds; disallowance.
"PART C-ESTABLISHMENT AND AMENDMENT OF STATE PLANS
"Sec. 1521. Description of strategic objectives and performance goals.
"Sec. 1522. Annual reports.
"Sec. 1523. Periodic. independent evaluations.
"Sec. 1524. Description of process for State plan development.
"Sec. 1525. Consultation in State plan development.
"Sec. 1526. Submittal and approval of State plans.
"Sec. 1527. Submittal and approval of plan amendments.
"Sec. 1528. Process for State withdrawal from program.
"Sec. 1529. Sanctions for noncompliance.
"Sec. 1530. Secretarial authority.
"PART D-PROGRAM INTEGRITY AND QUALITY
"Sec. 1551. Use of audits to achieve fiscal integrity.
"Sec. 1552. Fraud prevention program.
"Sec. 1553. Information concerning sanctions taken by State licensing au-
thorities against health care practitioners and providers.
"Sec. 1554. State fraud control units.
"Sec. 1555. Recoveries from third parties and others.
"Sec. 1556. Assignment of rights of payment.
"Sec. 1557. Quality assurance requirements for nursing facilities.
"Sec. 1558. Other provisions promoting program integrity.
"PART E-GENERAL PROVISIONS
"See. 1571. Definitions.
"Sec. 1572. Treatment of territories.
"See. 1573. Description of treatment of Indian Health Service facilities.
"See 1574. Application of certain general provisions.
See 1575. Optional master drug rebate agreements.
I
"SEC. 1500. PURPOSE; STATE PLANS.
:
"(a) PURPOSE.-The purpose of this title is to provide
"
funds to States to enable them to provide medical assistance
1.
to low-income individuals and families in a more effective, effi-
V.
cient. and responsive manner.
6
"(b) STATE PLAN REQUIRED.-A State is not eligible for
- J
payment under section 1512 unless the State has submitted to
8
the Secretary under part C a plan (in this title referred to as
4
a State plan') that-
10
"(1) sets forth how the State intends to use the funds
11
provided under this title to provide medical assistance to
12
needy individuals and families consistent with the provi-
13
sions of this title. and
June 11 1996
PVMEDICAID0mittee Print] Title II, Subtitle A
3
1
"(2) is approved under such part.
2
"(c) CONTINUED APPROVAL.-An approved State plan
3
shall continue in effect unless and until-
4
"(1) the State amends the plan under section 1527,
5
"(2) the State terminates participation under this title
6
under section 1528, or
7
"(3) the Secretary finds substantial noncompliance of
8
the plan with the requirements of this title under section
9
1529.
10
"(d) STATE ENTITLEMENT-This title constitutes budget
11
authority in advance of appropriations Acts and represents the
12
obligation of the Federal Government to provide for the pay-
13
ment to States of amounts provided under part B.
14
"(e) EFFECTIVE DATE.-No State is eligible for payments
15
under section 1512 for any calendar quarter beginning before
16
October 1, 1996.
17
"PART A-ELIGIBILITY AND BENEFITS
18
"SEC. 1501. GUARANTEED ELIGIBILITY AND BENEFITS.
19
"(a) GUARANTEED COVERAGE AND BENEFITS FOR CER-
20
TAIN POPULATIONS.-
21
"(1) IN GENERAL-Each State plan shall provide for
22
making medical assistance available for benefits in the
23
guaranteed benefit package (as defined in paragraph (2))
24
to individuals within each of the following categories:
25
"(A) POOR PREGNANT WOMEN.-Pregnant women
26
with family income below 133 percent of the poverty
27
line.
28
"(B) CHILDREN UNDER 6.-Children under 6
29
years of age whose family income does not exceed 133
30
percent of the poverty line.
31
"(C) CHILDREN 6 TO 12.-Children over 5 years
32
of age, but under 13 years of age, whose family income
33
does not exceed 100 percent of the poverty line.
34
"(D) DISABLED INDIVIDUALS.-As elected by the
35
State under paragraph (3), either-
June 11. 1996
F:VEGG\MEDICAID\REP\MEDICAI(mittee Print] Title II, Subtitle A
4
I
"(i) disabled individuals (as defined by the
2
State) who meet the income and resource standards
3
established under the plan, or
4
"(ii) individuals who are under 65 years of
5
age, who are disabled (as determined under section
6
1614(a)(3)), and who, using the methodology pro-
7
vided for determining eligibility for payment of sup-
8
plemental security income benefits under title XVI,
9
meet the income and resource standards for pay-
10
ment of such benefits.
11
"(E) POOR ELDERLY INDIVIDUALS.-Subject to
12
paragraph (4), elderly individuals who, using the meth-
13
odology provided for determining eligibility for payment
14
of supplemental security income benefits under title
15
XVI, meet the income and resource standards for pay-
16
ment of such benefits.
17
"(F) CHILDREN RECEIVING FOSTER CARE OR
18
ADOPTION ASSISTANCE.-Subject to paragraph (5),
19
children who meet the requirements for receipt of fos-
20
ter care maintenance payments or adoption assistance
21
under title IV.
22
"(G) CERTAIN LOW-INCOME FAMILIES.-Subject
23
to paragraph (6), individuals and members of families
24
who meet current AFDC income and resource stand-
25
ards (as defined in paragraph (6)(C)) in the State, de-
26
termined using the methodology for determining eligi-
27
bility for aid under the State plan under part A or part
28
E of title IV (as in effect as of May 1, 1996).
24
"(2) GUARANTEED BENEFITS PACKAGE.-In this title,
30
the term 'guaranteed benefit package' means benefits (in
31
an amount, duration, and scope specified under the State
32
plan) for at least the following categories of services:
33
"(A) Inpatient and outpatient hospital services.
34
"(B) Physicians' surgical and medical services.
35
"(C) Laboratory and x-ray services.
36
"(D) Nursing facility services.
June 11. 1996
\EGG PRMEDICAIDComittee Print] Title II, Subtitle A
5
1
"(E) Home health care.
2
"(F) Federally-qualified health center services and
3
rural health clinic services.
4
"(G) Immunizations for children (in accordance
5
with a schedule for immunizations established by the
6
Health Department of the State in consultation with
7
the State agency responsible for the administration of
8
the plan).
9
"(H) Prepregnancy family planning services and
10
supplies (as specified by the State).
11
"(I) Prenatal care.
12
"(J) Pediatric and family nurse practitioner serv-
13
ices and nurse midwife services.
14
"(K) EPSDT services (as defined in section
15
1571(e)) for individuals who are under the age of 21.
16
A State may establish criteria, including utilization review,
17
and cost effectiveness of alternative covered services, for
18
purposes of specifying the amount, duration. and scope of
19
benefits provided under the State plan.
20
"(3) STATE ELECTION OF DISABLED INDIVIDUALS TO
21
BE GUARANTEED COVERAGE.-
22
"(A) IN GENERAL.-Each State shall specify in its
23
State plan, before the beginning of each Federal fiscal
24
year. whether to guarantee coverage of disabled individ-
25
uals under the plan under the option described in para-
26
graph (1)(D)(i) or under the option described in para-
27
graph (1)(D)(ii). An election under this paragraph
28
shall continue in effect for the subsequent fiscal year
29
unless the election is changed before the beginning of
30
the fiscal year.
31
"(B) CONSEQUENCES OF ELECTION.-
32
"(i) STATE FLEXIBLE DEFINITION OPTION.-
33
If a State elects the option described in paragraph
34
(1)(D)(i) for a fiscal year-
June 11. 1996
EGG MEDICAID MEDICAIDCmmittee Print] Title II, Subtitle A
6
1
"(I) the State plan must provide under
2
section 1502(c) for a set aside of funds for dis-
3
abled individuals for the fiscal year, and
4
"(II) disabled individuals are not taken
5
into account in determining a State supple-
6
mental umbrella allotment under section
7
1511(g).
8
"(ii) SSI DEFINITION OPTION.-If a State
9
elects the option described in paragraph (1)(D)(ii)
10
for a fiscal year-
11
"(I) section 1502(c) shall not apply for the
12
fiscal year, and
13
"(II) the State is eligible for an increase
14
under section 1511(g) in its outlay allotment
15
for the fiscal year based on an increase in the
16
number of guaranteed and optional disabled in-
17
dividuals covered under the plan.
18
"(4) CONTINUATION OF SPECIAL ELIGIBILITY STAND-
19
ARDS FOR SECTION 209(b) STATES.-
20
"(A) IN GENERAL.-A section 209(b) State (as
21
defined in subparagraph (B)) may elect to treat any
22
reference in paragraph (1)(E) to 'elderly individuals
23
who meet the income and resource standards for the
24
payment of supplemental security income benefits
25
under title XVI' as a reference to 'elderly individuals
26
who meet the standards described in the first sentence
27
of section 1902(f) (as in effect on the day before the
28
date of the enactment of this title)'.
29
"(B) SECTION 209(b) STATE DEFINED.-In sub-
30
paragraph (A). the term 'section 209(b) State' means
31
a State to which section 1902(f) applied as of the day
32
before the date of the enactment of this title.
33
(5) OPTION FOR APPLICATION OF CURRENT REQUIRE-
34
MENTS FOR CERTAIN CHILDREN.-A State may elect to
35
apply paragraph (1)(F) by treating any reference to 're-
36
quirements for receipt of foster care maintenance payments
June 11. 1996
:\EGG\MEDICAID\REP\MEDICAI0mmittee Print] Title II, Subtitle A
7
1
or adoption assistance under title IV' as a reference to 're-
2
quirements for receipt of foster care maintenance payments
3
or adoption assistance as in effect under its State plan
4
under part E of title IV as of the date of the enactment
5
of this title'.
6
"(6) SPECIAL RULES FOR LOW-INCOME FAMILIES.-
7
"(A) OPTIONAL USE OF LOWER NATIONAL AVER-
8
AGE STANDARDS.-In the case of a State in which the
9
current AFDC income and resource standards are
10
above the national average of the current AFDC in-
11
come and resource standards for the 50 States and the
12
District of Columbia, as determined and published by
13
the Secretary, in applying paragraph (1)(G), the State
14
may elect to substitute such national average income
15
and resource standards for the current AFDC income
16
and resource standards in that State.
17
"(B) OPTIONAL ELIGIBILITY BASED ON LINK TO
18
OTHER ASSISTANCE.-
19
"(i) IN GENERAL.-Subject to clause (ii), in
20
the case of a State which maintains a link between
21
eligibility for aid or assistance under one or more
22
parts of title IV and eligibility for medical assist-
23
ance under this title, in applying paragraph (1)(G),
24
the State may elect to treat any reference in such
25
paragraph to 'individuals and members of families
26
who meet current AFDC income and resource
27
standards in the State' as a reference to 'members
28
of families who are receiving assistance under a
29
State plan under part A or E of title IV'.
30
"(ii) LIMITATION ON ELECTION.-A State may
31
only make the election described in clause (i) if,
32
and SO long as, the State demonstrates to the satis-
33
faction of the Secretary that the such election does
34
not result in Federal expenditures under this title
35
(taking into account any supplemental amounts
36
provided pursuant to section 1511(g)) that are
June 11. 1996
\EGG\MEDICAID\REP\MEDICAI0mmittee Print] Title II, Subtitle A
8
1
greater than the Federal expenditures that would
2
have been made under this title if the State had
3
not made such election.
4
"(C) CURRENT AFDC INCOME AND RESOURCE
5
STANDARDS DEFINED.-In this subsection, the term
6
'current AFDC income and resource standards' means,
7
with respect to a State, the income and resource stand-
8
ards for the payment of assistance under the State
9
plan under part A or E of title IV (as in effect as of
10
May 1, 1996).
11
"(D) STATE OPTION TO CONTINUE TO PROVIDE
12
MEDICAL ASSISTANCE DURING THE TRANSITION FROM
13
WELFARE TO work-Nothing in this title shall be con-
14
strued as preventing a State from continuing to provide
15
medical assistance under a State plan under this title
16
to an individual or a member of such individual's fam-
17
ily who—
18
"(i) is eligible for medical assistance under
19
this title as a result of a link between eligibility for
20
such medical assistance and aid or assistance under
21
one or more parts of title IV or any other program
22
of assistance based on need; and
23
"(ii) because of hours of. or income from, em-
24
ployment is no longer eligible for such aid or assist-
25
ance.
26
"(7) METHODOLOGY.-Family income shall be deter-
2-
mined for purposes of subparagraphs (A) through (C) of
28
paragraph (1) in the same manner (and using the same
?,
methodology) as income was determined under the State
30
medicaid plan under section 1902(1) (as in effect as of May
31
1. 1996).
32
"(b) GUARANTEED COVERAGE OF MEDICARE PREMIUMS
33
AND COST-SHARING FOR CERTAIN MEDICARE BENE-
34
FICLARIES.-
35
"(1) GUARANTEED ELIGIBILITY.-Each State plan
36
shall provide—
June 11. 1996
MEDICAID PMEDICAImmittee Print] Title II, Subtitle A
9
1
"(A) for making medical assistance available for
2
required medicare cost-sharing (as defined in para-
3
graph (2)) for qualified medicare beneficiaries de-
4
scribed in paragraph (3);
5
"(B) for making medical assistance available for
6
payment of medicare premiums under section 1818A
7
for qualified disabled and working individuals described
8
in paragraph (4); and
9
"(C) for making medical assistance available for
10
payment of medicare premiums under section 1839 for
11
individuals who would be qualified medicare bene-
12
ficiaries described in paragraph (3) but for the fact
13
that their income exceeds 100 percent, but is less than
14
120 percent, of the poverty line for a family of the size
15
involved.
