Tuesday, September 22, 2015

Introduction to Enhanced Primary Care Payment Program

The Affordable Care Act (ACA) requires that Medicaid reimburse eligible primary care providers at parity with Medicare rates in 2013 and 2014 for certain evaluation and management (E&M) and vaccination codes beginning with January 1, 2013 dates of service (42 CFR 447.400(a)). This document is intended to provide information to providers who wish to participate in the enhanced primary care payment program.

Prior to receiving the enhanced rate, eligible physicians and advanced practice registered nurses (APRNs) must self-attest. Physician assistants (PAs) are not required to complete a self-attestation form, but instead should be listed in the appropriate section of their supervising physician’s self-attestation form. Eligible services provided by all advanced practice clinicians providing services within their state scope of practice under the supervision of an eligible physician will be eligible for higher payment. APRNs must attest that they are under the supervision of, or in a collaborative relationship with, a physician who has self-attested and qualifies for the enhanced rates.

Physicians must first attest to a specialty designation of family medicine, general internal medicine, pediatric medicine, or subspecialties as defined by the following recognized boards: the American Board of Physician Specialties (ABPS), the American Osteopathic Association (AOA), or the American Board of Medical Specialties (ABMS).

Physicians who self-attest to one of the eligible specialties or related subspecialties must then attest that:

 They are Board-certified in the specialty or subspecialty to which they attest; or

 At least 60 percent of all the provider’s billed codes, in the most recently completed calendar year, were billed for qualifying evaluation and management (E&M) and/or qualifying vaccine administration codes, as specified in the federal rule.

o If a provider has not yet participated in the Medicaid program for a full calendar year, they can attest that 60 percent of the Medicaid claims billed in the previous 30 day period were for E&M and/or vaccine administration codes that are eligible for the enhanced payment.

APRNs must attest that they are under the supervision of, or have a collaborative relationship with, a qualifying physician.

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