I 

116TH CONGRESS 

1ST SESSION H. R. 1277 

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 HOUSE OF REPRESENTATIVES 

FEBRUARY 14, 2019 

Mr. LUJA ́N (for himself, Mr. BLUMENAUER, Mr. CARSON of Indiana, Mr. 

CICILLINE, Ms. CLARK of Massachusetts, Ms. CLARKE of New York, Mr. 

COHEN, Mr. DESAULNIER, Mr. MICHAEL F. DOYLE of Pennsylvania, Mr. 

ENGEL, Ms. FUDGE, Mr. GALLEGO, Mr. GARAMENDI, Ms. HILL of California, Ms. JAYAPAL, Mr. KHANNA, Mr. KRISHNAMOORTHI, Ms. MATSUI, 

Ms. MCCOLLUM, Mrs. NAPOLITANO, Mr. NEGUSE, Ms. NORTON, Ms. 

OMAR, Mr. PERLMUTTER, Mr. POCAN, Mr. ROUDA, Ms. ROYBALALLARD, Mr. SCHIFF, Ms. SCHRIER, Mr. TAKANO, Ms. TITUS, Mr. 

TONKO, Mrs. WATSON COLEMAN, Mr. WELCH, Ms. VELA ́ZQUEZ, Ms. 

MOORE, Mr. COX of California, Ms. WILD, Ms. KUSTER of New Hampshire, Ms. SCHAKOWSKY, and Mr. CLAY) introduced the following bill; 

which was referred to the Committee on Energy and Commerce, and in 

addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such 

provisions as fall within the jurisdiction of the committee concerned 

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, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘State Public Option 

3 Act’’. 

4 SEC. 2. MEDICAID BUY-IN OPTION. 

5 (a) IN GENERAL.—Section 1902 of the Social Secu6 rity Act (42 U.S.C. 1396a) is amended— 

7 (1) in subsection (a)(10)— 

8 (A) in subparagraph (A)(ii)— 

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

10 or’’ and inserting a semicolon; 

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

12 ‘‘or’’ at the end; and 

13 (iii) by adding at the end the fol14 lowing new subclause: 

15 ‘‘(XXIII) beginning January 1, 

16 2020, who are residents of the State 

17 and are not concurrently enrolled in 

18 another health insurance coverage 

19 plan, subject, in the case of individ20 uals described in subsection (qq) and 

21 notwithstanding section 1916 (except 

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

23 payment of premiums or other cost24 sharing charges;’’; and 

25 (B) in the matter following subparagraph 

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


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

2 (A)(i)(VIII)’’; and 

3 (2) by adding at the end the following new sub4 section: 

5 ‘‘(qq) PREVIOUSLY UNDESCRIBED INDIVIDUALS.— 

6 Individuals described in this subsection are individuals 

7 who are— 

8 ‘‘(1) described in subclause (XXIII) of sub9 section (a)(10)(A)(ii); and 

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

11 such subsection or any other provision in this Act 

12 which provides for eligibility for medical assist13 ance.’’. 

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

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

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

17 amended by inserting ‘‘or an individual described in 

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

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

20 place it appears. 

21 (2) CONFORMING AMENDMENT.—Section 

22 1903(i)(26) of the Social Security Act (42 U.S.C. 

23 1396b(i)(26)) is amended by striking ‘‘individuals 

24 described in subclause (VIII) of subsection 

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


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

2 1902’’. 

3 (c) FEDERAL FINANCIAL PARTICIPATION IN BUY-IN

4 PROGRAM.— 

5 (1) ENHANCED MATCH FOR ADMINISTRATIVE

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

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

8 (A) by redesignating paragraph (7) as 

9 paragraph (8); and 

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

11 following new paragraph: 

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

13 sums expended during such quarter which are at14 tributable to reasonable administrative expenses re15 lated to the administration of a Medicaid buy-in pro16 gram for individuals described in section 

17 1902(a)(10)(A)(ii)(XXIII); plus’’. 

