Ensuring Access to Primary Care for Women and Children Act - Amends title XIX (Medicaid) of the Social Security Act to require that the primary care services furnished in 2015 and 2016 by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine be paid at a rate that is not less than 100% of the payment rate that applies to such services and physician under Medicare part B (Supplementary Medical Insurance).
Extends this 100% of Medicare payment floor under certain conditions to the following providers, who are self-attested as Board-certified and at least 60% of whose services billed for under Medicaid must be for primary care services: (1) physicians with a primary specialty designation of obstetrics and gynecology; (2) advanced practice clinicians; (3) rural health clinics, federally-qualified health centers, or other specified health clinics; and (4) nurse practitioners, physician assistants, or certified nurse-midwives.
Excludes from coverage of primary care services any such services provided in an emergency department of a hospital.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[S. 2694 Introduced in Senate (IS)]
113th CONGRESS
2d Session
S. 2694
To amend title XIX of the Social Security Act to extend the application
of the Medicare payment rate floor to primary care services furnished
under Medicaid and to apply the rate floor to additional providers of
primary care services.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
July 30, 2014
Mr. Brown (for himself, Mrs. Murray, Mr. Rockefeller, and Ms. Landrieu)
introduced the following bill; which was read twice and referred to the
Committee on Finance
_______________________________________________________________________
A BILL
To amend title XIX of the Social Security Act to extend the application
of the Medicare payment rate floor to primary care services furnished
under Medicaid and to apply the rate floor to additional providers of
primary care services.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Ensuring Access to Primary Care for
Women & Children Act''.
SEC. 2. FINDINGS.
Congress finds as follows:
(1) Medicaid plays a key role in providing coverage for
millions of working families.
(2) Medicaid enrollees include families, pregnant women,
children, individuals with disabilities, and other low-income
individuals. Without Medicaid coverage, many enrollees would be
uninsured or lack coverage for services they need.
(3) In 2013, the Medicaid program covered 62,000,000
individuals, or 1 in every 5 Americans. This number will
continue to grow, particularly since the Affordable Care Act
significantly expanded eligibility to millions of uninsured
adults. Enrollment in Medicaid and the Children's Health
Insurance Program is projected to increase by 12,800,000 by
2016.
(4) If all States expand their Medicaid programs, an
estimated 7,000,000 women ages 18 to 64 would gain coverage
under Medicaid.
(5) In 47 States and in the District of Columbia, Medicaid
pays up to 67 percent less than Medicare for the same primary
care services.
(6) Multiple studies have concluded that higher Medicaid
payment rates would increase the probability of primary care
providers accepting new Medicaid patients, and would further
support current Medicaid providers.
(7) Congress has recognized that low provider participation
in Medicaid decreases access to health care. To address this
problem, Congress acted to increase Medicaid payments for
certain primary care services to be not less than the Medicare
payment rates for 2013 and 2014.
(8) As more Americans become insured and empowered
participants in their own health care, demand for primary care
services is expected to increase over the next few years.
(9) Six in 10 women ages 18 to 44 (58 percent) report they
see an obstetrics and gynecology (OB/GYN) physician on a
regular basis. They are more likely to see their OB/GYN
physician on a regular basis than any other type of provider.
Given that women comprise the majority of Medicaid enrollees,
it is critical that primary care providers, including OB/GYN
physicians, receive sufficient reimbursement to participate in
Medicaid.
(10) Nurse practitioners and other mid-level health
professionals deliver many primary care services. Applying
Medicare's rates for nurse practitioners and mid-level health
professionals encourages greater participation in Medicaid,
thereby increasing access to primary care, particularly in
underserved areas.
(11) The enhanced Medicaid reimbursement rate ensures
providers have the financial capability to serve their
patients' primary care needs. Furthermore, adding nurse
practitioners, physician assistants, certified nurse-midwives,
and OB/GYN physicians serving in primary care settings
increases access to critical health care services for women and
children nationwide.
SEC. 3. EXTENSION OF APPLICATION OF MEDICARE PAYMENT RATE FLOOR TO
PRIMARY CARE SERVICES FURNISHED UNDER MEDICAID AND
APPLICATION TO ADDITIONAL PROVIDERS.
