IIB 

114TH CONGRESS 

2D SESSION H. R. 3716 

IN THE SENATE OF THE UNITED STATES 

MARCH 3, 2016 

Received; read twice and referred to the Committee on Finance 

AN ACT 

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, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Ensuring Access to 

3 Quality Medicaid Providers Act’’. 

4 SEC. 2. INCREASING OVERSIGHT OF TERMINATION OF 

5 MEDICAID PROVIDERS. 

6 (a) INCREASED OVERSIGHT AND REPORTING.— 

7 (1) STATE REPORTING REQUIREMENTS.—Sec8 tion 1902(kk) of the Social Security Act (42 U.S.C. 

9 1396a(kk)) is amended— 

10 (A) by redesignating paragraph (8) as 

11 paragraph (9); and 

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

13 following new paragraph: 

14 ‘‘(8) PROVIDER TERMINATIONS.— 

15 ‘‘(A) IN GENERAL.—Beginning on July 1, 

16 2018, in the case of a notification under sub17 section (a)(41) with respect to a termination for 

18 a reason specified in section 455.101 of title 42, 

19 Code of Federal Regulations (as in effect on 

20 November 1, 2015) or for any other reason 

21 specified by the Secretary, of the participation 

22 of a provider of services or any other person 

23 under the State plan, the State, not later than 

24 21 business days after the effective date of such 

25 termination, submits to the Secretary with reVerDate Sep 11 2014 23:38 Mar 03, 2016 Jkt 059200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H3716.RFS H3716

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1 spect to any such provider or person, as appro2 priate— 

3 ‘‘(i) the name of such provider or per4 son; 

5 ‘‘(ii) the provider type of such pro6 vider or person; 

7 ‘‘(iii) the specialty of such provider’s 

8 or person’s practice; 

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

10 number, national provider identifier, Fed11 eral taxpayer identification number, and 

12 the State license or certification number of 

13 such provider or person; 

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

15 ‘‘(vi) a copy of the notice of termi16 nation sent to the provider or person; 

17 ‘‘(vii) the date on which such termi18 nation is effective, as specified in the no19 tice; and 

20 ‘‘(viii) any other information required 

21 by the Secretary. 

22 ‘‘(B) EFFECTIVE DATE DEFINED.—For 

23 purposes of this paragraph, the term ‘effective 

24 date’ means, with respect to a termination de25 scribed in subparagraph (A), the later of— 


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1 ‘‘(i) the date on which such termi2 nation is effective, as specified in the no3 tice of such termination; or 

4 ‘‘(ii) the date on which all appeal 

5 rights applicable to such termination have 

6 been exhausted or the timeline for any 

7 such appeal has expired.’’. 

8 (2) CONTRACT REQUIREMENT FOR MANAGED

9 CARE ENTITIES.—Section 1932(d) of the Social Se10 curity Act (42 U.S.C. 1396u–2(d)) is amended by 

11 adding at the end the following new paragraph: 

12 ‘‘(5) CONTRACT REQUIREMENT FOR MANAGED

13 CARE ENTITIES.—With respect to any contract with 

14 a managed care entity under section 1903(m) or 

15 1905(t)(3) (as applicable), no later than July 1, 

16 2018, such contract shall include a provision that 

17 providers of services or persons terminated (as de18 scribed in section 1902(kk)(8)) from participation 

19 under this title, title XVIII, or title XXI be termi20 nated from participating under this title as a pro21 vider in any network of such entity that serves indi22 viduals eligible to receive medical assistance under 

23 this title.’’. 

24 (3) TERMINATION NOTIFICATION DATABASE.— 

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


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1 1396a) is amended by adding at the end the fol2 lowing new subsection: 

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

4 the case of a provider of services or any other person 

5 whose participation under this title, title XVIII, or title 

6 XXI is terminated (as described in subsection (kk)(8)), 

7 the Secretary shall, not later than 21 business days after 

8 the date on which the Secretary terminates such participa9 tion under title XVIII or is notified of such termination 

10 under subsection (a)(41) (as applicable), review such ter11 mination and, if the Secretary determines appropriate, in12 clude such termination in any database or similar system 

13 developed pursuant to section 6401(b)(2) of the Patient 

14 Protection and Affordable Care Act (42 U.S.C. 1395cc 

15 note; Public Law 111–148).’’. 

