L:\XML\CPRT-114-HPRT-RU00-HR3716.XML
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mchinn
[Discussion Draft]
[Discussion Draft]
February 24. 2016
114th CONGRESS
2d Session
Rules Committee Print 114-45
Text of H.R. 3716, Ensuring Removal of Terminated Providers from Medicaid and CHIP Act
[Showing the texts of H.R. 3716 and H.R. 3821 as reported by the Committee on Energy and Commerce; with conforming changes.]
1.
This Act may be cited as the Ensuring Removal of Terminated Providers from Medicaid and CHIP Act
.
2.
Increasing oversight of termination of Medicaid providers
(a)
Increased oversight and reporting
(1)
State reporting requirements
Section 1902(kk) of the Social Security Act (42 U.S.C. 1396a(kk)) is amended—
(A)
by redesignating paragraph (8) as paragraph (9); and
(B)
by inserting after paragraph (7) the following new paragraph:
(8)
(A)
Beginning on January 1, 2017, in the case of a notification under subsection (a)(41) with respect to a termination for a reason specified in section 455.101 of title 42, Code of Federal Regulations (as in effect on November 1, 2015) or for any other reason specified by the Secretary, of the participation of a provider of services or any other person under the State plan, the State, not later than 21 business days after the effective date of such termination, submits to the Secretary with respect to any such provider or person, as appropriate—
(i)
the name of such provider or person;
(ii)
the provider type of such provider or person;
(iii)
the specialty of such provider’s or person’s practice;
(iv)
the date of birth, Social Security number, national provider identifier, Federal taxpayer identification number, and the State license or certification number of such provider or person;
(v)
the reason for the termination;
(vi)
a copy of the notice of termination sent to the provider or person;
(vii)
the effective date of such termination specified in such notice; and
(viii)
any other information required by the Secretary.
(B)
For purposes of this paragraph, the term effective date
means, with respect to a termination described in subparagraph (A), the later of—
(i)
the date on which such termination is effective, as specified in the notice of such termination; or
(ii)
the date on which all appeal rights applicable to such termination have been exhausted or the timeline for any such appeal has expired.
.
(2)
Reporting requirements for managed care entities
Section 1932(d) of the Social Security Act (42 U.S.C. 1396u–2(d)) is amended by adding at the end the following new paragraph:
(5)
State reporting requirements for managed care entities
(A)
With respect to any contract with a managed care entity under section 1903(m) or 1905(t)(3) (as applicable), beginning on the later of the first day of the first plan year for such managed care entity that begins after the date of the enactment of this paragraph or January 1, 2017, the State shall require that such contract include a provision that providers of services or persons terminated (as described in section 1902(kk)(8)) from participation under this title, title XVIII, or title XXI be terminated from participating under this title as a provider in any network of such entity that serves individuals eligible to receive medical assistance under this title.
(B)
Notification of termination
For the period beginning on January 1, 2017, and ending on the date on which the enrollment of providers under paragraph (6) is complete for a State, the State shall provide for a system for notifying managed care entities (as defined in subsection (a)(1)) of the termination (as described in section 1902(kk)(8)) of providers of services or persons from participation under this title, title XVIII, or title XXI.
.
(3)
Termination Notification Database
Section 1902 of the Social Security Act (42 U.S.C. 1396a) is amended by adding at the end the following new subsection:
(ll)
Termination notification database
In the case of a provider of services or any other person whose participation under this title, title XVIII, or title XXI is terminated (as described in subsection (kk)(8)), the Secretary shall, not later than 21 business days after the date on which the Secretary terminates such participation under title XVIII or is notified of such termination under subsection (a)(41) (as applicable), review such termination and, if the Secretary determines appropriate, include such termination in any database or similar system developed pursuant to section 6401(b)(2) of the Patient Protection and Affordable Care Act (42 U.S.C. 1395cc note; Public Law 111–148).
.
