Focus on Health Care Reform: 10% Primary Care Bonus Payments Under Medicare

The Medicare primary care incentive payment program runs from January 1, 2011 to January 1, 2016. “All” primary care practitioners receive the ten percent incentive payment as long as they meet the definition of “primary care practitioner” and perform “primary care services” as outlined in The Affordable Care Act.  Payments will be made on a quarterly basis.

Section 5501(a)(2)(A) of The Affordable Care Act defines a primary care practitioner as:

• A physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or

• A nurse practitioner, clinical nurse specialist, or physician assistant for whom primary care services accounted for at least 60 percent of the allowed charges under the Physician Fee Schedule (PFS) for the practitioner in a prior period as determined appropriate by the Secretary of Health and Human Services.

Section 5501(a)(2)(B) of The Affordable Care Act defines primary care services as those services identified by the following Current Procedure Terminology (CPT) codes as of January 1, 2009 (and as subsequently modified by the Secretary of Health and Human Services, as applicable):

• 99201 through 99215 for new and established patient office or other outpatient Evaluation and Management (E/M) visits;

• 99304 through 99340 for initial, subsequent, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home (e.g., boarding home), or custodial care E/M services; and domiciliary, rest home (e.g., assisted living facility), or home care plan oversight services; and

• 99341 through 99350 for new and established patient home E/M visits.

Any primary care provider meeting this definition will receive quarterly incentive payments equal to 10% of the reimbursement rate of eligible codes used.

Click here to access the NCMS Health System Reform Resource Center.


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