I 

114TH CONGRESS 

1ST SESSION H. R. 2253 

To amend title XIX of the Social Security Act to extend the application 

of the Medicare payment rate floor to primary care services furnished 

under Medicaid and to apply the rate floor to additional providers of 

primary care services. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 12, 2015 

Ms. CASTOR of Florida (for herself and Ms. SPEIER) 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 extend 

the application of the Medicare payment rate floor to 

primary care services furnished under Medicaid and to 

apply the rate floor to additional providers of primary 

care services. 

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 Access to 

5 Primary Care for Women & Children Act’’. 

6 SEC. 2. FINDINGS. 

7 Congress finds as follows: 


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1 (1) Medicaid plays a key role in providing cov2 erage for millions of working families. 

3 (2) Medicaid enrollees include families, preg4 nant women, children, individuals with disabilities, 

5 and other low-income individuals. Without Medicaid 

6 coverage, many enrollees would be uninsured or lack 

7 coverage for services they need. 

8 (3) In 2014, the Medicaid program covered 

9 69,000,000 individuals, or 1 in every 5 Americans. 

10 This number will continue to grow, particularly since 

11 the Affordable Care Act significantly expanded eligi12 bility to millions of uninsured adults. 

13 (4) If all States expand their Medicaid pro14 grams, an estimated 7,000,000 women ages 18 to 64 

15 would gain coverage under Medicaid. 

16 (5) In 47 States and in the District of Colum17 bia, Medicaid pays up to 67 percent less than Medi18 care for the same primary care services. 

19 (6) Congress has recognized that low provider 

20 participation in Medicaid decreases access to health 

21 care. To address this problem, Congress acted to in22 crease Medicaid payments for certain primary care 

23 services to be not less than the Medicare payment 

24 rates for 2013 and 2014. 


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1 (7) As more Americans become insured and em2 powered participants in their own health care, de3 mand for primary care services is expected to in4 crease over the next few years. 

5 (8) According to a study published earlier this 

6 year in the New England Journal of Medicine, high7 er Medicaid payment rates have significantly in8 creased appointment availability for Medicaid enroll9 ees. 

10 (9) Six in 10 women ages 18 to 44 (58 percent) 

11 report they see an obstetrics and gynecology (OB/ 

12 GYN) physician on a regular basis. They are more 

13 likely to see their OB/GYN physician on a regular 

14 basis than any other type of provider. Given that 

15 women comprise the majority of Medicaid enrollees, 

16 it is critical that primary care providers, including 

17 OB/GYN physicians, receive sufficient reimburse18 ment to participate in Medicaid. 

19 (10) Nurse practitioners and other health pro20 fessionals deliver many primary care services. Apply21 ing Medicare’s rates for nurse practitioners and 

22 other health professionals encourages greater partici23 pation in Medicaid, thereby increasing access to pri24 mary care, particularly in underserved areas. 


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1 (11) The enhanced Medicaid reimbursement 

2 rate ensures providers have the financial capability 

3 to serve their patients’ primary care needs. Further4 more, adding nurse practitioners, physician assist5 ants, certified nurse-midwives, and OB/GYN physi6 cians serving in primary care settings increases ac7 cess to critical health care services for women and 

8 children nationwide. 

9 SEC. 3. RENEWAL OF APPLICATION OF MEDICARE PAY10 MENT RATE FLOOR TO PRIMARY CARE SERV11 ICES FURNISHED UNDER MEDICAID AND IN12 CLUSION OF ADDITIONAL PROVIDERS. 

13 (a) RENEWAL OF PAYMENT FLOOR; ADDITIONAL

14 PROVIDERS.— 

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

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

17 amended by striking subparagraph (C) and inserting 

18 the following: 

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

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

21 less than 100 percent of the payment rate that 

22 applies to such services and physician under 

23 part B of title XVIII (or, if greater, the pay24 ment rate that would be applicable under such 

25 part if the conversion factor under section 


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1 1848(d) for the year involved were the conver2 sion factor under such section for 2009), and 

3 that is not less than the rate that would other4 wise apply to such services under this title if 

5 the rate were determined without regard to this 

6 subparagraph, and that are— 

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

8 physician with a primary specialty designa9 tion of family medicine, general internal 

10 medicine, or pediatric medicine; or 

11 ‘‘(ii) furnished in the 2-year period 

12 that begins on the first day of the first 

13 month that begins after the date of enact14 ment of the Ensuring Access to Primary 

15 Care for Women & Children Act— 

16 ‘‘(I) by a physician with a pri17 mary specialty designation of family 

18 medicine, general internal medicine, 

19 or pediatric medicine, but only if the 

20 physician self-attests that the physi21 cian is Board certified in family medi22 cine, general internal medicine, or pe23 diatric medicine; 

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1 rics and gynecology, but only if the 

2 physician self-attests that the physi3 cian is Board certified in obstetrics 

4 and gynecology; 

5 ‘‘(III) by an advanced practice 

6 clinician, as defined by the Secretary, 

7 that works under the supervision of— 

8 ‘‘(aa) a physician that satis9 fies the criteria specified in sub10 clause (I) or (II); or 

11 ‘‘(bb) a nurse practitioner or 

12 a physician assistant (as such 

13 terms are defined in section 

14 1861(aa)(5)(A)) who is working 

15 in accordance with State law, or 

16 a certified nurse-midwife (as de17 fined in section 1861(gg)) who is 

18 working in accordance with State 

19 law; 

