Federal

Kids’ Access to Primary Care Act of 2023

Source: Congress.gov · 2,342 words in original text

What This Bill Does

This bill extends and expands a federal payment floor for primary care services provided through Medicaid (a joint federal-state health insurance program for low-income people). The payment floor requires that doctors and other healthcare providers receive payment rates that match or exceed Medicare (the federal health insurance program for seniors) payment rates. The bill also adds new types of providers who qualify for these higher payment rates. ##

Who It Affects

- Doctors with specialties in family medicine, general internal medicine, pediatric medicine, and obstetrics and gynecology - Nurse practitioners, physician assistants, and certified nurse-midwives - Rural health clinics and Federally-qualified health centers - Managed care organizations (insurance companies that contract with Medicaid) - States that run Medicaid programs - Children enrolled in Medicaid - The Department of Health and Human Services ##

Key Provisions

- Medicaid must pay primary care providers at least as much as Medicare pays for the same services, starting from the first day of the first month after the bill becomes law (Sec. 2(a)(1)) - Payment rates now apply to obstetrics and gynecology doctors (in addition to family medicine, general internal medicine, and pediatric medicine doctors), but these doctors must confirm they are board-certified (Sec. 2(a)(1)) - Advanced practice clinicians (a category defined by the Health and Human Services Secretary) working under supervision of qualifying doctors or nurse practitioners now qualify for the payment floor (Sec. 2(a)(1)) - Managed care organizations contracting with Medicaid must ensure their payments to primary care providers meet the federal payment floor requirements and must provide documentation to prove compliance (Sec. 2(c)(1)) - The bill requires a study within 13 months after the bill becomes law comparing child enrollment numbers, the number of healthcare providers participating in Medicaid, and payment rates across states before and after the bill takes effect (Sec. 3(a)) ##

What Changes

If this becomes law, Medicaid will pay more healthcare providers at higher rates for primary care services. The payment floor will expand to cover obstetrics and gynecology doctors, nurse practitioners, physician assistants, and certified nurse-midwives who meet certain requirements. Managed care organizations will have to follow new rules ensuring they pass these higher payment rates through to providers. A federal study will examine whether more children enroll in Medicaid and whether more doctors participate after the payment increases take effect. ##

Important Definitions

- Primary care services: Not fully defined in the bill. The bill refers to an existing definition in section 1902(jj) of the Social Security Act and specifies that primary care services do not include services provided in hospital emergency departments (Sec. 2(b)(1)) - Advanced practice clinician: The bill states this term will be defined by the Health and Human Services Secretary but does not provide the specific definition in this bill text (Sec. 2(a)(1)) - Board-certified: Not defined in the bill text ##

Effective Date

Payment floor requirements begin on the first day of the first month after the bill becomes law (Sec. 2(a)(1)). Managed care organization contract requirements begin on the date the bill becomes law for all contracts entered into on or after that date (Sec. 2(c)(3)). The required study must be completed within 13 months after the bill becomes law (Sec. 3(a)).