16
"(2) REQUIRED MEDICARE COST-SHARING DEFINED.-
17
"(A) IN GENERAL.-In this subsection, the term
18
"required medicare cost-sharing' means, with respect to
19
an individual, costs incurred for medicare cost-sharing
20
described in paragraphs (1) through (4) of section
21
1571(c) (and, at the option of a State. section
22
1571(c)(5))) without regard to whether the costs in-
23
curred were for items and services for which medical
24
assistance is otherwise available under the plan.
25
"(B) LIMITATION ON OBLIGATION FOR CERTAIN
26
COST-SHARING ASSISTANCE.-In the case of medical as-
27
sistance furnished under this title for medicare cost-
28
sharing described in paragraph (2), (3), or (4) of sec-
29
tion 1571(e) relating to the furnishing of a service or
30
item to a medicare beneficiary, nothing in this title
31
shall be construed as preventing a State plan-
32
"(i) from limiting the assistance to the amount
33
(if any) by which (I) the amount that is otherwise
34
payable under the plan for the item or service for
35
eligible individuals who are not such medicare bene-
36
ficiaries (or. if payments for such items or services
June 11. 1996
REPVMEDICAImmittee Print] Title II, Subtitle A
10
I
are made on a capitated basis, an amount reason-
2
ably related or derived from such capitated pay-
3
ment amount), exceeds (II) amount of payment (if
4
any) made under title XVIII with respect to the
5
service or item, and
6
"(ii) if the amount described in subclause (II)
7
of clause (i) exceeds the amount described in
8
subclause (I) of such clause, from treating the
9
amount paid under title XVIII as payment in full
10
and not requiring or providing for any additional
11
medical assistance under this subsection.
12
"(3) QUALIFIED MEDICARE BENEFICIARY DEFINED.-
13
In this subsection, the term 'qualified medicare beneficiary'
14
means an individual-
15
"(A) who is entitled to hospital insurance benefits
16
under part A of title XVIII (including an individual en-
17
titled to such benefits pursuant to an enrollment under
18
section 1818, but not including an individual entitled to
19
such benefits only pursuant to an enrollment under sec-
20
tion 1818A),
21
"(B) whose income (as determined under section
22
1612 for purposes of the supplemental security income
23
program. except as provided in paragraph (5)) does not
X
exceed 100 percent of the poverty line applicable to a
25
family of the size involved, and
26
"(C) whose resources (as determined under section
27
1613 for purposes of the supplemental security income
26
program) do not exceed twice the maximum amount of
29
resources that an individual may have and obtain bene-
30
fits under that program.
31
"(4) QUALIFIED DISABLED AND WORKING INDIVIDUAL
32
DEFINED.-In this subsection, the term 'qualified disabled
33
and working individual' means an individual-
34
"(A) who is entitled to enroll for hospital insur-
35
ance benefits under part A of title XVIII under section
36
1818A:
June 11. 1996
MEDICAID REP MEDICAIDomittee Print] Title II, Subtitle A
11
1
"(B) whose income (as determined under section
2
1612 for purposes of the supplemental security income
3
program) does not exceed 200 percent of the poverty
4
line applicable to a family of the size involved;
5
"(C) whose resources (as determined under section
6
1613 for purposes of the supplemental security income
7
program) do not exceed twice the maximum amount of
8
resources that an individual or a couple (in the case of
9
an individual with a spouse) may have and obtain bene-
10
fits for supplemental security income benefits under
11
title XVI; and
12
"(D) who is not otherwise eligible for medical as-
13
sistance under this title.
14
"(5) INCOME DETERMINATIONS.
15
"(A) IN GENERAL.-In determining under this
16
subsection the income of an individual who is entitled
17
to monthly insurance benefits under title II for a tran-
18
sition month (as defined in subparagraph (B)) in a
19
year, such income shall not include any amounts attrib-
20
utable to an increase in the level of monthly insurance
21
benefits payable under such title which have occurred
22
pursuant to section 215(i) for benefits payable for
23
months beginning with December of the previous year.
24
"(B) TRANSITION MONTH DEFINED.-For pur-
25
poses of subparagraph (A), the term 'transition month'
26
means each month in a year through the month follow-
27
ing the month in which the annual revision of the pov-
28
erty line is published.
29
"SEC. 1502. OTHER PROVISIONS RELATING TO ELIGI-
30
BILITY AND BENEFITS.
31
"(a) OPTIONAL ELIGIBILITY GROUPS FOR WHICH UM-
32
BRELLA SUPPLEMENTAL FUNDING Is AVAILABLE.-In addi-
33
tion to the guaranteed coverage categories described in section
34
1501(a)(1). the following are population groups with respect to
35
which supplemental allotments may be made under section
36
1511(g). but only if (for the individual involved) medical assist-
June 11. 1996
F:\EGG\MEDICAID\REP\MEDICAIQCmmittee Print] Title II, Subtitle A
12
1
ance is made available under the State plan for the guaranteed
2
benefit package (as defined in section 1501(a)(2)):
3
"(1) CERTAIN POOR CHILDREN OVER 12 YEARS OF
4
AGE.-Children born after September 30, 1983, under 12
5
years of age, but under 19 years of age, and whose family
6
income does not exceed 100 percent of the poverty line.
7
"(2) CERTAIN DISABLED INDIVIDUALS-Individuals
8
(not described in section 1501(a)(1)(D)(ii)) who are dis-
9
abled (as determined under section 1614(a)(3)), covered
10
under the State plan, and meet the eligibility standards for
11
coverage under the State medicaid plan under title XIX (as
12
in effect as of May 1, 1996).
13
"(3) CERTAIN ELDERLY INDIVIDUALS-Elderly indi-
14
viduals (not described in section 1501(a)(1)(E)) who are
15
covered under the State plan and who meet the eligibility
16
standards for coverage under the State medicaid plan
17
under title XIX (as in effect as of May 1, 1996) other than
18
solely on the basis of being an individual described in sec-
19
tion 1902(a)(10)(E).
20
Family income under paragraph (1) and eligibility under para-
21
graphs (2) and (3) shall be determined using the methodologies
22
that are not more restrictive than the methodologies used under
23
the State medicaid plan as in effect as of May 1, 1996.
24
"(b) OTHER PROVISIONS RELATING TO GENERAL ELIGI-
25
BILITY AND BENEFITS.-
26
"(1) GENERAL DESCRIPTION.-Each State plan shall
27
include a description (consistent with this title) of the fol-
28
lowing:
29
"(A) ELIGIBILITY GUIDELINES FOR THE NON-
30
GUARANTEED. NON-UMBRELLA POPULATION-The
31
general eligibility guidelines of the plan for eligible low-
32
income individuals who are not covered under sub-
33
section (a) or (b) of section 1501 or under subsection
34
(a) of this section.
35
"(B) SCOPE OF ASSISTANCE.-The amount. dura-
36
tion. and scope of health care services and items cov-
June 11. 1996
MEDICAIDVREP\MEDICAICmmittee Print] Title II, Subtitle A
13
1
ered under the plan, including differences among dif-
2
ferent eligible population groups.
3
"(C) DELIVERY METHOD.-The State's approach
4
to delivery of medical assistance, including a general
5
description of-
6
"(i) the use (or intended use) of vouchers, fee-
7
for-service, or managed care arrangements (such as
8
capitated health care plans, case management, and
9
case coordination); and
10
"(ii) utilization control systems.
11
"(D) FEE-FOR-SERVICE BENEFITS.-To the extent
12
that medical assistance is furnished on a fee-for-service
13
basis-
14
"(i) how the State determines the qualifica-
15
tions of health care providers eligible to provide
16
such assistance; and
17
"(ii) how the State determines rates of reim-
18
bursement for providing such assistance.
19
"(E) COST-SHARING.-Beneficiary cost-sharing (if
20
any), including variations in such cost-sharing by popu-
21
lation group or type of service and financial responsibil-
22
ities of parents of recipients who are children and the
23
spouses of recipients.
24
"(F) UTILIZATION INCENTIVES.-Incentives or re-
25
quirements (if any) to encourage the appropriate utili-
26
zation of services.
27
"(G) SUPPORT FOR CERTAIN HOSPITALS.-
28
"(i) IN GENERAL.-With respect to hospitals
29
described in clause (ii) located in the State, a de-
30
scription of the extent to which provisions are made
31
for expenditures for items and services furnished by
32
such hospitals and covered under the State plan.
33
"(ii) HOSPITALS DESCRIBED.-A hospital de-
34
scribed in this clause is a short-term acute care
35
general hospital or a children's hospital. the low-in-
June 11. 1996
\MEDICAID \MEDICAIDCOmmittee Print] Title II, Subtitle A
14
1
come utilization rate of which exceeds the lesser
2
of-
3
"(I) 1 standard deviation above the mean
4
low-income utilization rate for hospitals receiv-
5
ing payments under a State plan in the State
6
in which such hospital is located, or
7
"(II) 1½ standard deviations above the
8
mean low-income utilization rate for hospitals
9
receiving such payments in the 50 States and
10
the District of Columbia.
11
"(iii) LOW-INCOME UTILIZATION RATE.-For
12
purposes of clause (ii), the term 'low-income utiliza-
13
tion rate' means, for a hospital, a fraction (ex-
14
pressed as a percentage), the numerator of which
15
is the hospital's number of patient days attrib-
16
utable to patients who (for such days) were eligible
17
for medical assistance under a State plan or were
18
uninsured in a period, and the denominator of
19
which is the total number of the hospital's patient
20
days in that period.
21
"(iv) PATIENT DAYS.-For purposes of clause
22
(iii). the term 'patient day' includes each day in
23
which—
24
"(I) an individual, including a newborn, is
25
an inpatient in the hospital, whether or not the
26
individual is in a specialized ward and whether
2-
or not the individual remains in the hospital for
28
lack of suitable placement elsewhere; or
29
"(II) an individual makes one or more out-
30
patient visits to the hospital.
31
"(2) CONDITIONS FOR GUARANTEES AND RELATION
32
OF GUARANTEES TO FINANCING.-The guarantees of
33
States required under subsection (a) and (b) of section
34
1501 and subsection (d) of this section are subject to the
35
limitations on payment to the States provided under section
36
1511 (including the provisions of subsection (g), relating to
June 11. 1996
MEDICAID EPVMEDICAIDmittee Print] Title II, Subtitle A
15
1
supplemental umbrella allotments). In submitting a plan
2
under this title, a State voluntarily agrees to accept pay-
3
ment amounts provided under such section as full payment
4
from the Federal Government in return for providing for
5
the benefits (including the guaranteed benefit package)
6
under this title.
7
"(3) SECONDARY PAYMENT.-Nothing in this section
8
shall be construed as preventing a State from denying ben-
9
efits to an individual to the extent such benefits are avail-
10
able to the individual under the medicare program under
11
title XVIII or under another public or private health care
12
insurance program.
13
"(4) RESIDENCY REQUIREMENT.-In the case of an
14
individual who—
15
"(A) is described in section 1501(a)(1),
16
"(B) changed residence from another State to the
17
State, and
18
"(C) has resided in the State for less than 180
19
days,
20
the State may limit the benefits provided to such individual
21
in the guaranteed benefits package under paragraph (2) of
22
section 1501(a) to the amount, duration, and scope of ben-
23
efits available under the State plan of the individual's pre-
24
vious State of residence.
25
"(c) SET-ASIDE OF FUNDS FOR THE LOW-INCOME DIS-
26
ABLED.-
27
"(1) IN GENERAL.-In the case of a State that has
28
elected the option described in section 1501(a)(1)(D)(i) for
29
a fiscal year. the State plan shall provide that the percent-
30
age of funds expended under the plan for medical assist-
31
ance for eligible low-income individuals who are not elderly
32
individuals and who are eligible for such assistance on the
33
basis of a disability, including being blind, for the fiscal
34
year is not less than the minimum low-income-disabled per-
35
centage specified in paragraph (2) of the total funds ex-
June 11. 1996
MEDICAID REP\MEDICAICmmittee Print] Title II, Subtitle A
16
1
pended under the plan for medical assistance for the fiscal
2
year.
3
"(2) MINIMUM LOW-INCOME-DISABLED PERCENT-
4
AGE.-The minimum low-income-disabled percentage speci-
5
fied in this paragraph for a State is equal to 90 percent
6
of the percentage of the expenditures under title XIX for
7
medical assistance in the State during Federal fiscal year
8
1995 which was attributable to expenditures for medical
9
assistance for benefits furnished to individuals whose cov-
10
erage (at such time) was on a basis directly related to dis-
11
ability status, including being blind.
12
"(3) COMPUTATIONS.-States shall calculate the mini-
13
mum percentage under paragraph (2) in a reasonable man-
14
ner consistent with reports submitted to the Secretary for
15
the fiscal years involved and medical assistance attributable
16
to the exception provided under section 1903(v)(2) shall
17
not be considered to be expenditures for medical assistance.
