Virginia study finds Medicaid pays less for preventive visits

A George Mason University-led study published in JAMA Health Forum found that Virginia’s Medicaid programs paid less than Medicare, employer plans and marketplace coverage for routine preventive care. The results suggest state-set Medicaid rates may influence what managed care plans pay, affecting access for the state’s largest public insurance population.

Why it matters: - Virginia’s Medicaid payment levels can shape whether doctors participate in the program and how easily patients find preventive care. - The findings give states a clearer benchmark for comparing Medicaid rates with other insurers. - Because most Medicaid members are now in managed care, the study focuses on the part of the program that covers the largest share of enrollees.

What happened: - George Mason University professor Alison Cuellar led a Virginia study published in JAMA Health Forum comparing payment for the same routine preventive visits across insurance types. - The researchers compared two Medicaid models, fee-for-service and managed care, with Medicare, employer-sponsored insurance and marketplace plans. - The study found both forms of Medicaid paid substantially less than the other insurance types studied. - Medicaid managed care plans paid 25% less than Medicare plans and more than 40% less than marketplace plans.

The details: - For a routine preventive visit for an established patient ages 40 to 64, Medicaid managed care plans paid a median of $96.22. - Virginia’s traditional Medicaid program paid a median of $90.86 for the same visit. - Medicare Advantage, employer-sponsored plans and marketplace plans all paid significantly more. - The researchers reported similar pricing patterns for the other preventive visits they examined. - The study used Transparency in Coverage data and Virginia claims data to compare what insurers reimbursed for the same services. - About 85% of Medicaid members nationwide are enrolled in Medicaid managed care, where states contract with private health plans. - The research was supported by the Robert Wood Johnson Foundation’s Health Data for Action program. - Cuellar conducted the study with Meredith Young of the Virginia Center for Health Innovation and Jennifer Mellor of William & Mary.

Between the lines: - The study suggests Virginia’s traditional Medicaid payment rate may act as an anchor for Medicaid managed care payment levels. - If state-set rates change, managed care payments could also shift because private plans appear to key off the traditional rate. - The results also show why older studies that focused only on fee-for-service Medicaid may have understated the full payment picture.

What’s next: - States can use the findings to reassess whether Medicaid rates are low enough to affect provider participation. - Future rate changes in Virginia may have spillover effects on managed care payments, not just traditional Medicaid. - The comparison could help policymakers weigh payment policy against access to routine preventive care.

The bottom line: - Virginia Medicaid pays less for preventive visits than major private and public insurance alternatives, and that gap may matter for access to care.