20 ‘‘(IV) by a rural health clinic, 

21 Federally qualified health center, or 

22 other health clinic that receives reim23 bursement on a fee schedule applica24 ble to a physician, a nurse practi25 tioner or a physician assistant (as 


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1 such terms are defined in section 

2 1861(aa)(5)(A)) who is working in ac3 cordance with State law, or a certified 

4 nurse-midwife (as defined in section 

5 1861(gg)) who is working in accord6 ance with State law, for services fur7 nished by a physician, nurse practi8 tioner, physician assistant, or certified 

9 nurse-midwife, or services furnished 

10 by an advanced practice clinician su11 pervised by a physician described in 

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

13 advanced practice clinician, or a cer14 tified nurse-midwife; or 

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

16 physician assistant (as such terms are 

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

18 who is working in accordance with 

19 State law, or a certified nurse-midwife 

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

21 is working in accordance with State 

22 law, in accordance with procedures 

23 that ensure that the portion of the 

24 payment for such services that the 

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1 ant, or certified nurse-midwife is paid 

2 is not less than the amount that the 

3 nurse practitioner, physician assist4 ant, or certified nurse-midwife would 

5 be paid if the services were provided 

6 under part B of title XVIII;’’. 

7 (2) CONFORMING AMENDMENTS.—Section 

8 1905(dd) of the Social Security Act (42 U.S.C. 

9 1396d(dd)) is amended— 

10 (A) by striking ‘‘Notwithstanding’’ and in11 serting the following: 

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

13 (B) by inserting ‘‘or furnished during an 

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

15 after ‘‘2015,’’; and 

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

17 ‘‘(2) ADDITIONAL PERIODS.—For purposes of 

18 paragraph (1), the following are additional periods: 

19 ‘‘(A) The 2-year period that begins on the 

20 first day of the first month that begins after 

21 the date of enactment of the Ensuring Access 

22 to Primary Care for Women & Children Act.’’. 

23 (b) IMPROVED TARGETING OF PRIMARY CARE.—Sec24 tion 1902(jj) of the Social Security Act (42 U.S.C. 

25 1396a(jj)) is amended— 


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

2 subparagraphs (A) and (B), respectively and realign3 ing the left margins accordingly; 

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

5 the following: 

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

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

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

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

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

11 emergency department of a hospital.’’. 

12 (c) ENSURING PAYMENT BY MANAGED CARE ENTI13 TIES.— 

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

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

16 is amended— 

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

18 the semicolon; 

19 (B) by realigning the left margin of clause 

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

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

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

23 (C) by inserting after clause (xiii) the fol24 lowing: 


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

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

3 primary care services defined in section 1902(jj) 

4 that are furnished during a year or period specified 

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

6 at least equal to the amounts set forth and required 

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

8 upon request, provide documentation to the State, 

9 sufficient to enable the State and the Secretary to 

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

11 Secretary shall deem payments described in sub12 clause (I) that are furnished through an agreed 

13 upon capitation, partial capitation, or other value14 based payment arrangement to comply with sub15 clause (I) if the capitation, partial capitation, or 

16 other value-based payment arrangement is based on 

17 a reasonable methodology and the entity provides 

18 documentation of the methodology to the Sec19 retary.’’. 

20 (2) CONFORMING AMENDMENT.—Section 

21 1932(f) of the Social Security Act (42 U.S.C. 

22 1396u–2(f)) is amended by inserting ‘‘and clause 

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


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1 SEC. 4. IMPROVING QUALITY AND VALUE FOR MEDICAID 

2 BENEFICIARIES. 

3 (a) GAO STUDY.—Not later than 1 year after the 

4 date of enactment of this Act, the Comptroller General 

5 of the United States shall submit to Congress a report 

6 that examines the use of alternative payment models in 

7 State Medicaid programs and identifies opportunities for 

8 disseminating successful payment models among such pro9 grams. 

10 (b) FUNDING THE DEVELOPMENT OF QUALITY

11 MEASURES.—The first sentence of section 1139B(e) of 

12 the Social Security Act (42 U.S.C. 1320b–9b(e)) is 

13 amended by inserting ‘‘, and for fiscal year 2016, 

14 $15,000,000,’’ before ‘‘for the purpose’’. 

15 (c) DEVELOPING QUALITY MEASURES FOR BENE16 FICIARIES WITH DISABILITIES.—Section 1139B(b)(5) of 

17 the Social Security Act (42 U.S.C. 1320b–9b(b)(5)) is 

18 amended by adding at the end the following: 

19 ‘‘(C) QUALITY MEASURES SPECIFIC TO

20 ADULT INDIVIDUALS WITH DISABILITIES.—The 

21 Secretary, acting through the Administrator for 

22 the Centers for Medicare & Medicaid Services 

23 and the Director of the Agency for Healthcare 

24 Research and Quality, shall develop adult 

25 health quality measures that are specific to 

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1 clude those measures in the Medicaid Quality 

2 Measurement Program. In developing such 

3 measures, priority shall be given to developing 

4 quality measures that assess the impact on 

5 adult individuals with disabilities of existing 

6 programs and to the development of quality 

7 measures that assess the impact of new service 

8 delivery innovations on such individuals.’’. 

Æ 


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