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 2015 and 2016— 
‘‘(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— 
‘‘(aa) the physician is Board 
certified in family medicine, gen-
eral internal medicine, or pedi-
atric medicine; or 
‘‘(bb) with respect to the 
most recently completed calendar 
year (or in the case of a newly el-
igible physician, the preceding 
month), 60 percent of all services 
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the physician billed for under the 
State plan or a waiver under this 
title, or provided through a med-
icaid 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 pri-
mary specialty designation of obstet-
rics and gynecology, but only if the 
physician self-attests that— 
‘‘(aa) the physician is Board 
certified in obstetrics and gyne-
cology; and 
‘‘(bb) with respect to the 
most recently completed calendar 
year (or in the case of a newly el-
igible 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 med-
icaid managed care organization 
(as 
defined 
in 
section 
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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 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 
a certified nurse-midwife (as de-
fined in section 1861(gg)) who is 
working in accordance with State 
law, but only if the nurse practi-
tioner, physician assistant, or 
certified nurse-midwife self-at-
tests that, with respect to the 
most recently completed calendar 
year (or in the case of a newly el-
igible nurse practitioner, physi-
cian assistant, or certified nurse- 
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midwife, the preceding month), 
60 percent of all services the 
nurse practitioner, physician as-
sistant, or certified nurse-midwife 
billed for under the State plan or 
a waiver under this title, or pro-
vided through a medicaid man-
aged care organization (as de-
fined in section 1903(m)(1)(A)), 
were for services described in 
subparagraph (A) or (B) of sub-
section (jj)(1); 
‘‘(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-
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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, but only if the 
rural health clinic or Federally-quali-
fied 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 
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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, but only 
if the nurse practitioner, physician as-
sistant, 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 assist-
ant, 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 subpara-
graph (A) or (B) of subsection 
(jj)(1);’’. 
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(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) CONFORMING AMENDMENT.—Section 1905(dd) 
of the Social Security Act (42 U.S.C. 1396d(dd)) is 
amended by striking ‘‘January 1, 2015’’ and inserting 
‘‘January 1, 2017’’. 
(d) EFFECTIVE DATE.—The amendments made by 
this section take effect on January 1, 2015. 
Æ 
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