I 

114TH CONGRESS 

1ST SESSION H. R. 3716 

To amend title XIX of the Social Security Act to require States to provide 

to the Secretary of Health and Human Services certain information 

with respect to provider terminations, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

OCTOBER 8, 2015 

Mr. BUCSHON (for himself, Mr. WELCH, and Mr. BUTTERFIELD) introduced 

the following bill; which was referred to the Committee on Energy and 

Commerce 

A BILL 

To amend title XIX of the Social Security Act to require 

States to provide to the Secretary of Health and Human 

Services certain information with respect to provider terminations, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Ensuring Terminated 

5 Providers are Removed from Medicaid and CHIP Act’’. 

6 SEC. 2. INCREASING OVERSIGHT OF TERMINATION OF 

7 MEDICAID PROVIDERS. 

8 (a) INCREASED OVERSIGHT AND REPORTING.— 


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1 (1) STATE REPORTING REQUIREMENTS.—Sec2 tion 1902(kk) of the Social Security Act (42 U.S.C. 

3 1396a(kk)) is amended— 

4 (A) by redesignating paragraph (8) as 

5 paragraph (9); and 

6 (B) by inserting after paragraph (7) the 

7 following new paragraph: 

8 ‘‘(8) PROVIDER TERMINATIONS.— 

9 ‘‘(A) IN GENERAL.—Beginning 180 days 

10 after the date of the enactment of this para11 graph, in the case of a notification under sub12 section (a)(41) with respect to a termination for 

13 cause of the participation of any individual or 

14 entity under the State plan under subsection 

15 (a)(39), the State, not later than 14 business 

16 days after the effective date of such termi17 nation, submits to the Secretary with respect to 

18 any such individual or entity— 

19 ‘‘(i) the name of such individual or 

20 entity; 

21 ‘‘(ii) the provider type of such indi22 vidual or entity; 

23 ‘‘(iii) the specialty of such individual’s 

24 or entity’s practice; 


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1 ‘‘(iv) the date of birth, Social Security 

2 number, national provider identifier, Fed3 eral taxpayer identification number, and 

4 the State license or certification number of 

5 such individual or entity; 

6 ‘‘(v) the reason for the termination; 

7 ‘‘(vi) the effective date of such termi8 nation; and 

9 ‘‘(vii) a copy of the notice of termi10 nation sent to the individual or entity. 

11 ‘‘(B) MANAGED CARE ENTITIES.— 

12 ‘‘(i) IN GENERAL.—With respect to 

13 managed care entities (as defined in sec14 tion 1932(a)(1)), beginning on the later of 

15 the date that is 180 days after the date of 

16 the enactment of this paragraph or the 

17 first day of the first plan year for such an 

18 entity that begins after such date of enact19 ment, the State requires that any contract 

20 the State plan has with any such entity in21 cludes a provision that individuals termi22 nated for cause from participation under 

23 the program under title XVIII, this title, 

24 or title XXI be terminated from participa25 tion in the provider networks of managed 


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1 care entities under this title that serve in2 dividuals eligible to receive medical assist3 ance under this title. 

4 ‘‘(ii) NOTIFICATION OF TERMI5 NATION.—For the period beginning on the 

6 date that is 180 days after the date of the 

7 enactment of this paragraph and ending on 

8 the date on which the enrollment of pro9 viders under section 1932(d)(5) is com10 plete for the State, the State provides for 

11 a system for notifying managed care enti12 ties (as defined in section 1932(a)(1)) of 

13 the termination of individuals or entities 

14 from participation under the program 

15 under title XVIII, this title, or title XXI.’’. 

16 (2) TERMINATION NOTIFICATION DATABASE.— 

17 Section 1902 of the Social Security Act (42 U.S.C. 

18 1396a) is amended by adding at the end the fol19 lowing new subsection: 

20 ‘‘(ll) TERMINATION NOTIFICATION DATABASE.—In 

21 the case of an individual or entity whose participation in 

22 the program under title XVIII, this title, or title XXI is 

23 terminated for cause under subsection (a)(39), the Sec24 retary shall, not later than 14 business days after the date 

25 on which the Secretary is notified of such termination 


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1 under subsection (a)(41), include such termination in any 

2 database or similar system developed pursuant to section 

3 6401(b)(2) of the Patient Protection and Affordable Care 

4 Act (42 U.S.C. 1395cc note; Public Law 111–148).’’. 

5 (3) NO FEDERAL FUNDS FOR ITEMS AND SERV6 ICES FURNISHED BY TERMINATED PROVIDERS.— 

7 Section 1903(i)(2) of the Social Security Act (42 

8 U.S.C. 1396b(i)(2)) is amended— 

9 (A) in subparagraph (A), by striking the 

10 comma at the end and inserting a semicolon; 

11 (B) in subparagraph (B), by striking ‘‘or’’ 

12 at the end; and 

13 (C) by adding at the end the following new 

14 subparagraph: 

15 ‘‘(D) beginning 2 years after the date of 

16 the enactment of this subparagraph, under the 

17 plan by any individual or entity whose partici18 pation in the State plan is terminated for cause 

19 under subsection (a)(39) of section 1902 after 

20 the date that is 60 days after the date on which 

21 such termination is included in the database or 

22 other system under subsection (ll) of such sec23 tion; or’’. 

