II 

116TH CONGRESS 

1ST SESSION S. 489 

To establish a State public option through Medicaid to provide Americans 

with the choice of a high-quality, low-cost health insurance plan. 

IN THE SENATE OF THE UNITED STATES 

FEBRUARY 14, 2019 

Mr. SCHATZ (for himself, Mr. HEINRICH, Mr. WHITEHOUSE, Mr. MURPHY, 

Ms. BALDWIN, Mr. MARKEY, Mrs. GILLIBRAND, Ms. KLOBUCHAR, Mr. 

BLUMENTHAL, Ms. ROSEN, Mr. MERKLEY, Ms. HARRIS, Mr. LEAHY, Mr. 

BOOKER, Mr. UDALL, Ms. SMITH, Ms. WARREN, Ms. HIRONO, Mr. 

BROWN, Mr. REED, Mrs. SHAHEEN, Ms. CORTEZ MASTO, and Mr. DURBIN) introduced the following bill; which was read twice and referred to 

the Committee on Finance 

A BILL 

To establish a State public option through Medicaid to provide Americans with the choice of a high-quality, lowcost health insurance plan. 

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 ‘‘State Public Option 

5 Act’’. 


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1 SEC. 2. MEDICAID BUY-IN OPTION. 

2 (a) IN GENERAL.—Section 1902 of the Social Secu3 rity Act (42 U.S.C. 1396a) is amended— 

4 (1) in subsection (a)(10)— 

5 (A) in subparagraph (A)(ii)— 

6 (i) in subclause (XXI), by striking ‘‘; 

7 or’’ and inserting a semicolon; 

8 (ii) in subclause (XXII), by adding 

9 ‘‘or’’ at the end; and 

10 (iii) by adding at the end the fol11 lowing new subclause: 

12 ‘‘(XXIII) beginning January 1, 

13 2020, who are residents of the State 

14 and are not concurrently enrolled in 

15 another health insurance coverage 

16 plan, subject, in the case of individ17 uals described in subsection (qq) and 

18 notwithstanding section 1916 (except 

19 for subsection (k) of such section), to 

20 payment of premiums or other cost21 sharing charges;’’; and 

22 (B) in the matter following subparagraph 

23 (G), in clause (XV), by inserting ‘‘or subsection 

24 (qq)’’ after ‘‘described in subparagraph 

25 (A)(i)(VIII)’’; and 


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1 (2) by adding at the end the following new sub2 section: 

3 ‘‘(qq) PREVIOUSLY UNDESCRIBED INDIVIDUALS.— 

4 Individuals described in this subsection are individuals 

5 who are— 

6 ‘‘(1) described in subclause (XXIII) of sub7 section (a)(10)(A)(ii); and 

8 ‘‘(2) are not described in any other subclause of 

9 such subsection or any other provision in this Act 

10 which provides for eligibility for medical assist11 ance.’’. 

12 (b) PROVISION OF AT LEAST MINIMUM COVERAGE.— 

13 (1) IN GENERAL.—Section 1902(k)(1) of the 

14 Social Security Act (42 U.S.C. 1396a(k)(1)) is 

15 amended by inserting ‘‘or an individual described in 

16 subsection (qq)’’ after ‘‘an individual described in 

17 subclause (VIII) of subsection (a)(10)(A)(i)’’ each 

18 place it appears. 

19 (2) CONFORMING AMENDMENT.—Section 

20 1903(i)(26) of the Social Security Act (42 U.S.C. 

21 1396b(i)(26)) is amended by striking ‘‘individuals 

22 described in subclause (VIII) of subsection 

23 (a)(10)(A)(i)’’ and inserting ‘‘individuals described 

24 in subsection (a)(10)(A)(i)(VIII) or (qq) of section 

25 1902’’. 


