H.R. 1433: Kids’ Access to Primary Care Act of 2025

The bill titled "Kids’ Access to Primary Care Act of 2025" aims to improve access to primary care services for children enrolled in Medicaid. Here’s a breakdown of the key provisions:

Renewal of Payment Rate Floor

The bill seeks to maintain a payment rate floor for primary care services under the Medicaid program. Specifically, it proposes that payments for these services must be at least 100% of what Medicare pays for similar services, thereby ensuring that providers are adequately reimbursed. This is crucial for attracting and retaining healthcare providers who serve Medicaid patients, especially in the fields of family medicine, general internal medicine, pediatric medicine, and obstetrics and gynecology. It also expands eligible providers to include:

• Board-certified physicians in family medicine, general internal medicine, pediatric medicine, or obstetrics and gynecology.
• Advanced practice clinicians working under the supervision of eligible physicians or nurse practitioners.
• Federally-qualified health centers and rural health clinics providing covered services.

Improved Targeting of Primary Care

The bill establishes clearer definitions and exclusions for what constitutes primary care services under Medicaid. It ensures that certain services provided in emergency departments are excluded from these definitions, focusing more on preventive and routine care for children.

Ensuring payment by Managed Care Entities

The legislation mandates that managed care organizations (MCOs) have contracts obligating them to ensure that payments for primary care services meet the specified minimum rates. This approach aims to enhance accountability and compliance among MCOs in their reimbursement practices.

Study Requirement

Within 13 months of the bill's enactment, the Secretary of Health and Human Services is required to conduct a study analyzing:

• The enrollment of children in Medicaid.
• The number of providers receiving payments for primary care services.
• A comparison of payment rates for primary care services across various states.

Authorization of Funds

The bill also includes provisions for funding, authorizing $200,000 for the fiscal year 2026 to support the aforementioned study.

Guidelines Recommendation

Lastly, the bill expresses a sense of Congress advocating for healthcare providers to follow established guidelines by the American Academy of Pediatrics for early and periodic screening, diagnosis, and treatment of children.

Relevant Companies

• UNH - UnitedHealth Group: As a major health insurance provider, changes in Medicaid payment structures can significantly impact their operations and provider partnerships.
• ANTM - Anthem, Inc.: Similar to UnitedHealth, Anthem’s Medicaid programs could be affected by the payment rate adjustments mandated by the bill.
• HUM - Humana Inc.: Changes to Medicaid reimbursement rates may influence Humana’s strategies regarding primary care offerings under Medicaid.