Medicaid, Core Principles

The AAFP supports specifying the following principles regarding the Medicaid program:

• The federal share should be increased if Medicaid enrollment is increased by federal legislation;
• Payment for primary care services should be at least equal to Medicare's payment rate for those services when provided by a primary care physician;
• The patient-centered medical home model of care with appropriate payment for case management and chronic care coordination should be implemented broadly and should include collaboration between the physician's practice and Medicaid case management programs;
• A benefit profile should be required that includes first-dollar coverage of preventive services;
• Cost-containment should be determined by evidence-based research;
• Medicaid programs should use a clear definition of medical necessity that is based on evidence;
• Medicaid should support health information exchange through adequate infrastructure investment and electronic medical records by means of adequate payment for electronic visits and related services;
• Pay for performance and other quality improvement activities should be rooted in evidence-based research;
• Current pharmaceutical benefits for dual eligibles should be maintained if those benefits cover more drug costs than Medicare does;
• Coverage of tobacco cessation counseling, pharmaceuticals and other assistive methods should be included;
• Coverage should be mandatory for pharmaceuticals, counseling and treatment for substance abuse, and oral and mental health measures;
• Federal financial participation in territorial assistance programs should be equitable;
• Medicaid programs should provide continuous eligibility for at least twelve months; and
• A clearly defined appeals process should facilitate fair and prompt resolution of disputed claims and administrative issues, e.g., determinations of meaningful use and pay-for-performance decisions.

In addition, Medicaid Managed Care Organizations should be held accountable for:

• Adequacy of primary care and specialist networks (especially with regard to the number of available physicians and geographic availability).
• Assignment of beneficiaries to a primary care physician who is geographically proximate.
• Assurance of continuity of care for Medicaid patients from the primary care physicians of their choice.
• Beneficiaries’ access to all allowable and covered services under federal and state law.

Medicaid Section 1115 Demonstration Waivers that seek to change Medicaid benefits, financing and cost-sharing must:

1.  Maintain and/or strengthen affordability protections.
2.  Maintain/and or strengthen benefits.
3.  Limit barriers to eligibility and coverage.
4.  Maintain and/or strengthen access to any qualified provider.
5.  Preserve and enhance existing funding mechanisms.
6.  Sustain and strengthen waiver transparency, stakeholder engagement, and evaluation of waiver impact on enrollees, families, and providers.
   (2005) (2020 COD)