Ensuring Access to Primary Care for Women & Children Act

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. Short title This Act may be cited as the Ensuring Access to Primary Care for Women & Children Act 2. Findings Congress finds as follows: (1) Medicaid plays a key role in providing coverage for millions of working families. (2) Medicaid enrollees include families, pregnant women, children, individuals with disabilities, and other low-income individuals. Without Medicaid coverage, many enrollees would be uninsured or lack coverage for services they need. (3) In 2013, the Medicaid program covered 62,000,000 individuals, or 1 in every 5 Americans. This number will continue to grow, particularly since the Affordable Care Act significantly expanded eligibility to millions of uninsured adults. Enrollment in Medicaid and the Children’s Health Insurance Program is projected to increase by 12,800,000 by 2016. (4) If all States expand their Medicaid programs, an estimated 7,000,000 women ages 18 to 64 would gain coverage under Medicaid. (5) In 47 States and in the District of Columbia, Medicaid pays up to 67 percent less than Medicare for the same primary care services. (6) Multiple studies have concluded that higher Medicaid payment rates would increase the probability of primary care providers accepting new Medicaid patients, and would further support current Medicaid providers. (7) Congress has recognized that low provider participation in Medicaid decreases access to health care. To address this problem, Congress acted to increase Medicaid payments for certain primary care services to be not less than the Medicare payment rates for 2013 and 2014. (8) As more Americans become insured and empowered participants in their own health care, demand for primary care services is expected to increase over the next few years. (9) Six in 10 women ages 18 to 44 (58 percent) report they see an obstetrics and gynecology (OB/GYN) physician on a regular basis. They are more likely to see their OB/GYN physician on a regular basis than any other type of provider. Given that women comprise the majority of Medicaid enrollees, it is critical that primary care providers, including OB/GYN physicians, receive sufficient reimbursement to participate in Medicaid. (10) Nurse practitioners and other mid-level health professionals deliver many primary care services. Applying Medicare’s rates for nurse practitioners and mid-level health professionals encourages greater participation in Medicaid, thereby increasing access to primary care, particularly in underserved areas. (11) The enhanced Medicaid reimbursement rate ensures providers have the financial capability to serve their patients’ primary care needs. Furthermore, adding nurse practitioners, physician assistants, certified nurse-midwives, and OB/GYN physicians serving in primary care settings increases access to critical health care services for women and children nationwide. 3. Extension of application of Medicare payment rate floor to primary care services furnished under Medicaid and application to additional providers (a) In general Section 1902(a)(13) of the Social Security Act ( 42 U.S.C. 1396a(a)(13) (C) payment for primary care services (as defined in subsection (jj)) at a rate that is not less than 100 percent of the payment rate that applies to such services and physician under part B of title XVIII (or, if greater, the payment rate that would be applicable under such part if the conversion factor under section 1848(d) for the year involved were the conversion factor under such section for 2009), and that is not less than the rate that would otherwise apply to such services under this title if the rate were determined without regard to this subparagraph, and that are— (i) furnished in 2013 and 2014, by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine; or (ii) furnished in 2015 and 2016— (I) by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine, but only if the physician self-attests that— (aa) the physician is Board certified in family medicine, general internal medicine, or pediatric medicine; or (bb) with respect to the most recently completed calendar year (or in the case of a newly eligible physician, the preceding month), 60 percent of all services the physician billed for under the State plan or a waiver under this title, or provided through a medicaid managed care organization (as defined in section 1903(m)(1)(A)), were for services described in subparagraph (A) or (B) of subsection (jj)(1); (II) by a physician with a primary specialty designation of obstetrics and gynecology, but only if the physician self-attests that— (aa) the physician is Board certified in obstetrics and gynecology; and (bb) with respect to the most recently completed calendar year (or in the case of a newly eligible physician, the preceding month), 60 percent of all services the physician billed for under the State plan or a waiver under this title, or provided through a medicaid managed care organization (as defined in section 1903(m)(1)(A)), were for services described in subparagraph (A) or (B) of subsection (jj)(1); (III) by an advanced practice clinician, as