Benchmarking Preventive Care Medicaid Rates to Private Payers

Abstract

This cross-sectional study used Current Procedural Terminology codes and 2023 claims data to compare preventive care rates across Medicaid managed care organizations and employer-sponsored, Marketplace, and Medicare Advantage plans in Virginia.

Introduction

US states have struggled to expand access to primary care for Medicaid members, and the conventional wisdom is that low reimbursement rates are a deterrent to clinician participation.¹ To date, studies of Medicaid payment rates have focused on fee-for-service (FFS) rates, even though 85% of Medicaid members have managed care coverage.¹ Moreover, states’ ability to evaluate the adequacy of their rates is constrained by limited information on other payers. To address these gaps, this study compared preventive care rates across Medicaid FFS, Medicaid managed care organizations (MCOs), employer-sponsored insurance (ESI) and Affordable Care Act Marketplace plans, and Medicare Advantage (MA) plans in Virginia.

Methods

This cross-sectional study was deemed exempt from review and informed consent by the George Mason University Institutional Review Board owing to the use of deidentified data. We followed the STROBE reporting guideline.

This analysis builds on prior studies examining variation in reimbursement using Transparency-in-Coverage (TiC) data.² We focused on periodic preventive visits for new and established adult patients (aged 18-65 years) using Current Procedural Terminology (CPT) codes 99385, 99386, 99395, and 99396 (eMethods in Supplement 1). We used 2023 to 2024 nonfacility physician rates in TiC data from the Mathematica PricePrism database, the Virginia All-Payer Claims Database (APCD), and the Virginia Medicaid Fee Schedule.³ Because the Mathematica-processed TiC file provided the median CPT code–specific payment rate at the level of the tax identification number (TIN), Core-Based Statistical Area (CBSA), individual payer (ie, a specific health plan), and plan category (ie, ESI or Marketplace), we similarly aggregated APCD 2023 claims to the same level. To remove so-called ghost rates from the TiC data, we limited our analysis of ESI and Marketplace plan rates to TINs with at least 1 commercial claim in a given CBSA as reported in the APCD for the selected group of 4 CPT codes.⁴ Due to differences across datasets for individually billing clinicians, we limited our analysis to employer identification numbers or employer TINs only.

For each procedure, we grouped rates at the TIN-CBSA level paid by individual payers in TiC and APCD data into 4 plan categories: ESI, Marketplace, Medicaid MCO, and MA. We constructed box plots of each rate distribution. We tested for statistically significant differences between mean rates in each category and the published Medicaid FFS rate using α = .05. We examined geographic variation in rates after controlling for differences in individual payer composition across CBSAs.

Two-tailed P < .05 was considered significant. Analyses were completed using Stata, version 18 (StataCorp LLC).

Results

Using 2023 data for Virginia, we observed the most preventive care rates for CPT code 99396 (established patient, aged 40-64 years), including 3655 ESI, 3039 Marketplace, 1097 MA, and 1824 Medicaid MCO rates. For CPT code 99396, Medicaid FFS published a single, statewide rate of $90.86. Median (IQR) rates were $122.90 ($113.16-$148.22) for ESI, $137.61 ($110.36-$182.61) for Marketplace, $120.36 ($120.36-$120.37) for MA, and $96.22 ($93.42-$99.87) for Medicaid MCOs, with wider IQRs observed for ESI and Marketplace rates (Figure 1). We observed a similar rate pattern for the other procedural codes.

Figure 1. Box Plots of 2023 Physician Preventive Care Rates in Virginia, by Insurance Plan Category and Current Procedural Terminology (CPT) Code.

Rates represent medians (IQRs), calculated at the tax identification number–Core-Based Statistical Area level within individual payers; error bars represent 95% CIs. Dashed lines represent the respective Virginia Medicaid Fee Schedule rates. ESI indicates employer-sponsored insurance; MA, Medicare Advantage; MCO, managed care organization.

Compared with the Medicaid FFS rate for CPT code 99396, Marketplace payers reported the highest rates, paying an average of $63.34 (69.7%) more (P < .001). ESI plans paid an average of $56.52 (62.2%) more than Medicaid FFS; MA plans paid $30.58 (33.7%) more, while Medicaid MCOs paid $23.46 (25.8%) more (all P < .001).

Figure 2 shows geographic variation in adjusted rates for CPT code 99396. While Medicaid MCOs had the least variation across CBSAs (range, $107.73-$118.09), adjusted ESI rates showed the greatest variation across CBSAs (range, $131.96-$163.38). Rates in Marketplace and Medicaid plans were higher in northern Virginia compared with the rest of the state, similar to the Medicare Fee Schedule Geographic Practice Cost Index as applied in Virginia.³

Figure 2. Map of Variation in 2023 Physician Preventive Care Rates in Virginia Across Core-Based Statistical Areas, by Insurance Plan Category (for Current Procedural Terminology Code 99396).

MCO indicates managed care organization.

Discussion

This study provides state-specific information on how Medicaid reimbursement for preventive care compared with other payers in Virginia in 2023. In contrast with previous studies, we combined TiC data with paid claims data to remove many ghost rates and make more accurate comparisons across payers.

On average, Medicaid MCOs reimbursed preventive care services at higher rates than Medicaid FFS, although there was evidence of rate variation across Medicaid plans and geographic areas. In addition, both ESI and Marketplace plans had reimbursement rates well above Medicaid MCOs and even MA payers, with Marketplace reporting the highest mean rates.

This study has some limitations. First, our analysis was limited to data for a single state (Virginia). Second, although the TiC data underwent an extensive cleaning process to remove redundant rates, the process of assigning rates to CBSAs could introduce some error. Third, our analysis was limited to rates paid to employer TINs; however, most primary care delivery in Virginia occurs in groups.⁵

In this cross-sectional study, ESI plans had the greatest geographic variation. Medicaid MCOs varied little across CBSAs, consistent with the Virginia Medicaid Fee Schedule. These differences highlight persistent payment disparities that may limit clinician participation and access to preventive care for Medicaid enrollees. Furthermore, incremental changes to Medicaid FFS rates, which appear to anchor Medicaid MCO rates, may have potential spillover effects.

Supplement 1.

eMethods

Supplement 2.

Data Sharing Statement