Senate Report 106-323 - BREAST AND CERVICAL CANCER TREATMENT ACT

[Senate Report 106-323]
[From the U.S. Government Publishing Office]

Calendar No. 641
106th Congress Report
SENATE
2d Session 106-323

======================================================================

BREAST AND CERVICAL CANCER TREATMENT ACT

_______

June 27, 2000.--Ordered to be printed

_______

Mr. Roth, from the Committee on Finance, submitted the following

R E P O R T

[To accompany S. 662]

[Including cost estimate of the Congressional Budget Office]

The Committee on Finance, to which was referred the bill
(S. 662) to amend title XIX of the Social Security Act to
provide medical assistance for certain woment screened and
found to have breast cancer under a federally funded screening
program, having considered the same, reports favorably thereon
with an amendment and recommends that the bill (as amended) do
pass.

CONTENTS

Page
I. Summary and Background............................................1
A. Summary............................................... 1
B. Background and Reasons for Legislation................ 2
C. Legislative History................................... 2
II. Explanation of the Bill...........................................2
A. Coverage as Optional Categorically Needy Group........ 2
B. Presumptive Eligibility............................... 4
C. Enhanced Match........................................ 6
D. Effective Date........................................ 6
III.Budget Effects of the Bill........................................6

IV. Vote of the Committee............................................10
V. Regulatory Impact................................................10
VI. Changes in Existing Law..........................................11

I. SUMMARY AND BACKGROUND

A. Summary

S. 662, as reported by the Committee on Finance, creates a
new option for states to extend Medicaid eligibility to
individuals receiving a cancer diagnosis through the Centers
for Disease Control's Breast and Cervical Cancer Early
Detection Program.

B. Background and Reasons for Legislation

Nearly 10 years ago, Congress created the National Breast
and Cervical Cancer Early Detection Program, through the
Centers for Disease Control, to help lower-income women receive
the early detection services that are the best protection
against breast and cervical cancer. This important program has
served more than a million women in subsequent years. However,
the screening program does not include a treatment component.
Instead, women who receive cancer diagnoses must rely on
informal networks of donated care.
S. 662 fulfills a promise made nearly 10 years ago. The
federal government will continue to help lower-income,
uninsured women access needed preventive health care services.
But now the federal commitment will not stop with screening. If
problems are found, the federal government will work with the
states to provide necessary treatment services to women facing
cancer diagnoses.
S. 662 makes treatment available to eligible women through
the Medicaid program. There are very valid concerns about
creating disease-specific Medicaid eligibility categories.
However, S. 662 deals with a thoroughly unique set of
circumstances. The new Medicaid eligibility category created in
S. 662 is specifically linked to a unique and existing federal
screening program, and shall not be viewed as a precedent for
extending Medicaid eligibility body-part by body-part.

C. Legislative History

Senator John Chafee introduced S. 662 on March 18, 1999,
and then on July 27th he chaired a Finance Committee Health
Subcommittee hearing on the bill. At the hearing, witnesses
from the health policy, medical, advocacy, and beneficiary
communities discussed the pressing need for a treatment
component to supplement the CDC screening programs.
On June 14, 2000, the Finance Committee ordered S. 662, the
Breast and Cervical Cancer Treatment Act, reported favorably,
as amended by the Chairman's mark, by a voice vote.

