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This bill would make it clear that states can use direct primary care arrangements in Medicaid to provide primary care services. In this model, a person gets primary care from a doctor or clinic for a fixed regular fee, instead of billing each visit separately. The bill also tells the federal health department to help states by collecting input from health care groups and then issuing guidance on how to use this model. It also requires a later report to Congress on how often states are using these arrangements and what the care and costs look like.
- States could use direct primary care arrangements under Medicaid in their regular state plans or waivers, including through Medicaid managed care organizations.
- The arrangement would cover only primary care services, and the provider would be paid through a fixed periodic fee.
- Within 1 year, the Secretary of Health and Human Services would have to hold at least one online public meeting, hear from providers, state Medicaid offices, and managed care groups, and then give states guidance.
- Within 2 years, the Secretary would have to send Congress a report on how states are working with independent doctors and practices, and on the quality and cost of care for people served through these arrangements.
The bill also says it should not be read to change Medicaid cost-sharing rules or to mean that Medicaid can only cover care through direct primary care arrangements.
Official Summaries
Medicaid Primary Care Improvement Act
This bill specifies that state Medicaid programs are authorized to provide primary care services through direct primary care arrangements (i.e., arrangements in which primary care providers receive a fixed periodic fee for their services).
The Centers for Medicare & Medicaid Services must (1) convene at least one virtual stakeholder meeting and issue related guidance on how state Medicaid programs may implement direct primary care arrangements, and (2) report on the extent to which state Medicaid programs contract with independent providers and on the quality and cost of care under direct primary care arrangements that are offered through Medicaid managed care organizations.
Current Full Text
[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1162 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 1162
To facilitate direct primary care arrangements under Medicaid.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
February 10, 2025
Mr. Crenshaw (for himself, Ms. Schrier, Mr. Smucker, and Ms. Pettersen)
introduced the following bill; which was referred to the Committee on
Energy and Commerce
_______________________________________________________________________
A BILL
To facilitate direct primary care arrangements under Medicaid.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Medicaid Primary Care Improvement
Act''.
SEC. 2. CLARIFYING THAT CERTAIN PAYMENT ARRANGEMENTS ARE ALLOWABLE
UNDER THE MEDICAID PROGRAM.
(a) Rule of Construction.--Nothing in title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.) shall be construed as prohibiting
a State, under its State plan (or waiver of such plan) under such title
(including through a medicaid managed care organization (as defined in
section 1903(m)(1)(A) of such Act)), from providing medical assistance
consisting of primary care services through a direct primary care
arrangement with a health care provider, including as part of a value-
based care arrangement established by the State. For purposes of the
preceding sentence, the term ``direct primary care arrangement'' means,
with respect to any individual, an arrangement under which such
individual is provided medical assistance consisting solely of primary
care services provided by primary care practitioners, if the sole
compensation for such care is a fixed periodic fee.
(b) Guidance.--Not later than 1 year after the date of the
enactment of this Act, the Secretary of Health and Human Services
shall--
(1) convene at least one virtual open door meeting to seek
input from stakeholders, including primary care providers who
practice under the direct primary care model, state Medicaid
agencies, and Medicaid managed care organizations; and
(2) taking into account such input, issue guidance to
States on how a State may implement direct primary care
arrangements (as defined in subsection (a)) under title XIX of
the Social Security Act (42 U.S.C. 1396 et seq.).
(c) Report.--Not later than 2 years after the date of the enactment
of this Act, the Secretary of Health and Human Services shall submit to
Congress a report containing--
(1) an analysis of the extent to which States are
contracting with independent physicians, independent physician
practices, and primary care practices for purposes of
furnishing medical assistance under State plans (or waivers of
such plans) under title XIX of the Social Security Act (42
U.S.C. 1396 et seq.); and
(2) an analysis of quality of care and cost of care
furnished to individuals enrolled under such title where such
care is paid for under a direct primary care arrangement (as
defined in subsection (a)) through a medicaid managed care
organization (as so defined).
(d) Rule of Construction.--Nothing in this section shall be
construed to alter statutory requirements under the State plan (or
waiver of such plan) under title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) for cost-sharing requirements or be construed to
limit medical assistance solely to those provided under a direct
primary care arrangement.
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