Sponsors (8)
The bill enables Medicaid payment for direct primary care arrangements to expand access and reduce billing burden, but risks fragmenting care, shifting costs, and imposing transition and administrative burdens if specialty integration and adequate payment levels are not ensured.
Medicaid beneficiaries could get increased access to primary care because States and MCOs could pay independent primary care practices via direct primary care arrangements (DPCAs).
States and Medicaid managed care plans gain flexibility to contract with independent primary care practices, which may increase provider participation in Medicaid and expand network options.
Independent practices and clinicians could face lower administrative billing burdens and costs by receiving fixed periodic fees instead of fee-for-service claims.
Medicaid beneficiaries may face more limited services if DPCAs only cover primary care and do not include specialty or ancillary services.
Shifting primary care toward DPCAs could fragment care or shift costs to patients or other parts of the system if specialty, hospital, or care-coordination services are not well integrated.
Fixed periodic fees might reduce revenue from higher-acuity visits and discourage some providers from participating if payments do not adequately reflect patient complexity.
Based on analysis of 2 sections of legislative text.
Clarifies States may use direct primary care arrangements (fixed-fee primary care) under Medicaid and requires HHS guidance and a report to Congress on implementation.
Allows States to offer primary care through direct primary care arrangements (DPCAs) under Medicaid state plans or waivers, including through Medicaid managed care organizations. It defines DPCAs as arrangements where an individual receives only primary care from clinicians who are paid only a fixed periodic fee. Requires the HHS Secretary to hold at least one virtual open-door stakeholder meeting within one year and to issue guidance to States on implementing DPCAs under Medicaid, and to report to Congress within two years on how States contract with independent physicians and on quality and cost outcomes when Medicaid enrollees receive DPCA-paid care through a managed care organization. Does not change State plan cost-sharing or limit Medicaid benefits to DPCAs; no new funding is specified.
Introduced February 10, 2025 by Daniel Crenshaw · Last progress February 10, 2025