On November 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulation implementing Section 1202 of the Affordable Care Act, which increases Medicaid payments for specified primary care services to 100% of Medicare levels in 2013 and 2014. (Medicaid.gov)
What primary care services are eligible for Medicare rates?
E&M codes 99201 through 99499 and vaccine administration codes 90460, 90461, 90471, 90472, 90473 and 90474 (or successor codes, where applicable) are eligible for higher payment.
E&M codes not paid by Medicare are also included:
- New Patient/Initial Comprehensive Preventive Medicine—codes 99381 – 99387;
- Established Patient/Periodic Comprehensive Preventive Medicine—codes 99391 – 99397;
- Counseling Risk Factor Reduction and Behavior Change Intervention—codes 99401 – 99404, 99408, 99409, 99411, 99412, 99420 and 99429;
- E&M/Non Face-to-Face physician service—codes 99441 – 99444.
- NOTE: Services billed using local codes will be eligible for higher payment if the state Medicaid agency submits, as part of the required state plan amendment, a crosswalk of those codes to the specified E&M codes. Inclusion of a code on this list does not require a state to pay for the service if it is not already covered under the state’s Medicaid program; it only requires the state to pay for the service at the Medicare rate if covered. All other state coverage and payment policy rules related to the service also remain in effect.
How do I get the Medicare rate of payment for Medicaid services?
The final rule provides for higher payment in both the fee for service and managed care settings for specific primary care services furnished by:
- Practicing physicians who self-attest that they are board certified with a specialty designation of family medicine, general internal medicine and pediatric medicine, or
- Subspecialists related to those specialty categories as recognized by the American Board of Medical Specialties, American Osteopathic Association, or the American Board of Physician Specialties who also self-attest that they are board certified, or
- Physicians related to the specialty categories of family medicine, internal medicine and pediatrics who self-attest that at least 60 percent of all Medicaid services they bill or provide in a managed care environment are for the specified Evaluation & Management (E&M) and vaccine administration codes.
- Advanced practice clinicians when the services are furnished under a physician’s personal supervision.
- This increase is not limited to office based primary care services, but will also include hospital observation and consultation for inpatient services provided by non-admitting physicians, emergency department services, and critical care services.
- Eligible services provided by all advanced practice clinicians providing services within their state scope of practice will receive the higher payment. Non-physician practitioners may use their own Medicaid number when billing for these services, however, it requires that an eligible physician have professional oversight or responsibility for the services provided by the practitioners under his or her supervision. If the state reimburses for services rendered by supervised advanced practice clinicians at a percentage of the physician fee schedule rate, it will continue to do so in 2013 and 2014.
- NOTE: Higher payment is not available for physicians who are reimbursed through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) or health department/clinic encounter or visit rate or as part of a nursing facility per diem rate.
Will this payment come automatically or do providers have to sign up?
Check on your state’s provisions here or check with your State Medicaid Agency. State Medicaid agencies may pay physicians based on self-attestation alone or in conjunction with any other state level provider enrollment requirements that currently exist. However, if a state relies on self-attestation, it must annually review a statistically valid sample of physicians who have self-attested that they are eligible primary care physicians to ensure that the physician is either board certified in an eligible specialty or subspecialty or that 60 percent of claims are eligible codes.
Is this in effect already?
The statute requires that states make higher payments for services provided on or after January 1, 2013.
CMS policy dictates that federal financial participation (FFP) is not available for services provided pursuant to an unapproved State Plan Amendment (SPA) and states have until March 31, 2013 to submit a SPA that is effective on January 1, 2013.
Therefore, states can either make the higher payments to physicians or wait to submit claims for FFP until the SPA is approved. If a state chooses to wait, it can pay physicians at the 2012 Medicaid state plan rates and make supplemental payments once the SPA is approved.
Theoretically, this means that a state could delay action until March 31 before submitting a SPA to CMS. CMS may then take another 90 days to review and approve the SPA, which means could be six months or longer before eligible physicians and practitioners receive the higher payments. CMS is requiring states to make the higher payments as either add-ons to existing rates or as lump sum payments. To ensure that physicians receive the benefit of higher payments in a timely manner, the final rule indicates that “lump sum payments should be made no less frequently than quarterly”.
What will the increase in payment equate to?
Though the pay increase will vary because Medicaid rates differ from state to state, the average pay increase will be about 73 percent given Medicare last year paid on average 66 percent of what Medicare pays for certain primary care services,according to a Henry J. Kaiser Family Foundationstudy. Doctors in some states could see payment increases of 100 percent or more. (Forbes)
