Ensuring Removal of Terminated Providers from Medicaidand CHIP Act

Summary: Ensuring Removal of Terminated Providers from Medicaid and CHIP Act This bill amends titles XIX (Medicaid) and XXI (Children's Health Insurance Program [CHIP]) of the Social Security Act to prohibit federal payment under Medicaid for nonemergency services furnished by providers whose participation in Medicaid, Medicare, or CHIP has been terminated. Under current law, a state must exclude from Medicaid participation any provider that has been terminated under any state's Medicaid program or under Medicare. The bill maintains those requirements and further requires a state to exclude from Medicaid participation any provider that has been terminated under CHIP. Furthermore, a state must exclude from CHIP participation any provider that has been terminated under Medicaid or Medicare. The bill also revises a state's reporting requirements with respect to terminating a provider under a state plan. A state shall require each Medicaid or CHIP provider, whether the provider participates on a fee-for-service (FFS) basis or within the network of a managed care organization (MCO), to enroll with the state by providing specified identifying information. When notifying the Department of Health and Human Services (HHS) that a provider has been terminated under a state plan, the state must submit this information as well as information regarding the termination date and reason. HHS shall review such termination notifications and, if appropriate, include them in a database or similar system, as specified by the bill. The bill prohibits federal payment under a state's Medicaid or CHIP program for services provided by an MCO unless: (1) the&nbsp;state has a system for notifying MCOs when a provider is terminated under Medicaid, Medicare, or CHIP; and (2) any contract between the state plan and an MCO provides that such providers be excluded from participation in the MCO provider network. 

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Ensuring Removal of Terminated 
Providers from Medicaid and CHIP Act''.

SEC. 2. INCREASING OVERSIGHT OF TERMINATION OF MEDICAID PROVIDERS.

    (a) Increased Oversight and Reporting.--
            (1) State reporting requirements.--Section 1902(kk) of the 
        Social Security Act (42 U.S.C. 1396a(kk)) is amended--
                    (A) by redesignating paragraph (8) as paragraph 
                (9); and
                    (B) by inserting after paragraph (7) the following 
                new paragraph:
            ``(8) Provider terminations.--
                    ``(A) In general.--Beginning on July 1, 2018, in 
                the case of a notification under subsection (a)(41) 
                with respect to a termination for a reason specified in 
                section 455.101 of title 42, Code of Federal 
                Regulations (as in effect on November 1, 2015), or for 
                any other reason specified by the Secretary, of the 
                participation of a provider of services or any other 
                person under the State plan, the State, not later than 
                21 business days after the effective date of such 
                termination, submits to the Secretary with respect to 
                any such provider or person, as appropriate--
                            ``(i) the name of such provider or person;
                            ``(ii) the provider type of such provider 
                        or person;
                            ``(iii) the specialty of such provider's or 
                        person's practice;
                            ``(iv) the date of birth, social security 
                        number, national provider identifier, Federal 
                        taxpayer identification number, and the State 
                        license or certification number of such 
                        provider or person;
                            ``(v) the reason for the termination;
                            ``(vi) a copy of the notice of termination 
                        sent to the provider or person;
                            ``(vii) the date on which such termination 
                        is effective, as specified in the notice; and
                            ``(viii) any other information required by 
                        the Secretary.
                    ``(B) Effective date defined.--For purposes of this 
                paragraph, the term `effective date' means, with 
                respect to a termination described in subparagraph (A), 
                the later of--
                            ``(i) the date on which such termination is 
                        effective, as specified in the notice of such 
                        termination; or
                            ``(ii) the date on which all appeal rights 
                        applicable to such termination have been 
                        exhausted or the timeline for any such appeal 
                        has expired.''.
            (2) Contract requirement for managed care entities.--
        Section 1932(d) of the Social Security Act (42 U.S.C. 1396u-
        2(d)) is amended by adding at the end the following new 
        paragraph:
            ``(5) Contract requirement for managed care entities.--With 
        respect to any contract with a managed care entity under 
        section 1903(m) or 1905(t)(3) (as applicable), no later than 
        July 1, 2018, such contract shall include a provision that 
        providers of services or persons terminated (as described in 
        section 1902(kk)(8)) from participation under this title, title 
        XVIII, or title XXI be terminated from participating under this 
        title as a provider in any network of such entity that serves 
        individuals eligible to receive medical assistance under this 
        title.''.