18
"(d) TRANSITIONAL PAYMENT FOR FEDERALLY-QUALI-
19
FIED HEALTH CENTER SERVICES AND RURAL HEALTH CLINIC
20
SERVICES.-Each State plan shall provide that, for Federally-
21
qualified health center services and rural health clinic services
22
(as defined in section 1571(f)) furnished under the plan during
23
the first 8 calendar quarters in which the plan is in effect and
24
for which payment is made under the plan, payment shall be
25
made for such services at a rate based on 100 percent of costs
26
which are reasonable and related to the cost of furnishing such
27
services or based on such other tests of reasonableness, as the
28
Secretary prescribes in regulations under section 1833(a)(3),
29
or. in the case of services to which those regulations do not
30
apply. on the same methodology used under section 1833(a)(3).
31
"(e) PREEXISTING CONDITION EXCLUSIONS.-Notwith-
32
standing any other provision of this title—
33
"(1) a State plan may not deny or exclude coverage
31
of any item or service for an eligible individual for benefits
35
under the State plan for such item or service on the basis
36
of a preexisting condition; and
June 11. 1996
F:\EGG\MEDICAID\REP\MEDICAICmmittee Print] Title II, Subtitle A
17
1
"(2) if a State contracts or makes other arrangements
2
(through the eligible individual or through another entity)
3
with a capitated health care organization, insurer, or other
4
entity, for the provision of items or services to eligible indi-
5
viduals under the State plan and the State permits such or-
6
ganization, insurer, or other entity to exclude coverage of
7
a covered item or service on the basis of a preexisting con-
8
dition, the State shall provide, through its State plan, for
9
such coverage (through direct payment or otherwise) for
10
any such covered item or service denied or excluded on the
11
basis of a preexisting condition.
12
"(f) SOLVENCY STANDARDS FOR CAPITATED HEALTH
13
CARE ORGANIZATIONS.-
14
"(1) IN GENERAL.-A State may not contract with a
15
capitated health care organization, as defined in section
16
1504(c)(1), for the provision of medical assistance under a
17
State plan under which the organization is-
18
"(A) at full financial risk, as defined by the State,
19
unless the organization meets solvency standards estab-
20
lished by the State for private health maintenance or-
21
ganizations. or
22
"(B) is not at such risk, unless the organization
23
meets solvency standards that are established under the
24
State plan.
25
"(2) TREATMENT OF PUBLIC ENTITIES.-Paragraph
26
(1) shall not apply to an organization that is a public entity
27
or if the solvency of such organization is guaranteed by the
28
State.
29
"(3) TRANSITION.-In the case of a capitated health
30
care organization that as of the date of the enactment of
31
this title has entered into a contract with a State for the
32
provision of medical assistance under title XIX under which
33
the organization assumes full financial risk and is receiving
34
capitation payments. paragraph (1) shall not apply to such
35
organization until 3 years after the date of the enactment
36
of this title.
June 11. 1996
MEDICAID MEDICAIComittee Print] Title II, Subtitle A
18
1
"SEC. 1503. LIMITATIONS ON PREMIUMS AND COST-
2
SHARING.
3
"(a) LIMITATION ON PREMIUMS.-
4
"(1) NONE FOR GUARANTEED POPULATION.-The
5
State plan shall not impose any enrollment fee, premium,
6
or similar charge for eligible individuals described in sub-
7
section (a) or (b) of section 1501 or section 1502(a).
8
"(2) INCOME-RELATED FOR OTHER POPULATIONS.-
9
The State plan may impose an enrollment fee, premium, or
10
similar charge for eligible individuals not described in para-
11
graph (1) if it is related to the individual's income (and
12
does not exceed 2 percent of the individual's gross income).
13
"(b) LIMITATION ON COST-SHARING.-Subject to sub-
14
section (c)—
15
"(1) GUARANTEED POPULATIONS.-With respect to
16
individuals covered under subsection (a) or (b) of section
17
1501 or section 1502, the State may not impose any cost-
18
sharing with respect to items and services unless the
19
amount is nominal in amount. For purposes of this para-
20
graph. an amount is nominal if it does not exceed 6 percent
21
of the amount otherwise payable, or, if greater, 50 cents.
22
"(2) OTHER POPULATIONS.-With respect to individ-
23
uals not described in paragraph (1), the State may not im-
24
pose any cost-sharing with respect to items and services
25
unless such cost sharing is pursuant to a public cost-shar-
26
ing schedule and such cost-sharing is not in excess of the
27
average. nominal cost-sharing imposed in the State for
28
health plans offered by health maintenance organizations
29
(and similar organizations) for the same or similar items
30
and services. as determined by the State insurance commis-
31
sioner.
32
"(c) CERTAIN COST-SHARING PERMITTED.-
33
"(1) IN GENERAL.-Subject to paragraph (2), a State
34
may-
35
"(A) impose additional cost-sharing to discourage
36
the inappropriate use of emergency medical services de-
June 11. 1996
F:VEGG\MEDICAID\REP\MEDICAImmittee Print] Title II, Subtitle A
19
1
livered through a hospital emergency room, a medical
2
transportation provider, or otherwise;
3
"(B) impose additional cost-sharing differentially
4
in order to encourage the use of primary and preventive
5
care and discourage unnecessary or less economical
6
care; and
7
"(C) from imposing additional cost-sharing based
8
on the failure to participate in employment training
9
programs, drug or alcohol abuse treatment, counseling
10
programs, or other programs promoting personal re-
11
sponsibility.
12
"(2) LIMITATION.-The additional cost-sharing im-
13
posed under paragraph (1) may not result-
14
"(A) in the case of an individual described in sub-
15
section (b)(1), in aggregate cost-sharing that exceeds
16
the maximum amount of cost-sharing that may be im-
17
posed under subsection (b)(2) (determined without re-
18
gard to this subsection); or
19
"(B) in the case of an individual described in sub-
20
section (b)(2), in aggregate cost-sharing that exceeds
21
twice the maximum amount of cost-sharing that may
22
be imposed under such subsection (determined without
23
regard to this subsection).
24
"(d) PROHIBITION ON BALANCE BILLING.-An individual
25
eligible for benefits for items and services under the State plan
26
who is furnished such an items or service by a provider under
27
the plan may not be billed by the provider for such item or
28
service. other than such amount of cost-sharing as is permitted
29
with this section."
30
"(e) COST-SHARING DEFINED.-In this section, the term
31
'cost-sharing' includes copayments, deductibles, coinsurance,
32
and other charges for the provision of health care services.
33
"SEC. 1504. DESCRIPTION OF PROCESS FOR DEVELOP-
34
ING CAPITATION PAYMENT RATES.
35
"(a) IN GENERAL.-If a State contracts (or intends to
36
contract) with a capitated health care organization (as defined
June 11. 1996
MEDICAID REP\MEDICAIC0mmittee Print] Title II, Subtitle A
20
1
in subsection (c)(1)) under which the State makes a capitation
2
payment (as defined in subsection (c)(2)) to the organization
3
for providing or arranging for the provision of medical assist-
4
ance under the State plan for a group of services, including at
5
least inpatient hospital services and physicians' services, the
6
plan shall include a description of the following:
7
"(1) USE OF ACTUARIAL SCIENCE.-The extent and
8
manner in which the State uses actuarial science—
9
"(A) to analyze and project health care expendi-
10
tures and utilization for individuals enrolled (or to be
11
enrolled) in such an organization under the State plan,
12
and
13
"(B) to develop capitation payment rates, includ-
14
ing a brief description of the general methodologies
15
used by actuaries.
16
"(2) QUALIFICATIONS OF ORGANIZATIONS.-The gen-
17
eral qualifications, including any accreditation, State licen-
18
sure or certification. or provider network standards, re-
19
quired by the State for participation of capitated health
20
care organizations under the State plan.
21
"(3) DISSEMINATION PROCESS.-The process used by
22
the State under subsection (b) and otherwise to dissemi-
23
nate. before entering into contracts with capitated health
24
care organizations. actuarial information to such organiza-
25
tions on the historical fee-for-service costs (or, if not avail-
26
able. other recent financial data associated with providing
27
covered services) and utilization associated with individuals
28
described in paragraph (1)(A).
29
"(b) PUBLIC NOTICE AND COMMENT.-Under the State
30
plan the State shall provide a process for providing, before the
31
beginning of each contract year-
32
"(1) public notice of-
33
"(A) the amounts of the capitation payments (if
34
any) made under the plan for the contract year preced-
35
ing the public notice. and
June 11. 1996
REPVMEDICAICommittee Print] Title II, Subtitle A
21
1
"(B)(i) the information described under subsection
2
(a)(1) with respect to capitation payments for the con-
3
tract year involved, or (ii) amounts of the capitation
4
payments the State expects to make for the contract
5
year involved,
6
unless such information is designated as proprietary and
7
not subject to public disclosure under State law, and
8
"(2) an opportunity for receiving public comment on
9
the amounts and information for which notice is provided
10
under paragraph (1).
11
"(c) DEFINITIONS.-In this title:
12
"(1) CAPITATED HEALTH CARE ORGANIZATION.-The
13
term 'capitated health care organization' means a health
14
maintenance organization or any other entity (including a
15
health insuring organization, managed care organization,
16
prepaid health plan, integrated service network, or similar
17
entity) which under State law is permitted to accept capita-
18
tion payments for providing (or arranging for the provision
19
of) a group of items and services including at least inpa-
20
tient hospital services and physicians' services.
21
"(2) CAPITATION PAYMENT.-The term 'capitation
22
payment' means, with respect to payment, payment on a
23
prepaid capitation basis or any other risk basis to an entity
24
for the entity's provision (or arranging for the provision)
25
of a group of items and services, including at least inpa-
26
tient hospital services and physicians' services.
27
"SEC. 1505. PREVENTING SPOUSAL IMPOVERISHMENT.
28
"(a) SPECIAL TREATMENT FOR INSTITUTIONALIZED
29
SPOUSES.-
30
"(1) SUPERSEDES OTHER PROVISIONS.-In determin-
31
ing the eligibility for medical assistance of an institutional-
32
ized spouse (as defined in subsection (h)(1)), the provisions
33
of this section supersede any other provision of this title
34
which is inconsistent with them.
June 11. 1996
MEDICAID P\MEDICAIDComittee Print] Title II, Subtitle A
22
1
"(2) DOES NOT AFFECT CERTAIN DETERMINATIONS.-
2
Except as this section specifically provides, this section
3
does not apply to-
4
"(A) the determination of what constitutes income
5
or resources, or
6
"(B) the methodology and standards for determin-
7
ing and evaluating income and resources.
8
"(3) No APPLICATION IN COMMONWEALTHS AND TER-
9
RITORIES.-This section shall only apply to a State that is
10
one of the 50 States or the District of Columbia.
11
"(b) RULES FOR TREATMENT OF INCOME.-
12
"(1) SEPARATE TREATMENT OF INCOME.-During any
13
month in which an institutionalized spouse is in the institu-
14
tion, except as provided in paragraph (2), no income of the
15
community spouse shall be deemed available to the institu-
16
tionalized spouse.
17
"(2) ATTRIBUTION OF INCOME.-In determining the
18
income of an institutionalized spouse or community spouse
19
for purposes of the post-eligibility income determination de-
20
scribed in subsection (d), except as otherwise provided in
21
this section and regardless of any State laws relating to
22
community property or the division of marital property, the
23
following rules apply:
24
"(A) NON-TRUST PROPERTY.-Subject to subpara-
25
graphs (C) and (D), in the case of income not from a
26
trust. unless the instrument providing the income oth-
27
erwise specifically provides-
28
"(i) if payment of income is made solely in the
29
name of the institutionalized spouse or the commu-
30
nity spouse, the income shall be considered avail-
31
able only to that respective spouse,
32
"(ii) if payment of income is made in the
33
names of the institutionalized spouse and the com-
34
munity spouse. 1/2 of the income shall be considered
35
available to each of them. and
June 11. 1996
(REP\MEDICAIDCmmittee Print] Title II, Subtitle A
23
I
"(iii) if payment of income is made in the
2
names of the institutionalized spouse or the com-
3
munity spouse, or both, and to another person or
4
persons, the income shall be considered available to
5
each spouse in proportion to the spouse's interest
6
(or, if payment is made with respect to both
7
spouses and no such interest is specified, 1/2 of the
8
joint interest shall be considered available to each
9
spouse).
10
"(B) TRUST PROPERTY.-In the case of a trust-
11
"(i) except as provided in clause (ii), income
12
shall be attributed in accordance with the provi-
13
sions of this title; and
14
"(ii) income shall be considered available to
15
each spouse as provided in the trust, or, in the ab-
16
sence of a specific provision in the trust—
17
"(I) if payment of income is made solely
18
to the institutionalized spouse or the commu-
19
nity spouse, the income shall be considered
20
available only to that respective spouse,
21
"(II) if payment of income is made to both
22
the institutionalized spouse and the community
23
spouse, 1/2 of the income shall be considered
24
available to each of them, and
25
"(III) if payment of income is made to the
26
institutionalized spouse or the community
27
spouse. or both, and to another person or per-
28
sons. the income shall be considered available
29
to each spouse in proportion to the spouse's in-
30
terest (or, if payment is made with respect to
31
both spouses and no such interest is specified,
32
1/2 of the joint interest shall be considered
33
available to each spouse).
34
"(C) PROPERTY WITH NO INSTRUMENT.-In the
35
case of income not from a trust in which there is no
36
instrument establishing ownership, subject to subpara-
June 11. 1996
:\EGGVMEDICAID\REP\MEDICAI(mmittee Print] Title II, Subtitle A
24
1
graph (D), 1/2 of the income shall be considered to be
2
available to the institutionalized spouse and 1/2 to the
3
community spouse.