16 (4) NO FEDERAL FUNDS FOR ITEMS AND SERV17 ICES FURNISHED BY TERMINATED PROVIDERS.— 

18 Section 1903 of the Social Security Act (42 U.S.C. 

19 1396b) is amended— 

20 (A) in subsection (i)(2)— 

21 (i) in subparagraph (A), by striking 

22 the comma at the end and inserting a 

23 semicolon; 

24 (ii) in subparagraph (B), by striking 

25 ‘‘or’’ at the end; and 


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1 (iii) by adding at the end the fol2 lowing new subparagraph: 

3 ‘‘(D) beginning not later than July 1, 

4 2018, under the plan by any provider of serv5 ices or person whose participation in the State 

6 plan is terminated (as described in section 

7 1902(kk)(8)) after the date that is 60 days 

8 after the date on which such termination is in9 cluded in the database or other system under 

10 section 1902(ll); or’’; and 

11 (B) in subsection (m), by inserting after 

12 paragraph (2) the following new paragraph: 

13 ‘‘(3) No payment shall be made under this title to 

14 a State with respect to expenditures incurred by the State 

15 for payment for services provided by a managed care enti16 ty (as defined under section 1932(a)(1)) under the State 

17 plan under this title (or under a waiver of the plan) unless 

18 the State— 

19 ‘‘(A) beginning on July 1, 2018, has a contract 

20 with such entity that complies with the requirement 

21 specified in such subparagraph; and 

22 ‘‘(B) beginning on January 1, 2018, complies 

23 with the requirement specified in section 

24 1932(d)(6)(A).’’. 


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1 (5) DEVELOPMENT OF UNIFORM TERMINOLOGY

2 FOR REASONS FOR PROVIDER TERMINATION.—Not 

3 later than July 1, 2017, the Secretary of Health and 

4 Human Services shall, in consultation with the 

5 heads of State agencies administering State Med6 icaid plans (or waivers of such plans), issue regula7 tions establishing uniform terminology to be used 

8 with respect to specifying reasons under subpara9 graph (A)(v) of paragraph (8) of section 1902(kk) 

10 of the Social Security Act (42 U.S.C. 1396a(kk)), as 

11 amended by paragraph (1), for the termination (as 

12 described in such paragraph) of the participation of 

13 certain providers in the Medicaid program under 

14 title XIX of such Act or the Children’s Health In15 surance Program under title XXI of such Act. 

16 (6) CONFORMING AMENDMENT.—Section 

17 1902(a)(41) of the Social Security Act (42 U.S.C. 

18 1396a(a)(41)) is amended by striking ‘‘provide that 

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

20 with subsection (kk)(8) (as applicable), that when21 ever’’. 

22 (b) INCREASING AVAILABILITY OF MEDICAID PRO23 VIDER INFORMATION.— 

24 (1) FFS PROVIDER ENROLLMENT.—Section 

25 1902(a) of the Social Security Act (42 U.S.C. 


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1 1396a(a)) is amended by inserting after paragraph 

2 (77) the following new paragraph: 

3 ‘‘(78) provide that, not later than January 1, 

4 2017, in the case of a State plan that provides med5 ical assistance on a fee-for-service basis, the State 

6 shall require each provider furnishing items and 

7 services to individuals eligible to receive medical as8 sistance under such plan to enroll with the State 

9 agency and provide to the State agency the pro10 vider’s identifying information, including the name, 

11 specialty, date of birth, Social Security number, na12 tional provider identifier, Federal taxpayer identi13 fication number, and the State license or certifi14 cation number of the provider;’’. 

15 (2) MANAGED CARE PROVIDER ENROLLMENT.— 

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

17 U.S.C. 1396u–2(d)), as amended by subsection 

18 (a)(2), is amended by adding at the end the fol19 lowing new paragraph: 

20 ‘‘(6) ENROLLMENT OF PARTICIPATING PRO21 VIDERS.— 

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

23 than January 1, 2018, a State shall require 

24 that, in order to participate as a provider in the 

25 network of a managed care entity that provides 


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1 services to, or orders, prescribes, refers, or cer2 tifies eligibility for services for, individuals who 

3 are eligible for medical assistance under the 

4 State plan under this title and who are enrolled 

5 with the entity, the provider is enrolled with the 

6 State agency administering the State plan 

7 under this title. Such enrollment shall include 

8 providing to the State agency the provider’s 

9 identifying information, including the name, 

10 specialty, date of birth, Social Security number, 

11 national provider identifier, Federal taxpayer 

12 identification number, and the State license or 

13 certification number of the provider. 

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

15 in subparagraph (A) shall be construed as re16 quiring a provider described in such subpara17 graph to provide services to individuals who are 

18 not enrolled with a managed care entity under 

19 this title.’’. 

