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
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.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91306
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.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91311
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.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91316
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.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91321
PCCM payments are not eligible for higher payment under this rule.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91326
Higher payment does not apply to services provided under another Medicaid benefit category such as clinic or FQHC or RHC.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91331
Yes. This information will be made available on Medicaid.gov. States will be asked to verify the payment amount in effect for each of the billing codes affected by the final rule as of July 1, 2009.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91336
Yes. CMS has provided a preprint for the reimbursement section of the Medicaid state plan that will describe payment for evaluation and management services and vaccine administration. The preprint is available on Medicaid.gov.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91341
A state is not required to cover all of the primary care service billing codes if it did not previously do so. Rather, to the extent that it reimburses physicians using any of the billing codes specified in the final rule, the state must pay at the Medicare rate in the calendar years (CYs) 2013 and 2014.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91346
A state may not add any of the eligible service codes solely for the purpose of obtaining enhanced federal matching funds. For example, a state may not eliminate a code currently in use and attempt to substitute it with another Evaluation and Management (E&M) code. However, we recognize that a handful of codes have been added to the E&M code set since 2009. States which added those codes to their fee schedules will receive higher match for those services.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91351