24 (4) DEVELOPMENT OF UNIFORM TERMINOLOGY

25 FOR REASONS FOR PROVIDER TERMINATION.—Not 


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1 later than 180 days after the date of the enactment 

2 of this Act, the Secretary of Health and Human 

3 Services shall issue regulations establishing uniform 

4 terminology to be used with respect to specifying 

5 reasons under paragraph (8)(A) of section 1902(kk) 

6 of the Social Security Act (42 U.S.C. 1396a(kk)) for 

7 the termination of the participation of certain pro8 viders in the Medicaid program under title XIX of 

9 such Act or the Children’s Health Insurance Pro10 gram under title XXI of such Act. 

11 (5) CONFORMING AMENDMENT.—Section 

12 1902(a)(41) of the Social Security Act (42 U.S.C. 

13 1396a(a)(41)) is amended by striking ‘‘provide that 

14 whenever’’ and inserting ‘‘provide, in accordance 

15 with subsection (kk)(8) (as applicable), that when16 ever’’. 

17 (b) INCREASING AVAILABILITY OF MEDICAID PRO18 VIDER INFORMATION.— 

19 (1) FFS PROVIDER ENROLLMENT.—Section 

20 1902(a) of the Social Security Act (42 U.S.C. 

21 1396a(a)) is amended by inserting after paragraph 

22 (77) the following new paragraph: 

23 ‘‘(78) provide that, not later than 180 days 

24 after the date of the enactment of this paragraph, 

25 in the case of a State plan that provides medical asVerDate Sep 11 2014 02:36 Oct 14, 2015 Jkt 059200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H3716.IH H3716

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1 sistance on a fee-for-service basis, the State shall re2 quire each provider furnishing items and services to 

3 individuals eligible to receive medical assistance 

4 under such plan to enroll with the State agency and 

5 provide to the State agency the provider’s identifying 

6 information, including the name, specialty, date of 

7 birth, Social Security number, national provider 

8 identifier, Federal taxpayer identification number, 

9 and the State license or certification number of the 

10 provider;’’. 

11 (2) MANAGED CARE PROVIDER ENROLLMENT.— 

12 Section 1932(d) of the Social Security Act (42 

13 U.S.C. 1396u–2(d)) is amended by adding at the 

14 end the following new paragraph: 

15 ‘‘(5) ENROLLMENT OF PARTICIPATING PRO16 VIDERS.— 

17 ‘‘(A) IN GENERAL.—Beginning not later 

18 than one year after the date of the enactment 

19 of this paragraph, a State shall require that, as 

20 a condition on the participation in the provider 

21 network of a managed care entity of a provider 

22 that provides services to, or orders or provides 

23 referrals for services for, individuals who are el24 igible for medical assistance under the State 

25 plan under this title and who are enrolled with 


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1 the entity, the provider enrolls with the State 

2 agency administering the State plan under this 

3 title. Such enrollment shall include providing to 

4 the State agency the provider’s identifying in5 formation, including the name, specialty, date 

6 of birth, Social Security number, national pro7 vider identifier, Federal taxpayer identification 

8 number, and the State license or certification 

9 number of the provider. 

10 ‘‘(B) RULE OF CONSTRUCTION.—Nothing 

11 in subparagraph (A) shall be construed as re12 quiring a provider described in such subpara13 graph to provide services to individuals who are 

14 not enrolled with a managed care entity under 

15 this title.’’. 

16 (c) COORDINATION WITH CHIP.— 

17 (1) IN GENERAL.—Section 2107(e)(1) of the 

18 Social Security Act (42 U.S.C. 1397gg(e)(1)) is 

19 amended— 

20 (A) by redesignating subparagraphs (B) 

21 through (O) as subparagraphs (D) through (Q), 

22 respectively; 

23 (B) by inserting after subparagraph (A) 

24 the following new subparagraphs: 


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1 ‘‘(B) Section 1902(a)(39) (relating to ter2 mination of participation of certain providers). 

3 ‘‘(C) Section 1902(a)(78) (relating to the 

4 enrollment of providers participating in State 

5 plans providing medical assistance on a fee-for6 service basis).’’; and 

7 (C) in subparagraph (O) (as redesignated 

8 by paragraph (1)), by striking ‘‘(a)(2)(C) and 

9 (h)’’ and inserting ‘‘(a)(2)(C) (relating to In10 dian enrollment), (d)(5) (relating to enrollment 

11 of providers participating with a managed care 

12 entity), and (h) (relating to special rules with 

13 respect to Indian enrollees, Indian health care 

14 providers, and Indian managed care entities)’’. 

15 (2) EXCLUDING FROM MEDICAID PROVIDERS

16 EXCLUDED FROM CHIP.—Section 1902(a)(39) of the 

17 Social Security Act (42 U.S.C. 1396a(a)(39)) is 

18 amended by striking ‘‘title XVIII or any other State 

19 plan under this title’’ and inserting ‘‘title XVIII, any 

20 other State plan under this title, or any State child 

21 health plan under title XXI’’. 

22 (d) RULE OF CONSTRUCTION.—Nothing in this sec23 tion shall be construed as changing the appeal rights of 


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1 providers or the process for appeals of States under the 

2 Social Security Act. 

Æ 


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