Sec. 202. Improving coverage transitions from Medicaid or CHIP to coverage under a qualified health plan
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/bill/113/s/2461/is/section-202·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Section 2105(d)(3)(B) ( 42 U.S.C. 1397ee(d)(3)(B) ) is amended— in the subparagraph heading, by striking and inserting shortfalls ; shortfalls; coordination requirements for transitioning to or from Exchange coverage in the first sentence, by striking In the event and inserting the following: In the event ; and by adding at the end the following: The State shall establish procedures to eliminate gaps in coverage and to assist a child's and pregnant woman's transition from coverage under the State plan under title XIX or the State child health plan under this title (whether implemented under this title, title XIX, or both) to coverage under a qualified health plan that has been certified by the Secretary under subparagraph
(C)and is offered through an Exchange and from coverage under a qualified health plan to coverage under the State plan under title XIX or the State child health plan under this title. Such procedures— shall provide for coverage for the child's or pregnant woman's medical home, regardless of whether the medical home providers are participating providers under the State plan under title XIX or the State child health plan under this title, for a transitional time to be determined under regulations promulgated by the Secretary; in the case of a child or pregnant woman with a chronic or complex condition, shall provide that the State plan under title XIX, or the State child health plan under this title (as applicable) shall permit the child or pregnant woman to continue to receive treatment from a non-network provider for a transitional period as determined under regulations promulgated by the Secretary; shall require that if the benefits available and cost-sharing imposed under a qualified health plan available to the child or pregnant woman (as applicable) are not comparable to the benefits and coverage available to the child or pregnant woman under the State plan under title XIX or the State child health plan under this title (as applicable) the child or pregnant woman shall remain enrolled in the State plan under title XIX or the State child health plan under this title for so long as the child or pregnant woman is otherwise eligible for coverage under the title XIX or XXI State plans; and shall establish a system under which the State shall record all transitions of children and pregnant women from coverage under the State plan under title XIX or the State child health plan under this title to coverage under a qualified health plan and from coverage under a qualified health plan to coverage under the State plan under title XIX or the State child health plan under this title and submit a report to the Secretary each fiscal quarter that includes data on the number of children and pregnant women who made such transitions in the preceding fiscal quarter. . Section 2105(d)(3)(C) ( 42 U.S.C. 1397ee(d)(3)(C) ) is amended— in the subparagraph heading, by striking ; Pediatric by striking With respect to and inserting the following: With respect to ; by inserting and pregnant women after children each place it appears; by striking are at least comparable to the benefits offered and cost-sharing protections provided under the State child health plan and inserting meet the comparability standards described in clause
(ii)and the continuous coverage requirements described in clause
(iii); and by adding at the end the following new clauses: The Secretary shall develop, in consultation with non-government stakeholder entities (including not less than 1 national non-profit organization focused on children's advocacy), comparability standards for qualified health plans seeking certification under clause (i). Such standards must include standards for the following areas: The plan must be comparable to the State child health plan in terms of affordability, including premiums, deductibles, co-payments, co-insurance, medical home maintenance costs, and the cost of purchasing supplementary coverage for health benefits and services that are covered under the State child health plan but are not covered under the qualified health plan. The plan must be comparable to the State child health plan in terms of pediatric and pregnancy-related benefits. The plan must be comparable to the State child health plan in terms of access to appropriate providers of pediatric and pregnancy-related services, and must provide flexibility for children with special health care needs to remain in their medical home or seek appropriate pediatric sub-specialists. The Secretary shall require health plans seeking certification as qualified health plans for purposes of an American Health Benefits Exchange to ensure that— with respect to a child or pregnant woman who is transitioning from coverage under a State child health plan or a State plan under title XIX— coverage under the qualified health plan shall be effective as of the 60-day period preceding the date on which the first premium payment is made for such coverage; coverage under the State child health plan or State plan under title XIX shall remain in effect during the 30-day period that precedes the 60-day period described in item (aa); the qualified health plan shall provide coverage for a child’s or a pregnant woman's medical home, regardless of whether the medical home provider is within the network of the plan, to allow the child or pregnant woman to finish a course of treatment for an acute illness or a treatment or surgery scheduled prior to the effective date for coverage under the plan under item
(aa)or for a period of up to 90 days if, by the end of such period, the child or pregnant woman is enrolled with a medical home provider that is within the network of the plan; and in the case of a child or pregnant woman with a chronic or complex condition, the qualified health plan shall permit the child or pregnant woman to continue to receive treatment from a non-network provider for a transitional time that is not less than 90 days, or until the child or pregnant woman can be enrolled with an in-network provider; similar requirements apply with respect to any child or pregnant woman who transitions from coverage under a qualified health plan to coverage under the State child health plan or the State plan under title XIX in accordance with subparagraph (B)(ii); and a child or pregnant woman transitioning to or from coverage under the State child health plan or the State plan under title XIX and a qualified health plan is informed of the differences between the benefits available and cost-sharing imposed under the coverage the child or pregnant woman is transitioning from and into, and that the pregnant woman or the parent or guardian of the child has the option of electing to remain enrolled in whichever coverage is the most affordable or provides the best benefits for the child or pregnant woman for such period as the Secretary shall specify. . No child who is eligible for coverage under CHIP shall be transitioned from a State child health plan to a qualified health plan unless that plan is certified under section 2105(d)(3)(C) of the Social Security Act (42 U.S.C. 1397ee(d)(3)(C)) (as amended by subsection (b)). Section 5000A(f) of the Internal Revenue Code of 1986 is amended by adding at the end the following: With respect to a targeted low-income pregnant woman (as defined in section 2112(d)(2) of the Social Security Act), notwithstanding paragraph (1)(A)(iii), the term minimum essential coverage , at the option of such a woman, shall not include pregnancy-related assistance (as defined in section 2112(d)(1) of the Social Security Act). . The amendment made by this subsection applies to taxable years beginning after December 31, 2014.
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Sec. 202
Improving coverage transitions from Medicaid or CHIP to coverage under a qualified health plan
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