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Budget restores Medicaid rates
Hill Jack
Sen. Jack Hill

When the Patient Protection and Affordable Care Act (PPACA) was signed into law in 2010 by President Obama, it included many provisions to expand Medicaid services. Medicaid is a jointly-funded program between states and the federal government that provides health care for low-income children and pregnant women, the elderly, and the disabled.

One of the most controversial pieces of the law required that every state expand Medicaid services to those who were previously ineligible, which includes individuals between the ages of 19 and 64 with incomes of up to 138 percent of the federal poverty level (FPL). In a 2012 decision by the Supreme Court in the case National Federation of Independent Business (NFIB) v. Sebelius, the mandatory expansion of Medicaid was ruled unconstitutional.

The Supreme Court reasoned that Medicaid expansion was an “unconstitutional coercion” because the original intent of the law was to claw back existing Medicaid funds from states that chose not to expand Medicaid. While mandatory Medicaid expansion was ruled unconstitutional, it still remains an option for states that choose to do so.

Supposedly to alleviate the strain placed on primary care physicians created by expansion, the federal government funded Medicaid reimbursement increases for two years starting January 1, 2013, whether or not the physician practiced in an expanded Medicaid state. The PPACA required that state Medicaid agencies reimburse primary care physicians at 100 percent of the 2012 Medicare reimbursement rate schedule.

Prior to the increase, primary care rates had not been updated since 2004, and Medicaid only reimbursed physicians at 84.65 percent of the 2000 Medicare rate schedule.

While Medicare reimbursement rates are significantly higher than normal Medicaid reimbursement rates, they are still much lower than private insurance reimbursement rates. With the reimbursement bump instituted by the PPACA, primary care physicians across the state found they were able to treat their existing Medicaid patients and take on new patients. Two positive effects of the increased delivery of Medicaid-provided care in this state were primary care physicians taking on additional Medicaid patients and some doctors started growing their practices by hiring nurse practitioners to help with the increased workload. Physicians were able to see their patients more frequently, which resulted in stronger managed care and decreased office visits in the future. Prior to the PPACA increase, reimbursement rates had not increased since 2003 and put some physicians who accepted Medicaid patients at risk.

Increased reimbursement and the 2015 Legislative session

According to Georgia’s Department of Community Health, there are 1.7 million Georgians enrolled in Medicaid, and over 160,000 enrolled in PeachCare for Kids, which provides low-cost insurance for children under 18. Physicians, treating Medicaid patients, had expressed concern that the low, outdated reimbursement rate they receive for treating these patients makes it hard to maintain their businesses. Some doctors have ceased accepting Medicaid patients or had to move or relocate their practices, leaving substantial areas of the state, especially rural, without primary health care or obstetrics and gynecology (OB/GYN) services. This issue is even more widespread with regard to OB care.

According to the Georgia Board for Physician Workforce, there are currently 38 counties with no OB services at all, which can lead to long travel times for pregnant, at-risk women. However, in both cases, lack of primary care and OB physicians can lead to expensive, unnecessary emergency room visits.

The General Assembly added funds in this year’s legislative session to continue increased reimbursement rates for primary care physicians, and extended the rate increase to OB/GYNs as well. The Medicaid payment and reimbursement process is made less complicated through assignment of codes for services offered through the program.

In a joint effort between the House and the Senate, $23.1 million in state funds was added to bring both OB/GYN reimbursement equal to 2014 Medicare rates and bring primary care reimbursement to 90 percent of the 2014 Medicare rates for certain codes. DCH stated that the codes will include common office visits, such as well child and preventative care visits.

Funds for primary care and OB/GYN physicians are necessary for the simple fact that the state of Georgia has a significant Medicaid population. Reimbursement rates can, and do, have a direct impact on the physician’s decision to take on Medicaid patients. It is important we recognize the value these physicians bring to health care in our state and provide assistance where possible.

Legislation and final action may be accessed online at and the state budget can be accessed online at the senate budget and evaluation Web site:

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