waive this requirement if it determines that the individual has good cause for refusing to cooperate.

The committee is concerned that application of these requirements to women who are applying only for pregnancy-related coverage may discourage many of them from seeking benefits that would give them access to early prenatal care. The committee notes that the Department's own manuals acknowledge that paternity determinations, which are based on one of several blood tests, cannot be made before an infant is at least 4 months old: "Blood must be drawn in sufficient quantity for the particular test to be performed....This may impose a mandatory delay in a case involving a newborn infant because it is difficult to obtain any significant volume of the baby's blood. Many technicians require that a child be 4 to 6 months old and be in good health before they will attempt to obtain a blood sample....Some laboratories will not draw blood for [one type of] testing unless the child is at least 12 months old. For the other tests [for paternity determination], it is generally prudent to avoid venipuncture until the child is 6 months old. An additional advantage in waiting this long after birth is the assurance that antigens in the blood are fully developed by this age. U.S. Department of Health and Human Services, Office of Child Support Enforcement, A Guide for Judges in Child Support Enforcement (1983) at pages 51-52.

Thus, the cooperation requirement is not only a potential barrier to prenatal care for the high-risk, low-income women that would most benefit from it, but it is also a bureaucratic hurdle that yields absolutely no useful information until months after the prenatal period has ended. The committee bill therefore exempts pregnant women applying for Medicaid on the basis of their pregnancy and low income from the cooperation requirements with respect to establishing paternity and obtaining child support.

Sec. 4206-Required Medicaid Notice and Coordination with Special Supplemental Food Program for Women, Infants, and Children (WIC)

The Special Supplemental Food Program for Women, Infants, and Children (WIC), which is not within the jurisdiction of this committee, serves low-income pregnant women, infants, and children under 5 who are determined by a medical professional to be at nutritional risk and who have incomes at or below 185 percent of the Federal poverty level. Women and children eligible for WIC receive nutrition assistance (including vouchers to purchase ironfortified cereals, infant formula or milk, eggs, juice, peanut butter), nutrition education, and some health-related services.

The National Commission on the Prevention of Infant Mortality identified WIC as one of the programs to which high-risk pregnant women should have early access. Under the committee bill, which would raise the income eligibility threshold under Medicaid to that of WIC over the next 4 years, the logic of coordinating the two programs becomes even more compelling. Under current law, the State's WIC program must include "a plan to coordinate operations under the program with . . . maternal and child health care, and Medicaid programs." While the Medicaid program is currently required to enter into agreements with providers receiving funds

under the Title V Maternal and Child Health Block Grant, there is no reciprocal coordination requirement with respect to WIC.

The committee bill would require States to coordinate their operations under Medicaid with their operations under WIC. In addition, States would be required to notify all women who are pregnant, breast-feeding, or postpartum, and all children below age 5, who are eligible for Medicaid, of the availability of WIC benefits. This notification must occur in a timely manner, either at the time of a determination that a woman is eligible (or presumptively eligible) for Medicaid, or immediately thereafter. The State must also provide for the referral of Medicaid-eligible women and children under 5 to the State agency responsible for administering WIC. This referral could be achieved at the same time as notification. The costs which States incur in carrying out these coordination responsibilities are necessary for the proper and efficient administration of the State Medicaid plan, and as such are subject to Federal matching at a 50 percent rate.

PART B-CHILD HEALTH AMENDMENTS

Sec. 4211-Phased-In Mandatory Coverage of Children Up to 100 Percent of Poverty Level

(a) In General. Under current law, States are required to offer Medicaid coverage to all children born after September 30, 1983, in families with incomes and resources below State AFDC standards, up to age 7. States are also required, as of July 1, 1990, to cover all infants up to age 1 in families with incomes below 100 percent of the Federal poverty level. In addition, States have the option of extending coverage to all children born after September 30, 1983, in families with incomes below 100 percent of the Federal poverty level, up to age 8. With respect to this poverty level group, States have the option of applying a resource test; if they do so, the resource standard and methodology may be no more restrictive than that under the State's AFDC program. As indicated in Table 1, as of January, 1989, 21 States had elected to cover children in poverty below ages 2 through 4, and 14 had elected to cover all poor children below ages 5 through 7.