4
"(D) REBUTTING OWNERSHIP.-The rules of sub-
5
paragraphs (A) and (C) are superseded to the extent
6
that an institutionalized spouse can establish, by a pre-
7
ponderance of the evidence, that the ownership inter-
8
ests in income are other than as provided under such
9
subparagraphs.
10
"(c) RULES FOR TREATMENT OF RESOURCES.-
11
"(1) COMPUTATION OF SPOUSAL SHARE AT TIME OF
12
INSTITUTIONALIZATION.-
13
"(A) TOTAL JOINT RESOURCES.-There shall be
14
computed (as of the beginning of the first continuous
15
period of institutionalization of the institutionalized
16
spouse)-
17
"(i) the total value of the resources to the ex-
18
tent either the institutionalized spouse or the com-
19
munity spouse has an ownership interest, and
20
"(ii) a spousal share which is equal to 1/2 of
21
such total value.
22
"(B) ASSESSMENT.-At the request of an institu-
23
tionalized spouse or community spouse, at the begin-
24
ning of the first continuous period of institutionaliza-
25
tion of the institutionalized spouse and upon the receipt
26
of relevant documentation of resources, the State shall
27
promptly assess and document the total value described
28
in subparagraph (A)(i) and shall provide a copy of such
29
assessment and documentation to each spouse and shall
30
retain a copy of the assessment for use under this sec-
31
tion. If the request is not part of an application for
32
medical assistance under this title, the State may, at
33
its option as a condition of providing the assessment,
34
require payment of a fee not exceeding the reasonable
35
expenses of providing and documenting the assessment.
36
At the time of providing the copy of the assessment,
June 11. 1996
:\EGG\MEDICAID\REP\MEDICAImmittee Print] Title II, Subtitle A
25
1
the State shall include a notice indicating that the
2
spouse will have a right to a fair hearing under sub-
3
section (e)(2).
4
"(2) ATTRIBUTION OF RESOURCES AT TIME OF INI-
5
TIAL ELIGIBILITY DETERMINATION.-In determining the
6
resources of an institutionalized spouse at the time of ap-
7
plication for medical assistance under this title, regardless
8
of any State laws relating to community property or the di-
9
vision of marital property-
10
"(A) except as provided in subparagraph (B), all
11
the resources held by either the institutionalized
12
spouse, community spouse, or both, shall be considered
13
to be available to the institutionalized spouse, and
14
"(B) resources shall be considered to be available
15
to an institutionalized spouse, but only to the extent
16
that the amount of such resources exceeds the amount
17
computed under subsection (f)(2)(A) (as of the time of
18
application for medical assistance).
19
"(3) ASSIGNMENT OF SUPPORT RIGHTS.-The institu-
20
tionalized spouse shall not be ineligible by reason of re-
21
sources determined under paragraph (2) to be available for
22
the cost of care where—
23
"(A) the institutionalized spouse has assigned to
24
the State any rights to support from the community
25
spouse.
26
"(B) the institutionalized spouse lacks the ability
27
to execute an assignment due to physical or mental im-
28
pairment but the State has the right to bring a support
29
proceeding against a community spouse without such
30
assignment, or
31
"(C) the State determines that denial of eligibility
32
would work an undue hardship.
33
"(4) SEPARATE TREATMENT OF RESOURCES AFTER
34
ELIGIBILITY FOR MEDICAL ASSISTANCE ESTABLISHED.-
35
During the continuous period in which an institutionalized
36
spouse is in an institution and after the month in which
June 11. 1996
MEDICAID REP\MEDICAICmittee Print] Title II, Subtitle A
26
1
an institutionalized spouse is determined to be eligible for
2
medical assistance under this title, no resources of the com-
3
munity spouse shall be deemed available to the institu-
4
tionalized spouse.
5
"(5) RESOURCES DEFINED.-In this section, the term
6
'resources' does not include—
7
"(A) resources excluded under subsection (a) or
8
(d) of section 1613, and
9
"(B) resources that would be excluded under sec-
10
tion 1613(a)(2)(A) but for the limitation on total value
11
described in such section.
12
"(d) PROTECTING INCOME FOR COMMUNITY SPOUSE.-
13
"(1) ALLOWANCES TO BE OFFSET FROM INCOME OF
14
INSTITUTIONALIZED SPOUSE.-After an institutionalized
15
spouse is determined or redetermined to be eligible for
16
medical assistance, in determining the amount of the
17
spouse's income that is to be applied monthly to payment
18
for the costs of care in the institution, there shall be de-
19
ducted from the spouse's monthly income the following
20
amounts in the following order:
21
"(A) A personal needs allowance (described in
22
paragraph (2)(A)), in an amount not less than the
23
amount specified in paragraph (2)(C).
24
"(B) A community spouse monthly income allow-
25
ance (as defined in paragraph (3)), but only to the ex-
26
tent income of the institutionalized spouse is made
27
available to (or for the benefit of) the community
28
spouse.
29
"(C) A family allowance, for each family member,
30
equal to at least 1/3 of the amount by which the amount
31
described in paragraph (4)(A)(i) exceeds the amount of
32
the monthly income of that family member.
33
"(D) Amounts for incurred expenses for medical
34
or remedial care for the institutionalized spouse as pro-
35
vided under paragraph (6).
June 11. 1996
EPVMEDICAIDMittee Print] Title II, Subtitle 4
27
1
In subparagraph (C), the term 'family member' only in-
2
cludes minor or dependent children, dependent parents, or
3
dependent siblings of the institutionalized or community
4
spouse who are residing with the community spouse.
5
"(2) PERSONAL NEEDS ALLOWANCE.-
6
"(A) IN GENERAL-The State plan must provide
7
that, in the case of an institutionalized individual or
8
couple described in subparagraph (B), in determining
9
the amount of the individual's or couple's income to be
10
applied monthly to payment for the cost of care in an
11
institution, there shall be deducted from the monthly
12
income (in addition to other allowances otherwise pro-
13
vided under the plan) a monthly personal needs allow-
14
ance-
15
"(i) which is reasonable in amount for clothing
16
and other personal needs of the individual (or cou-
17
ple) while in an institution, and
18
"(ii) which is not less (and may be greater)
19
than the minimum monthly personal needs allow-
20
ance described in subparagraph (C).
21
"(B) INSTITUTIONALIZED INDIVIDUAL OR COUPLE
22
DEFINED.-In this paragraph, the term 'institutional-
23
ized individual or couple' means an individual or mar-
24
ried couple—
25
"(i) who is an inpatient (or who are inpa-
26
tients) in a medical institution or nursing facility
27
for which payments are made under this title
28
throughout a month, and
29
"(ii) who is or are determined to be eligible for
30
medical assistance under the State plan.
31
"(C) MINIMUM ALLOWANCE.-The minimum
32
monthly personal needs allowance described in this sub-
33
paragraph is $40 for an institutionalized individual and
34
$80 for an institutionalized couple (if both are aged,
35
blind. or disabled. and their incomes are considered
36
available to each other in determining eligibility).
June 11. 1996
REP/MEDICAICmittee Print] Title II, Subtitle A
28
1
"(3) COMMUNITY SPOUSE MONTHLY INCOME ALLOW-
2
ANCE DEFINED.-
3
"(A) IN GENERAL.-In this section (except as pro-
4
vided in subparagraph (B)), the community spouse
5
monthly income allowance for a community spouse is
6
an amount by which—
7
"(i) except as provided in subsection (e), the
8
minimum monthly maintenance needs allowance
9
(established under and in accordance with para-
10
graph (4)) for the spouse, exceeds
11
"(ii) the amount of monthly income otherwise
12
available to the community spouse (determined
13
without regard to such an allowance).
14
"(B) COURT ORDERED SUPPORT.-If a court has
15
entered an order against an institutionalized spouse for
16
monthly income for the support of the community
17
spouse, the community spouse monthly income allow-
18
ance for the spouse shall be not less than the amount
19
of the monthly income so ordered.
20
"(4) ESTABLISHMENT OF MINIMUM MONTHLY MAIN-
21
TENANCE NEEDS ALLOWANCE.-
22
"(A) IN GENERAL-Each State shall establish a
23
minimum monthly maintenance needs allowance for
24
each community spouse which, subject to subparagraph
25
(B). is equal to or exceeds-
26
"(i) 150 percent of 1/12 of the poverty line ap-
27
plicable to a family unit of 2 members, plus
28
"(ii) an excess shelter allowance (as defined in
29
paragraph (4)).
30
A revision of the poverty line referred to in clause (i)
31
shall apply to medical assistance furnished during and
32
after the second calendar quarter that begins after the
33
date of publication of the revision.
34
"(B) CAP ON MINIMUM MONTHLY MAINTENANCE
35
NEEDS ALLOWANCE.-The minimum monthly mainte-
36
nance needs allowance established under subparagraph
June 11. 1996
MEDICAID PVMEDICAImittee Print] Title II, Subtitle A
29
1
(A) may not exceed $1,500 (subject to adjustment
2
under subsections (e) and (g)).
3
"(5) EXCESS SHELTER ALLOWANCE DEFINED.-In
4
paragraph (4)(A)(ii), the term 'excess shelter allowance'
5
means, for a community spouse, the amount by which the
6
sum of-
7
"(A) the spouse's expenses for rent or mortgage
8
payment (including principal and interest), taxes and
9
insurance and, in the case of a condominium or cooper-
10
ative, required maintenance charge, for the community
11
spouse's principal residence, and
12
"(B) the standard utility allowance (used by the
13
State under section 5(e) of the Food Stamp Act of
14
1977) or, if the State does not use such an allowance,
15
the spouse's actual utility expenses,
16
exceeds 30 percent of the amount described in paragraph
17
(4)(A)(i), except that, in the case of a condominium or co-
18
operative, for which a maintenance charge is included
19
under subparagraph (A), any allowance under subpara-
20
graph (B) shall be reduced to the extent the maintenance
21
charge includes utility expenses.
22
"(6) TREATMENT OF INCURRED EXPENSES.-With re-
23
spect to the post-eligibility treatment of income under this
24
section, there shall be disregarded reparation payments
25
made by the Federal Republic of Germany and, there shall
26
be taken into account amounts for incurred expenses for
27
medical or remedial care that are not subject to payment
28
by a third party. including-
29
"(A) medicare and other health insurance pre-
30
miums. deductibles, or coinsurance, and
31
"(B) necessary medical or remedial care recog-
32
nized under State law but not covered under the State
33
plan under this title, subject to reasonable limits the
34
State may establish on the amount of these expenses.
35
"(e) NOTICE AND FAIR HEARING.-
36
"(1) NOTICE.-Upon-
June 11. 1996
REP\MEDICAIDCOmmittee Print] Title II, Subtitle A
30
1
"(A) a determination of eligibility for medical as-
2
sistance of an institutionalized spouse, or
3
"(B) a request by either the institutionalized
4
spouse, or the community spouse, or a representative
5
acting on behalf of either spouse,
6
each State shall notify both spouses (in the case described
7
in subparagraph (A)) or the spouse making the request (in
8
the case described in subparagraph (B)) of the amount of
9
the community spouse monthly income allowance (described
10
in subsection (d)(1)(B)), of the amount of any family allow-
11
ances (described in subsection (d)(1)(C)), of the method for
12
computing the amount of the community spouse resources
13
allowance permitted under subsection (f), and of the
14
spouse's right to a fair hearing under the State plan re-
15
specting ownership or availability of income or resources,
16
and the determination of the community spouse monthly
17
income or resource allowance.
18
"(2) FAIR HEARING.-
19
"(A) IN GENERAL.-If either the institutionalized
20
spouse or the community spouse is dissatisfied with a
21
determination of-
22
"(i) the community spouse monthly income al-
23
lowance;
24
"(ii) the amount of monthly income otherwise
25
available to the community spouse (as applied
26
under subsection (d)(3)(A)(ii));
27
"(iii) the computation of the spousal share of
28
resources under subsection (c)(1);
29
"(iv) the attribution of resources under sub-
30
section (c)(2); or
31
"(v) the determination of the community
32
spouse resource allowance (as defined in subsection
33
(f)(2));
34
such spouse is entitled to a fair hearing under the
35
State plan with respect to such determination if an ap-
36
plication for benefits under this title has been made on
June 11. 1996
:\EGG\MEDICAID\REP\MEDICAI0mmittee Print] Title II, Subtitle A
31
1
behalf of the institutionalized spouse. Any such hearing
2
respecting the determination of the community spouse
3
resource allowance shall be held within 30 days of the
4
date of the request for the hearing.
5
"(B) REVISION OF MINIMUM MONTHLY MAINTE-
6
NANCE NEEDS ALLOWANCE.-If either such spouse es-
7
tablishes that the community spouse needs income,
8
above the level otherwise provided by the minimum
9
monthly maintenance needs allowance, due to excep-
10
tional circumstances resulting in significant financial
11
duress, there shall be substituted, for the minimum
12
monthly maintenance needs allowance in subsection
13
(d)(3)(A)(i), an amount adequate to provide such addi-
14
tional income as is necessary.
15
"(C) REVISION OF COMMUNITY SPOUSE RESOURCE
16
ALLOWANCE.-If either such spouse establishes that
17
the community spouse resource allowance (in relation
18
to the amount of income generated by such an allow-
19
ance) is inadequate to raise the community spouse's in-
20
come to the minimum monthly maintenance needs al-
21
lowance. there shall be substituted, for the community
22
spouse resource allowance under subsection (f)(2), an
23
amount adequate to provide such a minimum monthly
24
maintenance needs allowance.
