HR 1433
Kids’ Access to Primary Care Act of 2025
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Bill overview
The Kids’ Access to Primary Care Act of 2025 aims to improve access to primary care services for children enrolled in Medicaid. It seeks to align Medicaid payments with Medicare rates for certain primary care providers, including pediatricians, family medicine doctors, and obstetricians, and expands the types of providers eligible for these higher payments to include advanced practice clinicians and rural health clinics. The bill also requires a study to assess the impact of these changes and ensures managed care entities contractually commit to paying primary care providers at least the Medicare rate. Finally, it encourages the use of evidence-based guidelines for pediatric health supervision.
Key provisions
- Aligns Medicaid primary care payments with a Medicare payment rate floor.
- Expands the types of providers eligible for the higher payment rate to include advanced practice clinicians, rural health clinics, and obstetricians.
- Requires a study comparing children enrolled in Medicaid and primary care provider payments before and after implementation.
- Mandates that managed care entities contractually guarantee primary care payments meet Medicare rates.
- Redefines ‘primary care services’ to exclude emergency department services.
- Establishes an additional period for applying the new payment rates, starting after 2015.
- Requires documentation to ensure compliance with payment requirements.
- Encourages the use of the American Academy of Pediatrics’ Bright Futures guidelines for pediatric health supervision.
Who is affected
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119th CONGRESS — 1st Session
H. R. 1433
IN THE HOUSE OF REPRESENTATIVES
A BILL
To amend title XIX of the Social Security Act to renew the application of the Medicare payment rate floor to primary care services furnished under the Medicaid program, and for other purposes.
This Act may be cited as the Kids’ Access to Primary Care Act of 2025
.
Section 1902(a)(13) of the Social Security Act (42 U.S.C. 1396a(a)(13)) is amended by striking subparagraph (C) and inserting the following:
payment for primary care services (as defined in subsection (jj)) at a rate that is not less than 100 percent of the payment rate that applies to such services and physician under part B of title XVIII (or, if greater, the payment rate that would be applicable under such part if the conversion factor under section 1848(d) for the year involved were the conversion factor under such section for 2009), and that is not less than the rate that would otherwise apply to such services under this title if the rate were determined without regard to this subparagraph, and that are—
furnished in 2013 and 2014, by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine; or
Kids’ Access to Primary Care Act of 2025
—by a physician with a primary specialty designation of family medicine, general internal medicine, pediatric medicine, or obstetrics and gynecology, but only if the physician self-attests that the physician is board-certified in family medicine, general internal medicine, pediatric medicine, or obstetrics and gynecology, respectively;
by an advanced practice clinician, as defined by the Secretary, that works under the supervision of—
a physician described in subclause (I) or (II); or
a nurse practitioner or a physician assistant (as such terms are defined in section 1861(aa)(5)(A)) who is working in accordance with State law, or a certified nurse-midwife (as defined in section 1861(gg)(2)) who is working in accordance with State law;
by a rural health clinic, Federally-qualified health center, or other health clinic that receives reimbursement on a fee schedule applicable to a physician described in subclause (I) or (II), an advanced practice clinician described in subclause (III), or a nurse practitioner, physician assistant, or certified nurse-midwife described in subclause (III)(bb), for services furnished by—
such a physician, nurse practitioner, physician assistant, or certified nurse-midwife, respectively; or
an advanced practice clinician supervised by such a physician, nurse practitioner, physician assistant, or certified nurse-midwife; or
Section 1905(dd) of the Social Security Act (42 U.S.C. 1396d(dd)) is amended—
by striking Notwithstanding
and inserting the following:
Notwithstanding
by inserting or furnished during the additional period specified in paragraph (2),
after 2015,
; and
by adding at the end the following:
Kids’ Access to Primary Care Act of 2025
.by redesignating paragraphs (1) and (2) as subparagraphs (A) and (B), respectively, and moving the margin of each such subparagraph, as so redesignated, 2 ems to the right;
by striking For purposes of
and inserting the following:
For purposes of
by adding at the end the following:
Such term does not include any services described in subparagraph (A) or (B) of paragraph (1) if such services are provided in an emergency department of a hospital.
The amendments made by paragraph (1) shall apply with respect to primary care services provided on or after the first day of the period described in subparagraph (C)(ii) of section 1902(a)(13) of the Social Security Act (42 U.S.C. 1396a(a)(13)), as amended by section 2.
Section 1903(m)(2)(A) of the Social Security Act (42 U.S.C. 1396b(m)(2)(A)) is amended—
in clause (xii), by striking and
after the semicolon;
in clause (xiii)—
by moving the margin of such clause 2 ems to the left; and
by striking the period at the end and inserting ; and
; and
by inserting after clause (xiii) the following:
such contract provides that (I) payments to health care providers specified in section 1902(a)(13)(C) for furnishing primary care services defined in section 1902(jj) during a year or period specified in section 1902(a)(13)(C) are at least equal to the amounts set forth and required by the Secretary by regulation, (II) the entity shall, upon request, provide documentation to the State that is sufficient to enable the State and the Secretary to ensure compliance with subclause (I), and (III) the Secretary shall approve payments described in subclause (I) that are furnished through an agreed-upon capitation, partial capitation, or other value-based payment arrangement if the agreed-upon capitation, partial capitation, or other value-based payment arrangement is based on a reasonable methodology and the entity provides documentation to the State that is sufficient to enable the State and the Secretary to ensure compliance with subclause (I).
Section 1932(f) of the Social Security Act (42 U.S.C. 1396u–2(f)) is amended by inserting and clause (xiv) of section 1903(m)(2)(A)
before the period.
The amendments made by this subsection shall apply with respect to contracts entered into on or after the date of the enactment of this Act.
The indexes described in this subsection are each of the following:
A Medicaid-to-Medicare fee index, comparing each State’s average fee for primary care services under the Medicaid program under such title to the fee for such services under the Medicare program under title XVIII of such Act (42 U.S.C. 1395 et seq.).
It is the sense of Congress that health care providers should provide early and periodic screening, diagnostic, and treatment services (as defined in section 1905(r) of the Social Security Act (42 U.S.C. 1396d(r))) in accordance with the guidelines of the American Academy of Pediatrics entitled, Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents
.