18 (2) TREATMENT OF PREMIUM AND COST-SHAR19 ING REVENUES FROM MEDICAID BUY-IN PROGRAM.— 

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

21 1903(a)(1) of the Social Security Act (42 

22 U.S.C. 1396b(a)(1)), for any fiscal quarter dur23 ing which a State collects premiums, cost-shar24 ing, or similar charges under subsection (k) of 

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


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1 added by this Act), including any advance pay2 ments of premium tax credits under section 

3 1412 of the Patient Protection and Affordable 

4 Care Act or payments for cost-sharing reduc5 tions under section 1402 of such Act that are 

6 received by the State, the total amount ex7 pended during such quarter as medical assist8 ance for individuals who buy into Medicaid cov9 erage under subclause (XXIII) of section 

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

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

12 amount of such premiums or charges. 

13 (B) TREATMENT OF EXCESS PREMIUMS.— 

14 Each State that collects premiums or similar 

15 charges under subsection (k) of section 1916 of 

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

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

18 the Secretary of Health and Human Services, 

19 at such time and in such form and manner as 

20 the Secretary shall specify, an amount equal to 

21 50 percent of the amount, if any, by which— 

22 (i) the total amount of such premiums 

23 and charges collected by the State for such 

24 year; exceeds 


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1 (ii) the total amount expended by the 

2 State during such year as medical assist3 ance for individuals who buy into Medicaid 

4 coverage under subclause (XXIII) of sec5 tion 1902(a)(10)(A)(ii) of such Act (as 

6 added by this Act). 

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

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

9 adding at the end the following new subsection: 

10 ‘‘(k) PREMIUMS AND COST-SHARING FOR INDIVID11 UALS PARTICIPATING IN MEDICAID BUY-IN PROGRAM.— 

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

13 with respect to individuals who are eligible for med14 ical assistance under subsection 

15 (a)(10)(A)(ii)(XXIII) of section 1902 and are de16 scribed in subsection (qq) of such section, a State 

17 may— 

18 ‘‘(A) impose premiums, deductibles, cost19 sharing, or other similar charges that are actu20 arially fair; and 

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

22 individual based only on the factors described in 

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

24 Service Act and subject to the same limitations 


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1 on the weight which may be given to such fac2 tors under such section. 

3 ‘‘(2) LIMITATIONS.— 

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

5 premiums imposed for a year under this sub6 section with respect to all individuals described 

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

8 amount equal to 9.5 percent of the family’s 

9 household income (as defined in section 

10 36B(d)(2) of the Internal Revenue Code of 

11 1986) for the year involved. 

12 ‘‘(B) OTHER COST-SHARING.— 

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

14 limitations described in section 1302(c) of 

15 the Patient Protection and Affordable Care 

16 Act shall apply to cost-sharing (as defined 

17 in such section) for medical assistance pro18 vided under section 

19 1902(a)(10)(A)(ii)(XXIII) in the same 

20 manner as such limitations apply to cost21 sharing under qualified health plans under 

22 title I of such Act. 

23 ‘‘(ii) AVAILABILITY OF COST-SHARING

24 REDUCTIONS.—Individuals provided med25 ical assistance under section 


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1 1902(a)(10)(A)(ii)(XXIII) and subject to 

2 cost-sharing under this subsection are eli3 gible for cost-sharing reductions under sec4 tion 1402 of the Patient Protection and 

5 Affordable Care Act (subject to the income 

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

7 such section), and in applying such sec8 tion— 

9 ‘‘(I) enrollment in a State plan 

10 under section 

11 1902(a)(10)(A)(ii)(XXIII) shall be 

12 treated as coverage under a qualified 

13 health plan in the silver level of cov14 erage in the individual market offered 

15 through an Exchange established for 

16 or by the State under title I of the 

17 Patient Protection and Affordable 

18 Care Act; and 

19 ‘‘(II) the State agency admin20 istering such plan shall be treated as 

21 the issuer of such plan. 

22 ‘‘(3) PREMIUMS AND COST-SHARING FOR CER23 TAIN OTHER INDIVIDUALS.—If an individual is eligi24 ble for medical assistance under subsection 


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1 (a)(10)(A)(ii)(XXIII) of section 1902 and is not de2 scribed in subsection (qq) of such section, a State— 

3 ‘‘(A) shall not impose premiums and cost4 sharing on the individual under this subsection; 

5 and 

6 ‘‘(B) may impose premiums and cost-shar7 ing on the individual to the extent allowed by 

8 another provision of this Act (other than sec9 tion 1902(a)(10)(A)(ii)(XXIII)) which provides 

10 for eligibility for medical assistance, but only if 

11 the individual is described in such other provi12 sion. 

