Frequently Asked Questions

What is the problem the Medicaid Access Program in HB 1392 is trying to solve?

About 1 out of 4 people in Washington state have health insurance coverage through Apple Health, or Medicaid. Most Medicaid recipients are enrolled in managed care organization (MCO) plans, and it’s these plans that reimburse the cost of care to the clinics, physicians, and other advanced medical care professionals who provide it.

Washington state has made great strides in expanding insurance coverage to residents, but our reimbursement rates are some of the worst in the nation. Although the Legislature has improved rates for some important types of care, such as primary care, the overall rates are still less than the cost of delivering care, and in some specialties, significantly less than the cost of delivering care.

Reimbursement rates pay the office or clinic for the costs of supplies, rent, and all the staff salaries: the physician, nurse, bookkeeper, receptionist and more. Because the office gets paid less than it costs to take care of the patient, offices cannot take too many Medicaid patients at once, or they won’t be able to stay open.

As a result, it can be hard for Medicaid patients to get appointments, which means they may experience delays in care and worsening health conditions.

The Medicaid underpayment is especially bad for specialty services: Washington state has some of the lowest specialty care reimbursement rates in the country, affecting patients with cancer, joint pain, chronic diseases and more.

Is this a big problem?

Yes. Nearly 2 million people in our state are on Medicaid and vulnerable to this experience. In fall 2023, the Washington State Medical Association did a sample survey of Medicaid patients to get their perspective.

More than half (53%) had experienced denial of care or difficulty scheduling an appointment since they had been on Medicaid. Even patients who were referred by their doctors to specialists were sometimes denied care.

• Nearly 4 in 10 (37%) had been denied an appointment.
• 4 in 10 (39%) had trouble getting an appointment for specialty follow-up treatment that had been referred by their doctor.
• 1 in 4 (24%) had trouble getting an appointment for medical treatment.

Visit the “By the Numbers” page to read more about the patient experience.

How does Washington compare with other states?

Washington is one of the worst states in the nation when it comes to reimbursing the physicians, physician assistants, and advanced registered nurse practitioners who care for Medicaid patients. Because of this significant underpayment, many Washington state specialty physicians and advanced care practitioners are forced to turn Medicaid patients away.

Our state also receives the lowest federal contribution for Medicaid rates in the country, which means that every other state gets more federal resources to support their Medicaid program.

How does the Medicaid Access Program help solve the problem?

There is good news: By passing HB 1392, Washington state can strengthen our Medicaid system and improve access with a mix of new local and federal funds.

The Medicaid Access Program in HB 1392 puts in place a covered lives assessment to “assess,” or charge, health insurance carriers, primarily Medicaid managed care organizations, based on their enrollment. The federal government matches the resulting assessment revenue at a rate of about 2:1. The total amount increases the amount of funds available to reimburse clinics, medical groups, physicians, ARNPs and other advanced care practitioners so they can see more Medicaid patients and see them faster.

Similar to assessment programs already in place for Washington hospitals, nursing homes, and ambulances, the Medicaid Access Program in HB 1392 uses federal funding to support Washington’s Medicaid program.

In light of the state’s current budget deficit, how will the Medicaid Access Program be paid for?

The Medicaid Access Program relies primarily on federal funding. Similar to programs that are in place in California and elsewhere, by establishing the covered lives assessment we can leverage federal funding to support the investments while minimizing expenditures from the state’s general fund.

Will raising Medicaid reimbursement rates by passing HB 1392 help increase access to health care in my community?

Physicians and practices are contracted with Medicaid managed care organizations because they want to care for the Medicaid patients in their communities, but since reimbursement rates do not cover the cost of care, many must limit the number of Medicaid patients they see.

An improved Medicaid reimbursement rate helps community practices and clinics see more patients. Increasing Medicaid reimbursement rates has been demonstrated to be the most effective way to increase access to care for patients.

With a new “tax,” won’t insurance carriers just raise patient premiums?

The Medicaid Access Program’s assessments are very small and are mostly assessed on Medicaid managed care organizations. Since patients enrolled in Medicaid plans don’t pay premiums, they won’t be affected. This also doesn’t adversely impact MCOs, as the funding mechanism is essentially the state taxing itself a small amount in order to drawn down a much larger amount of federal funding (for every dollar Washington state invests in the Medicaid program, the federal government matches at about 2:1).

The law requires that the assessment also be placed on commercial insurance carriers, but their rates are held as low as possible while meeting federal requirements: approximately $.50 per person, per month, or $6 a year.

What type of health professionals will see their reimbursement rates go up under the Medicaid Access Program in HB 1392?

The Medicaid Access Program will raise Medicaid reimbursement rates for all professional services provided by physicians, physician assistants, ARNPs (nurse practitioners), and other advanced care practitioners to at least Medicare levels and will index to inflation. The increase will be for all professional services for all specialties, with no exceptions, no carve outs or caveats.

Don’t doctors already get paid enough?

Medicaid reimbursements do not directly go to any individual person’s salary. Medicaid reimbursements go toward covering the cost of care for the whole office, which includes the supplies, rent, and all the staff salaries: the physician, nurse, bookkeeper, receptionist and more.

Why Medicare levels?

Medicare reimbursement rates as established by the federal Centers for Medicare and Medicaid Services are traditionally designed to approximate the cost of delivering care.

Since hospitals received a Medicaid increase in 2023 and many doctors and nurses work in hospitals, will they be getting two increases?

The goal of the Medicaid Access Program in HB 1392 is simple and straightforward—it will establish a “floor” for Medicaid rates by pegging Medicaid rates to Medicare levels for the reimbursement of services provided by individual clinicians (physicians and advanced medical care professionals) regardless of setting, to help bring reimbursements closer to covering the cost of care. Our proposal complements the update to the hospital safety net assessment program that was approved by the Legislature in 2023 by putting professional service rate reimbursement on par with what is in place for facility reimbursement under the hospital safety net program.

What impact will the Medicaid Access Program have on health insurance affordability?

HB 1392 is designed to minimize impact on affordability by applying the assessment to as few commercial health plans as permitted by law and applying it at the lowest possible rate (no more than 50 cents per enrollee, per month). Increasing investments in Medicaid reimbursement will relieve pressure on commercial contracting, as practices will no longer be subsidizing the state by treating Medicaid enrollees. And the overall cost of care will be lowered by promoting access to care in a timely fashion, diminishing the need for Medicaid patients to seek care in emergency departments.

The federal funding under the Medicaid Access Program requires a waiver from the Centers for Medicare and Medicaid Services. With the change in administration at the federal level, will the waiver be approved?

While federal regulators have agitated for decades about curtailing states’ use of safety net assessments, programs similar to the Medicaid Access Program were approved by Republican and Democratic administrations, including the first Trump administration. Until there is clear indication that CMS will not approve a waiver, this continues to be our best opportunity to fund investments in Medicaid.