Ensuring Access to Primary Care for Women & Children Act

Summary: 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.

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.