25
"(f) PERMITTING TRANSFER OF RESOURCES TO COMMU-
26
NITY SPOUSE.-
27
"(1) IN GENERAL.-An institutionalized spouse may,
28
without regard to any other provision of the State plan to
29
the contrary. transfer an amount equal to the community
30
spouse resource allowance (as defined in paragraph (2)),
31
but only to the extent the resources of the institutionalized
32
spouse are transferred to, or for the sole benefit of, the
33
community spouse. The transfer under the preceding sen-
34
tence shall be made as soon as practicable after the date
35
of the initial determination of eligibility, taking into ac-
June 11. 1996
MEDICAID MEDICAImittee Print] Title II, Subtitle A
32
1
count such time as may be necessary to obtain a court
2
order under paragraph (3).
3
"(2) COMMUNITY SPOUSE RESOURCE ALLOWANCE DE-
4
FINED.-In paragraph (1), the 'community spouse resource
5
allowance' for a community spouse is an amount (if any)
6
by which—
7
"(A) the greatest of-
8
"(i) $12,000 (subject to adjustment under
9
subsection (g)), or, if greater (but not to exceed the
10
amount specified in clause (ii)(II)) an amount spec-
11
ified under the State plan,
12
"(ii) the lesser of (I) the spousal share com-
13
puted under subsection (c)(1), or (II) $60,000
14
(subject to adjustment under subsection (g)),
15
"(iii) the amount established under subsection
16
(e)(2), or
17
"(iv) the amount transferred under a court
18
order under paragraph (3);
19
exceeds
20
"(B) the amount of the resources otherwise avail-
21
able to the community spouse (determined without re-
22
gard to such an allowance).
23
"(3) TRANSFERS UNDER COURT ORDERS.-If a court
24
has entered an order against an institutionalized spouse for
25
the support of the community spouse, any provisions under
26
the plan relating to transfers or disposals of assets for less
27
than fair market value shall not apply to amounts of re-
28
sources transferred pursuant to such order for the support
29
of the spouse or a family member (as defined in subsection
30
(d)(1)).
31
"(g) INDEXING DOLLAR AMOUNTS.-For services fur-
32
nished during a calendar year after 1989, the dollar amounts
33
specified in subsections (d)(3)(C), (f)(2)(A)(i), and
34
(f)(2)(A)(ii)(III) shall be increased by the same percentage as
35
the percentage increase in the consumer price index for all
36
urban consumers (all items; U.S. city average) between Sep-
June 11. 1996
\EGG\MEDICAID\REP\MEDICAImmittee Print] Title II, Subtitle A
33
1
tember 1988 and the September before the calendar year in-
2
volved.
3
"(h) DEFINITIONS.-In this section:
4
"(1) INSTITUTIONALIZED SPOUSE.-The term 'institu-
5
tionalized spouse' means an individual-
6
"(A)(i) who is in a medical institution or nursing
7
facility, or
8
"(ii) at the option of the State (I) who would be
9
eligible under the State plan under this title if such in-
10
dividual was in a medical institution, (II) with respect
11
to whom there has been a determination that but for
12
the provision of home or community-based services
13
such individual would require the level of care provided
14
in a hospital, nursing facility or intermediate care facil-
15
ity for the mentally retarded the cost of which could be
16
reimbursed under the plan, and (III) who will receive
17
home or community-based services pursuant the plan;
18
and
19
"(B) is married to a spouse who is not in a medi-
20
cal institution or nursing facility;
21
but does not include any such individual who is not likely
22
to meet the requirements of subparagraph (A) for at least
23
30 consecutive days.
24
"(2) COMMUNITY SPOUSE.-The term 'community
25
spouse' means the spouse of an institutionalized spouse.
26
"SEC. 1506. PREVENTING FAMILY IMPOVERISHMENT.
27
"(a) RESPONSIBILITIES FOR LONG-TERM AND INSTITU-
28
TIONAL CARE GENERALLY.-A State plan may not-
29
"(1) require an adult child or any other individual
30
(other than the applicant or recipient of services or the
31
spouse of such an applicant or recipient) to contribute to
32
the cost of covered nursing facility services, other long-term
33
care services. and hospital and other institutional services
34
under the plan: and
35
"(2) take into account with respect to such services
36
the financial responsibility of any individual for any appli-
June 11, 1996
MEDICAID PVMEDICAIomittee Print] Title II, Subtitle A
34
1
cant or recipient of assistance under the plan unless such
2
applicant or recipient is such individual's spouse or such in-
3
dividual's child who is under age 21 or (with respect to
4
States eligible to participate in the State program estab-
5
lished under title XVI), is blind or permanently and totally
6
disabled, or is blind or disabled as defined in section 1614
7
(with respect to States which are not eligible to participate
8
in such program).
9
"(b) LIMITATIONS ON LIENS.-
10
"(1) IN GENERAL.-No lien may be imposed against
11
the property of any individual prior to the individual's
12
death on account of medical assistance paid or to be paid
13
on the individual's behalf under a State plan, except-
14
"(A) pursuant to the judgment of a court on ac-
15
count of benefits incorrectly paid on behalf of such in-
16
dividual; or
17
"(B) in the case of the real property of an individ-
18
ual-
19
"(i) who is an inpatient in a nursing facility,
20
intermediate care facility for the mentally retarded,
21
or other medical institution, if such individual is re-
22
quired. as a condition of receiving services in such
23
institution under the plan, to spend for costs of
24
medical care all but a minimal amount of the indi-
25
vidual's income required for personal needs, and
26
"(ii) with respect to whom the State deter-
27
mines. after notice and opportunity for a hearing
28
(in accordance with procedures established by the
29
State), that the individual cannot reasonably be ex-
30
pected to be discharged from the medical institu-
31
tion and to return home,
32
except as provided in paragraph (2).
33
"(2) EXCEPTION.-No lien may be imposed under
34
paragraph (1)(B) on such individual's home if-
35
"(A) the spouse of such individual,
June 11. 1996
MEDICAID REP\MEDICAImittee Print] Title II, Subtitle A
35
1
"(B) such individual's child who is under age 21,
2
or (with respect to States eligible to participate in the
3
State program established under title XVI) is blind or
4
permanently and totally disabled, or (with respect to
5
States which are not eligible to participate in such pro-
6
gram) is blind or disabled as defined in section 1614,
7
or
8
"(C) a sibling of such individual (who has an eq-
9
uity interest in such home and who was residing in
10
such individual's home for a period of at least one year
11
immediately before the date of the individual's admis-
12
sion to the medical institution),
13
is lawfully residing in such home.
14
"(3) DISSOLUTION UPON RETURN HOME.-Any lien
15
imposed with respect to an individual pursuant to para-
16
graph (1)(B) shall dissolve upon that individual's discharge
17
from the medical institution and return home.
18
"SEC. 1507. STATE FLEXIBILITY.
19
"(a) STATE FLEXIBILITY IN BENEFITS, GEOGRAPHICAL
20
COVERAGE AREA, AND SELECTION OF PROVIDERS.-The State
21
under its State plan may-
22
"(1) specify those items and services for which medical
23
assistance is provided (consistent with guarantees under
24
subsections (a) and (b) of section 1501), the providers
25
which may provide such items and services, and the amount
26
and frequency of providing such items and services (con-
27
sistent with the requirements of section 1502(d));
28
"(2) specify the extent to which the same medical as-
29
sistance will be provided in all geographical areas or politi-
30
cal subdivisions of the State, so long as medical assistance
31
is made available in all such areas or subdivisions;
32
"(3) specify the extent to which the medical assistance
33
made available to any individual eligible for medical assist-
34
ance is comparable in amount, duration, or scope to the
35
medical assistance made available to any other such indi-
36
vidual; and
June 11. 1996
MEDICAID \MEDICAImittee Print] Title II, Subtitle A
36
1
"(4) specify the extent to which an individual eligible
2
for medical assistance with respect to an item or service
3
may choose to obtain such assistance from any institution,
4
agency, or person qualified to provide the item or service.
5
"(b) STATE FLEXIBILITY WITH RESPECT TO MANAGED
6
CARE.-Nothing in this title shall be construed—
7
"(1) to limit a State's ability to contract with, on a
8
capitated basis or otherwise, health care plans or individual
9
health care providers for the provision or arrangement of
10
medical assistance,
11
"(2) to limit a State's ability to contract with health
12
care plans or other entities for case management services
13
or for coordination of medical assistance, or
14
"(3) to restrict a State from establishing capitation
15
rates on the basis of competition among health care plans
16
or negotiations between the State and one or more health
17
care plans.
18
"SEC. 1508. PRIVATE RIGHTS OF ACTION.
19
"(a) LIMITATION ON FEDERAL CAUSES OF ACTION.-Ex-
20
cept as provided in this section, no person or entity may bring
21
an action against a State in Federal court based on its failure
22
to comply with any requirement of this title.
23
"(b) STATE CAUSES OF ACTION.-
24
"(1) ADMINISTRATIVE AND JUDICIAL PROCEDURES.-
25
A State plan shall provide for-
26
"(A) an administrative procedure whereby an indi-
27
vidual alleging a denial of eligibility for benefits or a
28
denial of benefits under the State plan may receive a
29
hearing regarding such denial, and
30
"(B) judicial review, through a private right of ac-
31
tion in a State court by an individual or class of indi-
32
viduals. regarding such a denial, but a State may re-
33
quire exhaustion of administrative remedies before such
34
an action may be taken.
June 11. 1996
MEDICAID REP\MEDICAICmittee Print] Title II, Subtitle A
37
1
The administrative procedure under subparagraph (A) shall
2
include impartial decision makers and a fair process and
3
timely decisions.
4
"(2) WRIT OF CERTIORARI.-An individual or class
5
may file a petition for certiorari before the Supreme Court
6
of the United States in a case of a denial of benefits under
7
the State plan to review a determination of the highest
8
court of a State regarding such denial.
9
(3) CONSTRUCTION.-Nothing in this subsection shall
10
be construed as requiring a State to provide a private right
11
of action in State court by a provider, health plan, or a
12
class of providers or health plans.
13
"(c) SECRETARIAL RELIEF.-
14
"(1) IN GENERAL.-The Secretary may bring an ac-
15
tion in Federal court against a State and on behalf of an
16
individual or class of individuals in order to assure that a
17
State provides benefits to individuals and classes of individ-
18
uals as guaranteed under subsection (a) or (b) of section
19
1501 under its State plan.
20
"(2) No PRIVATE RIGHT.-No action may be brought
21
in any court against the Secretary based on the Secretary's
22
bringing. or failure to bring, an action under paragraph
23
(1).
24
"(3) CONSTRUCTION.-Nothing in this title shall be
25
construed as authorizing the Secretary to bring an action
26
on behalf of a provider, health plan, or a class of providers
27
or health plans.
28
"PART B-PAYMENTS TO STATES
29
"SEC. 1511. ALLOTMENT OF FUNDS AMONG STATES.
30
"(a) ALLOTMENTS.-
31
"(1) COMPUTATION.-The Secretary shall provide for
32
the computation of State obligation and outlay allotments
33
in accordance with this section for each fiscal year begin-
34
ning with fiscal year 1997. Nothing in this part shall be
35
construed as authorizing payment under this part to any
36
State for fiscal year 1996.
June 11. 1996
:\EGG\MEDICAID\REP\MEDICAImmittee Print] Title II, Subtitle A
38
1
"(2) LIMITATION ON OBLIGATIONS.--
2
"(A) IN GENERAL.-Subject to the succeeding pro-
3
visions of this paragraph, the Secretary shall not enter
4
into obligations with any State under this title for a fis-
5
cal year in excess of the sum of the following allot-
6
ments for the State for the fiscal year:
7
"(i) BASE OBLIGATION ALLOTMENT.-The
8
amount of the base obligation allotment for that
9
State for the fiscal year under paragraph (4).
10
"(ii) SUPPLEMENTAL ALLOTMENT FOR CER-
11
TAIN ALIENS.-The amount of any supplemental
12
allotment for that State for the fiscal year under
13
subsection (f).
14
"(iii) SUPPLEMENTAL PER BENEFICIARY UM-
15
BRELLA ALLOTMENT.-The amount of any supple-
16
mental per beneficiary umbrella allotment for that
17
State for the fiscal year under subsection (g).
18
"(iv) SUPPLEMENTAL ALLOTMENT FOR IN-
19
DIAN HEALTH SERVICES.-The amount of any sup-
20
plemental allotment for that State for the fiscal
21
year under subsection (h).
22
The sum of the base obligation allotments for all States in
23
any fiscal year (excluding amounts carried over under sub-
24
paragraph (B) and excluding changes in allotments effected
25
under paragraph (4)(D)) shall not exceed the aggregate
26
limit on new base obligation authority specified in para-
27
graph (3) for that fiscal year.
28
"(B) ADJUSTMENTS.-
29
"(i) CARRYOVER OF BASE ALLOTMENT PER-
30
MITTED.-Subject to clauses (ii), if the amount of
31
obligations entered into under this part with a
32
State for quarters in a fiscal year is less than the
33
amount of the obligation allotment under this sec-
34
tion to the State for the fiscal year, the amount of
35
the difference (less any amount computed under
36
clause (iii)) shall be added to the amount of the
June 11. 1996
REPVMEDICAIDCommittee Print] Title II, Subtitle A
39
1
State obligation allotment otherwise provided under
2
this section for the succeeding fiscal year.
