WeVote
Log In

Bill

Bill

HB 2385

Concerning the medicaid access program.

2025-2026 Regular Session Introduced by Beth Doglio and 6 co-sponsors

HB 2385 creates the Medicaid Access Program to raise professional service rates to a share of 2024 Medicare, funded by annual carrier assessments and CMS-approved waivers.

Effective date 6/11/2026.
0
WeVote Research Nonpartisan
Bill Summary · HB 2385

Summary of HB 2385 (Session 2025-2026) — Washington: Medicaid Access Program

Purpose and Intent

  • Establishes the Medicaid Access Program (MAP) designed to increase professional services payments under Washington’s Apple Health (Medicaid) program.
  • By September 1, 2025, requires CMS approval of state plan amendments or waivers necessary to implement the MAP, including any needed waivers of federal broad-based or uniformity requirements.
  • Beginning in the plan year after CMS approval, the program aims to raise professional services rates paid by Medicaid (both fee-for-service and managed care) to levels uniformly tied to a percentage of corresponding Medicare rates as of December 31, 2024, with automatic annual inflation adjustments thereafter.
  • The overall framework includes funding mechanisms, provider payments, and reporting/oversight to support expanded access, including a school-based health services component.

Key Provisions and Changes

1) Federal Approval and Implementation

  • HCA must submit all necessary state plan amendments or waivers to CMS to enable the MAP.
  • If required, waivers of 1903(w)(3)(E) and related federal regulations may be pursued.

2) Rate Increases for Professional Services

  • Once CMS approves the MAP, the State will implement higher professional service rates (both fee-for-service and managed care) beginning in the second plan year after CMS approval.
  • Rates will be set as a uniform percentage increase over Medicare rates applicable as of December 31, 2024.
  • Annual inflation adjustments to the increased rates will apply in subsequent years.
  • Affected professional service categories include:
    • Anesthesia
    • Diagnostics
    • Intensive outpatient
    • Opioid treatment programs
    • Emergency room
    • Inpatient and outpatient surgery
    • Inpatient visits
    • Low-level behavioral health
    • Maternity services
    • Office and home visits
    • Consults
    • Office-administered drugs
    • Other physician services

3) Covered Lives Assessment

  • All health carriers and Medicaid MCOs must pay an annual Covered Lives Assessment starting the plan year after CMS approval.
  • The HCA will determine the number of covered lives per calendar year.
  • Initial year (first plan year after CMS approval) assessment caps:
    • Medicaid MCOs: up to $16 per covered life per month (per member per month, PMPM)
    • Health carriers (non-Medicaid): up to $0.50 per covered life per month (PMPM) assessed by the Office of the Insurance Commissioner (OIC)
  • In subsequent years, assessments increase as necessary to fund the rate increases and are capped to the first 2.3 million member-months per health carrier.
  • Funds go into the Medicaid Access Program Account (MAPA) and may be disbursed for:
    • Payments to health care providers and MCOs that align with federal contracting requirements
    • Nonfederal share of increased capitation payments to MCOs
    • Administrative costs of the MAP
    • Up to $2 million for expanding Medicaid access in schools (school-based health services, clinics, on-site behavioral health)
    • Studies on the impact of rate increases on Medicaid access
    • Up to $35 million in FY 2027 to be used in lieu of State General Fund from the MAPA
    • Refunds of erroneous or excessive payments to carriers/MCOs
    • Repayment to the federal government if excess payments occurred due to noncompliant assessments or increases
  • Mechanisms for recoupment:
    • Providers who receive excess payments may be required to refund amounts to the MAPA
    • If refunds cannot be provided, the state may establish payment plans or withhold future Medicaid payments
  • Fund disbursement is contingent upon:
    • Final CMS approval
    • Necessary contract amendments between HCA and MCOs
    • OFM certification that appropriations are available to fully fund the rate increases for the upcoming calendar year

Who Is Affected

  • State agencies: Health Care Authority (HCA) and Office of Financial Management (OFM)
  • Medicaid MCOs and other health carriers operating in Washington
  • Health care providers receiving Medicaid/Managed Care payments (including those in anesthesia, surgery, behavioral health, maternity, etc.)
  • School-based health services: potential expansion of services in schools
  • Beneficiaries: Washington Apple Health enrollees (various categories including families, children, low-income adults, certain disabled individuals, pregnant women) who would ultimately benefit from increased access to professional services

Procedural and Timeline Highlights

  • By September 1, 2025: HCA must submit CMS state plan amendments/waivers necessary to implement MAP.
  • Plan year 1 after CMS approval: Assessment caps set (first year) and MAPA funding framework established; initial implementation steps begin.
  • Plan year 2 after CMS approval: Full implementation of MAP’s rate increases to professional services, with annual inflation adjustments thereafter.
  • Fiscal notes: Up to $35 million in FY 2027 may be used in lieu of State General Fund from the MAPA; other allocations include school-based expansions and administrative costs.
  • Effective date: Chapter becomes law upon signing, with specific effective dates tied to CMS approval and plan year timelines (Chapter 153, 2026 Laws; effective 6/11/2026).

Summary

HB 2385 creates the Washington Medicaid Access Program to boost professional service reimbursement rates under Apple Health, aligning them with a percentage of Medicare rates and adjusted annually for inflation. It imposes annual covered lives assessments on Medicaid MCOs and health carriers to fund rate increases and program administration, with caps and use limitations designed to ensure federal compliance and targeted expansion (notably in school-based health services). The program requires CMS approval of state plan amendments/waivers and depends on contractual and budgetary readiness before implementation. The measures aim to expand access to care for Medicaid enrollees while providing a framework for accountability, refunds of improper payments, and potential shifts in school-based health services.

Compiled from official sources — confirm details with the bill’s official record.

Sign in to ask a question.