As the Office of Technology Assessment documented in Healthy Children: Investing in the Future (1988), some preventive and other health care services for infants and children, notably newborn screening and immunizations, are cost-effective and can improve health status. Medicaid, with its early and periodic screening, diagnostic, and treatment (EPSDT) services benefit, is the major source of financing for preventive health care services for low-income children. Yet, according to the Congressional Research Service, Medicaid in 1986 reached only about half of all children in families with incomes below the poverty level; because of limited private health insurance coverage among the poor, about one third of all poor children were left with no public or private insurance coverage whatsoever (Medicaid Source Book: Background Data and Analysis (Committee Print 100-AA), p. 333).

To fill this coverage gap incrementally, the committee bill would convert the existing option to extend Medicaid coverage to poor children into a mandate. The bill would require States to extend

Medicaid coverage to all children born after September 30, 1983, in families with incomes below the Federal poverty level ($10,060 for a family of 3 in 1989), incrementally up to age 18. Under section 4201(c) of the bill, States would not have the option of applying a resource test to this population. This requirement would be effective July 1, 1990, except in Texas, when the requirement would apply on September 1, 1991. As under current law with respect to infants under age 1, this requirement would also apply to a State like Arizona that provides Medicaid coverage under a waiver under section 1115 of the Social Security Act.

The effect of this requirement is to phase in, over the next 12 years, mandatory Medicaid coverage for all poor children under 18. On July 1, 1990, all States would have to cover children born after September 30, 1983, in families with incomes below the poverty level, regardless of whether the family had one parent or two, and regardless of whether the family's resources exceeded the AFDC standard. On that date, the oldest of this cohort would be nearly 6 years old. As these children grew older, if their families remained poor, they would continue to be entitled to Medicaid coverage. By the year 2001, all States would be required to cover all poor children under age 18. The committee notes that States that want to extend coverage more quickly may elect, under the current law "Ribicoff child" option, to cover all children under age 21 whose family incomes and resources do not exceed AFDC levels.

Under the committee bill, in determining income eligibility for these children, States would be allowed to use a methodology that is less restrictive than that employed under the AFDC program. As under current law, they could not use a methodology for determining income that is more restrictive than that under AFDC. In addition, States would be required to disregard all costs for child care necessary for the employment of the child's parents or other caretaker relative.

(b) Applications Using Outreach Locations. Under current law, States have the option of accepting and processing applications for Medicaid eligibility at locations other than State or local welfare offices. (This option is in addition to the presumptive eligibility option, under which States designate certain providers to make presumptive determinations of eligibility with respect to pregnant women in order to expedite coverage for prenatal care). Many States currently station eligibility workers in hospitals, clinics, WIC clinics, and similar locations in order to enroll poor women and children in the program.

The committee is concerned that, unless poor women and children are able to apply for Medicaid in locations other than welfare offices, many of them will be deterred from obtaining the health care coverage they need in order to receive preventive health services. The committee bill would therefore require States to provide for the receipt and initial processing of applications for Medicaid coverage by poor pregnant women, infants, and children (whether optional or mandatory) at outreach locations such as hospitals and clinics that provide covered services to these populations. In designating hospitals or clinics for this purpose, States must include both public and private entities.

The committee bill does not require States to station eligibility workers at each and every hospital, clinic, and WIC program; however, the committee does intend that, at a minimum, eligibility workers be stationed on a full-time basis in each of the hospitals (such as disproportionate share facilities) and clinics that treat significant numbers of low-income women, infants, and children. These eligibility workers could be employees of the welfare agency, contractors to the agency, or employees of, or contractors to, the hospital, clinic, or other outreach location. As under current law, all costs incurred by the State with respect to the receipt and processing of Medicaid applications at these locations, including the salaries and equipment costs of eligibility workers, would, under the committee bill, be considered necessary for the proper and efficient administration of the State plan and subject to Federal matching payments at a 50 percent rate.