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1 (c) FEDERAL FINANCIAL PARTICIPATION IN BUY-IN

2 PROGRAM.— 

3 (1) ENHANCED MATCH FOR ADMINISTRATIVE

4 EXPENSES.—Section 1903(a) of the Social Security 

5 Act (42 U.S.C. 1396b(a)) is amended— 

6 (A) by redesignating paragraph (7) as 

7 paragraph (8); and 

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

9 following new paragraph: 

10 ‘‘(7) an amount equal to 90 percent of the 

11 sums expended during such quarter which are at12 tributable to reasonable administrative expenses re13 lated to the administration of a Medicaid buy-in pro14 gram for individuals described in section 

15 1902(a)(10)(A)(ii)(XXIII); plus’’. 

16 (2) TREATMENT OF PREMIUM AND COST-SHAR17 ING REVENUES FROM MEDICAID BUY-IN PROGRAM.— 

18 (A) IN GENERAL.—For purposes of section 

19 1903(a)(1) of the Social Security Act (42 

20 U.S.C. 1396b(a)(1)), for any fiscal quarter dur21 ing which a State collects premiums, cost-shar22 ing, or similar charges under subsection (k) of 

23 section 1916 of such Act (42 U.S.C. 1396o) (as 

24 added by this Act), including any advance pay25 ments of premium tax credits under section 


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1 1412 of the Patient Protection and Affordable 

2 Care Act or payments for cost-sharing reduc3 tions under section 1402 of such Act that are 

4 received by the State, the total amount ex5 pended during such quarter as medical assist6 ance for individuals who buy into Medicaid cov7 erage under subclause (XXIII) of section 

8 1902(a)(10)(A)(ii) of the Social Security Act 

9 (as added by this Act) shall be reduced by the 

10 amount of such premiums or charges. 

11 (B) TREATMENT OF EXCESS PREMIUMS.— 

12 Each State that collects premiums or similar 

13 charges under subsection (k) of section 1916 of 

14 the Social Security Act (42 U.S.C. 1396o) (as 

15 added by this Act) in a fiscal year shall pay to 

16 the Secretary of Health and Human Services, 

17 at such time and in such form and manner as 

18 the Secretary shall specify, an amount equal to 

19 50 percent of the amount, if any, by which— 

20 (i) the total amount of such premiums 

21 and charges collected by the State for such 

22 year; exceeds 

23 (ii) the total amount expended by the 

24 State during such year as medical assist25 ance for individuals who buy into Medicaid 


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1 coverage under subclause (XXIII) of sec2 tion 1902(a)(10)(A)(ii) of such Act (as 

3 added by this Act). 

4 (d) COST-SHARING REQUIREMENT.—Section 1916 of 

5 the Social Security Act (42 U.S.C. 1396o) is amended by 

6 adding at the end the following new subsection: 

7 ‘‘(k) PREMIUMS AND COST-SHARING FOR INDIVID8 UALS PARTICIPATING IN MEDICAID BUY-IN PROGRAM.— 

9 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

10 with respect to individuals who are eligible for med11 ical assistance under subsection 

12 (a)(10)(A)(ii)(XXIII) of section 1902 and are de13 scribed in subsection (qq) of such section, a State 

14 may— 

15 ‘‘(A) impose premiums, deductibles, cost16 sharing, or other similar charges that are actu17 arially fair; and 

18 ‘‘(B) vary the premium rate imposed on an 

19 individual based only on the factors described in 

20 section 2701(a)(1)(A) of the Public Health 

21 Service Act and subject to the same limitations 

22 on the weight which may be given to such fac23 tors under such section. 

24 ‘‘(2) LIMITATIONS.— 


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1 ‘‘(A) PREMIUMS.—The total amount of 

2 premiums imposed for a year under this sub3 section with respect to all individuals described 

4 in paragraph (1) in a family shall not exceed an 

5 amount equal to 9.5 percent of the family’s 

6 household income (as defined in section 

7 36B(d)(2) of the Internal Revenue Code of 

8 1986) for the year involved. 

9 ‘‘(B) OTHER COST-SHARING.— 

10 ‘‘(i) IN GENERAL.—The cost-sharing 

11 limitations described in section 1302(c) of 

12 the Patient Protection and Affordable Care 

13 Act shall apply to cost-sharing (as defined 

14 in such section) for medical assistance pro15 vided under section 

16 1902(a)(10)(A)(ii)(XXIII) in the same 

17 manner as such limitations apply to cost18 sharing under qualified health plans under 

19 title I of such Act. 

