process, which shall provide opportunities for stake-
holders to participate. 
(b) UPDATING METRICS.—The Director of the Agen-
cy for Healthcare Research and Quality, in consultation 
with the Deputy Administrator for the Center for Med-
icaid and CHIP Services and State Medicaid Directors, 
shall update the metrics developed under subsection (a) 
not less than once every 3 years. 
(c) STATE IMPLEMENTATION FUNDING.—The Direc-
tor of the Agency for Healthcare Research and Quality 
may award funds, from the amount appropriated under 
subsection (d), to States for the purpose of implementing 
the metrics developed under this section. 
(d) APPROPRIATION.—There is appropriated to the 
Director of the Agency for Healthcare Research and Qual-
ity, out of any funds in the Treasury not otherwise appro-
priated, $200,000,000 for fiscal year 2020, to remain 
available until expended, for the purpose of carrying out 
this section. 
SEC. 4. RENEWAL OF APPLICATION OF MEDICARE PAY-
MENT RATE FLOOR TO PRIMARY CARE SERV-
ICES FURNISHED UNDER MEDICAID AND IN-
CLUSION OF ADDITIONAL PROVIDERS. 
(a) RENEWAL
OF PAYMENT FLOOR; ADDITIONAL 
PROVIDERS.— 
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(1) IN GENERAL.—Section 1902(a)(13) of the 
Social Security Act (42 U.S.C. 1396a(a)(13)) is 
amended by striking subparagraph (C) and inserting 
the following: 
‘‘(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 pay-
ment rate that would be applicable under such 
part if the conversion factor under section 
1848(d) for the year involved were the conver-
sion factor under such section for 2009), and 
that is not less than the rate that would other-
wise 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 designa-
tion of family medicine, general internal 
medicine, or pediatric medicine; or 
‘‘(ii) furnished in the period that be-
gins on the first day of the first month 
that begins after the date of enactment of 
the State Public Option Act— 
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‘‘(I) by a physician with a pri-
mary specialty designation of family 
medicine, general internal medicine, 
or pediatric medicine, but only if the 
physician self-attests that the physi-
cian is Board certified in family medi-
cine, general internal medicine, or pe-
diatric medicine; 
‘‘(II) by a physician with a pri-
mary specialty designation of obstet-
rics and gynecology, but only if the 
physician self-attests that the physi-
cian is Board certified in obstetrics 
and gynecology; 
‘‘(III) by an advanced practice 
clinician, as defined by the Secretary, 
that works under the supervision of— 
‘‘(aa) a physician that satis-
fies the criteria specified in sub-
clause (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 
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a certified nurse-midwife (as de-
fined in section 1861(gg)) who is 
working in accordance with State 
law; 
‘‘(IV) by a rural health clinic, 
Federally-qualified health center, or 
other health clinic that receives reim-
bursement on a fee schedule applica-
ble to a physician, a nurse practi-
tioner or a physician assistant (as 
such terms are defined in section 
1861(aa)(5)(A)) who is working in ac-
cordance with State law, or a certified 
nurse-midwife (as defined in section 
1861(gg)) who is working in accord-
ance with State law, for services fur-
nished by a physician, nurse practi-
tioner, physician assistant, or certified 
nurse-midwife, or services furnished 
by an advanced practice clinician su-
pervised by a physician described in 
subclause (I)(aa) or (II)(aa), another 
advanced practice clinician, or a cer-
tified nurse-midwife; or 
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‘‘(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 assist-
ant, or certified nurse-midwife is paid 
is not less than the amount that the 
nurse practitioner, physician assist-
ant, or certified nurse-midwife would 
be paid if the services were provided 
under part B of title XVIII;’’. 
(2) 
CONFORMING
AMENDMENTS.—Section 
1905(dd) of the Social Security Act (42 U.S.C. 
1396d(dd)) is amended— 
(A) by striking ‘‘Notwithstanding’’ and in-
serting the following: 
‘‘(1) IN GENERAL.—Notwithstanding’’; 
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(B) by inserting ‘‘or furnished during the 
additional period specified in paragraph (2),’’ 
after ‘‘2015,’’; and 
(C) by adding at the end the following: 
‘‘(2) ADDITIONAL
PERIOD.—For purposes of 
paragraph (1), the additional period specified in this 
paragraph is the period that begins on the first day 
of the first month that begins after the date of en-
actment of the State Public Option Act.’’. 
(b) IMPROVED TARGETING OF PRIMARY CARE.—Sec-
tion 1902(jj) of the Social Security Act (42 U.S.C. 
1396a(jj)) is amended— 
(1) by redesignating paragraphs (1) and (2) as 
subparagraphs (A) and (B), respectively and realign-
ing the left margins accordingly; 
(2) by striking ‘‘For purposes of’’ and inserting 
the following: 
‘‘(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) ENSURING PAYMENT BY MANAGED CARE ENTI-
TIES.— 
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