II. EXPLANATION OF THE BILL

A. Coverage as Optional Categorically Needy Group

Current law

The requirements of federal law, coupled with decisions by
individual states in structuring their Medicaid programs,
determine who is eligible for Medicaid in a given state. In
general, federal law places limits on the categories or groups
of individuals that can be covered and establishes specific
eligibility rules for each category. Within these parameters,
states are given additional options. Medicaid is also a means-
tested entitlement program. To qualify, applicants' income and
resources must be within certain limits, most of which are
determined by states, again within federal statutory
parameters. Moreover, states have flexibility in defining
countable income and resources.
States must provide Medicaid coverage to certain groups and
have the option of covering others. Examples of major mandatory
eligibility groups relevant to individuals targeted by S. 662
(i.e., non-institutionalized adult females) include: (1)
persons who would be eligible for cash assistance under former
rules of the Aid to Families with Dependent Children (AFDC)
program (in effect on July 16, 1996, as adjusted) even if they
do not qualify for cash grants under the new Temporary
Assistance for Needy Families (TANF) program, (2) disabled
individuals receiving supplemental security income (SSI) and/or
state supplemental payments (except in those states that use
more restrictive disability or income standards for determining
Medicaid eligibility for such persons), (3) individuals
qualifying for transitional medical assistance for up to 12
months after Medicaid eligibility is lost due to increases in
hours of employment, support payments or earned income, and (4)
pregnant women who are in families with income up to 133
percent of the federal poverty level.
Examples of major optional coverage groups relevant to S.
662 include: (1) pregnant women in families with income between
133 percent and 185 percent of the federal poverty level, and
(2) persons qualifying as ``medically needy,'' that is, those
who fall into one of Medicaid's categorical coverage groups and
meet the (usually higher) income and resource requirements for
medically needy coverage. States may further expand eligibility
through waivers of federal rules, or use of existing provisions
that permit changes in income and resource standards or
calculation methods.
With the exception of the medically needy and special
categories for pregnant women, all of the above groups have
access to the full range of Medicaid benefits offered in a
state. States may specify a narrower set of benefits for the
medically needy, within federal parameters. Persons who qualify
as pregnant women are limited to pregnancy-related benefits
during the period of pregnancy (and for 60 days postpartum).
In general, Medicaid beneficiaries are permitted to have
other forms of health insurance. When a Medicaid beneficiary
has other insurance, Medicaid becomes the secondary payer and
would, for example, cover cost-sharing obligations under the
primary insurance plan, and would also pay for Medicaid covered
services not offered by the primary insurance plan. In some
circumstances, Medicaid pays the premiums required for other
insurance.
The Breast and Cervical Cancer Mortality Prevention Act of
1990 (P.L. 101-354) authorized the Centers for Disease Control
and Prevention (CDC) to begin a national program to increase
screening services for all women, with priority given to low-
income women. The CDC's National Breast and Cervical Cancer
Early Detection Program (Public Health Service Act, Title XV)
was reauthorized through FY2003 by P.L. 105-340. States are
required to contribute $1 for every $3 of federal grant funds.
To receive a grant, states must cover specified screening
services under Medicaid. The specified screening services for
breast cancer are physical breastexamination and mammography;
for cervical cancer, pelvic examination and pap smear. If a superior
screening procedure becomes available and is recommended for use, the
superior procedure is to be utilized. The law for this program does not
specify financial eligibility standards. Cost-sharing can be imposed on
a sliding scale based on income only for women above 100% of FPL. If
the woman is covered by other health benefits programs (e.g., private
insurance, Medicare, Medicaid) that pay for these screening services,
that other program is the first payer. The upper payment limit for
covered screening services is the Medicare rate.

Explanation of provision

S. 662 would establish a new optional categorically needy
coverage group under Medicaid. Eligible individuals are those
women who are under age 65, have been screened under the
Centers for Disease Control's Breast and Cervical Cancer Early
Detection Program, and need treatment for breast or cervical
cancer. In addition, such individuals must not otherwise be
eligible for Medicaid under a mandatory coverage group and must
not have other creditable health insurance coverage (as defined
in Section 2701(c) of the Public Health Service Act).
This definition of creditable health insurance coverage
does not include state programs to provide treatment services
to women diagnosed with breast or cervical cancer through the
National Breast and Cervical Cancer Early Detection Program. As
a result, women currently eligible for state-funded treatment
programs will not be disqualified from receiving Medicaid
services under this legislation.
As of March 1999, the upper income eligibility level in
most states (45 of 50) for individuals screened under the CDC
program was 200 to 250 percent of the federal poverty level.
Medicaid coverage would be limited to medical assistance
provided during the period in which the individual requires
breast or cervical cancer treatment.

Reason for change

Since its inception in 1990, the Center for Disease
Control's National Breast and Cervical Cancer Early Detection
Program has provided screening services to more than a million
women across the country. In the process, more than 6,000 cases
of breast cancer and 500 cases of cervical cancer have been
detected. Currently, women facing these diagnoses have to rely
upon informal systems of donated care to meet the costs
associated with treating their disease. S. 662 will give the
states the option of making women diagnosed through the CDC
screening programs eligible for Medicaid, bypassing the need to
rely on informal systems of care.