            (3) Termination notification database.--Section 1902 of the 
        Social Security Act (42 U.S.C. 1396a) is amended by adding at 
        the end the following new subsection:
    ``(ll) Termination Notification Database.--In the case of a 
provider of services or any other person whose participation under this 
title, title XVIII, or title XXI is terminated (as described in 
subsection (kk)(8)), the Secretary shall, not later than 21 business 
days after the date on which the Secretary terminates such 
participation under title XVIII or is notified of such termination 
under subsection (a)(41) (as applicable), review such termination and, 
if the Secretary determines appropriate, include such termination in 
any database or similar system developed pursuant to section 6401(b)(2) 
of the Patient Protection and Affordable Care Act (42 U.S.C. 1395cc 
note).''.
            (4) No federal funds for items and services furnished by 
        terminated providers.--Section 1903 of the Social Security Act 
        (42 U.S.C. 1396b) is amended--
                    (A) in subsection (i)(2)--
                            (i) in subparagraph (A), by striking the 
                        comma at the end and inserting a semicolon;
                            (ii) in subparagraph (B), by striking 
                        ``or'' at the end; and
                            (iii) by adding at the end the following 
                        new subparagraph:
                    ``(D) beginning not later than July 1, 2018, under 
                the plan by any provider of services or person whose 
                participation in the State plan is terminated (as 
                described in section 1902(kk)(8)) after the date that 
                is 60 days after the date on which such termination is 
                included in the database or other system under section 
                1902(ll); or''; and
                    (B) in subsection (m), by inserting after paragraph 
                (2) the following new paragraph:
    ``(3) No payment shall be made under this title to a State with 
respect to expenditures incurred by the State for payment for services 
provided by a managed care entity (as defined under section 1932(a)(1)) 
under the State plan under this title (or under a waiver of the plan) 
unless the State--
            ``(A) beginning on July 1, 2018, has a contract with such 
        entity that complies with the requirement specified in section 
        1932(d)(5); and
            ``(B) beginning on January 1, 2018, complies with the 
        requirement specified in section 1932(d)(6)(A).''.
            (5) Development of uniform terminology for reasons for 
        provider termination.--Not later than July 1, 2017, the 
        Secretary of Health and Human Services shall, in consultation 
        with the heads of State agencies administering State Medicaid 
        plans (or waivers of such plans), issue regulations 
        establishing uniform terminology to be used with respect to 
        specifying reasons under subparagraph (A)(v) of paragraph (8) 
        of section 1902(kk) of the Social Security Act (42 U.S.C. 
        1396a(kk)), as amended by paragraph (1), for the termination 
        (as described in such paragraph) of the participation of 
        certain providers in the Medicaid program under title XIX of 
        such Act or the Children's Health Insurance Program under title 
        XXI of such Act.
            (6) Conforming amendment.--Section 1902(a)(41) of the 
        Social Security Act (42 U.S.C. 1396a(a)(41)) is amended by 
        striking ``provide that whenever'' and inserting ``provide, in 
        accordance with subsection (kk)(8) (as applicable), that 
        whenever''.
    (b) Increasing Availability of Medicaid Provider Information.--
            (1) FFS provider enrollment.--Section 1902(a) of the Social 
        Security Act (42 U.S.C. 1396a(a)) is amended by inserting after 
        paragraph (77) the following new paragraph:
            ``(78) provide that, not later than January 1, 2017, in the 
        case of a State plan that provides medical assistance on a fee-
        for-service basis, the State shall require each provider 
        furnishing items and services to individuals eligible to 
        receive medical assistance under such plan to enroll with the 
        State agency and provide to the State agency the provider's 
        identifying information, including the name, specialty, date of 
        birth, social security number, national provider identifier, 
        Federal taxpayer identification number, and the State license 
        or certification number of the provider;''.
