Nurse Practitioners Could See Monthly Medicare Payments Under ‘Pay PCPs Act’

Senators Sheldon Whitehouse (D-RI) and Bill Cassidy (R-LA) announced on September 9 that they have reintroduced the Pay PCPs Act, a bipartisan bill that would appropriate $10 billion for a new Medicare payment model that pays primary care providers, including nurse practitioners, a monthly rate per patient instead of relying entirely on per-visit billing. The model would be optional: the bill authorizes CMS to establish it rather than requiring it, and no provider would have to participate. The American Association of Nurse Practitioners is among the groups endorsing the bill.

The senators formally introduced the legislation, S. 5269, on August 5. It is a new version of a bill the same pair first introduced in 2024, which did not advance out of committee.

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The bill would allow the Centers for Medicare and Medicaid Services to create a hybrid payment option within the Medicare physician fee schedule. Providers who opted in could receive:

• A set monthly payment per patient, paid up front for each Medicare patient assigned to the provider. CMS could fold into the monthly rate the communications work that rarely gets billed today, such as emails, phone calls, and patient portal messages, along with care management, behavioral health integration, and office visits whether in person or virtual.
• Fee-for-service payments, which CMS could continue for services outside the monthly rate. The bill requires that screenings, vaccinations, annual wellness visits, and other listed preventive services continue to be billed and paid separately.

According to the bill text, the monthly payment could represent between 40% and 70% of a provider’s expected annual total allowed charges under the physician fee schedule, and it should exceed what fee-for-service would have paid for the services moved into the monthly rate.

The bill would also authorize CMS to cut Medicare patients’ cost sharing in half for primary care services reimbursed through the hybrid payment model, as long as the patient designates that provider as their usual source of care.

Providers receiving hybrid payments would be excluded from the Merit-based Incentive Payment System, or MIPS. The bill separately lets CMS attach its own quality measures to the model, covering areas like patient experience and emergency department visit rates, and reward high performance through annual bonus payments.

The bill defines primary care provider as either a physician or one of Medicare’s listed practitioners, in each case only when they furnish primary care services. The practitioner list includes nurse practitioners, clinical nurse specialists, and certified nurse-midwives. The bill’s findings also name nurse practitioners specifically, stating that fee-for-service is poorly suited to supporting team-based care that leverages clinicians such as NPs, physician assistants, nutritionists, and pharmacists.

The bill does not change Medicare’s standard reimbursement rate for nurse practitioners, who are generally paid 85% of the physician fee schedule amount when billing under their own provider number.

“The American Association of Nurse Practitioners, on behalf of more than 461,000 nurse practitioners nationwide, commends Senators Whitehouse and Cassidy for the introduction of the Pay PCPs Act. This bill would lead to long overdue reforms in how we value and pay for primary care, and remove barriers to access for patients and clinicians alike. Nurse practitioners are critical to ensuring patients have access to high-quality primary care, and we look forward to partnering to improve primary care delivery across the country,” said AANP President Valerie J. Fuller, PhD, DNP, in the senators’ announcement.

The bill would establish a 13-member technical advisory committee within CMS to advise the agency on how it determines relative value units, the building blocks of physician fee schedule payment. The committee could design new ways to value services, recommend changes to how individual billing codes are valued, and evaluate whether related codes should be collapsed into fewer payment categories. It would terminate no later than five years after it is established. Nurse practitioners would be eligible to serve on it.

The committee would weigh in on how Medicare decides what each service is worth. Today, CMS sets those values, and it has historically relied on survey data and recommendations from the Relative Value Scale Update Committee, or RUC, a committee convened by the American Medical Association. CMS makes the final decisions.

The bill’s sponsors argue that process serves primary care poorly. The findings section says valuation starts with subjective, survey-based estimates of how much clinician time each service takes, calls that approach a poor fit for the comprehensive and continuous nature of primary care, and says the fee schedule’s more than 8,000 billing codes risk inaccuracy and let pricing distortions build over time.

Betty Rambur, professor of nursing at the University of Rhode Island and a former vice chair of the Medicare Payment Advisory Commission, argued during Nurse.org’s September 9 “Who Owns the Language of Healthcare Payment” LinkedIn Live that responsibility for valuing services should sit with a body independent of those being paid. “It needs to be an independent group whose responsibility is to taxpayers, to patients,” Rambur said. “That is where it needs to rest.”

The American Hospital Association defended the existing process in its 2024 comment letter on the earlier version of the bill, calling the RUC a robust process already in place, noting that the proposed committee’s membership does not appear to include participants in that process, and arguing the new committee should be synchronized with the existing infrastructure rather than run alongside it.

Separately, CMS asked for public input in its proposed rule for the 2027 physician fee schedule, published in July, on possible alternatives to the current CPT coding and RUC valuation processes. Comments on the rule are due September 14, and any nurse can submit one.

Support and Criticism

In addition to AANP, the bill is endorsed by the American Academy of Family Physicians, Families USA, the American College of Lifestyle Medicine, and the Primary Care Collaborative.

“Primary care providers know their patients and what they need to stay healthy. The Pay PCPs Act would allow providers to finally step off the fee-for-service treadmill and get paid fairly for their work,” Whitehouse said in the announcement.

Not every group backed the earlier version. Responding to the 2024 bill, the AHA warned that the hybrid structure could result in payment cuts for some providers, arguing that physician reimbursement already fails to keep pace with inflation. The letter was not uniformly critical, and it supported the bill’s cost-sharing reduction for patients.

The 2026 version addresses part of that concern. It drops 2024 language that allowed reduced fee-for-service payments for services outside the monthly rate, requires the listed preventive services to remain separately payable, and exempts the $10 billion from the fee schedule’s budget-neutrality rules, meaning the new payments would not trigger offsetting cuts to other services.

The bill has been referred to the Senate Finance Committee, where the 2024 version stalled. As of publication, no hearing or markup has been scheduled, and no further action is recorded beyond the August 5 referral.

The window is narrow. The current Congress ends in early January, and any bill not passed by then dies and must be reintroduced, which is how the 2024 version became the 2026 version. The signals worth watching are whether the Finance Committee schedules a hearing, whether senators beyond the two sponsors sign on, and whether a companion bill appears in the House.

Whatever happens in committee, one thing is already on paper: when two senators drew up a Medicare payment model built around primary care, nurse practitioners were written into it.

🤔 If you work in primary care, would a monthly per-patient payment change how you spend your time with patients? Share your thoughts in the comments below.