S. 5269: Pay PCPs Act of 2026

This bill would let Medicare create a new hybrid payment system for primary care. Instead of paying primary care doctors and other primary care providers only for each individual visit or service, Medicare could pay them partly through a regular monthly amount per patient and partly through the usual fee-for-service system.

What the new payment system would cover

The monthly payment could be used to help pay for services that are important in primary care but are not always paid well under today’s billing system. Examples include:

• care management;
• phone calls, emails, and portal messages with patients and caregivers;
• behavioral health integration services;
• office visits for new and existing patients, whether in person or by telehealth.

Other services not included in the monthly payment would still be billed separately under Medicare’s normal fee-for-service rules. The bill specifically says that screenings, preventive services, annual wellness visits, vaccinations, and initial preventive physical exams should remain separately payable and at least as well paid as they are now.

How the monthly payment would be set

The Secretary of Health and Human Services would have discretion to design the program. The bill says the monthly payment could represent roughly 40% to 70% of expected annual Medicare payments for a primary care provider’s services. The amount would be based on past Medicare payments and should be high enough to support things like care coordination, team-based care, and services that are not usually billed separately.

The Secretary could also adjust payments for different kinds of primary care providers and could use risk adjustment to account for patients who are more medically complex or who have social and demographic factors that affect the amount of care they need.

Who could participate

The new hybrid payment option would be available only to primary care providers as defined in the bill. Providers would not be required to take the new payment structure; participation would be voluntary.

Quality measures and oversight

The Secretary could set quality measures for providers who use the hybrid payment. These could include things like:

• patient experience;
• clinical quality;
• use of emergency rooms and hospitalizations;
• how efficiently referrals are made and how comprehensive the provider’s services are.

The bill also allows annual bonus payments tied to quality performance.

Patient assignment and cost sharing

Medicare would set procedures to assign beneficiaries to a primary care provider using past claims data, and the beneficiary would also confirm that provider as their usual source of care.

The Secretary could reduce Medicare Part B cost sharing by 50% for primary care services paid through the new hybrid system, but only if the beneficiary has designated a primary care provider as their usual source of care. The bill would also require HHS to report to Congress on how this cost-sharing reduction affects primary care use and whether it leads to fraud or abuse.

Changes to Medicare payment policy

The bill would exclude primary care providers receiving these hybrid payments from the Medicare quality payment program known as MIPS. It would also create a new technical advisory committee inside CMS to help update Medicare’s relative value system, which is the process Medicare uses to decide how much different services are worth.

This committee would advise the Secretary on how to better measure the time and resources needed for services, whether some billing codes should be combined or split, and how proposed changes might affect access, costs, quality, and fraud risk.

Funding

The bill would appropriate $10 billion over fiscal years 2027 through 2031 to pay for the hybrid primary care payments. It also allows up to $5 million per year for running the advisory committee and up to $10 million per year for research and development related to payment methodology.

Relevant Companies

None found