Sponsors (8)
The bill lets states experiment with paying Medicaid primary care practices via direct primary care arrangements to expand access and reduce billing burden, but it risks fragmenting care, creating provider revenue shortfalls, and imposing start-up administrative costs if payments and integration of specialty services are not well designed.
Medicaid beneficiaries could gain more timely access to primary care because Medicaid programs and MCOs can pay independent practices through direct primary care arrangements (DPCAs).
States get clearer flexibility to contract with independent primary care practices, which can increase provider participation in Medicaid and give states more program design options.
Independent primary care practices could reduce administrative billing burden and costs by receiving fixed periodic fees instead of processing fee-for-service claims.
Medicaid beneficiaries risk having limited access to specialty or ancillary services and weaker care coordination if DPCAs only cover primary care, potentially fragmenting care.
Fixed periodic payments could reduce revenue that practices currently receive from higher-acuity visits, which may discourage some providers from participating if payment levels are insufficient.
Shifting Medicaid primary care toward DPCAs could create cost-shifting or undermine comprehensive care coordination unless specialty and ancillary services are integrated into the model.
Based on analysis of 2 sections of legislative text.
Clarifies states may provide Medicaid primary care via direct primary care arrangements, requires HHS guidance and a 2-year report on DPCA use and outcomes.
Official title: To facilitate direct primary care arrangements under Medicaid.
Introduced February 10, 2025 by Daniel Crenshaw · Last progress February 10, 2025
Allows states to offer primary care through direct primary care arrangements (DPCAs) to Medicaid enrollees by clarifying that nothing in Medicaid law bars such arrangements, including when delivered through Medicaid managed care organizations. Requires the HHS Secretary to hold a virtual stakeholder meeting within one year, issue guidance to states, and deliver a report to Congress within two years analyzing state use of independent physician contracts and DPCA effects on cost and quality for Medicaid enrollees. The bill defines DPCAs as arrangements where a patient receives only primary care from practitioners paid solely by a fixed periodic fee, and it makes clear it does not change Medicaid cost-sharing rules or limit benefits to only DPCAs.