HHS has issued a proposed rule (pdf) in which primary care physicians serving Medicaid patients would see their Medicaid payments rise to Medicare levels.
States will receive a cumulative total of $11 billion in new funds for their Medicaid programs for this initiative, required under the Patient Protection and Affordable Care Act, and the increase in Medicaid payments for PCPs will only be in effect for 2013 and 2014.
Stephanie Kennan, senior vice president of McGuireWoods Consulting in Washington D.C., says the announcement works in conjunction with the PPACA provision that will expand Medicaid coverage to tens of millions of Americans in two years. "This [proposed rule] was a recognition that Congress needed to ensure primary care access in Medicaid, and reform puts more people in Medicaid beginning in 2014," Ms. Kennan says.
The proposed rule would also provide for a 100 percent federal matching rate for the difference between the state's Medicaid plan payment, with no matching payments required of states. "The real questions are: What happens when the federal match stops being 100 percent?" Ms. Kennan says. "Medicaid rates will likely fall again. So does Congress keep extending this or not? No one will know for a while."
HHS and CMS officials said the increased payments will hopefully spur PCPs to provide more preventive services and vaccines to Medicaid beneficiaries. "Promoting high-quality primary care is a pillar of the Affordable Care Act, and this proposed rule helps states and physicians provide every American, no matter where they live, access to the care they need to stay healthy," HHS Secretary Kathleen Sebelius said in a news release. "This new rule can help improve health and reduce costs by preventing illnesses before they happen and catching small problems before they turn into big ones."
Here are eight must-know points included in the proposed rule.
• In 2013, the federal cost will total $5.74 billion, and in 2014, the federal cost will equal $5.96 billion. Over those two years, states are expected to save $525 million. There will be a 100 percent federal matching rate, but the states will not have to match payments.
• The proposed rule also calls for an increase of the maximum rate states can pay providers for vaccines under the Vaccine for Children Program. The change is intended to increase states' vaccine administration rates.
• The increased Medicaid reimbursements will affect the following PCP specialties: family medicine, general internal medicine, pediatric medicine and related subspecialties recognized with the American Board of Medical Specialties designations. An example of a related subspecialty is, for example, a pediatric cardiologist who renders a specified primary care service within the qualifying specialty of internal medicine.
• For a physician to attest that he or she is an eligible primary care specialist or subspecialist but is not board-certified, at least 60 percent of the codes billed by that physician for all of calendar year 2012 must be for evaluation and management codes and vaccine administration codes.
• The requirement for payment at the Medicare rate extends to primary care services paid on a fee-for-service basis as well as those paid by Medicaid managed care plans.
• States have two options when it comes to the new Medicare levels for Medicaid-serving PCPs. They can either lock rates at the level of the Medicare physician fee schedule at the beginning of 2013 and 2014, or they can modify the rates in conjunction with all updates made by Medicare. The payment methodology will be independent of the Medicare sustainable growth rate.
• Increased payments for primary care services could also apply to services furnished "by or under the personal supervision" of a PCP. This would incorporate non-physician practitioners, such as nurse practitioners and physician assistants.
• There are some E/M codes that are not currently reimbursed by Medicare that would be covered under the proposed rule. They include "new patient/initial comprehensive preventive medicine — codes 99381 through 99387," "established patient/periodic comprehensive preventive medicine — codes 99391 through 99397," "counseling risk factor reduction and behavior change intervention — codes 99401 through 99404, 99408, 99408, 99411, 99412, 99420 and 99429" and "E/M/non-face-to-face physician service — codes 99441 through 99444."
Comments on the proposed rule are due June 11.
CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
States will receive a cumulative total of $11 billion in new funds for their Medicaid programs for this initiative, required under the Patient Protection and Affordable Care Act, and the increase in Medicaid payments for PCPs will only be in effect for 2013 and 2014.
Stephanie Kennan, senior vice president of McGuireWoods Consulting in Washington D.C., says the announcement works in conjunction with the PPACA provision that will expand Medicaid coverage to tens of millions of Americans in two years. "This [proposed rule] was a recognition that Congress needed to ensure primary care access in Medicaid, and reform puts more people in Medicaid beginning in 2014," Ms. Kennan says.
The proposed rule would also provide for a 100 percent federal matching rate for the difference between the state's Medicaid plan payment, with no matching payments required of states. "The real questions are: What happens when the federal match stops being 100 percent?" Ms. Kennan says. "Medicaid rates will likely fall again. So does Congress keep extending this or not? No one will know for a while."
HHS and CMS officials said the increased payments will hopefully spur PCPs to provide more preventive services and vaccines to Medicaid beneficiaries. "Promoting high-quality primary care is a pillar of the Affordable Care Act, and this proposed rule helps states and physicians provide every American, no matter where they live, access to the care they need to stay healthy," HHS Secretary Kathleen Sebelius said in a news release. "This new rule can help improve health and reduce costs by preventing illnesses before they happen and catching small problems before they turn into big ones."
Here are eight must-know points included in the proposed rule.
• In 2013, the federal cost will total $5.74 billion, and in 2014, the federal cost will equal $5.96 billion. Over those two years, states are expected to save $525 million. There will be a 100 percent federal matching rate, but the states will not have to match payments.
• The proposed rule also calls for an increase of the maximum rate states can pay providers for vaccines under the Vaccine for Children Program. The change is intended to increase states' vaccine administration rates.
• The increased Medicaid reimbursements will affect the following PCP specialties: family medicine, general internal medicine, pediatric medicine and related subspecialties recognized with the American Board of Medical Specialties designations. An example of a related subspecialty is, for example, a pediatric cardiologist who renders a specified primary care service within the qualifying specialty of internal medicine.
• For a physician to attest that he or she is an eligible primary care specialist or subspecialist but is not board-certified, at least 60 percent of the codes billed by that physician for all of calendar year 2012 must be for evaluation and management codes and vaccine administration codes.
• The requirement for payment at the Medicare rate extends to primary care services paid on a fee-for-service basis as well as those paid by Medicaid managed care plans.
• States have two options when it comes to the new Medicare levels for Medicaid-serving PCPs. They can either lock rates at the level of the Medicare physician fee schedule at the beginning of 2013 and 2014, or they can modify the rates in conjunction with all updates made by Medicare. The payment methodology will be independent of the Medicare sustainable growth rate.
• Increased payments for primary care services could also apply to services furnished "by or under the personal supervision" of a PCP. This would incorporate non-physician practitioners, such as nurse practitioners and physician assistants.
• There are some E/M codes that are not currently reimbursed by Medicare that would be covered under the proposed rule. They include "new patient/initial comprehensive preventive medicine — codes 99381 through 99387," "established patient/periodic comprehensive preventive medicine — codes 99391 through 99397," "counseling risk factor reduction and behavior change intervention — codes 99401 through 99404, 99408, 99408, 99411, 99412, 99420 and 99429" and "E/M/non-face-to-face physician service — codes 99441 through 99444."
Comments on the proposed rule are due June 11.
CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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