HB1162, titled the Medicaid Primary Care Improvement Act, would clarify that federal Medicaid law does not prohibit states from using direct primary care arrangements to deliver primary care services under a state Medicaid plan or waiver, including through Medicaid managed care organizations. The bill defines a direct primary care arrangement as one in which an individual receives only primary care services from primary care practitioners and the sole compensation is a fixed periodic fee. It also allows these arrangements to be used as part of state-designed value-based care models.
The bill directs the Secretary of Health and Human Services to hold at least one virtual open-door stakeholder meeting within one year of enactment, including input from direct primary care providers, state Medicaid agencies, and Medicaid managed care organizations. Within that same period, HHS must issue guidance to states on how to implement direct primary care arrangements under Medicaid. Within two years, HHS must report to Congress on the extent to which states contract with independent physicians and primary care practices for Medicaid services, and on the quality and cost of care delivered through direct primary care arrangements paid for by managed care organizations.
Impact
If enacted, the bill would not itself require states to adopt direct primary care, but it would remove uncertainty about whether such arrangements are permissible under Medicaid and would encourage state experimentation within existing Medicaid plans and waivers. It would affect Title XIX of the Social Security Act and could influence how states, Medicaid managed care organizations, and primary care providers structure payment and delivery models for Medicaid beneficiaries. The bill also preserves existing statutory cost-sharing rules and states that it does not limit Medicaid coverage solely to services furnished through direct primary care arrangements.
Sentiment
The available context suggests generally favorable or bipartisan interest in the concept, as the bill was introduced by members from both parties and referred to committee without recorded opposition or votes. The bill’s framing emphasizes flexibility for states, provider participation, and potential care-delivery innovation, which are typically attractive to supporters of primary care reform. No committee transcript or vote history is available to show formal debate, but the sponsorship pattern suggests the bill is not overtly partisan in its approach.
Contention
The main potential points of contention are whether direct primary care arrangements fit comfortably within Medicaid’s existing financing and managed care rules, and whether fixed periodic fees could create access, equity, or oversight concerns for Medicaid populations. Stakeholders may also differ on whether these arrangements improve quality and lower costs or instead complicate administration and accountability. The bill anticipates these concerns by requiring HHS guidance and a report on quality and cost, and by clarifying that it does not alter cost-sharing requirements or replace other Medicaid service options.
Kids' Access to Primary Care Act of 2025This bill modifies payments for Medicaid primary care services. Specifically, the bill applies a Medicare payment rate floor to Medicaid primary care services that are provided after the date of enactment of the bill and extends the payment rate to additional types of practitioners (e.g., obstetricians).The Centers for Medicare & Medicaid Services must conduct a study on the number of children enrolled in Medicaid, the number of providers receiving payment for primary care services, and associated payment rates before and after the bill's implementation.