Maintenance of effort

(A) In general The amount of the allotment for a State in a fiscal year (beginning with fiscal year 1999) shall be reduced by the amount by which— (i) the total of the State children’s health insurance expenditures in the preceding fiscal year, is less than (ii) the total of such expenditures in fiscal year 1996.

(B) State children’s health insurance expenditures The term “State children’s health insurance expenditures” means the following: (i) The State share of expenditures under this subchapter. (ii) The State share of expenditures under subchapter XIX that are attributable to an enhanced FMAP under the fourth sentence of section 1396d(b) of this title . (iii) State expenditures under health benefits coverage under an existing comprehensive State-based program, described in section 1397cc(d) of this title .

(A) In general During the period that begins on March 23, 2010 , and ends on September 30, 2029 , as a condition of receiving payments under section 1396b(a) of this title , a State shall not have in effect eligibility standards, methodologies, or procedures under its State child health plan (including any waiver under such plan) for children (including children provided medical assistance for which payment is made under section 1397ee(a)(1)(A) of this title ) that are more restrictive than the eligibility standards, methodologies, or procedures, respectively, under such plan (or waiver) as in effect on March 23, 2010 . During the period that begins on October 1, 2019 , and ends on September 30, 2029 , the preceding sentence shall only apply with respect to children in families whose income does not exceed 300 percent of the poverty line (as defined in section 1397jj(c)(5) of this title ) applicable to a family of the size involved. The preceding sentences shall not be construed as preventing a State during any such periods from— (i) applying eligibility standards, methodologies, or procedures for children under the State child health plan or under any waiver of the plan that are less restrictive than the eligibility standards, methodologies, or procedures, respectively, for children under the plan or waiver that are in effect on March 23, 2010 ; (ii) after September 30, 2015 , enrolling children eligible to be targeted low-income children under the State child health plan in a qualified health plan that has been certified by the Secretary under subparagraph (C); or (iii) imposing a limitation described in section 1397 ll (b)(7) of this title for a fiscal year in order to limit expenditures under the State child health plan to those for which Federal financial participation is available under this section for the fiscal year.

(B) Assurance of exchange coverage for targeted low-income children unable to be provided child health assistance as a result of funding shortfalls In the event that allotments provided under section 1397dd of this title are insufficient to provide coverage to all children who are eligible to be targeted low-income children under the State child health plan under this subchapter, a State shall establish procedures to ensure that such children are screened for eligibility for medical assistance under the State plan under subchapter XIX or a waiver of that plan and, if found eligible, enrolled in such plan or a waiver. In the case of such children who, as a result of such screening, are determined to not be eligible for medical assistance under the State plan or a waiver under subchapter XIX, the State shall establish procedures to ensure that the children are enrolled in a qualified health plan that has been certified by the Secretary under subparagraph (C) and is offered through an Exchange established by the State under section 18031 of this title . For purposes of eligibility for premium assistance for the purchase of a qualified health plan under section 36B of the Internal Revenue Code of 1986 and reduced cost-sharing under section 18071 of this title , children described in the preceding sentence shall be deemed to be ineligible for coverage under the State child health plan.

(C) Certification of comparability of pediatric coverage offered by qualified health plans With respect to each State, the Secretary, not later than April 1, 2015 , shall review the benefits offered for children and the cost-sharing imposed with respect to such benefits by qualified health plans offered through an Exchange established by the State under section 18031 of this title and shall certify those plans that offer benefits for children and impose cost-sharing with respect to such benefits that the Secretary determines are at least comparable to the benefits offered and cost-sharing protections provided under the State child health plan.