Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.
Frequently Asked Questions
The Affordable Care Act specifies increased payments for three primary care specialties: Family Medicine, General Internal Medicine and Pediatrics. The Final Rule interprets this language to include some subspecialties with a relation to the original three, but does not list the subspecialties. Please identify the subspecialists eligible for higher payment.
Subspecialists that qualify for higher payment are those recognized by the American Board of Medical Specialties (ABMS), American Board of Physician Specialties (ABPS) or American Osteopathic Association (AOA). For purposes of the rule, "General Internal Medicine" encompasses "Internal Medicine" and all recognized subspecialties. The websites of these organizations currently list the following subspecialty certifications within each specialty designation:
ABMS
Family Medicine - Adolescent Medicine; Geriatric Medicine; Hospice and Palliative Medicine; Sleep Medicine; Sports Medicine.
Internal Medicine - Adolescent Medicine; Advanced Heart Failure and Transplant Cardiology; Cardiovascular Disease; Clinical Cardiac Electrophysiology; Critical Care Medicine; Endocrinology, Diabetes and Metabolism; Gastroenterology; Geriatric Medicine; Hematology; Hospice and Palliative Medicine; Infectious Disease; Interventional Cardiology; Medical Oncology; Nephrology; Pulmonary Disease; Rheumatology; Sleep Medicine; Sports Medicine: Transplant Hepatology.
Pediatrics - Adolescent Medicine; Child Abuse Pediatrics; Developmental-Behavioral
Pediatrics; Hospice and Palliative Medicine; Medical Toxicology; Neonatal-Perinatal Medicine; Neurodevelopmental Disabilities, Pediatric Cardiology; Pediatric Critical Care Medicine; Pediatric Emergency Medicine; Pediatric Endocrinology; Pediatric Gastroenterology; Pediatric Hematology-Oncology; Pediatric Infectious Diseases; Pediatric Nephrology; Pediatric Pulmonology; Pediatric Rheumatology, Pediatric Transplant Hepatology; Sleep Medicine; Sports Medicine.
AOA
Family Physicians - No subspecialties
Internal Medicine - Allergy/Immunology; Cardiology; Endocrinology; Gastroenterology; Hematology; Hematology/Oncology; Infectious Disease; Pulmonary Diseases; Nephrology; Oncology; Rheumatology.
Pediatrics - Adolescent and Young Adult Medicine, Neonatology, Pediatric Allergy/immunology, Pediatric Endocrinology, Pediatric Pulmonology.
ABPS
The ABPS does not certify subspecialists. Therefore, eligible certifications are: American Board of Family Medicine Obstetrics; Board of Certification in Family Practice; and Board of Certification in Internal Medicine. There is no Board certification specific to Pediatrics.
Supplemental Links:
FAQ ID:91281
SHARE URLIs self-attestation required or may a state rely solely on information about Board certification gathered upon provider enrollment or data on a physician's MMIS claims history to determine eligibility for CMS 2370-F?
The rule requires that physicians first self-attest to an eligible specialty or subspecialty and then attest to either Board certification or an appropriate claims history. States cannot pay a physician without evidence of self-attestation.
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FAQ ID:91286
SHARE URLDoes the 60 percent threshold in CMS 2370-F include both Evaluation and Management (E&M) codes and vaccine administration codes?
Yes. The 60 percent threshold can be met by any combination of eligible E&M and vaccine administration codes.
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FAQ ID:91291
SHARE URLThe American Board of Physician Specialties does not certify subspecialists. Which Board certifications would qualify a physician for higher payment under CMS 2370-F?
Physicians who are Board-certified by the ABPS in Internal Medicine, Family Practice, or Family Medicine Obstetrics would qualify for higher payment.
Physicians with a certification in Family Medicine Obstetrics are all certified first in family medicine with additional certification in obstetrics. They practice as family practitioners and are therefore able to self-attest to a qualified specialty. This is not true of individuals certified in obstetrics by either the ABMS or AOA who do not qualify for higher payment.
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FAQ ID:91296
SHARE URLCan a physician self-attest to Board certification or a supporting claims history after January 1, 2013, when the CMS 2370-F primary care payment increase begins but expect higher payment back to the beginning of the year?
States must have the appropriate self-attestations in hand before they can pay physicians at the higher rate. States can impose reasonable requirements regarding "retroactive" self-attestations to facilitate program administration. For example, a state could limit retroactive payments to the beginning of the month or quarter in which the attestation is submitted. However, physicians must be made aware of the payment provision and of the requirements concerning self-attestation before January 1, 2013 through state provider bulletin or manual systems or other mechanisms.
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FAQ ID:91301
SHARE URLMay a state automate its process for identifying qualified providers under CMS 2370-F?
Yes. A state may automate its process for identifying physicians that qualify for this payment provided the process is transparent and legally binding. A state may not rely on a physician's taxonomy in place of self-attestation to Board certification or a supporting claims history. At the end of calendar years (CYs) 2013 and 2014 the Medicaid agency must review a statistically valid sample of physicians who self-attested either to Board certification or a supporting claims history to determine the validity of the data.
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FAQ ID:91306
SHARE URLHow will the Center for Medicare & Medicaid Services (CMS) ensure that only eligible providers receive the higher rate under CMS 2370-F?
The final rule requires physicians to self-attest to an eligible specialty designation and to further indicate whether they are Board certified in an eligible specialty or subspecialty or 60 percent of the services for which they bill are for eligible Evaluation & Management (E&M) or vaccine administration codes. Annually, states must conduct a review of a statistically valid sample of physicians that have self-attested to either Board certification or a supporting claims/service history. Physicians and State Medicaid agencies must keep all information necessary to support an audit trail for services reimbursed at the higher rate.
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FAQ ID:91311
SHARE URLIf the sampled data indicates the inclusion of non-qualified providers under CMS 2370-F should repayment be based upon data for all physicians who received higher payment or only the sampled providers?
The Center for Medicare & Medicaid Services (CMS) will require that the state repay erroneous payments found through the sampled pool of providers, and will not extrapolate data from the sample to the entire universe of physicians who received the higher primary care payment. States with high error rates should submit a plan for corrective action to reduce errors.
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FAQ ID:91316
SHARE URLCan mid-level/non-physician practitioners such as nurse practitioners receive the higher payment under CMS 2370-F?
The final rule specifies that services must be delivered under the Medicaid physician services benefit. This means that higher payment also will be made for primary care services rendered by practitioners working under the personal supervision of a qualifying physician. The rule makes clear that, while deferring to state requirements regarding supervision, the expectation is that physicians assume professional responsibility for the services provided under their supervision. This usually means that the physicians are legally liable for the quality of the services provided by individuals they're supervising. If this is not the case, the practitioners would be viewed as practicing independently and would not be eligible for higher payments.
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FAQ ID:91321
SHARE URLHow are case management fees in Primary Care Case Management (PCCM) programs affected by CMS 2370-F?
PCCM payments are not eligible for higher payment under this rule.
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FAQ ID:91326
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