defined by the Secretary, that works under the supervision of— (aa) a physician that satisfies the criteria specified in subclause (I) or (II); or (bb) a nurse practitioner or a physician assistant (as such terms are defined in section 1861(aa)(5)(A)) who is working in accordance with State law, or a certified nurse-midwife (as defined in section 1861(gg)) who is working in accordance with State law, but only if the nurse practitioner, physician assistant, or certified nurse-midwife self-attests that, with respect to the most recently completed calendar year (or in the case of a newly eligible nurse practitioner, physician assistant, or certified nurse-midwife, the preceding month), 60 percent of all services the nurse practitioner, physician assistant, or certified nurse-midwife billed for under the State plan or a waiver under this title, or provided through a medicaid managed care organization (as defined in section 1903(m)(1)(A)), were for services described in subparagraph (A) or (B) of subsection (jj)(1); (IV) by a rural health clinic, Federally-qualified health center, or other health clinic that receives reimbursement on a fee schedule applicable to a physician, a nurse practitioner or a physician assistant (as such terms are defined in section 1861(aa)(5)(A)) who is working in accordance with State law, or a certified nurse-midwife (as defined in section 1861(gg)) who is working in accordance with State law, for services furnished by a physician, nurse practitioner, physician assistant, or certified nurse-midwife, or services furnished by an advanced practice clinician supervised by a physician described in subclause (I)(aa) or (II)(aa), another advanced practice clinician, or a certified nurse-midwife, but only if the rural health clinic or Federally-qualified health center self-attests that 60 percent of all services billed for under the State plan or a waiver under this title, or provided through a medicaid managed care organization (as defined in section 1903(m)(1)(A)), were for services described in subparagraph (A) or (B) of subsection (jj)(1); or (V) by a nurse practitioner or a physician assistant (as such terms are defined in section 1861(aa)(5)(A)) who is working in accordance with State law, or a certified nurse-midwife (as defined in section 1861(gg)) who is working in accordance with State law, in accordance with procedures that ensure that the portion of the payment for such services that the nurse practitioner, physician assistant, or certified nurse-midwife is paid is not less than the amount that the nurse practitioner, physician assistant, or certified nurse-midwife would be paid if the services were provided under part B of title XVIII, but only if the nurse practitioner, physician assistant, or certified nurse-midwife self-attests that, with respect to the most recently completed calendar year (or in the case of a newly eligible nurse practitioner, physician assistant, or certified nurse-midwife, the preceding month), 60 percent of all services the nurse practitioner, physician assistant, or certified nurse-midwife billed for under the State plan or a waiver under this title, or provided through a medicaid managed care organization (as defined in section 1903(m)(1)(A)), were for services described in subparagraph (A) or (B) of subsection (jj)(1); 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(b) Improved targeting of primary care Section 1902(jj) of the Social Security Act ( 42 U.S.C. 1396a(jj) (1) by redesignating paragraphs (1) and (2) as subparagraphs (A) and (B), respectively and realigning the left margins accordingly; (2) by striking For purposes of (1) In general For purposes of ; and (3) by adding at the end the following: (2) Exclusions Such term does not include any services described in subparagraph (A) or (B) of paragraph (1) if such services are provided in an emergency department of a hospital. . (c) Conforming amendment Section 1905(dd) of the Social Security Act ( 42 U.S.C. 1396d(dd) January 1, 2015 January 1, 2017 (d) Effective date The amendments made by this section take effect on January 1, 2015.

Summary: Ensuring Access to Primary Care for Women and Children Act - Amends title XIX (Medicaid) of the Social Security Act to require that the primary care services furnished in 2015 and 2016 by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine be paid at a rate that is not less than 100% of the payment rate that applies to such services and physician under Medicare part B (Supplementary Medical Insurance). Extends this 100% of Medicare payment floor under certain conditions to the following providers, who are self-attested as Board-certified and at least 60% of whose services billed for under Medicaid must be for primary care services: (1) physicians with a primary specialty designation of obstetrics and gynecology; (2) advanced practice clinicians; (3) rural health clinics, federally-qualified health centers, or other specified health clinics; and (4) nurse practitioners, physician assistants, or certified nurse-midwives. Excludes from coverage of primary care services any such services provided in an emergency department of a hospital.