I 

113TH CONGRESS 

2D SESSION H. R. 5723 

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 

NOVEMBER 17, 2014 

Ms. CASTOR of Florida 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 2013, the Medicaid program covered 

9 62,000,000 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. Enrollment in 

13 Medicaid and the Children’s Health Insurance Pro14 gram is projected to increase by 12,800,000 by 

15 2016. 

16 (4) If all States expand their Medicaid pro17 grams, an estimated 7,000,000 women ages 18 to 64 

18 would gain coverage under Medicaid. 

19 (5) In 47 States and in the District of Colum20 bia, Medicaid pays up to 67 percent less than Medi21 care for the same primary care services. 

22 (6) Multiple studies have concluded that higher 

23 Medicaid payment rates would increase the prob24 ability of primary care providers accepting new MedVerDate Sep 11 2014 02:01 Nov 18, 2014 Jkt 049200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H5723.IH H5723

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1 icaid patients, and would further support current 

2 Medicaid providers. 

3 (7) Congress has recognized that low provider 

4 participation in Medicaid decreases access to health 

5 care. To address this problem, Congress acted to in6 crease Medicaid payments for certain primary care 

7 services to be not less than the Medicare payment 

8 rates for 2013 and 2014. 

9 (8) As more Americans become insured and em10 powered participants in their own health care, de11 mand for primary care services is expected to in12 crease over the next few years. 

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

14 report they see an obstetrics and gynecology (OB/ 

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

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

17 basis than any other type of provider. Given that 

18 women comprise the majority of Medicaid enrollees, 

19 it is critical that primary care providers, including 

20 OB/GYN physicians, receive sufficient reimburse21 ment to participate in Medicaid. 

22 (10) Nurse practitioners and other mid-level 

23 health professionals deliver many primary care serv24 ices. Applying Medicare’s rates for nurse practi25 tioners and mid-level health professionals encourages 


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1 greater participation in Medicaid, thereby increasing 

2 access to primary care, particularly in underserved 

3 areas. 

4 (11) The enhanced Medicaid reimbursement 

5 rate ensures providers have the financial capability 

6 to serve their patients’ primary care needs. Further7 more, adding nurse practitioners, physician assist8 ants, certified nurse-midwives, and OB/GYN physi9 cians serving in primary care settings increases ac10 cess to critical health care services for women and 

11 children nationwide. 

12 SEC. 3. EXTENSION OF APPLICATION OF MEDICARE PAY13 MENT RATE FLOOR TO PRIMARY CARE SERV14 ICES FURNISHED UNDER MEDICAID AND AP15 PLICATION TO ADDITIONAL PROVIDERS. 

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

17 Security Act (42 U.S.C. 1396a(a)(13)) is amended by 

18 striking subparagraph (C) and inserting 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 2015 and 2016— 

12 ‘‘(I) by a physician with a pri13 mary specialty designation of family 

14 medicine, general internal medicine, 

15 or pediatric medicine, but only if the 

16 physician self-attests that— 

17 ‘‘(aa) the physician is Board 

18 certified in family medicine, gen19 eral internal medicine, or pedi20 atric medicine; or 

21 ‘‘(bb) with respect to the 

22 most recently completed calendar 

23 year (or in the case of a newly el24 igible physician, the preceding 

25 month), 60 percent of all services 


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1 the physician billed for under the 

2 State plan or a waiver under this 

3 title, or provided through a med4 icaid managed care organization 

5 (as defined in section 

6 1903(m)(1)(A)), were for services 

7 described in subparagraph (A) or 

8 (B) of subsection (jj)(1); 

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— 

13 ‘‘(aa) the physician is Board 

14 certified in obstetrics and gyne15 cology; and 

16 ‘‘(bb) with respect to the 

17 most recently completed calendar 

18 year (or in the case of a newly el19 igible physician, the preceding 

20 month), 60 percent of all services 

21 the physician billed for under the 

22 State plan or a waiver under this 

23 title, or provided through a med24 icaid managed care organization 

25 (as defined in section 


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1 1903(m)(1)(A)), were for services 

2 described in subparagraph (A) or 

3 (B) of subsection (jj)(1); 

