The "Kids Access to Primary Care Act of 2025" ensures Medicaid pays primary care providers, including an expanded range of professionals, at least the same rate as Medicare, while also mandating a study on the impact of these changes on children's access to care and provider payment rates.
Patty Murray
Senator
WA
The "Kids Access to Primary Care Act of 2025" extends and expands a provision requiring Medicaid to pay primary care providers at least the same rate as Medicare, ensuring more healthcare professionals are adequately compensated for their services. It broadens the types of providers covered and mandates that managed care entities meet these payment standards. Additionally, the Act directs the Secretary of Health and Human Services to conduct a study comparing the number of children enrolled in Medicaid before and after the change, the number of healthcare providers receiving Medicaid payments for primary care before and after the same change in the law, and healthcare provider payment rates for primary care services under Medicaid across states after the change.
Kids' Access to Primary Care Act of 2025: Medicaid Pay Boost for Pediatricians and More
The Kids' Access to Primary Care Act of 2025 basically makes sure Medicaid pays doctors enough to keep seeing kids. It's extending an existing rule that says Medicaid has to pay at least as much as Medicare for primary care services – and it's expanding who qualifies for those rates.
Cash Rules Everything Around Medicaid
This bill is all about making sure doctors get paid fairly for treating kids on Medicaid. The core idea? Medicaid payments for primary care have to match Medicare rates. That's a big deal because Medicare generally pays more. This rule was already in place, but this Act extends it and, crucially, expands the types of providers it covers. Before, it was mainly just family doctors and pediatricians. Now, it includes OB/GYNs (Section 2), which is huge for pregnant teens and young mothers. It also brings in a bunch of other providers like:
- Board-certified physicians specializing in family medicine, general internal medicine, pediatrics, or OB/GYN.
- Physician subspecialists.
- Advanced practice clinicians (like nurse practitioners) working under those physicians.
- Rural health clinics and Federally Qualified Health Centers.
- Nurse practitioners, physician assistants, and certified nurse-midwives.
So, a family in a rural area with a nurse practitioner as their primary care provider? They're covered. A pregnant teen seeing an OB/GYN? Covered. This is about making sure more kids have access to more doctors.
Real-World Check
Imagine a single mom in a small town. Her kids are on Medicaid, and the only clinic nearby is staffed by a nurse practitioner. Under this bill, that nurse practitioner gets paid the Medicare rate, making it more likely they can afford to keep seeing Medicaid patients. Or picture a pediatrician in a busy city practice. Higher Medicaid rates mean they can take on more Medicaid patients without losing money. The bill does exclude emergency room services (Section 2), so this is specifically about regular check-ups and preventative care, not trips to the ER.
For managed care, the bill mandates in Section 2 that these entities must also pay healthcare providers at least the amounts required by the Secretary, with documentation to show compliance. It allows for things like capitation or value-based care, but the methodology has to be reasonable, and there's paperwork involved to prove they're sticking to the rules.
The Bigger Picture
This bill connects directly to the existing Medicaid law (Section 1902(a)(13)(C) and 1902(jj) of the Social Security Act). It's building on what's already there to try and improve access to care. The potential challenge? Making sure all those "reasonable methodologies" for value-based payments are actually, well, reasonable. There's room for interpretation, and that could lead to some providers getting shortchanged if it's not carefully monitored.
Within a year and a month of this Act becoming law, the Secretary of Health and Human Services has to do a study (Section 3). They're comparing how many kids were enrolled in Medicaid, and how many providers were getting Medicaid payments, before and after this change. They're also looking at payment rates across different states. This is good – it means they're tracking whether this bill actually works.