B. Presumptive Eligibility

Current law

Medicaid law stipulates that state Medicaid plans must
provide safeguards to assure that eligibility is determined in
a manner consistent with simplicity of administration and in
the best interests of beneficiaries. Regulations further
specify that state Medicaid agencies must establish and inform
applicants of time limits for determining eligibility and must
determine eligibility within those limits, except in unusual
circumstances. The largest permissible time limits are 90 days
for disability-based applications and 45 days for other
applications. The time standards must cover the period from the
date of application to the date the agency mails notice of its
decision to the applicant.
Currently, states have the option of extending what is
known as ``presumptive eligibility'' to two categories of
Medicaid beneficiaries--pregnant women and children under 19
years of age. Presumptive eligibility allows such individuals
whose family income appears to be below the state's Medicaid
income standards to enroll temporarily in Medicaid, until a
final formal determination of eligibility is made. The primary
purpose of this option is to make needed services immediately
available to these specified groups. Presumptive eligibility
has been permitted for pregnant women since 1986, and for
children under 19 since 1997.
For pregnant women and children, current law defines the
period of presumptive eligibility, entities qualified to
determine presumptive eligibility, and administrative
requirements for state Medicaid agencies and qualified entities
that make such determinations. The period of presumptive
eligibility begins with the date on which a qualified entity
determines, on the basis of preliminary information, that the
applicant's income does not exceed the applicable income
standard. The period ends with the earlier of either: (a) the
day on which the final eligibility determination is made, or
(b) for those beneficiaries who fail to submit an application,
the last day of the month following the month in which the
qualified entity established presumptive eligibility. Qualified
entities include Medicaid providers; Head Start programs;
Women, Infants and Children (WIC) supplemental nutrition
programs; and agencies that determine eligibility for
subsidized child care. Finally, state Medicaid agencies must
provide qualified entities with the necessary forms for
application, and information on how to assist individuals in
completing applications. In turn, qualifying entities must
notify the state Medicaid agency of presumptive eligibility
determinations within 5 working days, and inform applicants
that formal application is required within a specified time
frame using an appropriate form.
Payments for covered items and services provided to
beneficiaries during the period of presumptive eligibility will
be matched at the applicable federal medical assistance
percentage for those items and services.

Explanation of provision

S. 662 includes the option of extending presumptive
eligibility to individuals qualifying for Medicaid under the
new optional coverage group. With one exception, the rules
governing presumptive eligibility are the same as those already
specified in current law for pregnant women and children under
19 years of age. In S. 662, qualifying entities for determining
presumptiveeligibility would be limited to Medicaid providers
only.

Reason for change

Presumptive eligibility would give states the option to
ensure that no time lag exists between a diagnosis received
through the CDC screening program and Medicaid eligibility for
treatment.

C. Enhanced Match

Current law

Medicaid is a federal-state matching program. The federal
share of a state's payments for Medicaid benefits is called the
federal medical assistance percentage (FMAP). The FMAP for a
given state is determined by a formula that considers the
state's per capita income compared to the national average. The
law establishes a minimum FMAP of 50 percent and a maximum of
83 percent. The federal share of Medicaid payments for benefits
is higher in poor states. In FY2000, FMAPs range from 50
percent to 76.8 percent.
The law provides some exceptions to the FMAP for Medicaid
benefits. For example, family planning services (instruction in
contraceptive methods and family planning supplies) are
federally matched at a 90 percent rate. Benefits provided to
children who qualify for Medicaid via an expansion of
eligibility under the State Children's Health Insurance Program
are matched at an enhanced rate that can range from 65 percent
to 85 percent. Medicaid services received through an Indian
Health Service facility are fully funded by the federal
government with no state share.
With specific exceptions, Medicaid administrative expenses
are generally matched at the rate of 50 percent.

Explanation of provision

The Chairman's mark makes a change to S. 662 to fit within
the budget reserve account of $250 million over 5 years
included in the concurrent resolution on the budget for fiscal
year 2001. S. 662 as introduced stipulates that states would
receive a federal matching rate equal to 75 percent for
activities related to offering, arranging and furnishing
medical assistance to individuals eligible under the new
optional categorically needy group. However, S. 662 is scored
by the Congressional Budget Office as costing $360 million over
5 years. The Chairman's mark uses the enhanced matching rate
structure used for the state children's health insurance
program, which averages a 68 to 32 percent match rate (compared
to the Medicaid average match of 57 to 43 percent). This model,
with an October 1, 2000 start date, is scored at $250 million
over 5 years.

Reason for change

The enhanced match rate included in the bill is intended to
give states a financial incentive to take up the new option to
extend Medicaid eligibility to women receiving breast or
cervical cancer diagnoses through CDC's screening program.

D. Effective Date

All amendments made by S. 662 apply to medical assistance
provided on or after October 1, 2000, without regard to whether
final regulations to carry out these amendments have been
promulgated by that date.

III. BUDGET EFFECTS OF THE BILL

In compliance with sections 308 and 403 of the
Congressional Budget Act of 1974, and paragraph 11(a) of Rule
XXVI of the Standing Rules of the Senate, the following letter
has been received from the Congressional Budget Office on the
budgetary impact of the legislation:

U.S. Congress,
Congressional Budget Office,
Washington, DC, June 20, 2000.
Hon. William V. Roth, Jr.
Chairman, Committee on Finance,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S. 662, the Breast and
Cervical Cancer prevention and Treatment Act of 2000.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contacts are Eric
Rollins (for federal costs) and Leo Lex (for impacts on state
and local governments).
Sincerely,
Steven Lieberman
(For Dan L. Crippen, Director).
Enclosure.

