child

(13) Express Lane Option.— (A) In general.— (i) Option to use a finding from an express lane agency .— At the option of the State, the State plan may provide that in determining eligibility under this subchapter for a child (as defined in subparagraph (G)), the State may rely on a finding made within a reasonable period (as determined by the State) from an Express Lane agency (as defined in subparagraph (F)) when it determines whether a child satisfies one or more components of eligibility for medical assistance under this subchapter. The State may rely on a finding from an Express Lane agency notwithstanding sections 1396a(a)(46)(B) and 1320b–7(d) of this title or any differences in budget unit, disregard, deeming or other methodology, if the following requirements are met: (I) Prohibition on determining children ineligible for coverage .— If a finding from an Express Lane agency would result in a determination that a child does not satisfy an eligibility requirement for medical assistance under this subchapter and for child health assistance under subchapter XXI, the State shall determine eligibility for assistance using its regular procedures. (II) Notice requirement .— For any child who is found eligible for medical assistance under the State plan under this subchapter or child health assistance under subchapter XXI and who is subject to premiums based on an Express Lane agency’s finding of such child’s income level, the State shall provide notice that the child may qualify for lower premium payments if evaluated by the State using its regular policies and of the procedures for requesting such an evaluation. (III) Compliance with screen and enroll requirement .— The State shall satisfy the requirements under subparagraphs (A) and (B) of section 1397bb(b)(3) of this title (relating to screen and enroll) before enrolling a child in child health assistance under subchapter XXI. At its option, the State may fulfill such requirements in accordance with either option provided under subparagraph (C) of this paragraph. (IV) Verification of citizenship or nationality status .— The State shall satisfy the requirements of section 1396a(a)(46)(B) or 1397ee(c)(9) of this title , as applicable for verifications of citizenship or nationality status. (V) Coding .— The State meets the requirements of subparagraph (E). (ii) Option to apply to renewals and redeterminations .— The State may apply the provisions of this paragraph when conducting initial determinations of eligibility, redeterminations of eligibility, or both, as described in the State plan. (B) Rules of construction .— Nothing in this paragraph shall be construed— (i) to limit or prohibit a State from taking any actions otherwise permitted under this subchapter or subchapter XXI in determining eligibility for or enrolling children into medical assistance under this subchapter or child health assistance under subchapter XXI; or (ii) to modify the limitations in section 1396a(a)(5) of this title concerning the agencies that may make a determination of eligibility for medical assistance under this subchapter. (C) Options for satisfying the screen and enroll requirement.— (i) In general .— With respect to a child whose eligibility for medical assistance under this subchapter or for child health assistance under subchapter XXI has been evaluated by a State agency using an income finding from an Express Lane agency, a State may carry out its duties under subparagraphs (A) and (B) of section 1397bb(b)(3) of this title (relating to screen and enroll) in accordance with either clause (ii) or clause (iii). (ii) Establishing a screening threshold.— (I) In general .— Under this clause, the State establishes a screening threshold set as a percentage of the Federal poverty level that exceeds the highest income threshold applicable under this subchapter to the child by a minimum of 30 percentage points or, at State option, a higher number of percentage points that reflects the value (as determined by the State and described in the State plan) of any differences between income methodologies used by the program administered by the Express Lane agency and the methodologies used by the State in determining eligibility for medical assistance under this subchapter. (II) Children with income not above threshold .— If the income of a child does not exceed the screening threshold, the child is deemed to satisfy the income eligibility criteria for medical assistance under this subchapter regardless of whether such child would otherwise satisfy such criteria. (III) Children with income above threshold .— If the income of a child exceeds the screening threshold, the child shall be considered to have an income above the Medicaid applicable income level described in section 1397jj(b)(4) of this title and to satisfy the requirement under section 1397jj(b)(1)(C) of this title (relating to the requirement that CHIP matching funds be used only for children not eligible for Medicaid). If such a child is enrolled in child health assistance under subchapter XXI, the State shall provide the parent, guardian, or custodial relative with the following: (aa) Notice that the child may be eligible to receive medical assistance under the State plan under this subchapter if evaluated for such assistance under the State’s regular procedures and notice of the process through which a parent, guardian, or custodial relative can request that the State evaluate the child’s eligibility for medical assistance under this subchapter using such regular procedures. (bb) A description of differences between the medical assistance provided under this subchapter and child health assistance under subchapter XXI, including differences in cost-sharing requirements and covered benefits. (iii) Temporary enrollment in chip pending screen and enroll.