            (2) Managed care provider enrollment.--Section 1932(d) of 
        the Social Security Act (42 U.S.C. 1396u-2(d)), as amended by 
        subsection (a)(2), is amended by adding at the end the 
        following new paragraph:
            ``(6) Enrollment of participating providers.--
                    ``(A) In general.--Beginning not later than January 
                1, 2018, a State shall require that, in order to 
                participate as a provider in the network of a managed 
                care entity that provides services to, or orders, 
                prescribes, refers, or certifies eligibility for 
                services for, individuals who are eligible for medical 
                assistance under the State plan under this title and 
                who are enrolled with the entity, the provider is 
                enrolled with the State agency administering the State 
                plan under this title. Such enrollment shall include 
                providing to the State agency the provider's 
                identifying information, including the name, specialty, 
                date of birth, social security number, national 
                provider identifier, Federal taxpayer identification 
                number, and the State license or certification number 
                of the provider.
                    ``(B) Rule of construction.--Nothing in 
                subparagraph (A) shall be construed as requiring a 
                provider described in such subparagraph to provide 
                services to individuals who are not enrolled with a 
                managed care entity under this title.''.
    (c) Coordination With CHIP.--
            (1) In general.--Section 2107(e)(1) of the Social Security 
        Act (42 U.S.C. 1397gg(e)(1)) is amended--
                    (A) by redesignating subparagraphs (B), (C), (D), 
                (E), (F), (G), (H), (I), (J), (K), (L), (M), (N), and 
                (O) as subparagraphs (D), (E), (F), (G), (H), (I), (J), 
                (K), (M), (N), (O), (P), (Q), and (R), respectively;
                    (B) by inserting after subparagraph (A) the 
                following new subparagraphs:
                    ``(B) Section 1902(a)(39) (relating to termination 
                of participation of certain providers).
                    ``(C) Section 1902(a)(78) (relating to enrollment 
                of providers participating in State plans providing 
                medical assistance on a fee-for-service basis).'';
                    (C) by inserting after subparagraph (K) (as 
                redesignated by subparagraph (A)) the following new 
                subparagraph:
                    ``(L) Section 1903(m)(3) (relating to limitation on 
                payment with respect to managed care).''; and
                    (D) in subparagraph (P) (as redesignated by 
                subparagraph (A)), by striking ``(a)(2)(C) and (h)'' 
                and inserting ``(a)(2)(C) (relating to Indian 
                enrollment), (d)(5) (relating to contract requirement 
                for managed care entities), (d)(6) (relating to 
                enrollment of providers participating with a managed 
                care entity), and (h) (relating to special rules with 
                respect to Indian enrollees, Indian health care 
                providers, and Indian managed care entities)''.
            (2) Excluding from medicaid providers excluded from chip.--
        Section 1902(a)(39) of the Social Security Act (42 U.S.C. 
        1396a(a)(39)) is amended by striking ``title XVIII or any other 
        State plan under this title'' and inserting ``title XVIII, any 
        other State plan under this title, or any State child health 
        plan under title XXI''.
    (d) Rule of Construction.--Nothing in this section shall be 
construed as changing or limiting the appeal rights of providers or the 
process for appeals of States under the Social Security Act.
    (e) OIG Report.--Not later than March 31, 2020, the Inspector 
General of the Department of Health and Human Services shall submit to 
Congress a report on the implementation of the amendments made by this 
section. Such report shall include the following:
            (1) An assessment of the extent to which providers who are 
        included under subsection (ll) of section 1902 of the Social 
        Security Act (42 U.S.C. 1396a) (as added by subsection (a)(3)) 
        in the database or similar system referred to in such 
        subsection are terminated (as described in subsection (kk)(8) 
        of such section, as added by subsection (a)(1)) from 
        participation in all State plans under title XIX of such Act.
            (2) Information on the amount of Federal financial 
        participation paid to States under section 1903 of such Act in 
        violation of the limitation on such payment specified in 
        subsections (i)(2)(D) and (m)(3) of such section, as added by 
        subsection (a)(4).
            (3) An assessment of the extent to which contracts with 
        managed care entities under title XIX of such Act comply with 
        the requirement specified in section 1932(d)(5) of such Act, as 
        added by subsection (a)(2).
            (4) An assessment of the extent to which providers have 
        been enrolled under section 1902(a)(78) or 1932(d)(6)(A) of 
        such Act (42 U.S.C. 1396a(a)(78), 1396u-2(d)(6)(A)) with State 
        agencies administering State plans under title XIX of such Act.