Department of Public Health and Human Services

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Primary Care Enhanced Payment

Primary Care Enhanced Payment

THIS PROGRAM HAS EXPIRED AND IS NO LONGER IN EFFECT AS OF JULY 1, 2016.

The Department of Public Health and Human Services participated in a program to enhance payments to primary care practitioners. This program titled Payment for Services Furnished by Certain Primary Care Physicians and Charges for Vaccine Administration under the Vaccine for Children Program as defined in the Patient Protection and Affordable Care Act of 2010.

The Department first participated in 2013 and 2014, and has decided to continue this program through June 30, 2015.

 

CMS Final Rule

The CMS final rule implements the statutory payment provisions uniformly across states and provides the following information:

  • Primary care physicians are defined as physicians practicing within the scope of practice of medicine or osteopathy with a specialty designation of family medicine, general internal medicine and pediatric medicine. It also provides for higher payment for sub specialists related to those specialty categories as recognized by the American Board of Medical Specialties, American Osteopathic Association and the American Board of Physician Specialties (see below for links to those boards for specialties/ subspecialties).

  • For non-physician providers, this rule provides for higher payment for services provided under the personal supervision of qualifying physicians. A supervising physician assumes professional responsibility for the services provided under his/her supervision. This normally means that the physician is legally liable for the quality of the services provided by individuals he/she is supervising.

  • The Department permits payment based on self-attestation, but will perform an audit to confirm the self-attestation. Providers will self-attest that they are appropriately board certified or that 60% of their Medicaid claims during the previous year were for the identified evaluation and management (E/M) codes. If providers are attesting to board certification, a copy of the board certificate is required.

  • A link to the list of physicians and their individual percentage of qualifying claims is below in the Forms section.

  • Eligible primary care services are E/M codes 99201 through 99499 and vaccine administration codes 90460 through 90474 as covered by the Medicaid program.

  • Method of payment for E/Ms requires payment in CYs 2013 and 2014 of the current Medicare rate, unless the rate set using the CY 2009 conversion factor was higher.

  • Reimbursement for vaccine administrations under the Vaccines for Children (VFC) program will increase from $14.13 per administration to the lesser of the new regional maximum amount ($21.32) or the fee calculated using the methodology above.

Certifying Boards, Specialties, and Subspecialties

As determined by CMS, physicians attesting to board certification must have current certification through one of the following boards OR be board-certified under through another organization and qualify under the 60% threshold.

Click the links below for qualifying specialty and subspecialty information for that board. PD03062013

Centers for Medicare and Medicaid Services (CMS) Publications

PD07192013

Fee Schedules and Provider Notices

Forms, Threshold, and Monthly Enrollment

Forms

Primary Care Enhanced Payment Self-Attestation Form

Note: When providing a copy of board certification, ensure it is a copy of the provider's current board certification. If board certified under a board other than ABMS, ABPS, or AOA, you must qualify under the 60% threshold. Refer to the threshold list below.

Threshold

2015 60% Threshold List by NPI PDF
2015 60% Threshold List by NPI Excel

2014 60% Threshold List by NPI

2013 60% Threshold List by NPI

Monthly Enrollment

Enrollment as of June 29, 2015

PD07012015