The committee is concerned that the lengthy, complex application forms for AFDC eligibility can create a barrier to access for women and children who are not seeking cash assistance, but only Medicaid coverage. Much of the information relevant to eligibility for cash assistance, such as resources and family composition, are not relevant to the coverage groups mandated under sections 4201(a) and 4211(a). The committee bill would therefore require States to provide for the use of applications for Medicaid-only coverage at the hospitals, clinics, and other outreach locations that the State designates under the previous requirement.

Under these requirements, the committee expects the eligibility determination process for low-income pregnant women, infants, and children to work as follows. States would develop application forms for use at designated hospitals, clinics, and other outreach locations. These simplified forms would contain only those information requirements necessary to determine eligibility for Medicaid. This information would include verification of the woman's pregnancy; age of the child (which could be provided through methods other than a formal birth certificate, such as verification from a hospital or from a child's health care provider regarding the child's date of birth); size and income of the family; verification of lawful residence in the United States; information concerning third party liability; and, in the case of children only, disclosure of paternity information in circumstances where such information is applicable. States using initial intake applications that included this information would not be required to use separate applications for making final eligibility determinations.

The entire application process could be conducted at the hospitals, clinics, and other outreach locations. If the eligibility worker at the outreach location is a welfare agency employee or contractor, the final eligibility determination could be made at that location. However, even if the eligibility worker is an employee of the hospital or clinic, the pregnant woman or child would not be required to go to the welfare office for a face-to-face interview in order to complete the eligibility determination process. Instead, the simplified application form, along with necessary documentation, would then be forwarded to the welfare office for a final determination.

Sec. 4212-Extension of Medicaid Transition Coverage

Under current law, States are required, effective April 1, 1990, to extend Medicaid coverage for 12 months to families who lose AFDC benefits due to earnings, and who continue to report earnings during this period. During the first 6 months of the transition period, States may not impose any premium requirement for this coverage; during the second 6 months, States may, at their option, impose an income-related premium. This requirement is repealed on September 30, 1998.

This Medicaid transitional coverage requirement was one of the provisions of the Family Support Act of 1988 (Public Law 100-460) designed to encourage families to leave welfare and become selfsufficient. Many of these former welfare recipients are employed in low-wage jobs that do not offer health insurance coverage. According to a General Accounting Office study, more than half of former welfare recipients who work are uninsured (Evaluation of 1981 AFDC Changes: Final Report (GAO/PEMD-85-4, July, 1985)). The committee is concerned that, in many cases, 12 months is not sufficient time for a mother to make the transition from welfare to a job that offers health insurance coverage for her and her children. To further encourage welfare families to work, the committee bill would allow the States, at their option, to extend the current 12-month transitional coverage period for an additional 12 months (or 3, 6, or 9 months, as the State elects). Thus, a State could offer a working welfare family a total of 24 months of transitional Medicaid coverage (12 mandatory, 12 optional). Under the bill, the structure of the current mandatory benefit would remain unchanged. Thus, States could, at their option, impose the same income-related premium during this optional 12-month period that they are allowed to impose during the 2nd mandatory 6-month period. The committee bill would also repeal the sunset.

The committee bill would also make some technical corrections to current law. It clarifies that Medicaid transition coverage terminates at the close of the first month in which the family ceases to include a child, whether or not the child is a dependent child under part A of Title IV, or would be if needy. The committee bill also clarifies that families who, prior to April 1, 1990, are receiving Medicaid extension coverage under the current law 9-month provision are entitled to continue receiving this extension coverage after that date until their 9-month coverage period expires.

Sec. 4213-Early and Periodic Screening, Diagnostic, and Treatment Services

(a) In General. Under current law, States are required to offer early and periodic screening, diagnostic, and treatment (EPSDT) services to children under age 21. States are required to inform all Medicaid-eligible children of the availability of EPSDT services, to provide (or arrange for the provision of) screening services in all cases when they are requested, and, to arrange for (directly or through referral to appropriate agencies or providers) corrective treatment for which the child health screening indicates a need.

The EPSDT benefit is, in effect, the Nation's largest preventive health program for children. Each State must provide, at a mini