13 ‘‘(4) APPLICATION OF PREMIUM ASSISTANCE

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

15 premiums under this subsection for a year for med16 ical assistance shall be eligible for a premium assist17 ance credit under section 36B of the Internal Rev18 enue Code to the same extent that such individual 

19 would be eligible for a premium assistance credit 

20 under such section if such individual had paid the 

21 same amount in premiums for coverage under a 

22 qualified health plan for such year.’’. 

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

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

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


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1 eligible for such assistance after buying into such coverage 

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

3 State plan under this title’’. 

4 (f) OFFERING BUY-IN PROGRAM ON STATE EX5 CHANGE; ENROLLMENT PERIODS.— 

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

7 allow individuals to buy into Medicaid coverage 

8 under section 1902(a)(10)(A)(ii)(XXIII) of the So9 cial Security Act (as added by this Act) shall allow 

10 individuals to enroll in such coverage through the 

11 Federal, federally facilitated, or State Exchange es12 tablished pursuant to title I of the Patient Protec13 tion and Affordable Care Act. 

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

15 the enrollment of individuals into Medicaid coverage 

16 under section 1902(a)(10)(A)(ii)(XXIII) of the So17 cial Security Act (as added by this Act) to the en18 rollment periods provided for under section 

19 1311(c)(6) of the Patient Protection and Affordable 

20 Care Act. 

21 (g) APPLICATION OF ADVANCED PREMIUM TAX

22 CREDITS TO MEDICAID BUY-IN PLANS.— 

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

24 Revenue Code of 1986 is amended— 


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

2 the end the following new sentence: 

3 ‘‘If an applicable taxpayer resides in a rating 

4 area in which no silver plan is offered on the 

5 individual market but the taxpayer buys into 

6 Medicaid coverage under section 

7 1902(a)(10)(A)(ii)(XXIII) of the Social Secu8 rity Act, such Medicaid coverage shall be 

9 deemed to be the applicable second lowest cost 

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

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

12 subsection: 

13 ‘‘(h) APPLICATION TO INDIVIDUALS PURCHASING

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

15 buys into Medicaid coverage under section 

16 1902(a)(10)(A)(ii)(XXIII) of the Social Security Act, this 

17 section shall be applied with the following modifications: 

18 ‘‘(1) The amount determined under subsection 

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

20 monthly premiums paid for such coverage. 

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

22 treating coverage under the Medicaid program under 

23 title XIX of the Social Security Act in the same 

24 manner as a qualified health plan that was enrolled 

25 in through an Exchange. 


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

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

3 to be eligible for minimum essential coverage 

4 described in section 5000A(f)(1)(A)(ii) by rea5 son of eligibility for medical assistance under a 

6 State Medicaid program under section 

7 1902(a)(10)(A)(ii)(XXIII); and 

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

9 minimum essential coverage described in section 

10 5000A(f)(1)(B) shall not be considered to be el11 igible for such coverage.’’. 

12 (2) ADVANCED PAYMENT OF CREDIT.— 

13 (A) IN GENERAL.—The Secretary of 

14 Health and Human Services, in consultation 

15 with the Secretary of the Treasury, shall estab16 lish a program under which— 

17 (i) upon request of a State agency ad18 ministering a State Medicaid program 

19 under title XIX of the Social Security Act, 

20 advance determinations are made in a 

21 manner similar to advanced determinations 

22 under section 1412 of the Patient Protec23 tion and Affordable Care Act with respect 

24 to the income eligibility of individuals en25 rolling in such program for the premium 


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1 tax credit allowable under section 36B of 

2 the Internal Revenue Code of 1986 and 

3 the cost-sharing reductions under section 

4 1402 of the Patient Protection and Afford5 able Care Act; 

6 (ii) the Secretary notifies— 

7 (I) the State agency admin8 istering the program and the Sec9 retary of the Treasury of the advance 

10 determinations; and 

11 (II) the Secretary of the Treas12 ury of the name and employer identi13 fication number of each employer with 

14 respect to whom 1 or more employees 

15 of the employer were determined to be 

16 eligible for the premium tax credit 

17 under section 36B of the Internal 

18 Revenue Code of 1986 and the cost19 sharing reductions under section 1402 

20 of the Patient Protection and Afford21 able Care Act because— 

22 (aa) the employer did not 

23 provide minimum essential cov24 erage; or 


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1 (bb) the employer provided 

2 such minimum essential coverage 

3 but it was determined under sec4 tion 36B(c)(2)(C) of such Code 

5 to either be unaffordable to the 

6 employee or not provide the re7 quired minimum actuarial value; 

8 and 

9 (iii) the Secretary of the Treasury 

10 makes advance payments of such credit or 

11 reductions to the State agency admin12 istering the program in order to reduce the 

13 premiums payable by individuals eligible 

14 for such credit. 