20 (c) COORDINATION WITH CHIP.— 

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

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

23 amended— 

24 (A) by redesignating subparagraphs (B), 

25 (C), (D), (E), (F), (G), (H), (I), (J), (K), (L), 


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1 (M), (N), and (O) as subparagraphs (D), (E), 

2 (F), (G), (H), (I), (J), (K), (M), (N), (O), (P), 

3 (Q), and (R), respectively; 

4 (B) by inserting after subparagraph (A) 

5 the following new subparagraphs: 

6 ‘‘(B) Section 1902(a)(39) (relating to ter7 mination of participation of certain providers). 

8 ‘‘(C) Section 1902(a)(78) (relating to en9 rollment of providers participating in State 

10 plans providing medical assistance on a fee-for11 service basis).’’; 

12 (C) by inserting after subparagraph (K) 

13 (as redesignated by subparagraph (A)) the fol14 lowing new subparagraph: 

15 ‘‘(L) Section 1903(m)(3) (relating to limi16 tation on payment with respect to managed 

17 care).’’; and 

18 (D) in subparagraph (P) (as redesignated 

19 by subparagraph (A)), by striking ‘‘(a)(2)(C) 

20 and (h)’’ and inserting ‘‘(a)(2)(C) (relating to 

21 Indian enrollment), (d)(5) (relating to contract 

22 requirement for managed care entities), (d)(6) 

23 (relating to enrollment of providers partici24 pating with a managed care entity), and (h) 

25 (relating to special rules with respect to Indian 


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1 enrollees, Indian health care providers, and In2 dian managed care entities)’’. 

3 (2) EXCLUDING FROM MEDICAID PROVIDERS

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

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

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

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

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

9 health plan under title XXI’’. 

10 (d) RULE OF CONSTRUCTION.—Nothing in this sec11 tion shall be construed as changing or limiting the appeal 

12 rights of providers or the process for appeals of States 

13 under the Social Security Act. 

14 (e) OIG REPORT.—Not later than March 31, 2020, 

15 the Inspector General of the Department of Health and 

16 Human Services shall submit to Congress a report on the 

17 implementation of the amendments made by this section. 

18 Such report shall include the following: 

19 (1) An assessment of the extent to which pro20 viders who are included under subsection (ll) of sec21 tion 1902 of the Social Security Act (42 U.S.C. 

22 1396a) (as added by subsection (a)(3)) in the data23 base or similar system referred to in such subsection 

24 are terminated (as described in subsection (kk)(8) of 

25 such section, as added by subsection (a)(1)) from 


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1 participation in all State plans under title XIX of 

2 such Act. 

3 (2) Information on the amount of Federal fi4 nancial participation paid to States under section 

5 1903 of such Act in violation of the limitation on 

6 such payment specified in subsections (i)(2)(D) and 

7 subsection (m)(3) of such section, as added by sub8 section (a)(4). 

9 (3) An assessment of the extent to which con10 tracts with managed care entities under title XIX of 

11 such Act comply with the requirement specified in 

12 section 1932(d)(5) of such Act, as added by sub13 section (a)(2). 

14 (4) An assessment of the extent to which pro15 viders have been enrolled under section 1902(a)(78) 

16 or 1932(d)(6)(A) of such Act (42 U.S.C. 

17 1396a(a)(78), 1396u–2(d)(6)(A)) with State agen18 cies administering State plans under title XIX of 

19 such Act. 

20 SEC. 3. REQUIRING PUBLICATION OF FEE-FOR-SERVICE 

21 PROVIDER DIRECTORY. 

22 (a) IN GENERAL.—Section 1902(a) of the Social Se23 curity Act (42 U.S.C. 1396a(a)) is amended— 

24 (1) in paragraph (80), by striking ‘‘and’’ at the 

25 end; 


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1 (2) in paragraph (81), by striking the period at 

2 the end and inserting ‘‘; and’’; and 

3 (3) by inserting after paragraph (81) the fol4 lowing new paragraph: 

5 ‘‘(82) provide that, not later than January 1, 

6 2017, in the case of a State plan that provides med7 ical assistance on a fee-for-service basis or through 

8 a primary care case-management system described 

9 in section 1915(b)(1) (other than a primary care 

10 case management entity (as defined by the Sec11 retary)), the State shall publish (and update on at 

12 least an annual basis) on the public Website of the 

13 State agency administering the State plan, a direc14 tory of the physicians described in subsection (mm) 

15 and, at State option, other providers described in 

16 such subsection that— 

17 ‘‘(A) includes— 

18 ‘‘(i) with respect to each such physi19 cian or provider— 

20 ‘‘(I) the name of the physician or 

21 provider; 

