Virginia Medicaid Managed Care Reimburses Preventive Visits 25% Below Medicare Advantage

The JAMA Health Forum study used Transparency in Coverage data and Virginia claims to compare payments across fee-for-service Medicaid, managed care, Medicare Advantage, employer-sponsored, and marketplace plans for the same preventive services. Both Medicaid forms paid less, with managed care at $96.22 versus $90.86 for traditional Medicaid, establishing that private Medicaid plans track state-set rates rather than broader market levels. This pattern holds for multiple visit types examined. Prior analyses focused mainly on fee-for-service, missing how managed care—which covers 85% of national Medicaid enrollees—actually performs. The findings indicate lower rates may reduce physician participation and patient access, consistent with earlier observational work linking reimbursement gaps to narrower provider networks.

Context from related research shows similar disparities in other states, where Medicaid rates anchor below Medicare and commercial benchmarks, amplifying barriers in preventive services that rely on consistent primary care contact. The study highlights Virginia’s traditional rates as a potential lever for managed care adjustments, yet notes that without targeted increases, access inequities could widen as enrollment grows. Policy observers note that states using these data for rate-setting may face trade-offs between budget constraints and network adequacy requirements.

Next steps include multi-state replications using the same claims approach to test generalizability, plus longitudinal tracking of whether rate changes alter physician participation or preventive care utilization rates within two years. Regulators should monitor whether managed care plans adjust payments following any state fee-for-service updates.