I 118TH CONGRESS 1ST SESSION H. R. 952 To amend title XIX of the Social Security Act to renew the application of the Medicare payment rate floor to primary care services furnished under the Medicaid program, and for other purposes. IN THE HOUSE OF REPRESENTATIVES FEBRUARY 9, 2023 Ms. SCHRIER (for herself, Mr. FITZPATRICK, and Ms. CASTOR of Florida) in- troduced the following bill; which was referred to the Committee on En- ergy and Commerce A BILL To amend title XIX of the Social Security Act to renew the application of the Medicare payment rate floor to primary care services furnished under the Medicaid pro- gram, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘Kids’ Access to Pri- 4 mary Care Act of 2023’’. 5 VerDate Sep 11 2014 00:51 Mar 10, 2023 Jkt 039200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H952.IH H952 pbinns on DSKJLVW7X2PROD with $$_JOB 2 •HR 952 IH SEC. 2. RENEWAL OF APPLICATION OF MEDICARE PAY- 1 MENT RATE FLOOR TO PRIMARY CARE SERV- 2 ICES FURNISHED UNDER MEDICAID AND IN- 3 CLUSION OF ADDITIONAL PROVIDERS. 4 (a) RENEWAL OF PAYMENT FLOOR; ADDITIONAL 5 PROVIDERS.— 6 (1) IN GENERAL.—Section 1902(a)(13) of the 7 Social Security Act (42 U.S.C. 1396a(a)(13)) is 8 amended by striking subparagraph (C) and inserting 9 the following: 10 ‘‘(C) payment for primary care services (as 11 defined in subsection (jj)) at a rate that is not 12 less than 100 percent of the payment rate that 13 applies to such services and physician under 14 part B of title XVIII (or, if greater, the pay- 15 ment rate that would be applicable under such 16 part if the conversion factor under section 17 1848(d) for the year involved were the conver- 18 sion factor under such section for 2009), and 19 that is not less than the rate that would other- 20 wise apply to such services under this title if 21 the rate were determined without regard to this 22 subparagraph, and that are— 23 ‘‘(i) furnished in 2013 and 2014, by a 24 physician with a primary specialty designa- 25 VerDate Sep 11 2014 00:51 Mar 10, 2023 Jkt 039200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H952.IH H952 pbinns on DSKJLVW7X2PROD with $$_JOB 3 •HR 952 IH tion of family medicine, general internal 1 medicine, or pediatric medicine; or 2 ‘‘(ii) furnished during the period be- 3 ginning on the first day of the first month 4 beginning after the date of the enactment 5 of the Kids’ Access to Primary Care Act of 6 2023— 7 ‘‘(I) by a physician with a pri- 8 mary specialty designation of family 9 medicine, general internal medicine, 10 pediatric medicine, or obstetrics and 11 gynecology, but only if the physician 12 self-attests that the physician is 13 board-certified in family medicine, 14 general internal medicine, pediatric 15 medicine, or obstetrics and gyne- 16 cology, respectively; 17 ‘‘(II) by a physician with a pri- 18 mary specialty designation of a family 19 medicine subspecialty, an internal 20 medicine subspecialty, a pediatric sub- 21 specialty, or a subspecialty of obstet- 22 rics and gynecology, without regard to 23 the board that offers the designation 24 for such a subspecialty, but only if the 25 VerDate Sep 11 2014 00:51 Mar 10, 2023 Jkt 039200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H952.IH H952 pbinns on DSKJLVW7X2PROD with $$_JOB 4 •HR 952 IH physician self-attests that the physi- 1 cian is board-certified in such a sub- 2 specialty; 3 ‘‘(III) by an advanced practice 4 clinician, as defined by the Secretary, 5 that works under the supervision of— 6 ‘‘(aa) a physician described 7 in subclause (I) or (II); or 8 ‘‘(bb) a nurse practitioner or 9 a physician assistant (as such 10 terms are defined in section 11 1861(aa)(5)(A)) who is working 12 in accordance with State law, or 13 a certified nurse-midwife (as de- 14 fined in section 1861(gg)(2)) who 15 is working in accordance with 16 State law; 17 ‘‘(IV) by a rural health clinic, 18 Federally-qualified health center, or 19 other health clinic that receives reim- 20 bursement on a fee schedule applica- 21 ble to a physician described in sub- 22 clause (I) or (II), an advanced prac- 23 tice clinician described in subclause 24 (III), or a nurse practitioner, physi- 25 VerDate Sep 11 2014 00:51 Mar 10, 2023 Jkt 039200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H952.IH H952 pbinns on DSKJLVW7X2PROD with $$_JOB 5 •HR 952 IH cian assistant, or certified nurse-mid- 1 wife described in subclause (III)(bb), 2 for services furnished by— 3 ‘‘(aa) such a physician, 4 