— (I) In general .— Under this clause, a State enrolls a child in child health assistance under subchapter XXI for a temporary period if the child appears eligible for such assistance based on an income finding by an Express Lane agency. (II) Determination of eligibility .— During such temporary enrollment period, the State shall determine the child’s eligibility for child health assistance under subchapter XXI or for medical assistance under this subchapter in accordance with this clause. (III) Prompt follow up .— In making such a determination, the State shall take prompt action to determine whether the child should be enrolled in medical assistance under this subchapter or child health assistance under subchapter XXI pursuant to subparagraphs (A) and (B) of section 1397bb(b)(3) of this title (relating to screen and enroll). (IV) Requirement for simplified determination .— In making such a determination, the State shall use procedures that, to the maximum feasible extent, reduce the burden imposed on the individual of such determination. Such procedures may not require the child’s parent, guardian, or custodial relative to provide or verify information that already has been provided to the State agency by an Express Lane agency or another source of information unless the State agency has reason to believe the information is erroneous. (V) Availability of chip matching funds during temporary enrollment period .— Medical assistance for items and services that are provided to a child enrolled in subchapter XXI during a temporary enrollment period under this clause shall be treated as child health assistance under such subchapter. (D) Option for automatic enrollment.— (i) In general .— The State may initiate and determine eligibility for medical assistance under the State Medicaid plan or for child health assistance under the State CHIP plan without a program application from, or on behalf of, the child based on data obtained from sources other than the child (or the child’s family), but a child can only be automatically enrolled in the State Medicaid plan or the State CHIP plan if the child or the family affirmatively consents to being enrolled through affirmation in writing, by telephone, orally, through electronic signature, or through any other means specified by the Secretary or by signature on an Express Lane agency application, if the requirement of clause (ii) is met. (ii) Information requirement .— The requirement of this clause is that the State informs the parent, guardian, or custodial relative of the child of the services that will be covered, appropriate methods for using such services, premium or other cost sharing charges (if any) that apply, medical support obligations (under section 1396k(a) of this title ) created by enrollment (if applicable), and the actions the parent, guardian, or relative must take to maintain enrollment and renew coverage. (E) Coding; application to enrollment error rates.— (i) In general .— For purposes of subparagraph (A)(iv), the requirement of this subparagraph for a State is that the State agrees to— (I) assign such codes as the Secretary shall require to the children who are enrolled in the State Medicaid plan or the State CHIP plan through reliance on a finding made by an Express Lane agency for the duration of the State’s election under this paragraph; (II) annually provide the Secretary with a statistically valid sample (that is approved by Secretary) of the children enrolled in such plans through reliance on such a finding by conducting a full Medicaid eligibility review of the children identified for such sample for purposes of determining an eligibility error rate (as described in clause (iv)) with respect to the enrollment of such children (and shall not include such children in any data or samples used for purposes of complying with a Medicaid Eligibility Quality Control (MEQC) review or a payment error rate measurement (PERM) requirement); (III) submit the error rate determined under subclause (II) to the Secretary; (IV) if such error rate exceeds 3 percent for either of the first 2 fiscal years in which the State elects to apply this paragraph, demonstrate to the satisfaction of the Secretary the specific corrective actions implemented by the State to improve upon such error rate; and (V) if such error rate exceeds 3 percent for any fiscal year in which the State elects to apply this paragraph, a reduction in the amount otherwise payable to the State under section 1396b(a) of this title for quarters for that fiscal year, equal to the total amount of erroneous excess payments determined for the fiscal year only with respect to the children included in the sample for the fiscal year that are in excess of a 3 percent error rate with respect to such children. (ii) No punitive action based on error rate .— The Secretary shall not apply the error rate derived from the sample under clause (i) to the entire population of children enrolled in the State Medicaid plan or the State CHIP plan through reliance on a finding made by an Express Lane agency, or to the population of children enrolled in such plans on the basis of the State’s regular procedures for determining eligibility, or penalize the State on the basis of such error rate in any manner other than the reduction of payments provided for under clause (i)(V). (iii) Rule of construction .