Frequently Asked Questions

CMS believes that the process for reimbursing a health plan for the Health Insurance Providers Fee that was contracted with the state in 2013, but not in 2014, is primarily a matter to be negotiated between the state and the health plan. It is reasonable for a state to make a retroactive adjustment to the 2013 contract year rates for that health plan as it is possible that the state's actuary did not take the Health Insurance Providers Fee into consideration when developing the 2013 rates. In that case, the state may treat the fee in the same manner as it would an error in the development of the rates, and submit any necessary adjustment to CMS for approval.

However, there may be barriers to such adjustments under the contract or applicable state laws. Retroactive rate adjustments for a health plan that has left the market must be made under the contract and within the federal two-year period for timely claims. See Question 3 for more information. Going forward, states that account for the fee on a retroactive basis may want to address rate adjustments due to market exit in the contract. States that account for the fee on a prospective basis will not encounter this issue.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 159.2 KB)

FAQ ID:91396

Information on when states intend to reimburse contracted health plans for the Health Insurance Providers Fee is established in the contract. States that elect to reimburse health plans for the fee once the amount is known should establish a timeframe for payment, typically between 30 to 90 days, after receipt and review of the health plan's assessment from the Internal Revenue Service.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 159.2 KB) 

FAQ ID:91401

It is reasonable to consider the Health Insurance Providers Fee in these arrangements as they may exist in the contract between the state and the health plan. While CMS does not have specific requirements as to how the Health Insurance Providers Fee should be considered under these arrangements, CMS does recommend that the Health Insurance Providers Fee is generally treated in the same way as other taxes and fees for these purposes.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 159.2 KB)

FAQ ID:91386

Generally, the purpose of the 1202 payment increase is to directly benefit physicians performing primary care services. In the instance of salaried physicians, including those working for clinics or other employing organizations that bill on the Medicaid physician fee schedule, this could come in the form of an increased salary. Alternatively, where there is an employment agreement between the physician and the employing entity, the employment agreement might account for the payment increase by noting that the physician accepts his or her salary as payment in full, regardless of Medicaid reimbursement levels.

FAQ ID:91081

To the extent that physicians are already receiving payment for Medicaid services that is at least equal to the Medicare rate as required under section 1202 of the ACA, no additional payment under section 1202 should be made to either a managed care health plan or to a group practice or similar organization that employs physicians. The additional payment is to ensure that payment to the physician is at least equal to the 1202 Medicare rate.

FAQ ID:91086

States that pay for vaccine administration using the vaccine product codes were required to include a crosswalk to their administration codes as part of their ACA 1202 state plan amendment (SPA). They will therefore be required to submit a new SPA to reflect any changes in those codes. If a state does not use vaccine product codes to pay for vaccine administration and therefore there is no crosswalk in their 1202 SPA, then no updates are necessary to reflect the code changes.

FAQ ID:91091

Yes. The original SPAs contained a list of codes that had been added since 2009 that the state was planning on reimbursing at the higher ACA 1202 rate. Therefore, if a state adds codes, it should submit a revised SPA page, updating that list of codes eligible for higher payment.

FAQ ID:91096

In qualifying states, certain United States Preventive Services Task Force (USPSTF) grade A or B preventive services and vaccine administration codes are eligible for a one percent FMAP increase under section 4106 of the Affordable Care Act (which amended sections 1902(a)(13) and 1905(b) of the Act). Some of these services may also qualify as a primary care services eligible for an increase in the payment rates under section 1202 of the Affordable Care Act. For these services the federal matching rate is 100 percent for the difference between the Medicaid rate as of July 1, 2009 and the payment made pursuant to section 1202 (the increase). The federal matching payment for the portion of the rate related to the July 1, 2009 base payment would be the regular Federal Medical Assistance Percentage (FMAP) rate, except that this rate would be increased by one percent if the provisions of section 4106 of the Affordable Care Act are applicable.

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• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91076

Effective for dates of service on and after January 1, 2013 through December 31, 2014, states are required by law to reimburse qualified providers at the rate that would be paid for the service (if the service were covered) under Medicare. Most states and the District of Columbia will need to submit a Medicaid state plan amendment (SPA) to increase Medicaid rates up to this level. The Centers for Medicare & Medicaid Services (CMS) has issued a state plan amendment (SPA) preprint for the purpose of expediting review and approval of the primary care payment increase.

For dates of service starting January 1, 2013 qualified providers are entitled to receive the higher payment in accordance with the approved Medicaid state plan amendment. States may not have attestation procedures or higher fee schedule rates in place on January 1, 2013. In that event, providers will likely continue to be reimbursed the 2012 rates for a limited period of time. Once attestation procedures are in place and providers are identified as eligible for higher payment, the state will make one or more supplemental payments to ensure that providers receive payment for the difference between the amount paid and the Medicare rate. Qualified providers should receive the total due to them under the provision in a timely manner.

A state may draw federal financial participation for the higher payments only after the SPA methodology is approved.

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• This FAQ was released as part of a larger set. View the full set.

FAQ ID:91271

The statute specifies that higher payment applies to primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. The regulation specifies that specialists and subspecialists within those designations as recognized by the American Board of Medical Specialties (ABMS) the American Osteopathic Association (AOA) or the American Board of Physician Specialties (ABPS) also qualify for the enhanced payment. Under the regulation, "general internal medicine" encompasses internal medicine and all subspecialties recognized by the ABMS, ABPS and AOA. In order to be eligible for higher payment:

1. Physicians must first self-attest to a covered specialty or subspecialty designation.
2. As part of that attestation they must specify that they either are Board certified in an eligible specialty or subspecialty and/or that 60 percent of their Medicaid claims for the prior year were for the Evaluation and Management (E&M) codes specified in the regulation. It is quite possible that physicians could qualify on the basis of both Board certification and claims history.

Only physicians who can legitimately self-attest to a specialty designation of (general) internal medicine, family medicine or pediatric medicine or a subspecialty within those specialties recognized by the American Board of Physician Specialties (ABPS), American Osteopathic Association (AOA) or American Board of Physician Specialties (ABPS) qualify.

It is possible that a physician might maintain a particular qualifying Board certification but might actually practice in a different field. A physician who maintains one of the eligible certificates, but actually practices in a non-eligible specialty should not self-attest to eligibility for higher payment. Similarly, a physician Board certified in a non-eligible specialty (for example, surgery or dermatology) who practices within the community as, for example, a family practitioner could self-attest to a specialty designation of family medicine, internal medicine or pediatric medicine and a supporting 60 percent claims history. In either case, should the validity of that physician's self-attestation be reviewed by the state as part of the annual statistical sample, the physician's payments would be at risk if the agency finds that the attestation was not accurate.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 50.64 KB)

FAQ ID:91276