nurse practitioner, physician as- 5 sistant, or certified nurse-mid- 6 wife, respectively; or 7 ‘‘(bb) an advanced practice 8 clinician supervised by such a 9 physician, nurse practitioner, 10 physician assistant, or certified 11 nurse-midwife; or 12 ‘‘(V) by a nurse practitioner or a 13 physician assistant (as such terms are 14 defined in section 1861(aa)(5)(A)) 15 who is working in accordance with 16 State law, or a certified nurse-midwife 17 described in subclause (III)(bb) who is 18 working in accordance with State law, 19 in accordance with procedures that 20 ensure that the portion of the pay- 21 ment for such services that the nurse 22 practitioner, physician assistant, or 23 certified nurse-midwife is paid is not 24 less than the amount that the nurse 25 VerDate Sep 11 2014 00:51 Mar 10, 2023 Jkt 039200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H952.IH H952 pbinns on DSKJLVW7X2PROD with $$_JOB 6 •HR 952 IH practitioner, physician assistant, or 1 certified nurse-midwife would be paid 2 if the services were provided under 3 part B of title XVIII;’’. 4 (2) CONFORMING AMENDMENTS.—Section 5 1905(dd) of the Social Security Act (42 U.S.C. 6 1396d(dd)) is amended— 7 (A) by striking ‘‘Notwithstanding’’ and in- 8 serting the following: 9 ‘‘(1) IN GENERAL.—Notwithstanding’’; 10 (B) by inserting ‘‘or furnished during the 11 additional period specified in paragraph (2),’’ 12 after ‘‘2015,’’; and 13 (C) by adding at the end the following: 14 ‘‘(2) ADDITIONAL PERIOD.—For purposes of 15 paragraph (1), the additional period specified in this 16 paragraph is the period beginning on the first day 17 of the first month beginning after the date of the en- 18 actment of the Kids’ Access to Primary Care Act of 19 2023.’’. 20 (b) IMPROVED TARGETING OF PRIMARY CARE.— 21 (1) IN GENERAL.—Section 1902(jj) of the So- 22 cial Security Act (42 U.S.C. 1396a(jj)) is amend- 23 ed— 24 VerDate Sep 11 2014 00:51 Mar 10, 2023 Jkt 039200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H952.IH H952 pbinns on DSKJLVW7X2PROD with $$_JOB 7 •HR 952 IH (A) by redesignating paragraphs (1) and 1 (2) as subparagraphs (A) and (B), respectively, 2 and moving the margin of each such subpara- 3 graph, as so redesignated, 2 ems to the right; 4 (B) by striking ‘‘For purposes of’’ and in- 5 serting the following: 6 ‘‘(1) IN GENERAL.—For purposes of’’; and 7 (C) by adding at the end the following: 8 ‘‘(2) EXCLUSIONS.—Such term does not include 9 any services described in subparagraph (A) or (B) of 10 paragraph (1) if such services are provided in an 11 emergency department of a hospital.’’. 12 (2) EFFECTIVE DATE.—The amendments made 13 by paragraph (1) shall apply with respect to primary 14 care services provided on or after the first day of the 15 period described in subparagraph (C)(ii) of section 16 1902(a)(13) of the Social Security Act (42 U.S.C. 17 1396a(a)(13)), as amended by section 2. 18 (c) ENSURING PAYMENT BY MANAGED CARE ENTI- 19 TIES.— 20 (1) IN GENERAL.—Section 1903(m)(2)(A) of 21 the Social Security Act (42 U.S.C. 1396b(m)(2)(A)) 22 is amended— 23 (A) in clause (xii), by striking ‘‘and’’ after 24 the semicolon; 25 VerDate Sep 11 2014 00:51 Mar 10, 2023 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H952.IH H952 pbinns on DSKJLVW7X2PROD with $$_JOB 8 •HR 952 IH (B) in clause (xiii)— 1 (i) by moving the margin of such 2 clause 2 ems to the left; and 3 (ii) by striking the period at the end 4 and inserting ‘‘; and’’; and 5 (C) by inserting after clause (xiii) the fol- 6 lowing: 7 ‘‘(xiv) such contract provides that (I) payments 8 to health care providers specified in section 9 1902(a)(13)(C) for furnishing primary care services 10 defined in section 1902(jj) during a year or period 11 specified in section 1902(a)(13)(C) are at least equal 12 to the amounts set forth and required by the Sec- 13 retary by regulation, (II) the entity shall, upon re- 14 quest, provide documentation to the State that is 15 sufficient to enable the State and the Secretary to 16 ensure compliance with subclause (I), and (III) the 17 Secretary shall approve payments described in sub- 18 clause (I) that are furnished through an agreed- 19 upon capitation, partial capitation, or other value- 20 based payment arrangement if the agreed-upon capi- 21 tation, partial capitation, or other value-based pay- 22 ment arrangement is based on a reasonable method- 23 ology and the entity provides documentation to the 24 VerDate Sep 11 2014 00:51 Mar 10, 2023 Jkt 039200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H952.IH H952 pbinns on DSKJLVW7X2PROD with $$_JOB 9 •HR 952 IH State that is sufficient to enable the State and the 1 Secretary to ensure compliance with subclause (I).’’