3
"(ii) No CARRYOVER PERMITTED FOR STATES
4
RECEIVING SUPPLEMENTAL UMBRELLA ALLOT-
5
MENTS.-Clause (i) shall not apply, insofar as it
6
permits a carryover for a State from a particular
7
year to the next year, if in the particular year the
8
State receives a supplemental umbrella allotment
9
under subsection (g).
10
"(iii) No CARRYOVER OF ALIEN AND INDIAN
11
SUPPLEMENTAL ALLOTMENTS.-The amount of
12
any carryover under clause (i) from a fiscal year
13
shall be reduced by the amount (if any) by which
14
the amount of the outlays for expenditures de-
15
scribed in subsection (f) or (h) for the fiscal year
16
is less than the amount of any supplemental allot-
17
ment provided under the respective subsection for
18
the State and fiscal year involved.
19
"(C) REDUCTION FOR NEW OBLIGATIONS UNDER
20
TITLE XIX IN FISCAL YEAR 1997.-The amount of the
21
base obligation allotment otherwise provided under this
22
section for fiscal year 1997 for a State shall be reduced
23
by the amount of the obligations entered into with re-
24
spect to the State under section 1903(a) during such
25
fiscal year.
26
"(D) No EFFECT ON PRIOR YEAR OBLIGATIONS.-
27
Subparagraph (A) shall not apply to or affect obliga-
28
tions for a fiscal year prior to fiscal year 1997.
29
"(E) OBLIGATION.-For purposes of this section,
30
the Secretary's establishment of an estimate under sec-
31
tion 1512(b) of the amount a State is entitled to re-
32
ceive for a quarter (taking into account any adjust-
33
ments described in such subsection) beginning during
34
or after fiscal year 1997 shall be treated as the obliga-
35
tion of such amount for the State as of the first day
36
of the quarter.
June 11. 1996
EP\MEDICAIComittee Print] Title II, Subtitle A
40
1
"(F) RELATION TO GUARANTEES-The Federal
2
Government's obligations for payments under this title
3
are limited as provided under subparagraph (A) and
4
are only subject to adjustment based on any guarantee
5
provided under section 1501 as provided under sub-
6
section (g).
7
"(3) AGGREGATE LIMIT ON NEW BASE OBLIGATION
8
AUTHORITY.-
9
"(A) IN GENERAL-For purposes of this sub-
10
section, subject to subparagraph (C), the 'aggregate
11
limit on new base obligation authority', for a fiscal
12
year, is the base pool amount under subsection (b) for
13
the fiscal year, divided by the payout adjustment factor
14
(described in subparagraph (B)) for the fiscal year.
15
"(B) PAYOUT ADJUSTMENT FACTOR.-For pur-
16
poses of this subsection, the 'payout adjustment fac-
17
tor'-
18
"(i) for fiscal year 1997 is 0.950,
19
"(ii) for fiscal year 1998 is 0.986, and
20
"(iii) for a subsequent fiscal year is 0.998.
21
"(C) TRANSITIONAL ADJUSTMENT FOR PRE-FIS-
22
CAL YEAR 1997-OBLIGATION OUTLAYS.-In order to ac-
23
count for pre-fiscal year 1997-obligation outlays de-
24
scribed in paragraph (4)(C)(iv), in determining the ag-
25
gregate limit on new obligation authority under sub-
26
paragraph (A) for fiscal year 1997, the pool amount
27
for such fiscal year is equal to-
28
"(i) the pool amount for such year, reduced by
29
"(ii) $12,000,000,000.
30
"(4) BASE OBLIGATION ALLOTMENTS.-
31
"(A) GENERAL RULE FOR 50 STATES AND THE
32
DISTRICT OF COLUMBIA-Except as provided in this
33
paragraph. the 'base obligation allotment' for any of
34
the 50 States or the District of Columbia for a fiscal
35
year (beginning with fiscal year 1997) is an amount
36
that bears the same ratio to the base outlay allotment
June 11. 1996
F:\EGG MEDICAID MEDICAIDCmmittee Print] Title II, Subtitle .4
41
1
under subsection (c)(2) for such State or District (not
2
taking into account any adjustment due to an election
3
under subsection (c)(4)) for the fiscal year as the ratio
4
of-
5
"(i) the aggregate limit on new base obligation
6
authority (less the total of the obligation allotments
7
under subparagraph (B)) for the fiscal year, to
8
"(ii) the base pool amount (less the sum of the
9
base outlay allotments for the territories) for such
10
fiscal year.
11
"(B) TERRITORIES-The base obligation allot-
12
ment for each of the Commonwealths and territories
13
for a fiscal year is the base outlay allotment for such
14
Commonwealth or Territory (as determined under sub-
15
section (c)(5)) for the fiscal year divided by the payout
16
adjustment factor for the fiscal year (as defined in
17
paragraph (3)(B)).
18
"(C) TRANSITIONAL RULE FOR FISCAL YEAR
19
1997.-
20
"(i) IN GENERAL.-The obligation amount for
21
fiscal year 1997 for any State (including the Dis-
22
trict of Columbia. a Commonwealth, or Territory)
23
is determined according to the formula: A=(B-C)/
24
D. where—
25
"(I) 'A' is the base obligation amount for
26
such State,
27
"(II) 'B' is the base outlay allotment of
28
such State for fiscal year 1997, as determined
29
under subsection (c),
30
"(III) 'C" is the amount of the pre-enact-
31
ment-obligation outlays (as established for such
32
State under clause (ii)), and
33
"(IV) 'D' is the payout adjustment factor
34
for such fiscal year (as defined in paragraph
35
(3)(B)).
June 11. 1996
REP\MEDICAICmmittee Print] Title II, Subtitle A
42
1
"(ii) PRE-FISCAL YEAR 1997-OBLIGATION OUT-
2
LAY AMOUNTS.-Not later than November 1, 1996.
3
the Secretary shall estimate (based on the best
4
data available) and publish in the Federal Register
5
the amount of the pre-fiscal year 1997-obligation
6
outlays (as defined in clause (iv)) for each State
7
(including the District of Columbia, Common-
8
wealths, and Territories). The total of such
9
amounts shall equal the dollar amount specified in
10
paragraph (3)(C)(ii).
11
"(iii) AGREEMENT.-The submission of a
12
State plan by a State under this title is deemed to
13
constitute the State's acceptance of the obligation
14
allotment limitations under this subsection, includ-
15
ing the formula for computing the amount of the
16
base obligation allotment and any supplemental ob-
17
ligation allotments.
18
"(iv) PRE-FISCAL YEAR 1997-OBLIGATION OUT-
19
LAYS DEFINED.-In this subsection, the term 'pre-
20
fiscal year 1997-obligation outlays' means, for a
21
State. the outlays of the Federal Government that
22
result from obligations that have been incurred
23
under title XIX with respect to the State before
24
October 1, 1996, but for which payments to States
25
have not been made as of such date.
26
"(D) ADJUSTMENT TO REFLECT ADOPTION OF AL-
27
TERNATIVE GROWTH FORMULA-Any State that has
28
elected an alternative growth formula under subsection
29
(c)(4) which increases or decreases the dollar amount
30
of an outlay allotment for a fiscal year is deemed to
31
have increased or decreased, respectively, its obligation
32
amount for such fiscal year by the amount of such in-
33
crease or decrease.
34
"(E) TRANSITIONAL CORRECTION FOR FISCAL
35
YEAR 1997.-
June 11. 1996
EGG MEDICAIDOmmittee Print] Title II, Subtitle A
43
1
"(i) IN GENERAL.-The base obligation
2
amount for fiscal year 1998 for any State described
3
in clause (ii) shall be increased by the amount by
4
which the amount described in clause (ii)(I) exceeds
5
the amount described in clause (ii)(II), divided by
6
the payout adjustment factor specified in para-
7
graph (3)(B) for fiscal year 1997. The increase
8
under this clause shall be paid to a State in the
9
first quarter of fiscal year 1998.
10
"(ii) STATES DESCRIBED.-A State described
11
in this clause is a State for which—
12
"(I) the amount of the pre-fiscal year
13
1997-obligation outlays (as established for such
14
State under subparagraph (C)(ii)), exceeded
15
"(II) the outlays of the Federal Govern-
16
ment during fiscal year 1997 that are attrib-
17
utable to obligations that were incurred under
18
title XIX with respect to the State before Octo-
19
ber 1, 1996, but for which payments to States
20
had not been made as of such date.
21
"(5) SEQUENCE OF OBLIGATIONS.-For purposes of
22
carrying out this title, payments under section 1512 to a
23
State eligible for a supplemental outlay allotment that are
24
attributable to-
25
"(A) expenditures for medical assistance described
26
in the second sentence of subsection (f)(1) or the sec-
27
ond sentence of subsection (h)(1) shall first be counted
28
toward the supplemental outlay allotment provided
29
under subsection (f) or (h), respectively, rather than to-
30
ward the base outlay allotment otherwise provided
31
under this section; or
32
"(B) subsection (g) (relating to the umbrella fund)
33
shall first be counted toward the allotment provided
34
other than under such subsection, and then to such
35
subsection.
36
"(b) BASE POOL OF AVAILABLE FUNDS.-
June 11. 1996
REP\MEDICAIDCmittee Print] Title II, Subtitle A
44
1
"(1) IN GENERAL.-For purposes of this section, the
2
'base pool amount' under this subsection for-
3
"(A) fiscal year 1996 is $96,601,037,894,
4
"(B) fiscal year 1997 is $103,447,755,053,
5
"(C) fiscal year 1998 is $108,430,173,129,
6
"(D) fiscal year 1999 is $113,652,562,483,
7
"(E) fiscal year 2000 is $119,126,480,999,
8
"(F) fiscal year 2001 is $124,864,043,230,
9
"(G) fiscal year 2002 is $130,877,947,213, and
10
"(H) each subsequent fiscal year is the pool
11
amount under this paragraph for the previous fiscal
12
year increased by the lesser of 4.82 percent or the an-
13
nual percentage increase in the gross domestic product
14
for the 12-month period ending in June before the be-
15
ginning of that subsequent fiscal year.
16
"(2) NATIONAL GROWTH PERCENTAGE.-For purposes
17
of this section for a fiscal year (beginning with fiscal year
18
1997), the 'national growth percentage' is the percentage
19
by which-
20
"(A) the base pool amount under paragraph (1)
21
for the fiscal year, exceeds
22
"(B) such base pool amount for the previous fiscal
23
year.
24
"(c) STATE BASE OUTLAY ALLOTMENTS.-
25
"(1) FISCAL YEAR 1996.-
26
"(A) IN GENERAL.-For each of the 50 States
27
and the District of Columbia, the amount of the State
28
base outlay allotment under this subsection for fiscal
29
year 1996 is. subject to paragraph (4), determined in
30
accordance with the following table:
"State or District:
Outlay allotment (in dollars):
Alabama
1.517.652.207
Alaska
204.933.213
Arizona
1,385,781,297
Arkansas
1.011.457,933
California
8.946.838,461
Colorado
757,492,679
Connecticut
1.463.011.635
Delaware
212.327,763
June 11. 1996
MEDICAID MEDICAIDmittee Print] Title II, Subtitle A
45
"State or District:
Outlay allotment (in dollars):
District of Columbia
501.412,091
Florida
3,715,624,180
Georgia
2,426,320,602
Hawaii
323,124,375
Idaho
278,329,686
Illinois
3,467,274,342
Indiana
1,952,467,267
Iowa
835.235,895
Kansas
713,700,869
Kentucky
1,577,828,832
Louisiana
2,622,000,000
Maine
694,220,790
Maryland
1,369,699,847
Massachusetts
2,870,346,862
Michigan
3.465,182,886
Minnesota
1,793,776,356
Mississippi
1,261,781,330
Missouri
1,849,248,945
Montana
312,212,472
Nebraska
463,900,417
Nevada
257,896,453
New Hampshire
560,000,000
New Jersey
2,854,621,241
New Mexico
634,756,945
New York
12.901,793,038
North Carolina
2.587,883,809
North Dakota
241,168,563
Ohio
4,034,049,690
Oklahoma
911,198,775
Oregon
1,088,670,440
Pennsylvania
4.454.423,400
Rhode Island
545.686.262
South Carolina
1,621,021,815
South Dakota
262.804.959
Tennessee
2.519.934.251
Texas
6.351.909.343
Utah
484.274.254
Vermont
248.158.729
Virginia
1.144.962,509
Washington
1.763.460,996
West Virginia
1.156.813.157
Wisconsin
1.709,500,642
Wyoming
132,915,390.
I
"(2) FOR SUBSEQUENT FISCAL YEARS.-
2
"(A) IN GENERAL.-Subject to the succeeding pro-
3
visions of this subsection, the amount of the State base
4
outlay allotment under this subsection for one of the 50
5
States and the District of Columbia for a fiscal year
June 11. 1996
MEDICAID PVMEDICAImmittee Print] Title II, Subtitle A
46
1
(beginning with fiscal year 1997) is equal to the prod-
2
uct of-
3
"(i) the needs-based amount determined under
4
subparagraph (B) for such State or District for the
5
fiscal year, and
6
"(ii) the adjustment factor described in sub-
7
paragraph (C) for the fiscal year.