15 (B) DETERMINATIONS AND PAYMENTS.— 

16 Rules similar to subsections (b) and (c) of sec17 tion 1412 of the Patient Protection and Afford18 able Care Act shall apply for purposes of this 

19 subsection. 

20 (C) COORDINATION WITH CREDIT.— 

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

22 Internal Revenue Code of 1986 is amended 

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

24 the State Public Option Act’’ after ‘‘sec25 tion 1412 of the Patient Protection and 


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1 Affordable Care Act’’ each place it appears 

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

3 (ii) INFORMATION REPORTING.—Sec4 tion 36B(f)(3) of such Code is amended by 

5 adding at the end the following flush sen6 tence: ‘‘In the case of any coverage under 

7 the Medicaid program under title XIX of 

8 the Social Security Act for which a credit 

9 under this section is allowable by reason of 

10 subsection (h), the State agency admin11 istering the Medicaid program shall be 

12 treated as an Exchange for purposes of 

13 this paragraph and subparagraph (A) shall 

14 not apply.’’. 

15 (3) CONFORMING AMENDMENT RELATING TO

16 EMPLOYER RESPONSIBILITY.—Paragraph (6) of sec17 tion 4980H(c) of the Internal Revenue Code of 1986 

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

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

20 health plan’ shall include any plan described in sec21 tion 36B(h)’’ after ‘‘such Act’’. 

22 (h) CONFORMING AMENDMENTS.— 

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

24 Act (42 U.S.C. 1396a(a)(10)), as amended by subVerDate Sep 11 2014 02:15 Mar 01, 2019 Jkt 089200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\H1277.IH H1277

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1 section (a), is further amended, in the matter fol2 lowing subparagraph (G)— 

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

4 ‘‘, (XVII)’’; and 

5 (B) by inserting ‘‘, and (XVIII) the med6 ical assistance made available to an individual 

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

8 be limited to medical assistance described in 

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

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

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

12 ‘‘1902(a)(10)(A)(ii)(XXIII),’’ after 

13 ‘‘1902(a)(10)(A)(ii)(XXII),’’. 

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

15 (42 U.S.C. 1396d(a)) is amended, in the matter pre16 ceding paragraph (1)— 

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

18 (xvi); 

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

20 (xvii); and 

21 (C) by inserting after clause (xvii) the fol22 lowing new clause: 

23 ‘‘(xviii) individuals described in section 

24 1902(a)(10)(A)(ii)(XXIII),’’. 


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

2 Act (42 U.S.C. 1396o–1(a)(1)) is amended by strik3 ing ‘‘or (j)’’ and inserting ‘‘(j), or (k)’’. 

4 (5) Section 1937(a)(1)(B) of the Social Secu5 rity Act (42 U.S.C. 1396u–7(a)(1)(B)) is amended 

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

7 1902(a)(10)(A)(ii),’’ after ‘‘1902(a)(10)(A)(i)’’. 

8 SEC. 3. DEVELOPMENT OF STATE-LEVEL METRICS ON MED9 ICAID BENEFICIARY ACCESS AND SATISFAC10 TION. 

11 (a) IN GENERAL.— 

12 (1) DEVELOPMENT OF METRICS.—Not later 

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

14 the Director of the Agency for Healthcare Research 

15 and Quality, in consultation with State Medicaid Di16 rectors, shall develop standardized, State-level 

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

18 including primary care and specialist providers, with 

19 respect to individuals who are enrolled in State Med20 icaid plans under title XIX of the Social Security 

21 Act. 

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

23 Healthcare Research and Quality shall develop the 

24 metrics described in paragraph (1) through a public 


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1 process, which shall provide opportunities for stake2 holders to participate. 