(4)
No Federal funds for items and services furnished by terminated providers
Section 1903 of the Social Security Act (42 U.S.C. 1396b) is amended—
(A)
in subsection (i)(2)—
(i)
in subparagraph (A), by striking the comma at the end and inserting a semicolon;
(ii)
in subparagraph (B), by striking or
at the end; and
(iii)
by adding at the end the following new subparagraph:
(D)
beginning not later than January 1, 2018, under the plan by any provider of services or person whose participation in the State plan is terminated (as described in section 1902(kk)(8)) after the date that is 60 days after the date on which such termination is included in the database or other system under section 1902(ll); or
; and
(B)
in subsection (m), by inserting after paragraph (2) the following new paragraph:
(3)
No payment shall be made under this title to a State with respect to expenditures incurred by the State for payment for services provided by a managed care entity (as defined under section 1932(a)(1)) under the State plan under this title (or under a waiver of the plan) unless the State—
(A)
beginning on the applicable date specified in subparagraph (A) of section 1932(d)(5), has a contract with such entity that complies with the requirement specified in such subparagraph; and
(B)
(i)
for the period specified in subparagraph (B) of such section, has a system in effect that meets the requirement specified in such subparagraph; and
(ii)
after such period, complies with section 1932(d)(6).
.
(5)
Development of uniform terminology for reasons for provider termination
Not later than January 1, 2017, the Secretary of Health and Human Services shall, in consultation with the heads of State agencies administering State Medicaid plans (or waivers of such plans), issue regulations establishing uniform terminology to be used with respect to specifying reasons under subparagraph (A)(v) of paragraph (8) of section 1902(kk) of the Social Security Act (42 U.S.C. 1396a(kk)), as amended by paragraph (1), for the termination (as described in such paragraph) of the participation of certain providers in the Medicaid program under title XIX of such Act or the Children’s Health Insurance Program under title XXI of such Act.
(6)
Section 1902(a)(41) of the Social Security Act (42 U.S.C. 1396a(a)(41)) is amended by striking provide that whenever
and inserting provide, in accordance with subsection (kk)(8) (as applicable), that whenever
.
(b)
Increasing availability of Medicaid provider information
(1)
Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)) is amended by inserting after paragraph (77) the following new paragraph:
(78)
provide that, not later than January 1, 2017, in the case of a State plan that provides medical assistance on a fee-for-service basis, the State shall require each provider furnishing items and services to individuals eligible to receive medical assistance under such plan to enroll with the State agency and provide to the State agency the provider’s identifying information, including the name, specialty, date of birth, Social Security number, national provider identifier, Federal taxpayer identification number, and the State license or certification number of the provider;
.
(2)
Managed care provider enrollment
Section 1932(d) of the Social Security Act (42 U.S.C. 1396u–2(d)), as amended by subsection (a)(2), is amended by adding at the end the following new paragraph:
(6)
Enrollment of participating providers
(A)
Beginning not later than January 1, 2018, a State shall require that, in order to participate as a provider in the network of a managed care entity that provides services to, or orders, prescribes, refers, or certifies eligibility for services for, individuals who are eligible for medical assistance under the State plan under this title and who are enrolled with the entity, the provider is enrolled with the State agency administering the State plan under this title. Such enrollment shall include providing to the State agency the provider’s identifying information, including the name, specialty, date of birth, Social Security number, national provider identifier, Federal taxpayer identification number, and the State license or certification number of the provider.
(B)
Nothing in subparagraph (A) shall be construed as requiring a provider described in such subparagraph to provide services to individuals who are not enrolled with a managed care entity under this title.
.
(c)
(1)
Section 2107(e)(1) of the Social Security Act (42 U.S.C. 1397gg(e)(1)) is amended—
(A)
by redesignating subparagraphs (B), (C), (D), (E), (F), (G), (H), (I), (J), (K), (L), (M), (N), and (O) as subparagraphs (D), (E), (F), (G), (H), (I), (J), (K), (M), (N), (O), (P), (Q), and (R), respectively;
(B)
by inserting after subparagraph (A) the following new subparagraphs:
(B)
Section 1902(a)(39) (relating to termination of participation of certain providers).
(C)
Section 1902(a)(78) (relating to enrollment of providers participating in State plans providing medical assistance on a fee-for-service basis).