8
"(B) NEEDS-BASED AMOUNT.-The needs-based
9
amount under this subparagraph for a State or the
10
District of Columbia for a fiscal year is equal to the
11
product of-
12
"(i) the State's or District's aggregate expend-
13
iture need for the fiscal year (as determined under
14
subsection (d)), and
15
"(ii) the State's or District's old Federal medi-
16
cal assistance percentage (as defined in section
17
1512(d)) for the fiscal year (or, in the case of fiscal
18
year 1997, the Federal medical assistance percent-
19
age determined under section 1905(b) for fiscal
20
year 1996).
21
"(C) ADJUSTMENT FACTOR.-The adjustment fac-
22
tor under this subparagraph for a fiscal year is such
23
proportion so that, when it is applied under subpara-
24
graph (A)(ii) for the fiscal year (taking into account
25
the floors and ceilings under paragraph (3)), the total
26
of the base outlay allotments under this subsection for
27
all the 50 States and the District of Columbia for the
28
fiscal year (not taking into account any increase in a
29
base outlay allotment for a fiscal year attributable to
30
the election of an alternative growth formula under
31
paragraph (4)) is equal to the amount by which (i) the
32
base pool amount for the fiscal year (as determined
33
under subsection (b)), exceeds (ii) the sum of the base
34
outlay allotments provided under paragraph (5) for the
35
Commonwealths and Territories for the fiscal year.
36
"(3) FLOORS AND CEILINGS.-
June 11. 1996
MEDICAID PMEDICAIDCmittee Print] Title II, Subtitle A
47
1
"(A) FLOORS.-Subject to the ceiling established
2
under subparagraph (B), in no case shall the amount
3
of the State base outlay allotment under paragraph (2)
4
for a fiscal year be less than the greatest of the follow-
5
ing.
6
"(i) IN GENERAL.-Beginning with fiscal year
7
1998, 0.24 percent of the pool amount for the fis-
8
cal year.
9
"(ii) FLOOR BASED ON PREVIOUS YEAR'S OUT-
10
LAY ALLOTMENT.-Subject to clause (iii)-
11
"(I) for fiscal year 1997, 103.5 percent of
12
the amount of the State base outlay allotment
13
under this subsection for fiscal year 1996,
14
"(II) for fiscal year 1998, 103 percent of
15
the amount of the State base outlay allotment
16
under this subsection for fiscal year 1997,
17
"(III) for fiscal year 1999, 102.5 percent
18
of the amount of the State base outlay allot-
19
ment under this subsection for fiscal year
20
1998,
21
"(IV) for fiscal year 2000, 102.25 percent
22
of the amount of the State base outlay allot-
23
ment under this subsection for fiscal year
24
1999, and
25
"(V) for each of fiscal years 2001 and
26
2002, 102 percent of the amount of the State
27
base outlay allotment under this subsection for
28
the previous fiscal year.
29
"(iii) FLOOR BASED ON OUTLAY ALLOTMENT
30
GROWTH RATE IN FIRST YEAR-Beginning with
31
fiscal year 1998, in the case of a State for which
32
the outlay allotment under this subsection for fiscal
33
year 1997 exceeded its outlay allotment under this
34
subsection for the previous fiscal year by more than
35
95 percent of the national growth percentage for
June 11. 1996
:\EGG\MEDICAID\REP\MEDICAI0mittee Print] Title II, Subtitle A
48
1
fiscal year 1997, 90 percent of the national growth
2
percentage for the fiscal year involved.
3
"(B) CEILINGS.-
4
"(i) IN GENERAL.-Subject to clause (ii), in
5
no case shall the amount of the State base outlay
6
allotment under paragraph (2) for a fiscal year be
7
greater than the product of-
8
"(I) the State base outlay allotment under
9
this subsection for the State for the preceding
10
fiscal year, and
11
"(II) the applicable percent (specified in
12
clause (ii) or (iii)) for the fiscal year involved.
13
"(ii) GENERAL RULE FOR APPLICABLE PER-
14
CENT.-For purposes of clause (i), subject to
15
clause (iii), the 'applicable percent' for fiscal year
16
1997 is 126.98 percent and for a subsequent fiscal
17
year is 133 percent of the national growth percent-
18
age for the fiscal year.
19
"(iii) SPECIAL RULE.-For a fiscal year after
20
fiscal year 1997, in the case of a State (among the
21
50 States and the District of Columbia) that is one
22
of the 10 States with the lowest Federal spending
23
per resident-in-poverty rates (as determined under
24
clause (iv)) for the fiscal year, the 'applicable per-
25
cent' is 150 percent of the national growth percent-
26
age for the fiscal year.
27
"(iv) DETERMINATION OF FEDERAL SPENDING
28
PER RESIDENT-IN-POVERTY RATE.-For purposes
29
of clause (iii), the 'Federal spending per resident-
30
in-poverty rate' for a State for a fiscal year is equal
31
to-
32
"(I) the State's outlay allotment under
33
this subsection for the previous fiscal year (de-
34
termined without regard to paragraph (4)), di-
35
vided by
June 11. 1996
P\MEDICAIDCmittee Print] Title II, Subtitle A
49
1
"(II) the average annual number of resi-
2
dents of the State in poverty (as defined in
3
subsection (d)(2)) with respect to the fiscal
4
year.
5
"(C) SPECIAL RULE.-
6
"(i) IN GENERAL.-Notwithstanding the pre-
7
ceding subparagraphs of this paragraph, the State
8
base outlay allotment for—
9
"(I) Louisiana, subject to subclause (II),
10
for each of the fiscal years 1997 through 2000,
11
is $2,622,000,000,
12
"(II) Louisiana for fiscal year 1997 only,
13
as otherwise determined, shall be increased by
14
$37,048,207, and
15
"(III) Nevada for each of fiscal years
16
1997, 1998, and 1999, as otherwise deter-
17
mined, shall be increased by $90,000,000.
18
"(ii) EXCEPTION.-A State described in
19
subclause (I) of clause (i) may apply to the Sec-
20
retary for use of the State base outlay allotment
21
otherwise determined under this subsection for any
22
fiscal year, if such State notifies the Secretary not
23
later than March 1 preceding such fiscal year that
24
such State will be able to expend sufficient State
25
funds in such fiscal year to qualify for such allot-
26
ment.
27
"(iii) TREATMENT OF INCREASE AS SUPPLE-
28
MENTAL ALLOTMENT.-Any increase in an outlay
29
allotment under clause (i)(II) or (i)(III) shall not
30
be taken into account for purposes of determin-
31
ing-
32
"(I) the adjustment factor under para-
33
graph (2) for fiscal year 1997,
34
"(II) any State base outlay allotment for
35
a fiscal year after fiscal year 1997,
June 11. 1996
MEDICAID PVMEDICAICommittee Print] Title II, Subtitle A
50
1
"(III) the base pool amount for a fiscal
2
year after fiscal year 1997, or
3
"(IV) determination of the national
4
growth percentage for any fiscal year.
5
"(4) ELECTION OF ALTERNATIVE GROWTH FOR-
6
MULA-
7
"(A) ELECTION.-In order to reduce variations in
8
increases in outlay allotments over time, any of the 50
9
States or the District of Columbia may elect (by notice
10
provided to the Secretary by not later than April 1,
11
1997) to adopt an alternative growth rate formula
12
under this paragraph for the determination of the
13
State's base outlay allotment in fiscal year 1997 and
14
for the increase in the amount of such allotment in
15
subsequent fiscal years.
16
"(B) FORMULA.-The alternative growth formula
17
under this paragraph may be any formula under which
18
a portion of the State base outlay allotment for fiscal
19
year 1997 under paragraph (1) is deferred and applied
20
to increase the amount of its base outlay allotment for
21
one or more subsequent fiscal years, so long as the
22
total amount of such increases for all such subsequent
23
fiscal years does not exceed the amount of the base
24
outlay allotment deferred from fiscal year 1997.
25
"(5) COMMONWEALTHS AND TERRITORIES.-
26
"(A) IN GENERAL-The base outlay allotment for
27
each of the Commonwealths and Territories for a fiscal
28
year is the maximum amount that could have been cer-
29
tified under section 1108(c) (as in effect on the day be-
30
fore the date of the enactment of this title) with respect
31
to the Commonwealth or Territory for the fiscal year
32
with respect to title XIX, if the national growth per-
33
centage (as determined under subsection (b)(2)) for the
34
fiscal year had been substituted (beginning with fiscal
35
year 1997) for the percentage increase referred to in
36
section 1108(c)(1)(B) (as SO in effect).
June 11. 1996
Print] Title II, Subtitle A
51
I
"(B) DISREGARD OF ROUNDING REQUIRE-
2
MENTS.-For purposes of subparagraph (A), the
3
rounding requirements under section 1108(c) shall not
4
apply.
5
"(C) LIMITATION ON TOTAL AMOUNT FOR FISCAL
6
YEAR 1996.-Notwithstanding the provisions of sub-
7
paragraph (A), the total amount of the base outlay al-
8
lotments for the Commonwealths and Territories for
9
fiscal year 1996 may not exceed $139,950,000.
10
"(d) STATE AGGREGATE EXPENDITURE NEED DETER-
11
MINED.-
12
"(1) IN GENERAL.-For purposes of subsection (c),
13
the 'State aggregate expenditure need' for a State or the
14
District of Columbia for a fiscal year is equal to the prod-
15
uct of the following 4 factors:
16
"(A) PROGRAM NEED.-The program need for the
17
State for the fiscal year, as determined under para-
18
graph (2).
19
"(B) HEALTH CARE COST INDEX-The health
20
care cost index for the State (as determined under
21
paragraph (3)) for the most recent fiscal year for which
22
data are available.
23
"(C) PROJECTED INFLATION.-The CPI increase
24
factor for the fiscal year (as defined in subsection
25
(g)(4)(C)).
26
"(D) NATIONAL AVERAGE SPENDING PER RESI-
27
DENT IN POVERTY.-The national average spending per
28
resident in poverty (as determined under paragraph
29
(4)).
30
"(2) PROGRAM NEED.-
31
"(A) IN GENERAL.-In this subsection and subject
32
to subparagraph (D), the 'program need' of a State for
33
a fiscal year is equal to the sum, for each of the popu-
34
lation groups described in subparagraph (B), of the
35
product described in subparagraph (C) for that popu-
36
lation group.
June 11. 1996
":\EGG\MEDICAID\REP\MEDICAImmitee Print] Title II, Subtitle A
52
1
"(B) POPULATION GROUPS DESCRIBED.-The
2
population groups described in this subparagraph are
3
as follows:
4
"(i) INDIVIDUALS BETWEEN 60 AND 85.-Indi-
5
viduals who are least 60, but less than 85, years
6
of age.
7
"(ii) INDIVIDUALS 85 OR OLDER-Individuals
8
who are 85 years of age or older.
9
"(iii) DISABLED INDIVIDUALS-Individuals
10
who are eligible for medical assistance because such
11
individuals are blind or disabled and are not de-
12
scribed in clause (i) or (ii).
13
"(iv) CHILDREN-Individuals described in
14
subsection (g)(2)(B).
15
"(v) OTHER INDIVIDUALS.-Individuals not
16
described in a previous clause of this subparagraph.
17
"(C) PRODUCT DESCRIBED.-The product de-
18
scribed in this subparagraph, with respect to a popu-
19
lation group for a fiscal year for a State (or District),
20
is the product of the following 2 factors for that group,
21
year, and State (or District):
22
"(i) WEIGHTING FACTOR REFLECTING REL-
23
ATIVE NEED FOR THE GROUP.-For all States, the
24
national average per recipient expenditures under
25
this title in the 50 States and the District of Co-
26
lumbia for individuals in such group, as determined
27
under subparagraph (E), divided by the national
28
average of such averages for all such groups
29
(weighted by the number of recipients in each
30
group).
31
"(ii) NUMBER OF NEEDY IN GROUP.-The
32
product of-
33
"(I) for all groups, the average annual
34
number of residents in poverty in such State or
35
District (based on data made generally avail-
36
able by the Bureau of the Census from the
June 11. 1996
F:\EGG MEDICAID Print] Title II, Subtitle A
53
1
Current Population Survey) for the most recent
2
3-calendar-year period (ending before the fiscal
3
year) for which such data are available; and
4
"(II) the proportion, of all individuals who
5
received medical assistance under this title in
6
such State or District, that were individuals in
7
such group.
8
In clause (ii)(II), the term 'resident in poverty'
9
means an individual whose family income does not
10
exceed the poverty threshold (as such terms are de-
11
fined by the Office of Management and Budget and
12
are generally interpreted and applied by the Bu-
13
reau of the Census for the year involved).
14
"(D) FLOORS AND CEILINGS ON PROGRAM
15
NEED.-
16
"(i) IN GENERAL.-In no case shall the value
17
of the program need for a State for a fiscal year
18
be less than 90 percent, or be more than 115 per-
19
cent, of the program need based on national aver-
20
ages (determined under clause (ii)) for that State
21
for the fiscal year.
22
"(ii) PROGRAM NEED BASED ON NATIONAL
23
AVERAGES.-For purposes of clause (i), the 'pro-
24
gram need based on national average' for a fiscal
25
year is equal to the sum of the product (for each
26
of the population groups) of the following 3 factors
27
(for that group. year, and State or District):
28
"(I) WEIGHTING FACTOR FOR GROUP.-
29
The weighting factor for the group (described
30
in subparagraph (C)(i)).
31
"(II) TOTAL NUMBER OF NEEDY IN
32
STATE.-For all groups, the average annual
33
number of residents in poverty in such State or
34
District (as defined in subparagraph (C)(ii)(I)).