CONGRESSIONAL BUDGET OFFICE COST ESTIMATE

S.662--Breast and Cervical Cancer Prevention and Treatment Act of 2000

Sumary: S. 662 would allow states to receive federal
Medicaid funds for providing medical care to low-income women
who have been screened under a Centers for Disease Control and
Prevention (CDC) screening program and found to have breast or
cervical cancer. CBO estimates that S. 662 would increase
direct spending by $250 million over the 2000-2005 period.
Since this bill would affect direct spending, pay-as-you-go-
procedures would apply.
S. 662 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
A new coverage option in the bill would allow states to
increase spending in their Medicaid programs for the treatment
of breast and cervical cancer. CBO estimates that the state
portion of Medicaid expenditures for this optional coverage
would total $107 million over the 2000-2005 period.
Estimated cost to the Federal Government: The estimated
budgetary impact of S. 662 is shown in the following table. The
costs of this legislation fall within budget function 550
(health).

Estimated budget authority................................ 0 15 35 50 65 85
Estimated outlays......................................... 0 15 35 50 65 85
----------------------------------------------------------------------------------------------------------------

Basis of estimate: S. 662 would give states the option of
providing Medicaid coverage to women who have been screened
under the CDC's National Breast and Cervical Cancer Early
Detection Program and found to have breast or cervical cancer.
States would receive an enhanced federal Medicaid match rate
for services provided to women who become eligible for Medicaid
under the bill. (This enhanced federal match rate, which is
already used for services provided under the State Children's
Health Insurance Program, averages about 70 percent, compared
to 57 percent for the regular match rate.) Federal Medicaid
funds would be available beginning in fiscal year 2001.
Under current law, women with breast and cervical cancer
are eligible for Medicaid only if they fall into an existing
eligibility category. The principal eligibility categories for
low-income women are pregnancy, and welfare-related or
disability-related coverage (which is largely based on receipt
of either Temporary Assistance for Needy Families or
Supplemental Security Income). If a women is found to have
breast or cervical cancer, does not have health insurance, and
does not qualify for Medicaid, she either pays for the
treatment with her own funds, receives treatment through a
state, local, or privately funded program, receives charity
care, or goes without treatment.
The Congress created the National Breast and Cervical
Cancer Early Detection Program in 1990 and appropriated $166
million for the program for fiscal year 2000. The funds support
screening activities in all 50 states, in the District of
Columbia and U.S. territories, and for several American Indian/
Alaska Native organizations. States set their own income
eligibility levels, at or below 250 percent of the federal
poverty line. Most states have set eligibility criteria at
about 200 percent of poverty. The CDC estimates that the
program currently screens about 15 percent of the eligible
population. Program funds are not available for treating breast
and cervical cancer.
The bill's effect on federal Medicaid spending depends on
the number of women who would receive Medicaid-funded treatment
as a result of the bill, the cost of the treatment, and the
number of states that would choose the option. The following
discussion focuses on the estimate for breast cancer treatment,
which accounts for over 90 percent of the estimated costs of
the bill. A brief discussion of the cost of cervical cancer
treatment can be found at the end of the section.
Number of beneficiaries.--The states provided 224,000
mammograms with funds available under the CDC screening program
in 1998. Some states currently supplement the CDC screening
funds with their own funds for screening, diagnosis, and
treatment. Under the bill, CBO expects that the number of
mammograms under the CDC program would rise to 540,000 by 2005,
as states that fund diagnosis and treatment services redirect
their funds tosuplement the screening funds in the CDC program.
Because participation in that program would provide access to federal
Medicaid funds for diagnosis and treatment of breast cancer, states
would have an incentive to redirect their own funds into the CDC
screening program.
Of women screened for breast cancer by the CDC program
since its inception, about 0.5 percent, or 5 per 1,000, have
been found to have breast cancer. Another 7 percent have had
abnormal screens that required additional diagnosis and perhaps
minor treatment. CBO assumes that the same incidence of cancer
and other abnormal results would continue under the bill,
resulting in the identification of about 2,700 new cancers and
36,000 abnormal mammograms each year by 2005.
In addition to these new cases, CDC reports that it has
already diagnosed over 5,800 breast cancers. CBO anticipates
that about 2,400 of these women would receive coverage under
the bill if states adopt the option.
Cost of treatment--Based on data from a large health
maintenance organization, CBO has estimated the average cost of
breast cancer treatment by age and year since diagnosis. In the
first year after diagnosis, CBO estimates that cancer treatment
would cost about $20,000. In subsequent years, CBO estimates
about $6,000 a year in ongoing care costs, until the last year
of a patient's life, when costs total about $33,000. CBO used
information from the National Cancer Institute's Surveillance,
Epidemiology, and End Results Program to estimate age-specific
mortality rates from the time of diagnosis.
For women who have an abnormal mammogram, but who are not
ultimately diagnosed with cancer, CBO estimates average
treatment costs of about $2,000 in the year after the mammogram
for follow-up diagnostic and treatment services.
The costs discussed above are for cancer treatment only and
are expressed in fiscal year 2001 dollars. Because the bill
would extend full Medicaid coverage during the time the woman
needs cancer treatment, CBO added about $1,000 a year to the
costs of cancer treatment (one-third of the average per capita
Medicaid costs for adults) to determine total Medicaid costs
for women newly eligible because of the bill. CBO expects that
the average annual cost of treatment would rise at the same
rate as the Consumer Price Index for medical care (CPI-M)
State participation.--In 2001, CBO anticipates, that states
with 25 percent of potential Medicaid costs would choose to
cover breast cancer patients screened through the CDC program
in their Medicaid programs. By 2005, CBO projects that
proportion would rise to 50 percent.
Cervical cancer.--The costs of cervical cancer treatment
under the bill stem principally from treatment of pre-cancerous
conditions since screening often results in an abnormal finding
at an early stage of the disease. CBO anticipates that about
120 new cases of cervical cancer would be diagnosed each year
under the screening program, with average annual treatment
costs similar to the treatment costs for breast cancer. CBO
expects about 10,000 abnormal pap smears each year, with
treatment costs averaging $1,000 to $2,000. In total, CBO
estimates that treatment of cervical cancer under the bill
would cost $15 million over the 2000-2005 period.
Pay-as-you-go considerations: The Balanced Budget and
Emergency Deficit Control Act sets up pay-as-you-go procedures
for legislation affecting direct spending or receipts. The net
changes in outlays that are subject to pay-as-you-go procedures
are shown in the following table. (S. 662 would not affect
receipts.) For the purposes of enforcing pay-as-you-go
procedures, only the effects in the current year, the budget
year, and the succeeding four years are counted.