20 ‘‘(ii) AVAILABILITY OF COST-SHARING

21 REDUCTIONS.—Individuals provided med22 ical assistance under section 

23 1902(a)(10)(A)(ii)(XXIII) and subject to 

24 cost-sharing under this subsection are eli25 gible for cost-sharing reductions under secVerDate Sep 11 2014 04:01 Feb 22, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S489.IS S489

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1 tion 1402 of the Patient Protection and 

2 Affordable Care Act (subject to the income 

3 eligibility threshold in subsection (b)(2) of 

4 such section), and in applying such sec5 tion— 

6 ‘‘(I) enrollment in a State plan 

7 under section 

8 1902(a)(10)(A)(ii)(XXIII) shall be 

9 treated as coverage under a qualified 

10 health plan in the silver level of cov11 erage in the individual market offered 

12 through an Exchange established for 

13 or by the State under title I of the 

14 Patient Protection and Affordable 

15 Care Act; and 

16 ‘‘(II) the State agency admin17 istering such plan shall be treated as 

18 the issuer of such plan. 

19 ‘‘(3) PREMIUMS AND COST-SHARING FOR CER20 TAIN OTHER INDIVIDUALS.—If an individual is eligi21 ble for medical assistance under subsection 

22 (a)(10)(A)(ii)(XXIII) of section 1902 and is not de23 scribed in subsection (qq) of such section, a State— 


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1 ‘‘(A) shall not impose premiums and cost2 sharing on the individual under this subsection; 

3 and 

4 ‘‘(B) may impose premiums and cost-shar5 ing on the individual to the extent allowed by 

6 another provision of this Act (other than sec7 tion 1902(a)(10)(A)(ii)(XXIII)) which provides 

8 for eligibility for medical assistance, but only if 

9 the individual is described in such other provi10 sion. 

11 ‘‘(4) APPLICATION OF PREMIUM ASSISTANCE

12 TAX CREDITS.—An individual who is required to pay 

13 premiums under this subsection for a year for med14 ical assistance shall be eligible for a premium assist15 ance credit under section 36B of the Internal Rev16 enue Code to the same extent that such individual 

17 would be eligible for a premium assistance credit 

18 under such section if such individual had paid the 

19 same amount in premiums for coverage under a 

20 qualified health plan for such year.’’. 

21 (e) MANAGED CARE.—Section 1932(a)(1)(A)(i) of 

22 the Social Security Act (42 U.S.C. 1396u–2(a)(1)(A)(i)) 

23 is amended by inserting ‘‘, including an individual who is 

24 eligible for such assistance after buying into such coverage 


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1 under section 1902(a)(10)(A)(ii)(XXIII),’’ after ‘‘the 

2 State plan under this title’’. 

3 (f) OFFERING BUY-IN PROGRAM ON STATE EX4 CHANGE; ENROLLMENT PERIODS.— 

5 (1) IN GENERAL.—A State that has elected to 

6 allow individuals to buy into Medicaid coverage 

7 under section 1902(a)(10)(A)(ii)(XXIII) of the So8 cial Security Act (as added by this Act) shall allow 

9 individuals to enroll in such coverage through the 

10 Federal, federally facilitated, or State Exchange es11 tablished pursuant to title I of the Patient Protec12 tion and Affordable Care Act. 

13 (2) ENROLLMENT PERIODS.—A State may limit 

14 the enrollment of individuals into Medicaid coverage 

15 under section 1902(a)(10)(A)(ii)(XXIII) of the So16 cial Security Act (as added by this Act) to the en17 rollment periods provided for under section 

18 1311(c)(6) of the Patient Protection and Affordable 

19 Care Act. 

20 (g) APPLICATION OF ADVANCED PREMIUM TAX

21 CREDITS TO MEDICAID BUY-IN PLANS.— 

22 (1) IN GENERAL.—Section 36B of the Internal 

23 Revenue Code of 1986 is amended— 

24 (A) in subsection (b)(3)(B), by adding at 

25 the end the following new sentence: 


