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Payments for Primary Care Physician Services - Status Update

Friday, December 28, 2012

Payments for Primary Care Physician Services - Status Update

Rates will be set at 100% of the Medicare rates in effect for CY 13 and 14 or, if higher, the rate that would be applicable using the CY 2009 Medicare conversion factor.

The Department of Health Care Finance (DHCF) is working to implement Section 1902(a)(13) of the Affordable Care Act which requires State Medicaid agencies to increase payment rates for certain primary care services beginning January 1, 2013 through December 31, 2014. Rates will be set at 100% of the Medicare rates in effect for CY 13 and 14 or, if higher, the rate that would be applicable using the CY 2009 Medicare conversion factor.

Eligible physicians include primary care physicians with a specialty designation of family medicine, general medicine, or pediatric medicine and all subspecialists, as designated by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS), and the American Osteopathic Association (AOA). An eligible physician will be required to self-attest that he or she practices in an eligible specialty or subspecialty and either that they are board- certified in that specialty or subspecialty and/or that at least 60 percent of the Medicaid codes he or she has billed during the most recently completed calendar year were authorized codes for evaluation and management services and/or vaccine administration services. The requirement to increase payment rates for certain primary care services applies to both fee-for-service and managed care arrangements. Advanced practice nurses and physician assistants who work under the supervision of an eligible physician also are eligible for an increase in payment.

Although the requirement to pay the increased rates is effective January 1, 2013, the Centers for Medicare and Medicaid Services (CMS) did not finalize its implementing regulations until November 6, 2012 and has yet to answer key questions. CMS has advised States that payments cannot commence until the State has received approval of its State Plan Amendment (SPA) and managed care contracts. SPA and contract amendments are due to CMS no later than March 31, 2013 but cannot be submitted before January 1, 2013. Based upon CMS’s timetables, it is expected that all States will be implementing the rate increase on a retroactive basis.

DHCF is currently developing an application form for all eligible providers, drafting its SPA and working on issues relating to the implementation of the rate increase for physicians participating in managed care. We will continue providing regular updates at monthly Medical Care Advisory Committee (MCAC) meetings and will be reaching out to provider associations. We anticipate that DHCF will submit its SPA to CMS in the first quarter of CY 2013 and will implement the rate increase by making retroactive adjustments to eligible claims.

Please direct any questions to Claudia Schlosberg, Director, Health Care Policy and Research Administration (HCPRA) at (202) 442-9107 or Claudia.schlosberg@dc.gov.