3 (b) UPDATING METRICS.—The Director of the Agen4 cy for Healthcare Research and Quality, in consultation 

5 with the Deputy Administrator for the Center for Med6 icaid and CHIP Services and State Medicaid Directors, 

7 shall update the metrics developed under subsection (a) 

8 not less than once every 3 years. 

9 (c) STATE IMPLEMENTATION FUNDING.—The Direc10 tor of the Agency for Healthcare Research and Quality 

11 may award funds, from the amount appropriated under 

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

13 the metrics developed under this section. 

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

15 Director of the Agency for Healthcare Research and Qual16 ity, out of any funds in the Treasury not otherwise appro17 priated, $200,000,000 for fiscal year 2020, to remain 

18 available until expended, for the purpose of carrying out 

19 this section. 

20 SEC. 4. RENEWAL OF APPLICATION OF MEDICARE PAY21 MENT RATE FLOOR TO PRIMARY CARE SERV22 ICES FURNISHED UNDER MEDICAID AND IN23 CLUSION OF ADDITIONAL PROVIDERS. 

24 (a) RENEWAL OF PAYMENT FLOOR; ADDITIONAL

25 PROVIDERS.— 


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

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

3 amended by striking subparagraph (C) and inserting 

4 the following: 

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

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

7 less than 100 percent of the payment rate that 

8 applies to such services and physician under 

9 part B of title XVIII (or, if greater, the pay10 ment rate that would be applicable under such 

11 part if the conversion factor under section 

12 1848(d) for the year involved were the conver13 sion factor under such section for 2009), and 

14 that is not less than the rate that would other15 wise apply to such services under this title if 

16 the rate were determined without regard to this 

17 subparagraph, and that are— 

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

19 physician with a primary specialty designa20 tion of family medicine, general internal 

21 medicine, or pediatric medicine; or 

22 ‘‘(ii) furnished in the period that be23 gins on the first day of the first month 

24 that begins after the date of enactment of 

25 the State Public Option Act— 


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1 ‘‘(I) by a physician with a pri2 mary specialty designation of family 

3 medicine, general internal medicine, 

4 or pediatric medicine, but only if the 

5 physician self-attests that the physi6 cian is Board certified in family medi7 cine, general internal medicine, or pe8 diatric medicine; 

9 ‘‘(II) by a physician with a pri10 mary specialty designation of obstet11 rics and gynecology, but only if the 

12 physician self-attests that the physi13 cian is Board certified in obstetrics 

14 and gynecology; 

15 ‘‘(III) by an advanced practice 

16 clinician, as defined by the Secretary, 

17 that works under the supervision of— 

18 ‘‘(aa) a physician that satis19 fies the criteria specified in sub20 clause (I) or (II); or 

21 ‘‘(bb) a nurse practitioner or 

22 a physician assistant (as such 

23 terms are defined in section 

24 1861(aa)(5)(A)) who is working 

25 in accordance with State law, or 


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1 a certified nurse-midwife (as de2 fined in section 1861(gg)) who is 

3 working in accordance with State 

4 law; 

5 ‘‘(IV) by a rural health clinic, 

6 Federally-qualified health center, or 

7 other health clinic that receives reim8 bursement on a fee schedule applica9 ble to a physician, a nurse practi10 tioner or a physician assistant (as 

11 such terms are defined in section 

12 1861(aa)(5)(A)) who is working in ac13 cordance with State law, or a certified 

14 nurse-midwife (as defined in section 

15 1861(gg)) who is working in accord16 ance with State law, for services fur17 nished by a physician, nurse practi18 tioner, physician assistant, or certified 

19 nurse-midwife, or services furnished 

20 by an advanced practice clinician su21 pervised by a physician described in 

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

23 advanced practice clinician, or a cer24 tified nurse-midwife; or 


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1 ‘‘(V) by a nurse practitioner or a 

2 physician assistant (as such terms are 

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

4 who is working in accordance with 

5 State law, or a certified nurse-midwife 

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

7 is working in accordance with State 

8 law, in accordance with procedures 

9 that ensure that the portion of the 

10 payment for such services that the 

11 nurse practitioner, physician assist12 ant, or certified nurse-midwife is paid 

13 is not less than the amount that the 

14 nurse practitioner, physician assist15 ant, or certified nurse-midwife would 

16 be paid if the services were provided 

17 under part B of title XVIII;’’. 

