Kids’ Access to Primary Care Act of 2025
- Sponsor
- Rep. Schrier, Kim [D-WA-8]
- Committees
- Energy and Commerce Committee (primary)
- Last action
- Feb 18, 2025
Bottom line
This bill aims to improve access to primary care for Medicaid beneficiaries, particularly children, by increasing and standardizing reimbursement rates for a wider range of primary care providers and ensuring managed care compliance.
What it actually does
This bill renews and expands the application of the Medicare payment rate floor to primary care services furnished under the Medicaid program, ensuring providers are paid at least 100% of Medicare rates. It broadens the types of eligible providers to include certain subspecialists, advanced practice clinicians, and specific health centers, and explicitly excludes emergency department services from the definition of primary care for this enhanced payment. The bill also mandates a study on the impact of these changes and expresses a Sense of Congress regarding pediatric care guidelines.
Proponents argue
Supporters argue that renewing and expanding the Medicare payment rate floor for Medicaid primary care services is crucial for ensuring that Medicaid beneficiaries, especially children, have adequate access to care. They contend that higher reimbursement rates incentivize more providers to accept Medicaid patients, reducing access barriers and improving health outcomes. Including a broader range of primary care providers and advanced practice clinicians will further strengthen the primary care workforce serving this vulnerable population.
Opponents contend
Opponents might argue that mandating Medicare payment rates for Medicaid services places an undue financial burden on states, potentially leading to cuts in other essential Medicaid services or requiring states to increase their own funding contributions. Concerns could also be raised about the administrative complexity of implementing and overseeing these payment changes across various provider types and managed care entities.
The bill is concise and its core provisions are clearly stated, making it accessible for a quick review.
Section 2(a)(1)
Renews and Expands Medicare Payment Rate Floor for Medicaid Primary Care
This provision reinstates the requirement that Medicaid programs pay primary care providers at least 100% of the Medicare payment rate for primary care services, or the 2009 Medicare rate if higher. It expands the types of eligible providers beyond family medicine, general internal medicine, and pediatric medicine physicians to include board-certified physicians in obstetrics and gynecology, various subspecialties, advanced practice clinicians (APCs) under supervision, and certain health clinics. It also ensures nurse practitioners, physician assistants, and certified nurse-midwives are paid at least the Medicare rate for their services.
Supporters argue
Proponents argue that this renewal and expansion are essential to address the ongoing shortage of primary care providers willing to accept Medicaid, thereby improving health equity and access for vulnerable populations. The inclusion of more provider types reflects the evolving landscape of primary care delivery and ensures comprehensive coverage.
Critics contend
Opponents may argue that while the goal is laudable, the financial burden on states could be substantial, potentially forcing states to reduce other services or increase state taxes. They might also question the effectiveness of payment parity alone in solving complex access issues.
Tradeoffs
The bill balances the goal of improving access to care for Medicaid beneficiaries with the potential fiscal impact on state budgets. It also balances the need for broad primary care access with the administrative complexities of implementing and overseeing these payment mandates across diverse provider types.
Section 2(b)(1)
Excludes Emergency Department Services from Primary Care Definition
This provision amends the definition of "primary care services" for the purpose of the enhanced payment rate to explicitly exclude services provided in an emergency department of a hospital. This ensures that the higher payment rates are targeted specifically at preventive and routine primary care, rather than acute emergency care, promoting appropriate utilization of healthcare settings.
Section 2(c)(1)
Mandates Managed Care Organizations to Adhere to Payment Floor
This provision requires contracts between State Medicaid agencies and managed care entities to ensure that payments to primary care providers for services covered by the Medicare payment rate floor are at least equal to the amounts set by regulation. It also mandates that managed care entities provide documentation to the State to ensure compliance and allows for approval of capitated or value-based payment arrangements if they meet the payment floor through a reasonable methodology.
Section 3
Mandates Study on Impact of Payment Rate Renewal
This section directs the Secretary of Health and Human Services to conduct a study within 13 months of the bill's enactment. The study will compare the number of children enrolled in Medicaid, the number of primary care providers receiving Medicaid payments, and provider payment rates (using specific indexes) before and after the renewed payment floor takes effect.
Section 4
Sense of Congress on Bright Futures Guidelines
This section expresses the sense of Congress that health care providers should provide early and periodic screening, diagnostic, and treatment (EPSDT) services in accordance with the American Academy of Pediatrics' "Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents." This is a non-binding statement encouraging best practices.
This clause ensures that the Medicaid payment rate floor for primary care services is not only 100% of the current Medicare rate but also not less than what the Medicare rate would have been if the 2009 conversion factor (a component of Medicare's physician fee schedule) were still in effect. This acts as an additional safeguard against potential future reductions in Medicare physician payment rates.
Section 1902(a)(13)(C) of the Social Security Act, as amended by Section 2(a)(1) of the bill.
Why it matters:This is standard legislative practice for referencing complex statutory formulas and providing a "floor" or "hold harmless" provision. It's a technical detail to ensure the intended payment level is maintained regardless of future Medicare payment policy changes.
Case for: Supporters would argue this ensures the payment floor remains robust and isn't eroded by future Medicare payment adjustments that might reduce physician fees, thereby providing greater stability and incentive for providers to participate in Medicaid.
Case against: Critics might argue it adds another layer of complexity to payment calculations and could potentially lock in higher costs for states even if Medicare rates are adjusted downwards for legitimate reasons.
Estimated impact: Potentially significant long-term fiscal impact, as it insulates Medicaid primary care payments from certain Medicare rate reductions.