– Part 2 –

Medicaid Primary Care Rate IncreaseThe Affordable Care Act specifies increased payments for three primary care medical specialties as they relate to Medicaid’s Primary Care Rate Increase: Family Medicine, General Internal Medicine and Pediatrics. The Final Rule interprets this language to include some subspecialties with a relation to the original three, but does not list the subspecialties.

Subspecialists that qualify for higher payment in accordance with the Primary Care Rate Increase are those recognized by the American Board of Medical Specialties (ABMS), American Board of Physician Specialties (ABPS) or American Osteopathic Association (AOA). For purposes of the rule, “General Internal Medicine” encompasses “Internal Medicine” and all recognized subspecialties. The websites of these organizations currently list the following subspecialty certifications within each specialty designation:


  • Family Medicine – Adolescent Medicine; Geriatric Medicine; Hospice and Palliative Medicine; Sleep Medicine; Sports Medicine
  • Internal Medicine – Adolescent Medicine; Advanced Heart Failure and Transplant Cardiology; Cardiovascular Disease; Clinical Cardiac Electrophysiology; Critical Care Medicine; Endocrinology, Diabetes and Metabolism; Gastroenterology; Geriatric Medicine; Hematology; Hospice and Palliative Medicine; Infectious Disease; Interventional Cardiology; Medical Oncology; Nephrology; Pulmonary Disease; Rheumatology; Sleep Medicine; Sports Medicine; Transplant Hepatology
  • Pediatrics – Adolescent Medicine; Child Abuse Pediatrics; Developmental-Behavioral Pediatrics; Hospice and Palliative Medicine; Medical Toxicology; Neonatal-Perinatal Medicine; Neurodevelopmental Disabilities, Pediatric Cardiology; Pediatric Critical Care Medicine; Pediatric Emergency Medicine; Pediatric Endocrinology; Pediatric Gastroenterology; Pediatric Hematology-Oncology; Pediatric Infectious Diseases; Pediatric Nephrology; Pediatric Pulmonology; Pediatric Rheumatology, Pediatric Transplant Hepatology; Sleep Medicine; Sports Medicine


  • Family Physicians – No subspecialties
  • Internal Medicine – Allergy/Immunology; Cardiology; Endocrinology; Gastroenterology; Hematology; Hematology/Oncology; Infectious Disease; Pulmonary Diseases; Nephrology; Oncology; Rheumatology.
  • Pediatrics – Adolescent and Young Adult Medicine, Neonatology, Pediatric Allergy/Immunology, Pediatric Endocrinology, Pediatric Pulmonology


The ABPS does not certify subspecialists. Therefore, eligible certifications are:

  • American Board of Family Medicine Obstetrics
  • Board of Certification in Family Practice
  • Board of Certification in Internal Medicine

There is no board certification specific to Pediatrics.

The preamble of the final rule for Primary Care Rate Increase makes it clear that salaried eligible physicians employed by counties must receive the higher payment for eligible E&M and vaccine services. Does this same logic apply to physicians employed by hospitals and, if so, is it CMS’s expectation that the Medicaid agency will assure that the salaries of those physicians are increased?

Physicians employed by hospitals whose services are reimbursed by Medicaid on a physician fee schedule must receive the benefit of Primary Care Rate Increase. It is the Medicaid agency’s responsibility to ensure that hospitals receiving payments on behalf of those physicians comply with all requirements of the program. While hospitals could increase salaries they could also provide additional/bonus payments to eligible physicians to ensure that they receive the benefit of higher Medicaid payment.

The final rule for Primary Care Rate Increase clarifies that the 60 percent threshold for eligibility is based on services billed. Are billed services to be defined based on the number of units submitted or dollars?

The 60 percent threshold is based on the number of billed services as identified by individual billing codes for the primary specialty being asserted. That is, the numerator equals total billed codes for E&M services for the primary specialty, plus vaccine administration services, and the denominator equals the total number of billed codes. Please note that a state may choose to use paid billing codes/services in place of billed codes.

Does a physician have to self-attest in 2014 as well as 2013? The Primary Care Rate Increase rule does not indicate that the physician has to self-attest a second time and we don’t want to do that, but some who qualified in 2013 (based on 2012 claims history) may not qualify in 2014 (based on 2013 claims history).

The rule does not require the physician to submit a new self-attestation in 2014 although states could impose such a requirement. States can rely on the initial self-attestation for purposes of 2014 payments since we would not expect provider practices to vary significantly from year to year.

How should a physician who is certified in internal medicine, family practice or pediatrics by a Board other than the ABMS, the AOA or the ABPS self-attest?

Such a physician would self-attest to a primary specialty designation of family medicine, pediatric medicine or internal medicine and would then attest to, and qualify based on, a 60 percent claims history.

End of Part 2

This concludes Part 2 of the 2-part series, What You Should Know About the Medicaid Primary Care Rate Increase (PCRI). If you’d like to learn more about increasing Medicaid payments, contact the experts at BHM Healthcare Solutions today.

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