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1 ‘‘If an applicable taxpayer resides in a rating 

2 area in which no silver plan is offered on the 

3 individual market but the taxpayer buys into 

4 Medicaid coverage under section 

5 1902(a)(10)(A)(ii)(XXIII) of the Social Secu6 rity Act, such Medicaid coverage shall be 

7 deemed to be the applicable second lowest cost 

8 silver plan with respect to such taxpayer.’’; and 

9 (B) by adding at the end the following new 

10 subsection: 

11 ‘‘(h) APPLICATION TO INDIVIDUALS PURCHASING

12 MEDICAID COVERAGE.—In the case of any individual who 

13 buys into Medicaid coverage under section 

14 1902(a)(10)(A)(ii)(XXIII) of the Social Security Act, this 

15 section shall be applied with the following modifications: 

16 ‘‘(1) The amount determined under subsection 

17 (b)(2)(A) shall be increased by the amount of the 

18 monthly premiums paid for such coverage. 

19 ‘‘(2) Subsection (c)(2)(A)(i) shall be applied by 

20 treating coverage under the Medicaid program under 

21 title XIX of the Social Security Act in the same 

22 manner as a qualified health plan that was enrolled 

23 in through an Exchange. 

24 ‘‘(3) In applying subsection (c)(2)(B)— 


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1 ‘‘(A) an individual shall not be considered 

2 to be eligible for minimum essential coverage 

3 described in section 5000A(f)(1)(A)(ii) by rea4 son of eligibility for medical assistance under a 

5 State Medicaid program under section 

6 1902(a)(10)(A)(ii)(XXIII); and 

7 ‘‘(B) an individual who is not covered by 

8 minimum essential coverage described in section 

9 5000A(f)(1)(B) shall not be considered to be el10 igible for such coverage.’’. 

11 (2) ADVANCED PAYMENT OF CREDIT.— 

12 (A) IN GENERAL.—The Secretary of 

13 Health and Human Services, in consultation 

14 with the Secretary of the Treasury, shall estab15 lish a program under which— 

16 (i) upon request of a State agency ad17 ministering a State Medicaid program 

18 under title XIX of the Social Security Act, 

19 advance determinations are made in a 

20 manner similar to advanced determinations 

21 under section 1412 of the Patient Protec22 tion and Affordable Care Act with respect 

23 to the income eligibility of individuals en24 rolling in such program for the premium 

25 tax credit allowable under section 36B of 


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1 the Internal Revenue Code of 1986 and 

2 the cost-sharing reductions under section 

3 1402 of the Patient Protection and Afford4 able Care Act; 

5 (ii) the Secretary notifies— 

6 (I) the State agency admin7 istering the program and the Sec8 retary of the Treasury of the advance 

9 determinations; and 

10 (II) the Secretary of the Treas11 ury of the name and employer identi12 fication number of each employer with 

13 respect to whom 1 or more employees 

14 of the employer were determined to be 

15 eligible for the premium tax credit 

16 under section 36B of the Internal 

17 Revenue Code of 1986 and the cost18 sharing reductions under section 1402 

19 of the Patient Protection and Afford20 able Care Act because— 

21 (aa) the employer did not 

22 provide minimum essential cov23 erage; or 

24 (bb) the employer provided 

25 such minimum essential coverage 


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1 but it was determined under sec2 tion 36B(c)(2)(C) of such Code 

3 to either be unaffordable to the 

4 employee or not provide the re5 quired minimum actuarial value; 

6 and 

7 (iii) the Secretary of the Treasury 

8 makes advance payments of such credit or 

9 reductions to the State agency admin10 istering the program in order to reduce the 

11 premiums payable by individuals eligible 

12 for such credit. 

13 (B) DETERMINATIONS AND PAYMENTS.— 

14 Rules similar to subsections (b) and (c) of sec15 tion 1412 of the Patient Protection and Afford16 able Care Act shall apply for purposes of this 

17 subsection. 