----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
----------------------------------------------------------------------------
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
----------------------------------------------------------------------------------------------------------------
Changes in outlays................. 0 15 35 50 65 85 105 120 145 165 190
Changes in receipts................ Not applicable.
----------------------------------------------------------------------------------------------------------------

Intergovernmental and private-sector impact: S. 662
contains no intergovernmental or private-sector mandates as
defined in the Unfunded Mandates Reform Act. The bill would
allow states to increase spending in their Medicaid programs
for the treatment of breast and cervical cancer. CBO estimates
that the state portion of Medicaid expenditures for this
optional coverage would total $107 million over the 2000-2005
period.
State spending for the treatment of breast and cervical
cancer among certain women who would otherwise be ineligible
for Medicaid would qualify for a 70 percent federal match on
average. Some states may already be covering this type of
treatment in state-funded public health programs. In those
cases, the federal matching funds would allow states to
increase their overall level of spending for existing programs
or to redirect a portion of their current spending to screening
or other state programs.
Previous CBO estimate: On November 10, 1999, CBO estimated
that section 2 of H.R. 1070, as ordered reported by the House
Committee on Commerce on October 28, 1999, would increase
federal Medicaid spending by $205 million over the 2000-2004
period. The provisions of that section are almost identical to
those in S. 662, except for the federal match rate that would
apply to Medicaid services provided under the new state option.
Under H.R. 1070, the federal match rate would be 75 percent or
the state's regular rate, whichever is higher. Since the
federal match rate under S. 662 would generally be lower (70
percent, on average), CBO assumed that state participation in
the new Medicaid option would also be lower. CBO's estimate for
S. 662 also incorporates more recent data on the CDC screening
program, new projections for the CPI-M, and budgetary effects
in 2005.
Estimate prepared by: Federal costs: Eric Rollins; impact
on State, local, and tribal governments: Leo Lex; impact on the
private sector: Rekha Ramesh.
Estimate approved by: Robert A. Sunshine, Assistant
Director for Budget Analysis.

IV. VOTE OF THE COMMITTEE

In compliance with section 133 of the Legislative
Reorganization Act of 1946, the Committee states that S. 662,
as amended by the Chairman's mark, was ordered reported
favorably by a voice vote, a quorum being present.

V. REGULATORY IMPACT

In compliance with paragraph 11(b) of Rule XXVI of the
Standing Rules of the Senate, the Committee states that the
legislation will not significantly regulate any individuals or
businesses, will not impact the personal privacy of
individuals, and will result in no significant additional
paperwork. The regulatory impact of the bill on the government
will be limited to the need for the Health Care Financing
Administration to develop regulations for the implementation of
the new state option.
This new option set forth in the bill will not impose a
federal intergovernmental mandate on state, local, or tribal
governments.