— Nothing in this paragraph shall be construed as relieving a State that elects to apply this paragraph from being subject to a penalty under section 1396b(u) of this title , for payments made under the State Medicaid plan with respect to ineligible individuals and families that are determined to exceed the error rate permitted under that section (as determined without regard to the error rate determined under clause (i)(II)). (iv) Error rate defined .— In this subparagraph, the term “error rate” means the rate of erroneous excess payments for medical assistance (as defined in section 1396b(u)(1)(D) of this title ) for the period involved, except that such payments shall be limited to individuals for which eligibility determinations are made under this paragraph and except that in applying this paragraph under subchapter XXI, there shall be substituted for references to provisions of this subchapter corresponding provisions within subchapter XXI. (F) Express lane agency.— (i) In general .— In this paragraph, the term “Express Lane agency” means a public agency that— (I) is determined by the State Medicaid agency or the State CHIP agency (as applicable) to be capable of making the determinations of one or more eligibility requirements described in subparagraph (A)(i); (II) is identified in the State Medicaid plan or the State CHIP plan; and (III) notifies the child’s family— (aa) of the information which shall be disclosed in accordance with this paragraph; (bb) that the information disclosed will be used solely for purposes of determining eligibility for medical assistance under the State Medicaid plan or for child health assistance under the State CHIP plan; and (cc) that the family may elect to not have the information disclosed for such purposes; and (IV) enters into, or is subject to, an interagency agreement to limit the disclosure and use of the information disclosed. (ii) Inclusion of specific public agencies and Indian tribes and tribal organizations .— Such term includes the following: (I) A public agency that determines eligibility for assistance under any of the following: (aa) The temporary assistance for needy families program funded under part A of subchapter IV. (bb) A State program funded under part D of subchapter IV. (cc) The State Medicaid plan. (dd) The State CHIP plan. (ee) The Food and Nutrition Act of 2008 ( 7 U.S.C. 2011 et seq.). (ff) The Head Start Act [ 42 U.S.C. 9831 et seq.]. (gg) The Richard B. Russell National School Lunch Act ( 42 U.S.C. 1751 et seq.). (hh) The Child Nutrition Act of 1966 ( 42 U.S.C. 1771 et seq.). (ii) The Child Care and Development Block Grant Act of 1990 [ 42 U.S.C. 9857 et seq.]. (jj) The Stewart B. McKinney Homeless Assistance Act 1 ( 42 U.S.C. 11301 et seq.). (kk) The United States Housing Act of 1937 ( 42 U.S.C. 1437 et seq.). (ll) The Native American Housing Assistance and Self-Determination Act of 1996 ( 25 U.S.C. 4101 et seq.). (II) A State-specified governmental agency that has fiscal liability or legal responsibility for the accuracy of the eligibility determination findings relied on by the State. (III) A public agency that is subject to an interagency agreement limiting the disclosure and use of the information disclosed for purposes of determining eligibility under the State Medicaid plan or the State CHIP plan. (IV) The Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization (as defined in section 1320b–9(c) of this title ). (iii) Exclusions .— Such term does not include an agency that determines eligibility for a program established under the Social Services Block Grant established under subchapter XX or a private, for-profit organization. (iv) Rules of construction .— Nothing in this paragraph shall be construed as— (I) exempting a State Medicaid agency from complying with the requirements of section 1396a(a)(4) of this title relating to merit-based personnel standards for employees of the State Medicaid agency and safeguards against conflicts of interest); or (II) authorizing a State Medicaid agency that elects to use Express Lane agencies under this subparagraph to use the Express Lane option to avoid complying with such requirements for purposes of making eligibility determinations under the State Medicaid plan. (v) Additional definitions .— In this paragraph: (I) State .— The term “State” means 1 of the 50 States or the District of Columbia. (II) State chip agency .— The term “State CHIP agency” means the State agency responsible for administering the State CHIP plan. (III) State chip plan .— The term “State CHIP plan” means the State child health plan established under subchapter XXI and includes any waiver of such plan. (IV) State medicaid agency .— The term “State Medicaid agency” means the State agency responsible for administering the State Medicaid plan. (V) State medicaid plan .— The term “State Medicaid plan” means the State plan established under subchapter XIX and includes any waiver of such plan. (G) Child defined .— For purposes of this paragraph, the term “child” means an individual under 19 years of age, or, at the option of a State, such higher age, not to exceed 21 years of age, as the State may elect. (H) State option to rely on state income tax data or return .— At the option of the State, a finding from an Express Lane agency may include gross income or adjusted gross income shown by State income tax records or returns. (I) Application .— This paragraph shall not apply with respect to eligibility determinations made after September 30, 2027 .

Source

42 USC § 1396a(e)(13)


Scoping language

in this paragraph
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