18 (C) COORDINATION WITH CREDIT.— 

19 (i) IN GENERAL.—Section 36B of the 

20 Internal Revenue Code of 1986 is amended 

21 by inserting ‘‘and under section 2(g)(2) of 

22 the State Public Option Act’’ after ‘‘sec23 tion 1412 of the Patient Protection and 

24 Affordable Care Act’’ each place it appears 

25 in subsections (f)(1), (f)(2), and (g)(1). 


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1 (ii) INFORMATION REPORTING.—Sec2 tion 36B(f)(3) of such Code is amended by 

3 adding at the end the following flush sen4 tence: ‘‘In the case of any coverage under 

5 the Medicaid program under title XIX of 

6 the Social Security Act for which a credit 

7 under this section is allowable by reason of 

8 subsection (h), the State agency admin9 istering the Medicaid program shall be 

10 treated as an Exchange for purposes of 

11 this paragraph and subparagraph (A) shall 

12 not apply.’’. 

13 (3) CONFORMING AMENDMENT RELATING TO

14 EMPLOYER RESPONSIBILITY.—Paragraph (6) of sec15 tion 4980H(c) of the Internal Revenue Code of 1986 

16 is amended by inserting ‘‘, except that for purposes 

17 of subsections (a)(2) and (b)(2), the term ‘qualified 

18 health plan’ shall include any plan described in sec19 tion 36B(h)’’ after ‘‘such Act’’. 

20 (h) CONFORMING AMENDMENTS.— 

21 (1) Section 1902(a)(10) of the Social Security 

22 Act (42 U.S.C. 1396a(a)(10)), as amended by sub23 section (a), is further amended, in the matter fol24 lowing subparagraph (G)— 


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1 (A) by striking ‘‘and (XVII)’’ and inserting 

2 ‘‘, (XVII)’’; and 

3 (B) by inserting ‘‘, and (XVIII) the med4 ical assistance made available to an individual 

5 described in subparagraph (A)(ii)(XXIII) shall 

6 be limited to medical assistance described in 

7 subsection (k)(1)’’ before the semicolon. 

8 (2) Section 1903(f)(4) of the Social Security 

9 Act (42 U.S.C. 1396b(f)(4)) is amended by inserting 

10 ‘‘1902(a)(10)(A)(ii)(XXIII),’’ after 

11 ‘‘1902(a)(10)(A)(ii)(XXII),’’. 

12 (3) Section 1905(a) of the Social Security Act 

13 (42 U.S.C. 1396d(a)) is amended, in the matter pre14 ceding paragraph (1)— 

15 (A) by striking ‘‘or’’ at the end of clause 

16 (xvi); 

17 (B) by inserting ‘‘or’’ at the end of clause 

18 (xvii); and 

19 (C) by inserting after clause (xvii) the fol20 lowing new clause: 

21 ‘‘(xviii) individuals described in section 

22 1902(a)(10)(A)(ii)(XXIII),’’. 

23 (4) Section 1916A(a)(1) of the Social Security 

24 Act (42 U.S.C. 1396o–1(a)(1)) is amended by strik25 ing ‘‘or (j)’’ and inserting ‘‘(j), or (k)’’. 


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1 (5) Section 1937(a)(1)(B) of the Social Secu2 rity Act (42 U.S.C. 1396u–7(a)(1)(B)) is amended 

3 by inserting ‘‘, subclause (XXIII) of section 

4 1902(a)(10)(A)(ii),’’ after ‘‘1902(a)(10)(A)(i)’’. 

5 SEC. 3. DEVELOPMENT OF STATE-LEVEL METRICS ON MED6 ICAID BENEFICIARY ACCESS AND SATISFAC7 TION. 

8 (a) IN GENERAL.— 

9 (1) DEVELOPMENT OF METRICS.—Not later 

10 than 1 year after the date of enactment of this Act, 

11 the Director of the Agency for Healthcare Research 

12 and Quality, in consultation with State Medicaid Di13 rectors, shall develop standardized, State-level 

14 metrics of access to, and satisfaction with, providers, 

15 including primary care and specialist providers, with 

16 respect to individuals who are enrolled in State Med17 icaid plans under title XIX of the Social Security 

18 Act. 

19 (2) PROCESS.—The Director of the Agency for 

20 Healthcare Research and Quality shall develop the 

21 metrics described in paragraph (1) through a public 

22 process, which shall provide opportunities for stake23 holders to participate. 