VI. CHANGES IN EXISTING LAW

In compliance with paragraph 12 of rule XXVI of the
Standing Rules of the Senate, changes in existing law made by
the bill, as reported, are shown as follows (existing law
opposed to be omitted is enclosed in black brackets, new matter
is printed in italic, existing law in which no change is
proposed is shown in roman):

SOCIAL SECURITY ACT

* * * * * * *

TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

* * * * * * *

state plans for medical assistance

Sec. 1902. (a) A State plan for medical assistance must--
(1) * * *

* * * * * * *

(10) provide--
(A) for making medical assistance available,
including at least the care and services listed
in paragraphs (1) through (5), (17) and (21) of
section 1905(a), to--
(i) * * *
(ii) at the option of the State, to
any group or groups of individuals
described in section 1905(a) (or, in
the case of individuals described in
section 1905(a)(i), to any reasonable
categories of such individuals) who are
not individuals described in clause (i)
of this subparagraph but--
(I) * * *

* * * * * * *

(XVI) who are employed
individuals with a medically
improved disability described
in section 1905(v)(1) and whose
assets, resources, and earned
or unearned income (or both) do
not exceed such limitations (if
any) as the State may
establish, only if the State
provides medical assistance to
individuals described in
subclause (XV); [or]
(XVII) who are independent
foster care adolescents (as
defined in section 1905(w)(1)),
or who are within any
reasonable categories of such
adolescents specified by the
State; or
(XVIII) who are described in
subsection (aa) (relating to
certain breast or cervical
cancer patients);

* * * * * * *

(G) that, in applying eligibility criteria of
the supplemental security income program under
title XVI for purposes of determining
eligibility for medical assistance under the
State plan of an individual who is not
receiving supplemental security income, the
State will disregard the provisions of
subsections (c) and (e) of section 1613;
except that (I) the making available of the services
described in paragraph (4), (14), or (16) of section
1905(a) to individuals meeting the age requirements
prescribed therein shall not, by reason of this
paragraph (10), require the making available of any
such services, or the making available of such services
of the same amount, duration, and scope, to individuals
of any other ages, (II) the making available of
supplementary medical insurance benefits under part B
of title XVIII of individuals eligible therefore
(either pursuant to an agreement entered into under
section 1843 or by reason of the payment of premiums
under such title by the State agency on behalf of such
individuals), or cost sharing, or similar charges under
part B of title XVIII for individuals eligible for
benefits under such part, shall not, by reason of this
paragraph (10), require the making available of any
such benefits, of the making available of services of
the same amount, duration, and scope, to any other
individuals, (III) the making available of medical
assistance equal in amount, duration, and scope to the
medical assistance made available to individuals
described in clause (A) to any classification of
individuals approved by the Secretary with respect to
whom there is being paid, or who are eligible, or would
be eligible if they were not in a medical institution,
to have paid with respect to them, a State
supplementary payment shall not, by reason of this
paragraph (10), require the making available of any
such assistance, or the making available of such
assistance of the same amount, duration, and scope, to
any other individuals not described in clause (A), (IV)
the imposition of a deductible, cost sharing , or
similar charge for any item or service furnished to an
individual not eligible for the exemption under section
1916(a)(2) or (b)(2) shall not require the imposition
of a deductible, cost sharing, or similar charge for
the same item or service furnished to an individual who
is eligible for such exemption, (V) the making
available to pregnant women covered under the plan of
services relating to pregnancy (including prenatal,
delivery, and postpartum services) or to any other
condition which may complicate pregnancy shall not, by reason for this
paragraph (10), require the making available of such services, or the
making available of such services of the same amount, duration, and
scope, to any other individuals, provided such services are made
available (in the same amount duration, and scope) to all pregnant
women covered under the State plan, (VI) with respect to the making
available of medical assistance for hospice care to terminally ill
individuals who have made a voluntary election described in section
1905(o) to receive hospice care instead of medical assistance for
certain other services, such assistance may not be made available in an
amount, duration, or scope less than that provided under title XVIII,
and the making available of such assistance shall not, by reason of
this paragraph (10), require the making available to medical assistance
for hospice care to other individuals or the making available of
medical assistance for services waived by such terminally ill
individuals, (VII) the medical assistance made available to an
individual described in subsection (l)(1)(A) who is eligible for
medical assistance only because of subparagraph (A)(i)(IV) or
(A)(ii)(IX) shall be limited to medical assistance for services related
to pregnancy (including prenatal, delivery, postpartum, and family
planning services) and to other conditions which may complicate
pregnancy, (VIII) the medical assistance made available to a qualified
medicare beneficiary described in section 1905(p)(1) who is only
entitle to medical assistance because the individual is such a
beneificary shall be limited to medical assistance for medicare cost-
sharing (described in section 1905(p)(3)), subject to the provisions of
subsection (n) and section 1916(b), (IX) the making available of
respiratory care services in accordance with subsection (e)(9) shall
not, by reason of this paragraph (10) require the making available of
such services, or the making available of such services of the same
amount, duration, and scope, to any individuals not included under
subsection (e)(9)(A), provided such services are made available (in the
same amount, duration, and scope) to all individuals described in such
subsection, (X) if the plan provides for any fixed durational limit on
medical assistance for inpatient hospital services (whether or not such
a limit varies by medical condition or diagnosis), the plan must
establish exceptions to such a limit for medically necessary inpatient
hospital services furnished with respect to individuals under one year
of age in a hospital defined under the State plan, pursuant to section
1923(a)(1)(A), as a disproportionate share hospital and subparagraph
(B) (relating to comparability) shall not be construed as requiring
such an exception for other individuals, services, or hospitals, (XI)
the making available of medical assistance to cover to the costs of
premiums, deductibles, coinsurance, and other cost-sharing obligations
for certain individuals for private health coverage as described in
section 1906 shall not, by reason of paragraph (10), require the making
available of any such benefits or the making available of services of
the same amounts, duration, and scope of such private coverage to any
other individuals, (XII) the medical assistance made available to an
individual described in subsection (u)(1) who is eligible for medical
assistance only because of subparagraph (F) shall be limited to medical
assistance for COBRA continuation premiums (as defined in subsection
(u)(2)), [and (XIII)] (XIII) the medical assistance made available to
an individual described in subsection (z)(1) who is eligible for
medical assistance only because of subparagraph (A)(ii)(XII) shall be
limited to medical assistance for TB-related services (described in
subsection (z)(2), and (XIV) the medical assistance made available to
an individual described in subsection (aa) who is eligible for medical
assistance only because of subparagraph (A)(10)(ii)(XVIII) shall be
limited to medical assistance provided during the period in which such
an individual requires treatment for breast or cervical cancer;

