H.R. 3716 — what changed

changed This Act may be cited as the “Ensuring Removal of Terminated Providers are Removed from Medicaid and CHIP Act”.

“(8) Provider terminations

changed “(A) In general—Beginning 180 days after the date of the enactment of this paragraph, on January 1, 2017, in the case of a notification under subsection (a)(41) with respect to a termination for cause 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 any individual a provider of services or entity any other person under the State plan under subsection (a)(39), plan, the State, not later than 14 21 business days after the effective date of such termination, submits to the Secretary with respect to any such individual provider or entity—person, as appropriate—

changed “(i) the name of such individual provider or entity;person;

changed “(ii) the provider type of such individual provider or entity;person;

changed “(iii) the specialty of such individual’s provider’s or entity’s person’s practice;

changed “(iv) the date of birth, Social Security number, national provider identifier, Federal taxpayer identification number, and the State license or certification number of such individual provider or entity;person;

“(v) the reason for the termination;

changed “(vi) a copy of the effective date notice of such termination; andtermination sent to the provider or person;

changed “(vii) a copy of the notice effective date of such termination sent to the individual or entity.specified in such notice; and

changed “(B) Managed care entities“(viii) any other information required by the Secretary.

changed “(i) In general—With respect to managed care entities (as defined in section 1932(a)(1)), beginning on the later of the date that is 180 days after the “(B) Effective date of the enactment defined—For purposes of this paragraph or the first day of the first plan year for such an entity that begins after such date of enactment, the State requires that any contract paragraph, the State plan has term “effective date” means, with any such entity includes respect to a provision that individuals terminated for cause from participation under the program under title XVIII, this title, or title XXI be terminated from participation termination described in subparagraph (A), the provider networks of managed care entities under this title that serve individuals eligible to receive medical assistance under this title.later of—

changed “(ii) Notification of termination—For the period beginning on the date that is 180 days after the date of the enactment of this paragraph and ending on “(i) the date on which the enrollment of providers under section 1932(d)(5) such termination is complete for the State, the State provides for a system for notifying managed care entities (as defined effective, as specified in section 1932(a)(1)) of the termination notice of individuals or entities from participation under the program under title XVIII, this title, or title XXI.”such termination; or

added “(ii) the date on which all appeal rights applicable to such termination have been exhausted or the timeline for any such appeal has expired.”

added “(5) State reporting requirements for managed care entities

added “(A) In general—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.

added “(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.”

added “(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).”

removed “(ll) Termination notification database—In the case of an individual or entity whose participation in the program under title XVIII, this title, or title XXI is terminated for cause under subsection (a)(39), the Secretary shall, not later than 14 business days after the date on which the Secretary is notified of such termination under subsection (a)(41), 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).”

added “(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”

added “(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—

added “(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

added “(B)

added “(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

added “(ii) after such period, complies with section 1932(d)(6).”

removed “(D) beginning 2 years after the date of the enactment of this subparagraph, under the plan by any individual or entity whose participation in the State plan is terminated for cause under subsection (a)(39) of section 1902 after the date that is 60 days after the date on which such termination is included in the database or other system under subsection (ll) of such section; or”

changed “(78) provide that, not later than 180 days after the date of the enactment of this paragraph, 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;”

changed “(5) “(6) Enrollment of participating providers

changed “(A) In general—Beginning not later than one year after the date of the enactment of this paragraph, January 1, 2018, a State shall require that, in order to participate as a condition on the participation provider in the provider network of a managed care entity of a provider that provides services to, or orders orders, prescribes, refers, or provides referrals 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 enrolls 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) Rule of construction—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.”

“(B) Section 1902(a)(39) (relating to termination of participation of certain providers).

changed “(C) Section 1902(a)(78) (relating to the enrollment of providers participating in State plans providing medical assistance on a fee-for-service basis).”

added “(L) Section 1903(m)(3) (relating to limitation on payment with respect to managed care).”