HR 1162119th CongressIn Committee

Medicaid Primary Care Improvement Act

Introduced: Feb 10, 2025

Standard Summary

Comprehensive overview in 1-2 paragraphs

Medicaid Primary Care Improvement Act would explicitly allow states to use direct primary care (DPC) arrangements within Medicaid, including as part of value-based care models and through Medicaid managed care organizations (MCOs). A DPC arrangement, as defined in the bill, pays primary care practitioners a fixed periodic fee in exchange for providing primary care services—the model is focused on primary care and does not involve payment for a broader set of services beyond primary care. The bill also requires the federal health agency (HHS) to (1) convene stakeholder input and issue guidance within a year on how states may implement DPC under Medicaid, and (2) deliver a congressional report within two years assessing how often states contract with independent physicians or practices for Medicaid, and evaluating the quality and cost of care under DPC arrangements within managed care. The measure preserves existing cost-sharing rules and does not require that Medicaid only pay through DPC arrangements.

Key Points

1Clarifies that nothing in Medicaid’s Title XIX prohibits states from providing primary care through a direct primary care arrangement, including as part of value-based care or within an MCO framework.
2Defines a direct primary care arrangement as an arrangement where the individual’s medical assistance is solely for primary care services provided by primary care practitioners, with compensation paid as a fixed periodic fee.
3Requires the Secretary of Health and Human Services to hold at least one virtual open-door meeting with stakeholders within 1 year and to issue guidance to states on implementing DPC under Title XIX.
4Requires a report to Congress within 2 years analyzing (a) how often states contract with independent physicians/independent practices for Medicaid, and (b) the quality and cost of care delivered under DPC arrangements paid through Medicaid managed care.
5Contains a rule of construction stating that nothing in the section alters current cost-sharing requirements or limits medical assistance solely to DPC arrangements.

Impact Areas

Primary group/area affected- Medicaid beneficiaries seeking primary care services, especially those accessible through direct primary care models.- Primary care providers and independent practices that might participate in DPC arrangements under Medicaid.- State Medicaid agencies and Medicaid managed care organizations.Secondary group/area affected- State flexibility to design value-based care models and waivers that include DPC elements.- Payers and health systems exploring DPC as a cost-quality lever within Medicaid.Additional impacts- Regulatory clarity and guidance from HHS that could shape how states implement DPC, with potential effects on access, care coordination, and costs.- Data collection and analysis on the use, quality, and cost of DPC arrangements within Medicaid, informing future policy decisions.- Maintenance of current cost-sharing rules, ensuring that expansion of DPC does not inadvertently alter beneficiaries’ cost obligations or require exclusive reliance on DPC services.

Generated by gpt-5-nano on Nov 18, 2025