* * * * * * *

(47) at the option of the State, provide for making
ambulatory prenatal care available to pregnant women
during a presumptive eligibility period in accordance
with section 1920 and provide for making medical
assistance for items and services described in
subsection (a) of section 1920A available to children
during a presumptive eligibility period in accordance
with such section and provide for making medical
assistance available to individuals described in
subsection (a) of section 1920B during a presumptive
eligibility period in accordance with such section:

* * * * * * *

(aa) Individuals described in this subsection individuals
who--
(1) are not described in subsection (a)(10)(a)(i);
(2) have not attained age 65;
(3) have been screened for breast and cervical
concern under the Centers for Disease Control and
Prevention breast and cervical cancer early detection
program established under title XV of the Public Health
Service Act (42 U.S.C. 300k et seq.) in accordance with
the requirements of section 1504 of that Act (42 U.S.C.
300n) and need treatment for breast or cervical cancer;
and
(4) are not otherwise covered under creditable
coverage, as defined in section 2701(c) of the Public
Health Service Act (45 U.S.C. 300gg(c)).

payment to states

Sec. 1903. (a) * * *

* * * * * * *

(u)(1)(A) * * *

* * * * * * *

(D)(i) * * *

* * * * * * *

(v) In determining the amount of erroneous excess payments,
there shall not be included any erroneous payments made for
ambulatory prenatal care provided during a presumptive
eligibility period (as defined in section 1920(b)(1)) [or for],
for items and services described in subsection (a) of section
1920A provided to a child during a presumptive eligibility
period under such section, or for medical assistance provided
to an individual described in subsection (a) of section 1920B
during a presumptive eligibility period under such section.

* * * * * * *

Definitions

Sec. 1905. For purposes of this title--
(a) The term ``medical assistance'' means payment of part
or all of the cost of the following care and services (if
provided in or after the third month before the month in which
the recipient makes application for assistance or, in the case
of medicare cost-sharing with respect to a qualified medicare
beneficiary described in subsection (p)(1), if provided after
the month in which the individual becomes such a beneficiary)
for individuals, and, with respect to physicians' or dentists'
servcies, at the option of the State, to individuals (other
than individuals with respect to whom there is being paid, or
who are eligible, or would be eligible if they were not in a
medical institution, to have paid with respect to them a State
supplementary payment and are eligible for medical assistance
equal in amount, duration, and scope to the medical assistance
made available to individuals described in section
1902(a)(10)(A)) not receiving aid or assistance under any plan
of the State approved under title I, X, XIV, or XVI, or part A
of title IV, and with respect to whom supplemental security
income benefits are not being paid under title XVI, who are--
(i) * * *

* * * * * * *

(xi) individuals described in section 1902(z)(1),
[or]
(xii) employed individuals with a medically improved
disability (as defined in subsection (v)), or
(xiii) individuals described in section 1902(aa),
but whose income and resources are insufficient to meet all of
such cost--
(1) inpatient hospital services (other than services
in an institution for mental diseases);