22 ‘‘(II) the specialty of the physi23 cian or provider; 


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1 ‘‘(III) the address at which the 

2 physician or provider provides serv3 ices; and 

4 ‘‘(IV) the telephone number of 

5 the physician or provider; and 

6 ‘‘(ii) with respect to any such physi7 cian or provider participating in such a 

8 primary care case-management system, in9 formation regarding— 

10 ‘‘(I) whether the physician or 

11 provider is accepting as new patients 

12 individuals who receive medical assist13 ance under this title; and 

14 ‘‘(II) the physician’s or provider’s 

15 cultural and linguistic capabilities, in16 cluding the languages spoken by the 

17 physician or provider or by the skilled 

18 medical interpreter providing interpre19 tation services at the physician’s or 

20 provider’s office; and 

21 ‘‘(B) may include, at State option, with re22 spect to each such physician or provider— 

23 ‘‘(i) the Internet website of such phy24 sician or provider; or 


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1 ‘‘(ii) whether the physician or provider 

2 is accepting as new patients individuals 

3 who receive medical assistance under this 

4 title.’’. 

5 (b) DIRECTORY PHYSICIAN OR PROVIDER DE6 SCRIBED.—Section 1902 of the Social Security Act (42 

7 U.S.C. 1396a), as amended by section 2(a)(3), is amended 

8 by adding at the end the following new subsection: 

9 ‘‘(mm) DIRECTORY PHYSICIAN OR PROVIDER DE10 SCRIBED.—A physician or provider described in this sub11 section is— 

12 ‘‘(1) in the case of a physician or provider of 

13 a provider type for which the State agency, as a con14 dition on receiving payment for items and services 

15 furnished by the physician or provider to individuals 

16 eligible to receive medical assistance under the State 

17 plan, requires the enrollment of the physician or pro18 vider with the State agency, a physician or a pro19 vider that— 

20 ‘‘(A) is enrolled with the agency as of the 

21 date on which the directory is published or up22 dated (as applicable) under subsection (a)(82); 

23 and 


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1 ‘‘(B) received payment under the State 

2 plan in the 12-month period preceding such 

3 date; and 

4 ‘‘(2) in the case of a physician or provider of 

5 a provider type for which the State agency does not 

6 require such enrollment, a physician or provider that 

7 received payment under the State plan in the 12- 

8 month period preceding the date on which the direc9 tory is published or updated (as applicable) under 

10 subsection (a)(82).’’. 

11 (c) RULE OF CONSTRUCTION.— 

12 (1) IN GENERAL.—The amendment made by 

13 subsection (a) shall not be construed to apply in the 

14 case of a State (as defined for purposes of title XIX 

15 of the Social Security Act) in which all the individ16 uals enrolled in the State plan under such title (or 

17 under a waiver of such plan), other than individuals 

18 described in paragraph (2), are enrolled with a med19 icaid managed care organization (as defined in sec20 tion 1903(m)(1)(A) of such Act (42 U.S.C. 

21 1396b(m)(1)(A))), including prepaid inpatient health 

22 plans and prepaid ambulatory health plans (as de23 fined by the Secretary of Health and Human Serv24 ices). 


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1 (2) INDIVIDUALS DESCRIBED.—An individual 

2 described in this paragraph is an individual who is 

3 an Indian (as defined in section 4 of the Indian 

4 Health Care Improvement Act (25 U.S.C. 1603)) or 

5 an Alaska Native. 

6 (d) EXCEPTION FOR STATE LEGISLATION.—In the 

7 case of a State plan under title XIX of the Social Security 

8 Act (42 U.S.C. 1396 et seq.), which the Secretary of 

9 Health and Human Services determines requires State 

10 legislation in order for the respective plan to meet one or 

11 more additional requirements imposed by amendments 

12 made by this section, the respective plan shall not be re13 garded as failing to comply with the requirements of such 

14 title solely on the basis of its failure to meet such an addi15 tional requirement before the first day of the first calendar 

16 quarter beginning after the close of the first regular ses17 sion of the State legislature that begins after the date of 

18 enactment of this Act. For purposes of the previous sen19 tence, in the case of a State that has a 2-year legislative 


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1 session, each year of the session shall be considered to be 

2 a separate regular session of the State legislature. 

Passed the House of Representatives March 2, 

2016. 

Attest: KAREN L. HAAS, 

Clerk. 


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