18 (2) CONFORMING AMENDMENTS.—Section 

19 1905(dd) of the Social Security Act (42 U.S.C. 

20 1396d(dd)) is amended— 

21 (A) by striking ‘‘Notwithstanding’’ and in22 serting the following: 

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


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

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

3 after ‘‘2015,’’; and 

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

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

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

7 paragraph is the period that begins on the first day 

8 of the first month that begins after the date of en9 actment of the State Public Option Act.’’. 

10 (b) IMPROVED TARGETING OF PRIMARY CARE.—Sec11 tion 1902(jj) of the Social Security Act (42 U.S.C. 

12 1396a(jj)) is amended— 

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

14 subparagraphs (A) and (B), respectively and realign15 ing the left margins accordingly; 

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

17 the following: 

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

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

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

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

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

23 emergency department of a hospital.’’. 

24 (c) ENSURING PAYMENT BY MANAGED CARE ENTI25 TIES.— 


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

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

3 is amended— 

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

5 the semicolon; 

6 (B) by realigning the left margin of clause 

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

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

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

10 (C) by inserting after clause (xiii) the fol11 lowing: 

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

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

14 primary care services defined in section 1902(jj) 

15 that are furnished during a year or period specified 

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

17 at least equal to the amounts set forth and required 

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

19 upon request, provide documentation to the State, 

20 sufficient to enable the State and the Secretary to 

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

22 Secretary shall approve payments described in sub23 clause (I) that are furnished through an agreed 

24 upon capitation, partial capitation, or other value25 based payment arrangement if the capitation, partial 


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1 capitation, or other value-based payment arrange2 ment is based on a reasonable methodology and the 

3 entity provides documentation to the State sufficient 

4 to enable the State and the Secretary to ensure com5 pliance with subclause (I).’’. 

6 (2) CONFORMING AMENDMENT.—Section 

7 1932(f) of the Social Security Act (42 U.S.C. 

8 1396u–2(f)) is amended by inserting ‘‘and clause 

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

10 SEC. 5. INCREASED FMAP FOR MEDICAL ASSISTANCE TO 

11 NEWLY ELIGIBLE INDIVIDUALS. 

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

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

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

15 2015, and 2016’’ and inserting ‘‘each of the first 3 

16 consecutive 12-month periods in which the State 

17 provides medical assistance to newly eligible individ18 uals’’; 

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

20 and inserting ‘‘the fourth consecutive 12-month pe21 riod in which the State provides medical assistance 

22 to newly eligible individuals’’; 

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

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


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1 in which the State provides medical assistance to 

2 newly eligible individuals’’; 

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

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

5 in which the State provides medical assistance to 

6 newly eligible individuals’’; and 

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

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

9 consecutive 12-month period in which the State pro10 vides medical assistance to newly eligible individuals 

11 and each such period thereafter’’. 

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

13 subsection (a) shall take effect as if included in the enact14 ment of Public Law 111–148. 

15 SEC. 6. MEDICAID COVERAGE OF COMPREHENSIVE REPRO16 DUCTIVE HEALTH CARE SERVICES. 

17 (a) INCLUSION OF COMPREHENSIVE REPRODUCTIVE

18 HEALTH CARE SERVICES AS MEDICAL ASSISTANCE.— 

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

20 1396d(a)), as amended by section 2(h), is further amend21 ed— 

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

23 end; 

24 (2) by redesignating paragraph (30) as para25 graph (31); and 


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1 (3) by inserting after paragraph (29) the fol2 lowing new paragraph: 

3 ‘‘(30) comprehensive reproductive health care 

4 services, including abortion services; and’’. 

5 (b) REQUIRING COVERAGE OF COMPREHENSIVE RE6 PRODUCTIVE HEALTH CARE SERVICES AS CONDITION OF

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

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

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

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

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

12 (c) CONFORMING AMENDMENT.—Section 

13 1932(e)(1)(B) of the Social Security Act (42 U.S.C. 

14 1396u–2(e)(1)(B)) is amended by striking ‘‘Clause (i)’’ 

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

16 January 1, 2021, clause (i)’’. 

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

18 this section shall apply with respect to medical assistance 

19 furnished on or after January 1, 2021. 

Æ 


kjohnson on DSK79L0C42 with BILLS