Medicaid same-day primary and behavioral care

Full Title:
Improving CARE for Youth Act

Summary#

The bill would change Medicaid rules so states may not refuse payment when a Medicaid patient gets a mental health service or substance use disorder service and a primary care service on the same day at the same clinic. It defines “same-day qualifying services” to include in-person and telehealth visits provided by clinicians who work for, or under contract with, the same physician’s office, Federally qualified health center, rural health clinic, or other outpatient facility. The broad goal appears to be to make it easier to get both behavioral health and primary care on the same day at the same place.

Key changes

  • States would have to allow payment under their Medicaid plans for a mental health or substance use disorder (SUD) service and a primary care service furnished the same day, when those services meet the bill’s “same-day qualifying service” definition.
  • “Same-day qualifying service” includes services given via telehealth.
  • The rule applies when services are provided by clinicians employed by or under contract with the same office, FQHC, rural health clinic, or outpatient facility, including when different clinicians deliver the two services.
  • The bill language applies to Medicaid state plan requirements (title XIX) and does not limit the policy to youth despite the bill’s title.

What it means for you#

  • Medicaid beneficiaries (including youth): You could be able to receive and have covered both a primary care visit and a behavioral health (mental health or SUD) visit on the same day at the same clinic, whether in person or by telehealth.
  • Primary care and behavioral health clinicians: Clinics and clinicians working for or contracted with the same facility could bill Medicaid for both a primary care service and a behavioral health service provided to the same patient on the same day.
  • Federally qualified health centers and rural health clinics: These facilities would explicitly be covered by the rule allowing payment for same-day primary and behavioral health services.
  • State Medicaid agencies: States would need to ensure their Medicaid plans do not contain rules that bar payment for same-day primary and behavioral health services as defined by the bill.
  • Managed care organizations (MCOs): The bill modifies state plan requirements; it is unclear how it would interact with Medicaid managed care payment policies (see “What is unclear”).

Expenses#

No publicly available information.

  • The bill text does not include a fiscal note or an estimate of costs.
  • This change could mean states or Medicaid programs may pay for two services on the same day more often than before, which could increase Medicaid spending; the bill itself does not estimate how much.
  • Implementing the change may require administrative work by state Medicaid agencies and providers (policy updates, training, billing-system changes). Exact staffing or IT costs are not specified.

Proponents' View#

  • The bill appears intended to reduce barriers that prevent patients from receiving both primary care and behavioral health services on the same day at the same clinic.
  • Supporters may argue this could improve care coordination by making it easier for clinics to offer integrated services and for patients to get comprehensive care in one visit.
  • Including telehealth in the definition could expand access for patients who use virtual visits.
  • The bill explicitly names FQHCs and rural health clinics, which could support access in areas with fewer providers.

Opponents' View#

  • One concern is that the bill does not explain how payment levels or billing rules should work when two services are billed the same day; this could lead to disputes or inconsistent implementation across states.
  • It is unclear whether and how the rule applies to Medicaid managed care contracts and capitated payments; that gap could create implementation challenges.
  • The bill does not set guardrails against duplicate or unnecessary billing, which could raise concerns about higher costs or improper payments.
  • Administrative costs for states and providers to change policies and billing systems are not estimated and could be nontrivial.
  • The bill’s title mentions youth, but the text applies broadly to Medicaid beneficiaries; this discrepancy may raise questions about the intended scope.