Update — Enhanced Medicaid Payments to Primary Care Physicians

To help promote primary care physician participation, the Affordable Care Act (ACA) increases Medicaid reimbursements for evaluation and management and immunization services to 100 percent of Medicare reimbursement in 2013 and 2014. The increase will apply to both fee-for-service and managed care Medicaid plans. Under the new rule, which was finalized by the Centers for Medicare & Medicaid Services in November, Medicaid is federally required to pay up to the Medicare rate for certain primary care services and to reimburse 100 percent of the Medicare Cost Share for services rendered and paid in calendar years 2013 and 2014.

Now,  physicians with a primary specialty designation of family medicine, general internal medicine or pediatric medicine are primary care providers. Those who render evaluation and management (E&M) codes and services related to immunization administration for vaccines and toxoids for specified codes would be eligible for reimbursement.

Providers can attest to having board certification in a specialty (family medicine, general internal medicine or pediatric medicine) or subspecialty designated in the statute and attest to billing at least 60 percent for Evaluation & Management (E&M) and vaccine/toxoid codes through a North Carolina Division of Medical Assistance (DMA) website portal using their N.C. Medicaid provider numbers.

This rule provides for the higher payment for services provided under the personal supervision of eligible physicians by all advanced practice clinicians. Advanced clinical practitioners are required to attest to being under the supervision of a board certified physician.

N.C. Medicaid will reimburse providers retroactively if they attested prior to implementation.

The codes included in this provision include E&M services and immunization administration for vaccines and toxoids. The MMIS+ claims processing system will reference both the Medicaid fee schedule, as well as the Medicare fee schedule to determine the enhanced payment amount.

DMA will notify providers through upcoming Medicaid bulletins, e-mail blasts, remittance advices or banner messages as the ACA Enhanced Payments to Primary Care Physicians implementation efforts progress.

 Read the Final Rule here.


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