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The Affordable Care Act (ACA) called for enhanced payment provisions for physicians providing specified Medicaid primary care services. This is quite a breakthrough as payments for Medicaid services have, until now, been less than those for Medicare. It is also expected that this provision will improve patient access to Medicaid services by encouraging more physicians and providers to participate in the Medicaid program.

On May 9, 2013, the Centers for Medicare and Medicaid Services (CMS) published a final rule that made Medicaid enrollees eligible for higher payments for specific primary care services as well as for vaccine administration under the Vaccines for Children program. The payment increases also applies for services provided to persons enrolled in Medicaid managed care plans. Payments for these Medicaid programs will now be on par with Medicare payment levels for the same type of services for 2013 and 2014. The CPT® codes affected include evaluation and management (E/M) codes 99201-99499, and vaccine administration codes 90460, 90461, 90471, 90472, 90473, and 90474.
The provision covers:

  • 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 who self-attest that they are board certified and are associated with specialty categories accepted by the American Board of Medical Specialties, American Osteopathic Association, or the American Board of Physician Specialties, 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.

Federally qualified health centers or rural health clinics are exempt from this rule.

CMS reports that as of July 1, Medicaid fee-for-service programs in several states such as Alabama, Arkansas, Florida, Kansas, Massachusetts, Maryland, Maine, Michigan, Missouri, Montana, Pennsylvania, Vermont and Wyoming, had rolled out the temporary payment increase. Medicaid programs in the rest of the states are expected to implement this provision in the coming weeks.

Proof of Physician Eligibility Necessary

Though the provision took effect on January 1, 2013, several factors delayed implementation. However, states will have to pay qualified physicians on a retroactive basis, starting January 1. Physicians who wish to be paid will have to prove their eligibility by the specified date which varies by state. To prove eligibility, physicians must self-attest that they are board-certified and/or have provided E/M services and vaccine administration, which has accounted for at least 60 percent of the codes that have been billed for their total Medicaid enrollees.

Implementation Issues

Medicaid’s top officials have pointed out that operational problems had delayed implementation. While the parity provision was enacted as a fee-for-service (FFS) payment mechanism, most state Medicaid programs provide primary care services in a managed care environment, thereby resulting in payment issues. With FFS, patients can see any physician they want, whenever necessary, but under managed care, payment is ensured only if the physician is affiliated with the plan. So shifting from the fee-for-service environment to managed care poses difficulties.

CMS had instructed the states to submit a state plan amendment (SPA) by March 31, on the way they proposed to implement the higher payment rates for Medicaid such as whether on a monthly or quarterly basis, and so on. Compared to strict fee-for-service, physicians in managed care networks will experience payment delays, say Medicaid officials as the procedure is lengthy and time consuming – the state has to amend the contract with the managed care company to include the increased rates after the SPA is approved by CMS.

Make this a Long Term Benefit, Say Physicians

Physicians who provide services for a large number of Medicaid patients would like to see this provision extended beyond 2014. They point out that their Medicaid patients. Will continue to need their services in the long-term too, and that these patients have greater healthcare needs than the rest of the population. In fact, if the government wants to encourage physicians to take on new Medicaid patients, making the parity provision a long-term measure could be the answer.