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Idaho Legislature Approved Medicaid Reimbursement Rate Increase for Nurse Practitioners Effective July 1, 2022

Posted over 1 year ago

Idaho Legislature Approved Medicaid Reimbursement Rate Increase for Nurse Practitioners--Effective July 1, 2022

Colleen M. Shackelford, DNP, APRN, NP-C
Legislative Chair, Nurse Practitioners of Idaho

Printed in RN IDAHO, May, 2022, Vol. 45, No. 2, Page 10.

It is reported that 70,000 Idahoans received health care with the 2020 expansion of Medicaid (Reilly, 2020). Broadening health care coverage was an important step in improving access to care for Idahoans. However, we must also recognize the other factors that influence access to care including overall cost, transportation, geographic barriers, distribution of providers and the willingness of providers to accept new Medicaid patients.  Medicaid reimbursement rates, which are generally lower than private insurance payments, may restrict the number of Medicaid enrollee's private practices accept. 

The rising population and demands for healthcare are outpacing the supply of primary care providers, creating an access to care crisis for Idaho. Despite the lower reimbursement potential, NPs are more likely to practice in the rural areas (Barnes et al., 2018, as cited in National Academy of Science, Engineering and Medicine, 2021, p. 116) and accept new Medicaid patients. Nurse practitioners are providing nearly half of the primary care in rural Idaho (Hudspeth, 2020). “Achieving better care, smarter spending and healthier people is dependent on the robust availability of primary care providers. Projections demonstrate the supply of NPs will outpace the growth of the primary care physicians” (US Department of Health and Human Services, 2016, p. 18).

According to the Robert Graham Center (2020), Idaho will need an additional 382 primary care providers by 2030, a 44% increase to meet the demands of population growth. Fortunately, Idaho has experienced a 29% growth rate of the overall statewide NP workforce in the past two years and importantly, the rural, medically underserved areas experienced a nearly 33% growth rate in primary care NPs between 2018 and 2020. It is imperative to provide adequate reimbursement to sustain and grow the primary care workforce. Excluding those few employed by Federally Qualified Health Centers (FQHCs), NPs in primary care settings have been reimbursed 15-30% less than physicians for the same billed services from state and federally funded Medicaid. Medicaid was signed into law in 1965 with federally funded Medicare under Title XIX of the Social Security Act. All states, the District of Columbia, and the U.S. territories have Medicaid programs designed to provide health coverage for low-income people (Idaho State Legislature, 2019). Although the federal government establishes certain parameters for all states to follow, each state uniquely administers the Medicaid program, resulting in variations in Medicaid coverage and reimbursement rates across the country.

Idaho statute 56-265 regulates that provider payments “may be up to but shall not exceed 100% of the current Medicare rate for primary care procedure codes as defined by the Center for Medicare and Medicaid (CMS) and shall be 90% of the current Medicare rate for all other procedure codes” (Idaho Legislature, 2021). Medicare reimburses NPs at 85% of the physician rate for primary care services and despite being a forerunner in NP practice laws, Idaho is one of just four states in the nation that continues to align Medicaid rates with this 86% Medicare rate limit. The Nurse Practitioners of Idaho (NPI) found that many primary care NPs are reimbursed up to 20% less for primary care services. This is in addition to the already discounted Medicare rate. Data analysis demonstrated that if rates were increased to 100% of the NP Medicare rate (an increase of 20%), a single NP practice would recognize over $8,000 in additional revenue annually. 

Concerns that increased reimbursement for NPs may drive up health care costs are 
not substantiated. Evidence supports NP cost effectiveness in all settings including primary care, acute care, and long-term care (American Association of Nurse Practitioners, 2013). NP led care reduces emergency room utilization, pharmacy 
cost, inpatient hospitalizations, and results in monthly cost savings (American Association of Nurse Practitioners, 2013.)

After several meetings with key stakeholders over the past two years, NPI has successfully negotiated a rate increase for NP primary care services! This 20% rate increase was recently proposed by the department of health and welfare in their annual budget. As of this writing, the rate increase has passed the Joint Finance-Appropriations Committee (JFAC) and is pending approval by the legislature. It is important to note that these rates are evaluated annually and dependent on budgetary constraints. NPI should continue lobbying efforts to ensure NPs are adequately reimbursed for their valuable services. The importance of membership is ever apparent. All NPs in Idaho should become members of NPI. It is vital to health equity that NPs remain engaged and responsive to legislation. These impactful changes, which improve reimbursement for every Idaho NP could not have been achieved without organization support and lobbying efforts. 


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