Ensuring Access to Primary Care for Women & Children Act

Summary: Ensuring Access to Primary Care for Women &amp; Children Act Amends title XIX (Medicaid) of the Social Security Act (SSAct) to require that the primary care services furnished in the two years after enactment of this Act 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 under Medicare part B (Supplementary Medical Insurance), but only if the physician self-attests as being Board certified in those areas. Extends this 100% of Medicare payment floor, subject to certain conditions, to the following providers: (1) physicians with a primary specialty designation of obstetrics and gynecology, and self-attesting they are Board certified; (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. Prescribes additional requirements for any contract between a state and a Medicaid managed care organization. Directs the Government Accountability Office to examine the use of alternative payment models in state Medicaid programs and identify opportunities for disseminating successful payment models among them. Amends SSAct title XI to: (1) extend funding for development of adult health quality measures; and (2) direct the Administrator for the Centers for Medicaid and Medicaid Services and the Director of the Agency for Healthcare Research and Quality to develop such measures specific to adult individuals with disabilities and include them in the Medicaid Quality Measurement Program.

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 2014, the Medicaid program covered 69,000,000 
        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.
            (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) 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.
            (7) 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.
            (8) According to a study published earlier this year in the 
        New England Journal of Medicine, higher Medicaid payment rates 
        have significantly increased appointment availability for 
        Medicaid enrollees.
            (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 health professionals 
        deliver many primary care services. Applying Medicare's rates 
        for nurse practitioners and other 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. RENEWAL OF APPLICATION OF MEDICARE PAYMENT RATE FLOOR TO 
              PRIMARY CARE SERVICES FURNISHED UNDER MEDICAID AND 
              INCLUSION OF ADDITIONAL PROVIDERS.

    (a) Renewal of Payment Floor; Additional Providers.--
            (1) 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 the 2-year period that 
                        begins on the first day of the first month that 
                        begins after the date of enactment of the 
                        Ensuring Access to Primary Care for Women & 
                        Children Act--
                                    ``(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 the 
                                physician is Board certified in family 
                                medicine, general internal medicine, or 
                                pediatric medicine;
                                    ``(II) by a physician with a 
                                primary specialty designation of 
                                obstetrics and gynecology, but only if 
                                the physician self-attests that the 
                                physician is Board certified in 
                                obstetrics and gynecology;
                                    ``(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;
                                    ``(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; 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;''.
            (2) Conforming amendments.--Section 1905(dd) of the Social 
        Security Act (42 U.S.C. 1396d(dd)) is amended--
                    (A) by striking ``Notwithstanding'' and inserting 
                the following:
            ``(1) In general.--Notwithstanding'';
                    (B) by inserting ``or furnished during an 
                additional period specified in paragraph (2),'' after 
                ``2015,''; and
                    (C) by adding at the end the following:
            ``(2) Additional periods.--For purposes of paragraph (1), 
        the following are additional periods:
                    ``(A) The 2-year period that begins on the first 
                day of the first month that begins after the date of 
                enactment of the Ensuring Access to Primary Care for 
                Women & Children Act.''.
    (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) Ensuring Payment by Managed Care Entities.--
            (1) In general.--Section 1903(m)(2)(A) of the Social 
        Security Act (42 U.S.C. 1396b(m)(2)(A)) is amended--
                    (A) in clause (xii), by striking ``and'' after the 
                semicolon;
                    (B) by realigning the left margin of clause (xiii) 
                so as to align with the left margin of clause (xii) and 
                by striking the period at the end of clause (xiii) and 
                inserting ``; and''; and
                    (C) by inserting after clause (xiii) the following:
            ``(xiv) such contract provides that (I) payments to 
        providers specified in section 1902(a)(13)(C) for primary care 
        services defined in section 1902(jj) that are furnished during 
        a year or period specified in section 1902(a)(13)(C) and 
        section 1905(dd) are at least equal to the amounts set forth 
        and required by the Secretary by regulation, (II) the entity 
        shall, upon request, provide documentation to the State, 
        sufficient to enable the State and the Secretary to ensure 
        compliance with subclause (I), and (III) the Secretary shall 
        deem payments described in subclause (I) that are furnished 
        through an agreed upon capitation, partial capitation, or other 
        value-based payment arrangement to comply with subclause (I) if 
        the capitation, partial capitation, or other value-based 
        payment arrangement is based on a reasonable methodology and 
        the entity provides documentation of the methodology to the 
        Secretary.''.
            (2) Conforming amendment.--Section 1932(f) of the Social 
        Security Act (42 U.S.C. 1396u-2(f)) is amended by inserting 
        ``and clause (xiv) of section 1903(m)(2)(A)'' before the 
        period.

SEC. 4. IMPROVING QUALITY AND VALUE FOR MEDICAID BENEFICIARIES.

    (a) GAO Study.--Not later than 1 year after the date of enactment 
of this Act, the Comptroller General of the United States shall submit 
to Congress a report that examines the use of alternative payment 
models in State Medicaid programs and identifies opportunities for 
disseminating successful payment models among such programs.
    (b) Funding the Development of Quality Measures.--The first 
sentence of section 1139B(e) of the Social Security Act (42 U.S.C. 
1320b-9b(e)) is amended by inserting ``, and for fiscal year 2016, 
$15,000,000,'' before ``for the purpose''.
    (c) Developing Quality Measures for Beneficiaries With 
Disabilities.--Section 1139B(b)(5) of the Social Security Act (42 
U.S.C. 1320b-9b(b)(5)) is amended by adding at the end the following:
                    ``(C) Quality measures specific to adult 
                individuals with disabilities.--The Secretary, acting 
                through the Administrator for the Centers for Medicare 
                & Medicaid Services and the Director of the Agency for 
                Healthcare Research and Quality, shall develop adult 
                health quality measures that are specific to adult 
                individuals with disabilities and shall include those 
                measures in the Medicaid Quality Measurement Program. 
                In developing such measures, priority shall be given to 
                developing quality measures that assess the impact on 
                adult individuals with disabilities of existing 
                programs and to the development of quality measures 
                that assess the impact of new service delivery 
                innovations on such individuals.''.