;
(C)
by inserting after subparagraph (K) (as redesignated by paragraph (1)) the following new subparagraph:
(L)
Section 1903(m)(3) (relating to limitation on payment with respect to managed care).
; and
(D)
in subparagraph (P) (as redesignated by paragraph (1)), by striking (a)(2)(C) and (h)
and inserting (a)(2)(C) (relating to Indian enrollment), (d)(5) (relating to reporting requirements for managed care entities), (d)(6) (relating to enrollment of providers participating with a managed care entity), and (h) (relating to special rules with respect to Indian enrollees, Indian health care providers, and Indian managed care entities)
.
(2)
Excluding from Medicaid providers excluded from CHIP
Section 1902(a)(39) of the Social Security Act (42 U.S.C. 1396a(a)(39)) is amended by striking title XVIII or any other State plan under this title
and inserting title XVIII, any other State plan under this title, or any State child health plan under title XXI
.
(d)
Nothing in this section shall be construed as changing or limiting the appeal rights of providers or the process for appeals of States under the Social Security Act.
3.
Requiring publication of fee-for-service provider directory
(a)
Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)) is amended—
(1)
in paragraph (80), by striking and
at the end;
(2)
in paragraph (81), by striking the period at the end and inserting ; and
; and
(3)
by inserting after paragraph (81) the following new paragraph:
(82)
provide that, not later than 180 days after the date of the enactment of this paragraph, in the case of a State plan that provides medical assistance on a fee-for-service basis or through a primary care case-management system described in section 1915(b)(1) (other than a primary care case management entity (as defined by the Secretary)), the State shall publish (and update on at least an annual basis) on the public Website of the State agency administering the State plan, a directory of the providers (including, at a minimum, primary and specialty care physicians) described in subsection (mm) that includes—
(A)
with respect to each such provider—
(i)
the name of the provider;
(ii)
the specialty of the provider;
(iii)
the address of the provider; and
(iv)
the telephone number of the provider; and
(B)
with respect to any such provider participating in such a primary care case-management system, information regarding—
(i)
whether the provider is accepting as new patients individuals who receive medical assistance under this title; and
(ii)
the provider’s cultural and linguistic capabilities, including the languages spoken by the provider or by the skilled medical interpreter providing interpretation services at the provider’s office.
.
(b)
Directory providers described
Section 1902 of the Social Security Act (42 U.S.C. 1396a), as amended by section 2(a)(3), is amended by adding at the end the following new subsection:
(mm)
Directory providers described
A provider described in this subsection is—
(1)
in the case of a provider of a provider type for which the State agency, as a condition on receiving payment for items and services furnished by the provider to individuals eligible to receive medical assistance under the State plan, requires the enrollment of the provider with the State agency, a provider that—
(A)
is enrolled with the agency as of the date on which the directory is published or updated (as applicable) under subsection (a)(82); and
(B)
received payment under the State plan in the 12-month period preceding such date; and
(2)
in the case of a provider of a provider type for which the State agency does not require such enrollment, a provider that received payment under the State plan in the 12-month period preceding the date on which the directory is published or updated (as applicable) under subsection (a)(82).
.
(c)
(1)
The amendment made by subsection (a) shall not be construed to apply in the case of a State in which all the individuals enrolled in the State plan under title XIX of the Social Security Act (or under a waiver of such plan), other than individuals described in paragraph (2), are enrolled with a medicaid managed care organization (as defined in section 1903(m)(1)(A) of such Act (42 U.S.C. 1396b(m)(1)(A))), including prepaid inpatient health plans and prepaid ambulatory health plans (as defined by the Secretary of Health and Human Services).
(2)
An individual described in this paragraph is an individual who is an Indian (as defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603)) or an Alaska Native.
(d)
Exception for State legislation
In the case of a State plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), which the Secretary determines requires State legislation in order for the respective plan to meet one or more additional requirements imposed by amendments made by this section, the respective plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such an additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of enactment of this section. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of the session shall be considered to be a separate regular session of the State legislature.