. 2 (2) CONFORMING AMENDMENT.—Section 3 1932(f) of the Social Security Act (42 U.S.C. 4 1396u–2(f)) is amended by inserting ‘‘and clause 5 (xiv) of section 1903(m)(2)(A)’’ before the period. 6 (3) EFFECTIVE DATE.—The amendments made 7 by this subsection shall apply with respect to con- 8 tracts entered into on or after the date of the enact- 9 ment of this Act. 10 SEC. 3. STUDY. 11 (a) IN GENERAL.—Not later than the date that is 12 one year and one month after the date of the enactment 13 of this Act, the Secretary of Health and Human Services 14 shall conduct a study— 15 (1) comparing the number of children enrolled 16 in a State plan under title XIX of the Social Secu- 17 rity Act (42 U.S.C. 1396 et seq.) (or a waiver of 18 such plan) during the 12-month period preceding the 19 first day of the period described in subparagraph 20 (C)(ii) of section 1902(a)(13) of such Act (42 21 U.S.C. 1396a(a)(13)), as amended by section 2, to 22 the number of children so enrolled during the 12- 23 month period beginning on such first day; 24 VerDate Sep 11 2014 00:51 Mar 10, 2023 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H952.IH H952 pbinns on DSKJLVW7X2PROD with $$_JOB 10 •HR 952 IH (2) comparing the number of health care pro- 1 viders receiving payments for primary care services 2 under the Medicaid program under such title during 3 the 12-month period preceding the first day of the 4 period described in subparagraph (C)(ii) of section 5 1902(a)(13) of such Act (42 U.S.C. 1396a(a)(13)), 6 as amended by section 2, to the number of health 7 care providers receiving such payments during the 8 12-month period beginning on such first day; and 9 (3) comparing health care provider payment 10 rates for primary care services under the Medicaid 11 program under such title during the 12-month pe- 12 riod beginning on the first day of the period de- 13 scribed in subparagraph (C)(ii) of section 14 1902(a)(13) of such Act (42 U.S.C. 1396a(a)(13)), 15 as amended by section 2, across States, using the in- 16 dexes described in subsection (b). 17 (b) INDEXES DESCRIBED.—The indexes described in 18 this subsection are each of the following: 19 (1) A Medicaid fee index, comparing each 20 State’s average fee for primary care services under 21 the Medicaid program under such title to the na- 22 tional average for such services. 23 (2) A Medicaid-to-Medicare fee index, com- 24 paring each State’s average fee for primary care 25 VerDate Sep 11 2014 00:51 Mar 10, 2023 Jkt 039200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H952.IH H952 pbinns on DSKJLVW7X2PROD with $$_JOB 11 •HR 952 IH services under the Medicaid program under such 1 title to the fee for such services under the Medicare 2 program under title XVIII of such Act (42 U.S.C. 3 1395 et seq.). 4 (3) A Medicaid fee change index, comparing 5 fees for primary care services under the Medicaid 6 program under such title during the 12-month pe- 7 riod preceding the first day of the period described 8 in subparagraph (C)(ii) of section 1902(a)(13) of 9 such Act (42 U.S.C. 1396a(a)(13)), as amended by 10 section 2, to the fees for such services during the 11 12-month period beginning on such first day. 12 (c) AUTHORIZATION OF APPROPRIATIONS.—For pur- 13 poses of this section, there is authorized to be appro- 14 priated $200,000 for fiscal year 2024, to be available until 15 expended. 16 SEC. 4. SENSE OF CONGRESS REGARDING USE OF BRIGHT 17 FUTURES GUIDELINES. 18 It is the sense of Congress that health care providers 19 should provide early and periodic screening, diagnostic, 20 and treatment services (as defined in section 1905(r) of 21 the Social Security Act (42 U.S.C. 1396d(r))) in accord- 22 ance with the guidelines of the American Academy of Pe- 23 VerDate Sep 11 2014 00:51 Mar 10, 2023 Jkt 039200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H952.IH H952 pbinns on DSKJLVW7X2PROD with $$_JOB 12 •HR 952 IH diatrics entitled, ‘‘Bright Futures: Guidelines for Health 1 Supervision of Infants, Children, and Adolescents’’. 2 Æ VerDate Sep 11 2014 00:51 Mar 10, 2023 Jkt 039200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6301 E:\BILLS\H952.IH H952 pbinns on DSKJLVW7X2PROD with $$_JOB

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