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 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.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91286
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.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91076
Yes. The 60 percent threshold can be met by any combination of eligible E&M and vaccine administration codes.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91291
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.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91296
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.
Supplemental Links:
Date: February 11, 2014
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 91301
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