The proposed legislation, known as the Medicaid and Commercial Primary Care Rate Enhancement and Sustainability Act, aims to address the financial challenges faced by independent primary care practices in Rhode Island. It seeks to expand the patient-centered medical home (PCMH) program to all Medicaid-accepting independent primary care practices and nurse practitioners. The act mandates that managed care organizations (MCOs) provide enhanced per-member-per-month (PMPM) supplements ranging from $10 to $20 for each attributed Medicaid patient enrolled in the PCMH program.

Additionally, the act accelerates the primary care rate increase to 100% of Medicare rates by FY2026 and includes a temporary 25% bonus for independent (non-hospital-employed) practices. It also requires MCOs to pay an automatic access payment supplement of $8 to $15 PMPM for every attributed Medicaid patient in qualifying independent practices.

Furthermore, the act requires commercial insurers and Medicare Advantage plans to align primary care reimbursement rates with those in Massachusetts and Connecticut, implementing a phased approach that starts with a 15% increase by January 1, 2027, and aims for full alignment by July 1, 2027. Eligibility for these enhancements is limited to independent primary care physicians and nurse practitioners who accept Medicaid and meet specific quality and reporting requirements established by the executive office of health and human services (EOHHS).

On and after January 1, 2027, EOHHS is tasked with submitting necessary state-directed payment preprints to the Centers for Medicare & Medicaid Services, updating MCO contracts to incorporate these payments, building on the existing multi-payer PCMH program, and issuing annual reports on access, retention, and cost savings. The office of the health insurance commissioner will also amend regulations and insurer contracts to enforce commercial parity. The act will take effect on January 1, 2027, and includes provisions for enforcement by the office of the health insurance commissioner and EOHHS.