Reapplication of Medicare payment rate floor to primary care services furnished under Medicaid and inclusion of additional providers

(a) Reapplication of payment floor; additional providers (1) In general Section 1902(a)(13) of the Social Security Act (42 U.S.C. 1396a(a)(13)) is amended— (A) in subparagraph (B), by striking; and and inserting a semicolon; (B) in subparagraph (C), by striking the semicolon and inserting; and; and (C) by adding at the end the following new subparagraph: (D) payment for primary care services (as defined in subsection (jj)(1)) furnished in the period that begins on the first day of the first month that begins after the date of enactment of the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services Act by a provider described in subsection (jj)(2)— (i) at a rate that is not less than 100 percent of the payment rate that applies to such services and the provider of such services 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 were the conversion factor under such section for 2009); (ii) in the case of items and services that are not items and services provided under such part, at a rate to be established by the Secretary; and (iii) in the case of items and services that are furnished in rural areas (as defined in section 1886(d)(2)(D)), health professional shortage areas (as defined in section 332(a)(1)(A) of the Public Health Service Act (42 U.S.C. 254e(a)(1)(A))), or medically underserved areas (according to a designation under section 330(b)(3)(A) of the Public Health Service Act (42 U.S.C. 254b(b)(3)(A))), at the rate otherwise applicable to such items or services under clause (i) or (ii) increased, at the Secretary's discretion, by not more than 25 percent;. (2) Conforming amendments (A) Section 1902(a)(13)(C) of the Social Security Act (42 U.S.C. 1396a(a)(13)(C)) is amended by striking subsection (jj) and inserting subsection (jj)(1). (B) Section 1905(dd) of the Social Security Act (42 U.S.C. 1396d(dd)) is amended— (i) by striking Notwithstanding and inserting the following: (1) In general Notwithstanding; (ii) in paragraph (1), as added by clause (i)— (I) by striking section 1902(a)(13)(C) and inserting subparagraph (C) of section 1902(a)(13); (II) by inserting or for services described in subparagraph (D) of section 1902(a)(13) furnished during an additional period specified in paragraph (2), after 2015,; and (III) by striking under such section and inserting under subparagraph (C) or (D) of section 1902(a)(13), as applicable; and (iii) by adding at the end the following: (2) Additional period For purposes of paragraph (1), the additional period shall be the period that begins on the first day of the first month that begins after the date of enactment of the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services Act.. (b) Improved targeting of primary care Section 1902(jj) of the Social Security Act (42 U.S.C. 1396a(jj)) is amended— (1) by redesignating paragraphs (1) and (2) as clauses (i) and (ii), respectively and realigning the left margins accordingly; (2) by striking For purposes of subsection (a)(13)(C) and inserting the following: (1) In general (A) Definition For purposes of subparagraphs (C) and (D) of subsection (a)(13); and (3) by inserting after clause (ii) (as so redesignated) the following: (B) 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. (2) Additional providers For purposes of subparagraph (D) of subsection (a)(13), a provider described in this paragraph is any of the following: (A) A physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine, or obstetrics and gynecology. (B) An advanced practice clinician, as defined by the Secretary, that works under the supervision of— (i) a physician that satisfies the criteria specified in subparagraph (A); (ii) 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 (iii) a certified nurse-midwife (as defined in section 1861(gg)) or a certified professional midwife who is working in accordance with State law. (C) A rural health clinic, federally qualified health center, health center that receives funding under title X of the Public Health Service Act, or other health clinic that receives reimbursement on a fee schedule applicable to a physician. (D) An advanced practice clinician supervised by a physician described in subparagraph (A), another advanced practice clinician, or a certified nurse-midwife. (E) A midwife who is working in accordance with State law.. (c) Ensuring payment by managed care entities (1) In general Section 1903(m)(2)(A) of the Social Security Act (42 U.S.C. 1396b(m)(2)(A)) is amended— (A) in clause (xii), by striking and after the semicolon; (B) by realigning the left margin of clause (xiii) so as to align with the left margin of clause (xii) and by striking the period at the end of clause (xiii) and inserting; and; and (C) by inserting after clause (xiii) the following: (xiv) such contract provides that (I) payments to providers specified in section 1902(a)(13)(D) for primary care services defined in section 1902(jj) that are furnished during a year or period specified in section 1902(a)(13)(D) and section 1905(dd) are at least equal to the amounts set forth and required by the Secretary by regulation, (II) the entity shall, upon request, provide documentation to the State, sufficient to enable the State and the Secretary to ensure compliance with subclause (I), and (III) the Secretary shall approve payments described in subclause (I) that are furnished through an agreed upon capitation, partial capitation, or other value-based payment arrangement if the capitation, partial capitation, or other value-based payment arrangement is based on a reasonable methodology and the entity provides documentation to the State sufficient to enable the State and the Secretary to ensure compliance with subclause (I).. (2) Conforming amendment Section 1932(f) of the Social Security Act (42 U.S.C. 1396u–2(f)) is amended— (A) by striking section 1902(a)(13)(C) and inserting subsections (C) and (D) of section 1902(a)(13); and (B) by inserting and clause (xiv) of section 1903(m)(2)(A) before the period.