24 (b) UPDATING METRICS.—The Director of the Agen25 cy for Healthcare Research and Quality, in consultation 


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1 with the Deputy Administrator for the Center for Med2 icaid and CHIP Services and State Medicaid Directors, 

3 shall update the metrics developed under subsection (a) 

4 not less than once every 3 years. 

5 (c) STATE IMPLEMENTATION FUNDING.—The Direc6 tor of the Agency for Healthcare Research and Quality 

7 may award funds, from the amount appropriated under 

8 subsection (d), to States for the purpose of implementing 

9 the metrics developed under this section. 

10 (d) APPROPRIATION.—There is appropriated to the 

11 Director of the Agency for Healthcare Research and Qual12 ity, out of any funds in the Treasury not otherwise appro13 priated, $200,000,000 for fiscal year 2020, to remain 

14 available until expended, for the purpose of carrying out 

15 this section. 

16 SEC. 4. RENEWAL OF APPLICATION OF MEDICARE PAY17 MENT RATE FLOOR TO PRIMARY CARE SERV18 ICES FURNISHED UNDER MEDICAID AND IN19 CLUSION OF ADDITIONAL PROVIDERS. 

20 (a) RENEWAL OF PAYMENT FLOOR; ADDITIONAL

21 PROVIDERS.— 

22 (1) IN GENERAL.—Section 1902(a)(13) of the 

23 Social Security Act (42 U.S.C. 1396a(a)(13)) is 

24 amended by striking subparagraph (C) and inserting 

25 the following: 


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1 ‘‘(C) payment for primary care services (as 

2 defined in subsection (jj)) at a rate that is not 

3 less than 100 percent of the payment rate that 

4 applies to such services and physician under 

5 part B of title XVIII (or, if greater, the pay6 ment rate that would be applicable under such 

7 part if the conversion factor under section 

8 1848(d) for the year involved were the conver9 sion factor under such section for 2009), and 

10 that is not less than the rate that would other11 wise apply to such services under this title if 

12 the rate were determined without regard to this 

13 subparagraph, and that are— 

14 ‘‘(i) furnished in 2013 and 2014, by a 

15 physician with a primary specialty designa16 tion of family medicine, general internal 

17 medicine, or pediatric medicine; or 

18 ‘‘(ii) furnished in the period that be19 gins on the first day of the first month 

20 that begins after the date of enactment of 

21 the State Public Option Act— 

22 ‘‘(I) by a physician with a pri23 mary specialty designation of family 

24 medicine, general internal medicine, 

25 or pediatric medicine, but only if the 


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1 physician self-attests that the physi2 cian is Board certified in family medi3 cine, general internal medicine, or pe4 diatric medicine; 

5 ‘‘(II) by a physician with a pri6 mary specialty designation of obstet7 rics and gynecology, but only if the 

8 physician self-attests that the physi9 cian is Board certified in obstetrics 

10 and gynecology; 

11 ‘‘(III) by an advanced practice 

12 clinician, as defined by the Secretary, 

13 that works under the supervision of— 

14 ‘‘(aa) a physician that satis15 fies the criteria specified in sub16 clause (I) or (II); or 

17 ‘‘(bb) a nurse practitioner or 

18 a physician assistant (as such 

19 terms are defined in section 

20 1861(aa)(5)(A)) who is working 

21 in accordance with State law, or 

22 a certified nurse-midwife (as de23 fined in section 1861(gg)) who is 

24 working in accordance with State 

25 law; 


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1 ‘‘(IV) by a rural health clinic, 

2 federally qualified health center, or 

3 other health clinic that receives reim4 bursement on a fee schedule applica5 ble to a physician, a nurse practi6 tioner or a physician assistant (as 