35
"(III) NATIONAL PROPORTION OF NEEDY
36
IN GROUP.-The proportion, of all individuals
June 11. 1996
MEDICAID EPVMEDICAICmmittee Print] Title II, Subtitle A
54
1
who received medical assistance under this title
2
in all of the States and the District in all such
3
groups, that were individuals in such group.
4
"(E) DETERMINATION OF NATIONAL AVERAGES
5
AND PROPORTIONS-The national averages per recipi-
6
ent and the proportions referred to in subparagraph
7
(C)(ii) and (C)(iii), respectively, shall be determined by
8
the Secretary using the most recent data available.
9
"(F) EXPENDITURE DEFINED.-For purposes of
10
this paragraph, the term 'expenditure' means medical
11
vendor payments by basis of eligibility as reported by
12
HCFA Form 2082.
13
"(3) HEALTH CARE COST INDEX-
14
"(A) IN GENERAL.-In this section, the 'health
15
care cost index' for a State or the District of Columbia
16
for a fiscal year is the sum of-
17
"(i) 0.15, and
18
"(ii) 0.85 multiplied by the ratio of (I) the an-
19
nual average wages for hospital employees in such
20
State or District for the fiscal year (as determined
21
under subparagraph (B)), to (II) the annual aver-
22
age wages for hospital employees in the 50 States
23
and the District of Columbia for such year (as de-
24
termined under such subparagraph).
25
"(B) DETERMINATION OF ANNUAL AVERAGE
26
WAGES OF HOSPITAL EMPLOYEES.-The Secretary
27
shall provide for the determination of annual average
28
wages for hospital employees in a State or the District
29
of Columbia and, collectively, in the 50 States and the
30
District of Columbia for a fiscal year based on the area
31
wage data applicable to hospitals under section
32
1886(d)(2)(E) (or, if such data no longer exists, com-
33
parable data of hospital wages) for discharges occur-
34
ring during the fiscal year involved.
June 11. 1996
(REP\MEDICAIDomittee Print] Title II, Subtitle A
55
1
"(4) NATIONAL AVERAGE SPENDING PER RESIDENT IN
2
POVERTY.-For purposes of this subsection, the national
3
average spending per resident in poverty'-
4
"(A) for fiscal year 1997 is equal to-
5
"(i) the sum (for each of the 50 States and
6
the District of Columbia) of the total of the Fed-
7
eral and State expenditures under title XIX for cal-
8
endar quarters in fiscal year 1994, increased by the
9
percentage by which (I) the base pool amount for
10
fiscal year 1997, exceeds (II) $83,213,431,458
11
(which represents Federal medicaid expenditures
12
for such States and District for fiscal year 1994);
13
divided by
14
"(ii) the sum of the number of residents in
15
poverty (as defined in paragraph (2)(C)(ii)(I)) for
16
all of the 50 States and the District of Columbia
17
for fiscal year 1994; and
18
"(B) for a succeeding fiscal year is equal to the
19
national average spending per resident in poverty under
20
this paragraph for the preceding fiscal year increased
21
by the national growth percentage (as defined in sub-
22
section (b)(2)) for the fiscal year involved.
23
"(e) PUBLICATION OF OBLIGATION AND OUTLAY ALLOT-
24
MENTS.-
25
"(1) NOTICE OF PRELIMINARY ALLOTMENTS.-Not
26
later than April 1 before the beginning of each fiscal year
27
(beginning with fiscal year 1997), the Secretary shall ini-
28
tially compute. after consultation with the Comptroller
29
General. and publish in the Federal Register notice of the
30
proposed base obligation allotment, base outlay allotment,
31
and supplemental allotments under subsections (f) and (h)
32
for each State under this section (not taking into account
33
subsection (a)(2)(B)) for the fiscal year. The Secretary
34
shall include in the notice a description of the methodology
35
and data used in deriving such allotments for the year.
June 11. 1996
:\EGGAMEDICAID\REPVMEDICAImmittee Print] Title II, Subtitle A
56
1
"(2) REVIEW BY GAO.-The Comptroller General shall
2
submit to Congress by not later than May 15 of each such
3
fiscal year, a report analyzing such allotments and the ex-
4
tent to which they comply with the precise requirements of
5
this section.
6
"(3) NOTICE OF FINAL ALLOTMENTS.-Not later than
7
July 1 before the beginning of each such fiscal year, the
8
Secretary, taking into consideration the analysis contained
9
in the report of the Comptroller General under paragraph
10
(2), shall compute and publish in the Federal Register no-
11
tice of the final allotments under this section (both taking
12
into account and not taking into account subsection
13
(a)(2)(B)) for the fiscal year. The Secretary shall include
14
in the notice a description of any changes in such allot-
15
ments from the initial allotments published under para-
16
graph (1) for the fiscal year and the reasons for such
17
changes. Once published under this paragraph, the Sec-
18
retary is not authorized to change such allotments.
19
"(4) GAO REPORT ON FINAL ALLOTMENTS.-The
20
Comptroller General shall submit to Congress by not later
21
than August 1 of each such fiscal year, a report analyzing
22
the final allotments under paragraph (3) and the extent to
23
which they comply with the precise requirements of this
24
section.
25
"(5) TRANSITIONAL RULE FOR FISCAL YEAR 1997.-
26
With respect to fiscal year 1997, the deadlines under the
27
previous provisions of this subsection shall be extended by
28
a number of days equal to the number of days between
29
May 1. 1996. and the date of the enactment of this title.
30
"(f) SUPPLEMENTAL ALLOTMENT FOR CERTAIN HEALTH
31
CARE SERVICES TO CERTAIN ALIENS.-
32
"(1) IN GENERAL.-For purposes of this section for
33
each of fiscal years 1998 through 2002 in the case of a
34
subsection (f) supplemental allotment eligible State, the
35
amount of the supplemental allotment under this subsection
36
is the amount provided under paragraph (2) for the State
June 11. 1996
MEDICAID P\MEDICAIComittee Print] Title II, Subtitle A
57
1
for that year. Such amount may only be used for the pur-
2
pose of providing medical assistance for care and services
3
for aliens described in paragraph (1) of section 1513(f) and
4
for which the exception described in paragraph (2) of such
5
section applies. Section 1512(f)(4) shall apply to such as-
6
sistance in the same manner as it applies to medical assist-
7
ance described in such section.
8
"(2) SUPPLEMENTAL AMOUNT.-
9
"(A) IN GENERAL.-For purposes of paragraph
10
(1), the supplemental amount for a subsection (f) sup-
11
plemental allotment eligible State for a fiscal year is
12
equal to the subsection (f) supplemental allotment ratio
13
(as defined in subparagraph (C)) multiplied by the sub-
14
section (f) supplemental pool amount (specified in sub-
15
paragraph (D)) for the fiscal year.
16
"(B) SUBSECTION (f) SUPPLEMENTAL ALLOTMENT
17
ELIGIBLE STATE.-In this subsection, the term 'sub-
18
section (f) supplemental allotment eligible State' means
19
one of the 15 States with the highest number of un-
20
documented alien residents of all the States.
21
"(C) SUBSECTION (f) SUPPLEMENTAL ALLOTMENT
22
RATIO.-In this paragraph, the 'subsection (f) supple-
23
mental allotment ratio' for a State is the ratio of-
24
"(i) the number of undocumented aliens resid-
25
ing in the State, to
26
"(ii) the sum of such numbers for all sub-
27
section (f) supplemental allotment eligible States.
28
"(D) SUBSECTION (f) SUPPLEMENTAL POOL
29
AMOUNT.-In this paragraph, the 'subsection (f) sup-
30
plemental pool amount'-
31
"(i) for fiscal year 1998 is $500,000,000,
32
"(ii) for fiscal year 1999 is $600,000,000,
33
"(iii) for fiscal year 2000 is $700,000,000,
34
"(iv) for fiscal year 2001 is $800,000,000. and
35
"(v) for fiscal year 2002 is $900,000,000.
36
"(E) DETERMINATION OF NUMBER-
June 11. 1996
MEDICAID P\MEDICAICmittee Print] Title II, Subtitle A
58
1
"(i) IN GENERAL.-The number of undocu-
2
mented aliens residing in a State under this para-
3
graph—
4
"(I) for fiscal year 1998 shall be deter-
5
mined based on estimates of the resident illegal
6
alien population residing in each State pre-
7
pared by the Statistics Division of the Immi-
8
gration and Naturalization Service as of Octo-
9
ber 1992, and
10
"(II) for a subsequent fiscal year shall be
11
determined based on the most recent updated
12
estimate made under clause (ii).
13
"(ii) UPDATING ESTIMATE.-For each fiscal
14
year beginning with fiscal year 1999, the Secretary,
15
in consultation with the Commission of the Immi-
16
gration and Naturalization Service, States, and
17
outside experts, shall estimate the number of un-
18
documented aliens residing in each of the 50 States
19
and the District of Columbia.
20
"(g) SUPPLEMENTAL PER BENEFICIARY UMBRELLA AL-
21
LOTMENT FOR STATES WITH EXCESS GROWTH IN CERTAIN
22
POPULATION GROUPS.-
23
"(1) IN GENERAL.-Subject to paragraphs (5) through
24
(7). for purposes of this section the amount of the supple-
25
mental allotment under this subsection for a State for a fis-
26
cal year (beginning with fiscal year 1997) is the sum, for
27
each supplemental allotment population group described in
28
paragraph (2), of the product of the following:
29
"(A) EXCESS NUMBER OF INDIVIDUALS.-The ex-
30
cess number of individuals (if any, determined under
31
paragraph (3)) for State and the fiscal year who are
32
in the population group.
33
"(B) APPLICABLE PER BENEFICIARY AMOUNT.-
34
The applicable per beneficiary amount (determined
35
under paragraph (4)) for the State and fiscal year for
36
the population group.
June 11. 1996
MEDICAID REPVMEDICAIDCommittee Print] Title II, Subtitle A
59
1
"(C) FMAP.-The old Federal medical assistance
2
percentage (as defined in section 1512(d)) for the State
3
and fiscal year.
4
"(2) SUPPLEMENTAL ALLOTMENT POPULATION
5
GROUP.-In this subsection, each of the following shall be
6
considered to be a separate 'supplemental allotment popu-
7
lation group':
8
"(A) POOR PREGNANT WOMEN.-Individuals de-
9
scribed in section 1501(a)(1)(A).
10
"(B) POOR CHILDREN-Individuals (not described
11
in subparagraph (C))-
12
"(i) described in subparagraph (B) or (C) of
13
section 1501(a)(1),
14
"(ii) described in subparagraph (F) or (G) of
15
section 1501(a)(1) who are under 21 years of age
16
and who are not pregnant women, or
17
"(iii) described in section 1502(a) under para-
18
graph (1) of that section.
19
"(C) POOR DISABLED INDIVIDUALS.-Only in the
20
case of a State that has elected the option (of guaran-
21
teeing coverage of disabled individuals) described in
22
section 1501(a)(1)(D)(ii) for the fiscal year (and, in
23
the case of a fiscal year after fiscal year 1997, for the
24
previous fiscal year), individuals—
25
"(i) who are described in such section; or
26
"(ii) who are described in section 1502(a)
27
under paragraph (2) of that section.
28
"(D) POOR ELDERLY INDIVIDUALS-Individuals
29
who are-
30
"(i) described in section 1501(a)(1)(E); or
31
"(ii) described in section 1502(a) under para-
32
graph (3) of that section.
33
"(E) QUALIFIED MEDICARE BENEFICIARIES.-In-
34
dividuals described in section 1501(b)(1)(A) who are
35
not described in subparagraph (D).
June 11. 1996
:\EGG/MEDICAID\REP\MEDICAIDmmittee Print] Title II, Subtitle A
60
1
"(F) QUALIFIED DISABLED AND WORKING INDI-
2
VIDUALS.-Individuals described in section
3
1501(b)(1)(B) who are not described in subparagraph
4
(D).
5
"(G) CERTAIN OTHER MEDICARE BENE-
6
FICIARIES-Individuals described in section
7
1501(b)(1)(C) who are not described in subparagraph
8
(D).
9
"(H) OTHER POOR ADULTS-Individuals de-
10
scribed in section 1501(a)(1)(G) who are not within a
11
population group described in a previous subparagraph.
12
"(3) EXCESS NUMBER OF INDIVIDUALS.-
13
"(A) IN GENERAL.-In this subsection, the 'excess
14
number of individuals', for a State for a fiscal year
15
with respect to a supplemental allotment population
16
group, is equal to the amount (if any) by which—
17
"(i) the number of full-year equivalent individ-
18
uals in the population group for the State and fis-
19
cal year, exceeds
20
"(ii) the anticipated number of such individ-
21
uals (as determined under subparagraph (B)) for
22
the State and fiscal year in such group.
23
"(B) ANTICIPATED NUMBER.-
24
"(i) IN GENERAL.-In subparagraph (A)(ii),
25
the 'anticipated number' of individuals for a State
26
in a supplemental allotment population group for-
27
"(I) fiscal year 1997 is equal to the num-
28
ber of full-year equivalent individuals in such
29
group enrolled in the State medicaid plan
30
under title XIX in fiscal year 1996 increased
31
by the percentage increase factor (described in
32
clause (ii)) for fiscal year 1997; or
33
"(II) a subsequent fiscal year is equal to
34
the number of full-year equivalent individuals
35
in the population group for the State for the
36
previous fiscal year increased by the percentage
June 11. 1996