– Part 1 –
Under the terms of the Patient Protection and Affordable Care Act (ACA), Medicaid payment rates were to be increased to (at least) match Medicare reimbursement rates for primary care and immunization services provided in 2013 and 2014. For 2013, this increase was projected to reach 73%.
This initiative, referred to as the Medicaid Primary Care Rate Increase (PCRI), was envisioned as an incentive to bring new physicians into the Medicaid fold and to provide greater support for those already participating in the program.
To qualify for this increase, physicians are required to self-attest that they are board certified in at least one of 146 specific primary care specialties (e.g. family medicine), or demonstrate that at least 60 percent of the evaluation and management codes they submit to Medicaid are for primary care services.
How many states are participating in Primary Care Rate Increase?
A study by the American Academy of Family Physicians (AAFP) finds that, as of November 2013, “most states have started paying Medicaid primary care physicians at the enhanced rates, at least in Medicaid fee-for-service programs. But there are at least seven states in which implementation has begun for fee-for-service Medicaid, but not managed care Medicaid programs, and another seven where no payments have been reported.”
Which Medicaid providers qualify for Primary Care Rate Increase?
www.healthcare.gov has published the following guidelines regarding eligibility for the Medicaid Primary Care Rate Increase:
The statute specifies that higher payment applies to primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. The regulation specifies that specialists and subspecialists within those designations as recognized by the American Board of Medical Specialties (ABMS) the American Osteopathic Association (AOA) or the American Board of Physician Specialties (ABPS) also qualify for the enhanced payment. Under the regulation, “general internal medicine” encompasses internal medicine and all subspecialties recognized by the ABMS, ABPS and AOA.
In order to be eligible for Primary Care Rate Increase:
- Physicians must first self-attest to a covered specialty or subspecialty designation.
- As part of that attestation they must specify that they either are board certified in an eligible specialty or subspecialty and/or that 60 percent of their Medicaid claims for the prior year were for the E&M codes specified in the regulation. It is quite possible that physicians could qualify on the basis of both board certification and claims history.
Only physicians who can legitimately self-attest to a specialty designation of (general) internal medicine, family medicine or pediatric medicine or a subspecialty within those specialties recognized by the American Board of Physician Specialties (ABPS), American Osteopathic Association (AOA) or American Board of Physician Specialties (ABPS) qualify.
It is possible that a physician might maintain a particular qualifying board certification but might actually practice in a different field. A physician who maintains one of the eligible certificates, but actually practices in a non-eligible specialty should not self-attest to eligibility for higher payment. Similarly, a physician board certified in a non-eligible specialty (for example, surgery or dermatology) who practices within the community as, for example, a family practitioner could self-attest to a specialty designation of family medicine, internal medicine or pediatric medicine and a supporting 60% claims history. In either case, should the validity of that physician’s self-attestation be reviewed by the state as part of the annual statistical sample, the physician’s payments would be at risk if the agency finds that the attestation was not accurate.
Does higher Primary Care Rate Increase apply to CHIP?
The primary care provider rate increase does apply to Children’s Health Insurance Program (CHIP) Medicaid expansions but not separate (stand-alone) CHIPs. Qualified physicians who render the primary care services and vaccine administration services specified in the regulation will receive the benefit of higher payment for services provided to these Medicaid beneficiaries.
The State will receive 100 percent federal matching funds for the difference between the rate in effect 7/1/09 and the rate in CYs 2013 and 2014. The remainder of the payment will be funded at the CHIP matching rate, through the CHIP allotment. Services provided under separate (stand-alone) CHIPs are not eligible for higher payment.
End of Part 1
This concludes Part 1 of the 4-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.