H.R. 5210 — what changed

added “(8) Provider terminations

added “(A) In general—Beginning on July 1, 2018, 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 (or under a waiver of the 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—

added “(i) the name of such provider or person;

added “(ii) the provider type of such provider or person;

added “(iii) the specialty of such provider’s or person’s practice;

added “(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;

added “(v) the reason for the termination;

added “(vi) a copy of the notice of termination sent to the provider or person;

added “(vii) the date on which such termination is effective, as specified in the notice; and

added “(viii) any other information required by the Secretary.

added “(B) Effective date defined—For purposes of this paragraph, the term “effective date” means, with respect to a termination described in subparagraph (A), the later of—

added “(i) the date on which such termination is effective, as specified in the notice of 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) Contract requirement for managed care entities—With respect to any contract with a managed care entity under section 1903(m) or 1905(t)(3) (as applicable), no later than July 1, 2018, such contract shall 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 “(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).”

added “(D) beginning not later than July 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 July 1, 2018, has a contract with such entity that complies with the requirement specified in section 1932(d)(5); and

added “(B) beginning on January 1, 2018, complies with the requirement specified in section 1932(d)(6)(A).”

added “(78) provide that, not later than January 1, 2017, in the case of a State plan (or a waiver of the 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;”

added “(6) Enrollment of participating providers

added “(A) In general—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 (or under a waiver of the plan) and who are enrolled with the entity, the provider is enrolled with the State agency administering the State plan under this title (or waiver of the plan). 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.

added “(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.”

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

added “(C) Section 1902(a)(78) (relating to 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).”

removed The Secretary of Health and Human Services shall extend the transition period described in clause (i) of section 414.210(g)(9) of title 42, Code of Federal Regulations, from June 30, 2016, to September 30, 2017 (with the full implementation described in clause (ii) of such section applying to items and services furnished with dates of service on or after October 1, 2017).

added “(82) provide that, not later than January 1, 2017, in the case of a State plan (or waiver of the 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 physicians described in subsection (mm) and, at State option, other providers described in such subsection that—

added “(A) includes—

added “(i) with respect to each such physician or provider—

added “(I) the name of the physician or provider;

added “(II) the specialty of the physician or provider;

added “(III) the address at which the physician or provider provides services; and

added “(IV) the telephone number of the physician or provider; and

added “(ii) with respect to any such physician or provider participating in such a primary care case-management system, information regarding—

added “(I) whether the physician or provider is accepting as new patients individuals who receive medical assistance under this title; and

added “(II) the physician’s or provider’s cultural and linguistic capabilities, including the languages spoken by the physician or provider or by the skilled medical interpreter providing interpretation services at the physician’s or provider’s office; and

added “(B) may include, at State option, with respect to each such physician or provider—

added “(i) the Internet website of such physician or provider; or

added “(ii) whether the physician or provider is accepting as new patients individuals who receive medical assistance under this title.”

removed Section 1847(b)(5) of the Social Security Act (42 U.S.C. 1395w–3(b)(5)) is amended—

added “(mm) Directory physician or provider described—A physician or provider described in this subsection is—

added “(1) in the case of a physician or provider of a provider type for which the State agency, as a condition on receiving payment for items and services furnished by the physician or provider to individuals eligible to receive medical assistance under the State plan, requires the enrollment of the physician or provider with the State agency, a physician or a provider that—

added “(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

added “(B) received payment under the State plan in the 12-month period preceding such date; and

added “(2) in the case of a physician or provider of a provider type for which the State agency does not require such enrollment, a physician or provider that received payment under the State plan (or waiver of the plan) in the 12-month period preceding the date on which the directory is published or updated (as applicable) under subsection (a)(82).”

removed “(E) Bid ceiling for durable medical equipment

removed “(i) In general—The ceiling for a bid submitted for applicable covered items may not be less than the fee schedule amount that would otherwise be determined for such items under section 1834(a), section 1834(h), or section 1842(s)(1) on January 1, 2015, updated by the covered item update for such items under section 1834(a)(14)(L), section 1834(h), or section 1842(s)(1), respectively, as appropriate for the year with respect to which the bid ceiling is established for such applicable covered item.

removed “(ii) Application to new covered items—The Secretary shall establish a process for purposes of applying clause (i) with respect to applicable covered items for which no fee schedule amount would otherwise be paid under section 1834(a), section 1834(h), or section 1842(s), as appropriate, on January 1, 2015.

removed “(iii) Applicable covered items defined—For purposes of this subparagraph, the term applicable covered items means competitively priced items and services described in subsection (a)(2) that are furnished with respect to rounds of competition that begin on or after January 1, 2017.”

removed Section 1834(a)(1)(G) of the Social Security Act (42 U.S.C. 1395m(a)(1)(G)) is amended by adding at the end the following new sentence:

removed “(i) solicit and take into account stakeholder input; and

removed “(ii) take into account the highest amount bid by a winning supplier in a competitive acquisition area and a comparison of each of the following with respect non-competitive acquisition areas and competitive acquisition areas:

removed “(I) The average travel distance and cost associated with furnishing items and services in the area.

removed “(II) Any barriers to access for items and services in the area.

removed “(III) The average delivery time in furnishing items and services in the area.

removed “(IV) The average volume of items and services furnished by suppliers in the area.

removed “(V) The number of suppliers in the area.”

removed Not later than the first of each month (beginning with May 1, 2016, and ending with September 1, 2017), the Secretary of Health and Human Services shall publish on the Internet website of the Centers for Medicare & Medicaid Services the results of the monitoring of access of Medicare beneficiaries to durable medical equipment and of health outcomes, as described on page 66228 in the final rule published by the Center for Medicare & Medicaid Services on November 6, 2014, and entitled “Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies” (79 Fed. Reg. 66120–66265).

changed It is the sense Section 1898(b)(1) of Congress that this Act should not be enacted unless the increase in Federal expenditures under this Social Security Act (42 U.S.C. 1395iii(b)(1)) is fully offset through a decrease in other Federal expenditures.amended by striking “$0” and inserting “$3,000,000”.