(a) In General.--Section 1902(a)(13) of the Social Security Act (42
U.S.C. 1396a(a)(13)) is amended by striking subparagraph (C) and
inserting the following:
``(C) payment for primary care services (as defined
in subsection (jj)) at a rate that is not less than 100
percent of the payment rate that applies to such
services and physician under part B of title XVIII (or,
if greater, the payment rate that would be applicable
under such part if the conversion factor under section
1848(d) for the year involved were the conversion
factor under such section for 2009), and that is not
less than the rate that would otherwise apply to such
services under this title if the rate were determined
without regard to this subparagraph, and that are--
``(i) furnished in 2013 and 2014, by a
physician with a primary specialty designation
of family medicine, general internal medicine,
or pediatric medicine; or
``(ii) furnished in 2015 and 2016--
``(I) by a physician with a primary
specialty designation of family
medicine, general internal medicine, or
pediatric medicine, but only if the
physician self-attests that--
``(aa) the physician is
Board certified in family
medicine, general internal
medicine, or pediatric
medicine; or
``(bb) with respect to the
most recently completed
calendar year (or in the case
of a newly eligible physician,
the preceding month), 60
percent of all services the
physician billed for under the
State plan or a waiver under
this title, or provided through
a medicaid managed care
organization (as defined in
section 1903(m)(1)(A)), were
for services described in
subparagraph (A) or (B) of
subsection (jj)(1);
``(II) by a physician with a
primary specialty designation of
obstetrics and gynecology, but only if
the physician self-attests that--
``(aa) the physician is
Board certified in obstetrics
and gynecology; and
``(bb) with respect to the
most recently completed
calendar year (or in the case
of a newly eligible physician,
the preceding month), 60
percent of all services the
physician billed for under the
State plan or a waiver under
this title, or provided through
a medicaid managed care
organization (as defined in
section 1903(m)(1)(A)), were
for services described in
subparagraph (A) or (B) of
subsection (jj)(1);
``(III) by an advanced practice
clinician, as defined by the Secretary,
that works under the supervision of--
``(aa) a physician that
satisfies the criteria
specified in subclause (I) or
(II); or
``(bb) a nurse practitioner
or a physician assistant (as
such terms are defined in
section 1861(aa)(5)(A)) who is
working in accordance with
State law, or a certified
nurse-midwife (as defined in
section 1861(gg)) who is
working in accordance with
State law, but only if the
nurse practitioner, physician
assistant, or certified nurse-
midwife self-attests that, with
respect to the most recently
completed calendar year (or in
the case of a newly eligible
nurse practitioner, physician
assistant, or certified nurse-
midwife, the preceding month),
60 percent of all services the
nurse practitioner, physician
assistant, or certified nurse-
midwife billed for under the
State plan or a waiver under
this title, or provided through
a medicaid managed care
organization (as defined in
section 1903(m)(1)(A)), were
for services described in
subparagraph (A) or (B) of
subsection (jj)(1);
``(IV) by a rural health clinic,
Federally-qualified health center, or
other health clinic that receives
reimbursement on a fee schedule
applicable to a physician, a nurse
practitioner or a physician assistant
(as such terms are defined in section
1861(aa)(5)(A)) who is working in
accordance with State law, or a
certified nurse-midwife (as defined in
section 1861(gg)) who is working in
accordance with State law, for services
furnished by a physician, nurse
practitioner, physician assistant, or
certified nurse-midwife, or services
furnished by an advanced practice
clinician supervised by a physician
described in subclause (I)(aa) or
(II)(aa), another advanced practice
clinician, or a certified nurse-
midwife, but only if the rural health
clinic or Federally-qualified health
center self-attests that 60 percent of
all services billed for under the State
plan or a waiver under this title, or
provided through a medicaid managed
care organization (as defined in
section 1903(m)(1)(A)), were for
services described in subparagraph (A)
or (B) of subsection (jj)(1); or
``(V) by a nurse practitioner or a
physician assistant (as such terms are
defined in section 1861(aa)(5)(A)) who
is working in accordance with State
law, or a certified nurse-midwife (as
defined in section 1861(gg)) who is
working in accordance with State law,
in accordance with procedures that
ensure that the portion of the payment
for such services that the nurse
practitioner, physician assistant, or
certified nurse-midwife is paid is not
less than the amount that the nurse
practitioner, physician assistant, or
certified nurse-midwife would be paid
if the services were provided under
part B of title XVIII, but only if the
nurse practitioner, physician
assistant, or certified nurse-midwife
self-attests that, with respect to the
most recently completed calendar year
(or in the case of a newly eligible
nurse practitioner, physician
assistant, or certified nurse-midwife,
the preceding month), 60 percent of all
services the nurse practitioner,
physician assistant, or certified
nurse-midwife billed for under the
State plan or a waiver under this
title, or provided through a medicaid
managed care organization (as defined
in section 1903(m)(1)(A)), were for
services described in subparagraph (A)
or (B) of subsection (jj)(1);''.
(b) Improved Targeting of Primary Care.--Section 1902(jj) of the
Social Security Act (42 U.S.C. 1396a(jj)) is amended--
(1) by redesignating paragraphs (1) and (2) as
subparagraphs (A) and (B), respectively and realigning the left
margins accordingly;
(2) by striking ``For purposes of'' and inserting the
following:
``(1) In general.--For purposes of''; and
(3) by adding at the end the following:
``(2) Exclusions.--Such term does not include any services
described in subparagraph (A) or (B) of paragraph (1) if such
services are provided in an emergency department of a
hospital.''.
(c) Conforming Amendment.--Section 1905(dd) of the Social Security
Act (42 U.S.C. 1396d(dd)) is amended by striking ``January 1, 2015''
and inserting ``January 1, 2017''.
(d) Effective Date.--The amendments made by this section take
effect on January 1, 2015.
<all>
Introduced in Senate
Read twice and referred to the Committee on Finance.
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