7 such terms are defined in section 

8 1861(aa)(5)(A)) who is working in ac9 cordance with State law, or a certified 

10 nurse-midwife (as defined in section 

11 1861(gg)) who is working in accord12 ance with State law, for services fur13 nished by a physician, nurse practi14 tioner, physician assistant, or certified 

15 nurse-midwife, or services furnished 

16 by an advanced practice clinician su17 pervised by a physician described in 

18 subclause (I)(aa) or (II)(aa), another 

19 advanced practice clinician, or a cer20 tified nurse-midwife; or 

21 ‘‘(V) by a nurse practitioner or a 

22 physician assistant (as such terms are 

23 defined in section 1861(aa)(5)(A)) 

24 who is working in accordance with 

25 State law, or a certified nurse-midwife 


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1 (as defined in section 1861(gg)) who 

2 is working in accordance with State 

3 law, in accordance with procedures 

4 that ensure that the portion of the 

5 payment for such services that the 

6 nurse practitioner, physician assist7 ant, or certified nurse-midwife is paid 

8 is not less than the amount that the 

9 nurse practitioner, physician assist10 ant, or certified nurse-midwife would 

11 be paid if the services were provided 

12 under part B of title XVIII;’’. 

13 (2) CONFORMING AMENDMENTS.—Section 

14 1905(dd) of the Social Security Act (42 U.S.C. 

15 1396d(dd)) is amended— 

16 (A) by striking ‘‘Notwithstanding’’ and in17 serting the following: 

18 ‘‘(1) IN GENERAL.—Notwithstanding’’; 

19 (B) by inserting ‘‘or furnished during the 

20 additional period specified in paragraph (2),’’ 

21 after ‘‘2015,’’; and 

22 (C) by adding at the end the following: 

23 ‘‘(2) ADDITIONAL PERIOD.—For purposes of 

24 paragraph (1), the additional period specified in this 

25 paragraph is the period that begins on the first day 


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1 of the first month that begins after the date of en2 actment of the State Public Option Act.’’. 

3 (b) IMPROVED TARGETING OF PRIMARY CARE.—Sec4 tion 1902(jj) of the Social Security Act (42 U.S.C. 

5 1396a(jj)) is amended— 

6 (1) by redesignating paragraphs (1) and (2) as 

7 subparagraphs (A) and (B), respectively and realign8 ing the left margins accordingly; 

9 (2) by striking ‘‘For purposes of’’ and inserting 

10 the following: 

11 ‘‘(1) IN GENERAL.—For purposes of’’; and 

12 (3) by adding at the end the following: 

13 ‘‘(2) EXCLUSIONS.—Such term does not include 

14 any services described in subparagraph (A) or (B) of 

15 paragraph (1) if such services are provided in an 

16 emergency department of a hospital.’’. 

17 (c) ENSURING PAYMENT BY MANAGED CARE ENTI18 TIES.— 

19 (1) IN GENERAL.—Section 1903(m)(2)(A) of 

20 the Social Security Act (42 U.S.C. 1396b(m)(2)(A)) 

21 is amended— 

22 (A) in clause (xii), by striking ‘‘and’’ after 

23 the semicolon; 

24 (B) by realigning the left margin of clause 

25 (xiii) so as to align with the left margin of 


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1 clause (xii) and by striking the period at the 

2 end of clause (xiii) and inserting ‘‘; and’’; and 

3 (C) by inserting after clause (xiii) the fol4 lowing: 

5 ‘‘(xiv) such contract provides that (I) payments 

6 to providers specified in section 1902(a)(13)(C) for 

7 primary care services defined in section 1902(jj) 

8 that are furnished during a year or period specified 

9 in section 1902(a)(13)(C) and section 1905(dd) are 

10 at least equal to the amounts set forth and required 

11 by the Secretary by regulation, (II) the entity shall, 

12 upon request, provide documentation to the State, 

13 sufficient to enable the State and the Secretary to 

14 ensure compliance with subclause (I), and (III) the 

15 Secretary shall approve payments described in sub16 clause (I) that are furnished through an agreed 

17 upon capitation, partial capitation, or other value18 based payment arrangement if the capitation, partial 

19 capitation, or other value-based payment arrange20 ment is based on a reasonable methodology and the 

21 entity provides documentation to the State sufficient 

22 to enable the State and the Secretary to ensure com23 pliance with subclause (I).’’. 