4 ‘‘(III) by an advanced practice 

5 clinician, as defined by the Secretary, 

6 that works under the supervision of— 

7 ‘‘(aa) a physician that satis8 fies the criteria specified in sub9 clause (I) or (II); or 

10 ‘‘(bb) a nurse practitioner or 

11 a physician assistant (as such 

12 terms are defined in section 

13 1861(aa)(5)(A)) who is working 

14 in accordance with State law, or 

15 a certified nurse-midwife (as de16 fined in section 1861(gg)) who is 

17 working in accordance with State 

18 law, but only if the nurse practi19 tioner, physician assistant, or 

20 certified nurse-midwife self-at21 tests that, with respect to the 

22 most recently completed calendar 

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1 midwife, the preceding month), 

2 60 percent of all services the 

3 nurse practitioner, physician as4 sistant, or certified nurse-midwife 

5 billed for under the State plan or 

6 a waiver under this title, or pro7 vided through a medicaid man8 aged care organization (as de9 fined in section 1903(m)(1)(A)), 

10 were for services described in 

11 subparagraph (A) or (B) of sub12 section (jj)(1); 

13 ‘‘(IV) by a rural health clinic, 

14 Federally-qualified health center, or 

15 other health clinic that receives reim16 bursement on a fee schedule applica17 ble to a physician, a nurse practi18 tioner or a physician assistant (as 

19 such terms are defined in section 

20 1861(aa)(5)(A)) who is working in ac21 cordance with State law, or a certified 

22 nurse-midwife (as defined in section 

23 1861(gg)) who is working in accord24 ance with State law, for services fur25 nished by a physician, nurse practiVerDate Sep 11 2014 02:01 Nov 18, 2014 Jkt 049200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H5723.IH H5723

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1 tioner, physician assistant, or certified 

2 nurse-midwife, or services furnished 

3 by an advanced practice clinician su4 pervised by a physician described in 

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

6 advanced practice clinician, or a cer7 tified nurse-midwife, but only if the 

8 rural health clinic or Federally-quali9 fied health center self-attests that 60 

10 percent of all services billed for under 

11 the State plan or a waiver under this 

12 title, or provided through a medicaid 

13 managed care organization (as defined 

14 in section 1903(m)(1)(A)), were for 

15 services described in subparagraph 

16 (A) or (B) of subsection (jj)(1); or 

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

18 physician assistant (as such terms are 

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

20 who is working in accordance with 

21 State law, or a certified nurse-midwife 

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

23 is working in accordance with State 

24 law, in accordance with procedures 

25 that ensure that the portion of the 


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1 payment for such services that the 

2 nurse practitioner, physician assist3 ant, or certified nurse-midwife is paid 

4 is not less than the amount that the 

5 nurse practitioner, physician assist6 ant, or certified nurse-midwife would 

7 be paid if the services were provided 

8 under part B of title XVIII, but only 

9 if the nurse practitioner, physician as10 sistant, or certified nurse-midwife self11 attests that, with respect to the most 

12 recently completed calendar year (or 

13 in the case of a newly eligible nurse 

14 practitioner, physician assistant, or 

15 certified nurse-midwife, the preceding 

16 month), 60 percent of all services the 

17 nurse practitioner, physician assist18 ant, or certified nurse-midwife billed 

19 for under the State plan or a waiver 

20 under this title, or provided through a 

21 medicaid managed care organization 

22 (as defined in section 1903(m)(1)(A)), 

23 were for services described in subpara24 graph (A) or (B) of subsection 

25 (jj)(1);’’. 


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1 (b) IMPROVED TARGETING OF PRIMARY CARE.—Sec2 tion 1902(jj) of the Social Security Act (42 U.S.C. 

3 1396a(jj)) is amended— 

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

5 subparagraphs (A) and (B), respectively and realign6 ing the left margins accordingly; 

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

8 the following: 

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

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

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

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

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

14 emergency department of a hospital.’’. 

15 (c) CONFORMING AMENDMENT.—Section 1905(dd) 

16 of the Social Security Act (42 U.S.C. 1396d(dd)) is 

17 amended by striking ‘‘January 1, 2015’’ and inserting 

18 ‘‘January 1, 2017’’. 

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

20 this section take effect on January 1, 2015. 

Æ 


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