* * * * * * *

(b) Subject to section 1933(d), the term ``Federal medical
assistance percentage'' for any State shall be 100 per centum
less the State percentage; and the State percentage shall be
that percentage which bears the same ratio to 45 per centum as
the square of the per capital income of such State bears to the
square of the per capital income of the continental United
States (including Alaska) and Hawaii; except that (1) the
Federal medical assistance percentage shall in no case be less
than 50 per centum or more than 83 per centum, (2) the Federal
medical assistance percentage for Puerto Rico, the Virgin
Islands, Guam, the Northern Mariana Islands, and American Samoa
shall be 50 per centum, [and] (3) for purposes of this title
and title XXI, the Federal medical assistance percentage for
the District of Columbia shall be 70 percent, and (4) the
Federal medical assistance percentage shall be equal to the
enhanced FMAP described in section 2105(b) with respect to
medical assistance provided to individuals who are eligible for
such assistance only on the basis of section
1902(a)(10)(A)(ii)(XVIII). The Federal medical assistance
percentage for any State shall be determined and promulgated in
accordance with the provisions of section 1101(a)(8)(B).
Notwithstanding the first sentence of this section, the Federal
medical assistance percentage shall be 100 per centum with
respect to amounts expended as medical assistance for services
which are received through an Indian Health Service facility
whether operated by the Indian Health Service or by an Indian
tribe or tribal organization (as defined in section 4o of the
Indian Health Care Improvement Act). Notwithstanding the first
sentence of this subsection, in the case of a State plan that
meets the condition described in subsection (u)(1), with
respect to expenditures (other than expenditures under section
1923) described in subsection (u)(2)(A) or subsection (u)(3)
for the State for a fiscal year, and that do not exceed the
amount of the State's allotment under section 2104 (not taking
into account reductions under section 2104(d)(2)) for the
fiscal year reduced by the amount of any payments made under
section 2105 to the State from such allotment for such fiscal
year, the Federal medical assistance percentage is equal to the
enhanced FMAP described in section 2105(b).

* * * * * * *

presumptive eligibility for children

Sec. 1920A. * * *

* * * * * * *

presumptive eligibility for certain breast and cervical cancer patients

Sec. 1920B. (a) State Option.--A State plan approved under
section 1902 may provide for making medical assistance
available to an individual described in section 1902(aa)
(relating to certain breast and cervical cancer patients)
during a presumptive eligibility period.
(b) Definitions.--For purposes of this section:
(1) Presumptive Eligibility period.--The term
``presumptive eligibility period'' means, with respect
to an individual described in subsection (a), the
period that--
(A) begins with the date on which a qualified
entity determines, on the basis of preliminary
information, that the individual is described
in section 1902(aa); and
(B) ends with (and includes) the earlier of--
(i) the day on which a determination
is made with respect to the eligibility
of such individual for services under
the State plan; or
(ii) in the case of such an
individual who does not file an
application by the last day of the
month following the month during which
the entity makes the determination
referred to in subparagraph (A), such
last day.
(2) Qualified entity.--
(A) In general.--Subject to subparagraph (B),
the term ``qualified entity'' means any entity
that--
(i) is eligible for payments under a
State plan approved under this title;
and
(ii) is determined by the State
agency to be capable of making
determinations of the type described in
paragraph (1)(A).
(B) Regulations.--The Secretary may issue
regulations further limiting those entities
that may become qualified entities in order to
prevent fraud and abuse and for other reasons.
(C) Rule of construction.--Nothing in this
paragraph shall be construed as preventing a
State from limiting the classes of entities
that may become qualified entities, consistent
with any limitations imposed under subparagraph
(B).
(c) Administration.--
(1) In general.--The State agency shall provide
qualified entities with--
(A) such forms as are necessary for an
application to be made by an individual
described in subsection (a) for medical
assistance under the State plan; and
(B) information on how to assist such
individuals in completing and filing such
forms.
(2) Notification requirements.--A qualified entity
that determines under subsection (b)(1)(A) that an
individual described in subsection (a) is presumptively
eligible for medical assistance under a State plan
shall--
(A) notify the State agency of the
determination within 5 working days after the
date on which determination is made; and
(B) inform such individual at the time the
determination is made that an application for
medical assistance under the State plan is
required to be made by not later than the last
day of the month following the month during
which the determination is made.
(3) Application for medical assistance.--In the case
of an individual described in subsection (a) who is
determined by a qualified entity to be presumptively
eligible for medical assistance under a State plan, the
individual shall apply for medical assistance under
such plan by not later than the last day of the month
following the month during which the determination is
made.
(d) Payment.--Notwithstanding any other provision of this
title, medical assistance that--
(1) is furnished to an individual described in
subsection (a)--
(A) during a presumptive eligibility period;
(B) by a entity that is eligible for payments
under the State plan; and
(2) is included in the care and services covered by
the State plan;
shall be treated as medical assistance provided by such plan
for purposes of clause (4) of the first sentence of section
1905(b).

* * * * * * *