Improved Medicaid Payment for Primary Care

Distributed by Heath magazine in Spanish

Outline

CMS is releasing a projected procedure to implement a provision of the Affordable Care Act, as contained in section 1202 of the Health Care and Education Reconciliation Act of 2010, that offers increased expenses for specific Medicaid primary care professional services. Under this provision, some specific health professionals that provide allowed primary care assistance would be remunerated the Medicare rates in effect in calendar years (CY) 2013 in addition to 2014 (or if greater, the Medicare rate in place in 2009) as an alternative to their conventional state-established Medicaid rates, which may be less than federally developed Medicare charges. Enhanced fees applies to primary care expert services provided by a specialist with a specialty designation of family medicine, general internal medicine, or pediatric medicine as well as pertaining subspecialists. States can get 100 percent Federal financial participation (FFP) for the difference between the Medicaid State program payment amount as of July 1, 2009 together with the official Medicare rate. The increase refers to a specific group of services and types of procedures that CMS designates as “primary care services”.

The particular concept provides you with info about just how CMS and States will attempt to work as a group to make the improved payments in place. The guidelines contain data about the classification of eligible providers and services and how to satisfy the statutory prerequisites when making such payments for expert services provided through managed care. The guidelines also has information about how this plan is good for the Vaccines for Children (VFC) program, which contains its own statutory details for billing as well as payment.

Qualifying Suppliers

Under the Affordable Care Act, primary care services qualified to apply for the higher payment may be offered by a health care provider who specializes in family medicine, general internal medicine, or pediatric medicine. In the projected guideline, we specify that subspecialists associated with these primary care specialists are entitled to the improved payment. We as well clarify that services needs to be offered under the Medicaid healthcare practitioner services benefit. What this means is larger payment would be specifically for primary care services offered by practitioners-including, for instance, nurse practitioners-working under the authority of the qualified practitioner and billing under that physician’s Medicaid provider number.

putting into practice the Increased Payments in Fee for Service and Managed Care

The projected practice allows States two solutions: (1) “lock” rates at the standard of the Medicare physician service fee schedule effectively early in 2013 and 2014; or (2) modify the rates in conjunction with all changes made by Medicare. The rule provides that most of the details associated with the improved payments apply to products and services remunerated by Medicaid managed care plans. We recommend that States implement the improved payment into agreements with such entities.

Interaction with the Vaccines for Children Program

The procedure proposes payment of vaccine administration expenses under the VFC program at the smaller of the VFC regional highest administration fee (the VFC “ceiling”) or the Medicare charges in 2013 and 2014, whichever cost is least expensive. This is consistent with VFC plan specifications which restrict payments to the VFC ceiling, that is certainly the total billed by the provider, and to one payment per vaccine administered. Due to the fact the VFC ceiling rates were given on an interim basis in 1994 and have never been kept up to date, we are recommending to update these rates by rising them as mentioned by the Medicare Economic Index (MEI), which is a measure of medical practice cost inflation.

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