24 (2) CONFORMING AMENDMENT.—Section 

25 1932(f) of the Social Security Act (42 U.S.C. 


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25 

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1 1396u–2(f)) is amended by inserting ‘‘and clause 

2 (xiv) of section 1903(m)(2)(A)’’ before the period. 

3 SEC. 5. INCREASED FMAP FOR MEDICAL ASSISTANCE TO 

4 NEWLY ELIGIBLE INDIVIDUALS. 

5 (a) IN GENERAL.—Section 1905(y)(1) of the Social 

6 Security Act (42 U.S.C. 1396d(y)(1)) is amended— 

7 (1) in subparagraph (A), by striking ‘‘2014, 

8 2015, and 2016’’ and inserting ‘‘each of the first 3 

9 consecutive 12-month periods in which the State 

10 provides medical assistance to newly eligible individ11 uals’’; 

12 (2) in subparagraph (B), by striking ‘‘2017’’ 

13 and inserting ‘‘the fourth consecutive 12-month pe14 riod in which the State provides medical assistance 

15 to newly eligible individuals’’; 

16 (3) in subparagraph (C), by striking ‘‘2018’’ 

17 and inserting ‘‘the fifth consecutive 12-month period 

18 in which the State provides medical assistance to 

19 newly eligible individuals’’; 

20 (4) in subparagraph (D), by striking ‘‘2019’’ 

21 and inserting ‘‘the sixth consecutive 12-month period 

22 in which the State provides medical assistance to 

23 newly eligible individuals’’; and 

24 (5) in subparagraph (E), by striking ‘‘2020 and 

25 each year thereafter’’ and inserting ‘‘the seventh 


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1 consecutive 12-month period in which the State pro2 vides medical assistance to newly eligible individuals 

3 and each such period thereafter’’. 

4 (b) EFFECTIVE DATE.—The amendments made by 

5 subsection (a) shall take effect as if included in the enact6 ment of Public Law 111–148. 

7 SEC. 6. MEDICAID COVERAGE OF COMPREHENSIVE REPRO8 DUCTIVE HEALTH CARE SERVICES. 

9 (a) INCLUSION OF COMPREHENSIVE REPRODUCTIVE

10 HEALTH CARE SERVICES AS MEDICAL ASSISTANCE.— 

11 Section 1905(a) of the Social Security Act (42 U.S.C. 

12 1396d(a)), as amended by section 2(h), is further amend13 ed— 

14 (1) in paragraph (29), by striking ‘‘and’’ at the 

15 end; 

16 (2) by redesignating paragraph (30) as para17 graph (31); and 

18 (3) by inserting after paragraph (29) the fol19 lowing new paragraph: 

20 ‘‘(30) comprehensive reproductive health care 

21 services, including abortion services; and’’. 

22 (b) REQUIRING COVERAGE OF COMPREHENSIVE RE23 PRODUCTIVE HEALTH CARE SERVICES AS CONDITION OF

24 STATE PLAN APPROVAL.—Section 1902(a)(10)(A) of the 

25 Social Security Act (42 U.S.C. 1396a(a)(10)(A)), as 


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1 amended by subsections (a) and (h) of section 2, is further 

2 amended, in the matter preceding clause (i), by striking 

3 ‘‘and (29)’’ and inserting ‘‘(29), and (30)’’. 

4 (c) CONFORMING AMENDMENT.—Section 

5 1932(e)(1)(B) of the Social Security Act (42 U.S.C. 

6 1396u–2(e)(1)(B)) is amended by striking ‘‘Clause (i)’’ 

7 and inserting ‘‘With respect to the period beginning before 

8 January 1, 2021, clause (i)’’. 

9 (d) EFFECTIVE DATE.—The amendments made by 

10 this section shall apply with respect to medical assistance 

11 furnished on or after January 1, 2021. 

Æ 


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