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 60 percent threshold is based on the number of billed services as identified by individual billing codes for the primary specialty being asserted. That is, the numerator equals total billed codes for Evaluation & Management (E&M) services for the primary specialty, plus vaccine administration services, and the denominator equals the total number of billed codes. Please note that a state may choose to use paid billing codes/services in place of billed codes.
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This is acceptable.
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States can establish reasonable timeframes regarding the submission of attestations by physicians. We are aware that many states are experiencing delays in implementing the provisions of the regulation and we have also been made aware that there is considerable confusion on the part of providers regarding enrollment. We expect that states will provide physicians with ample notice of the procedures for enrollment that physicians will be given several months to comply with the requirements. If the state sets a reasonable timeframe, such as three months, and physicians do not enroll within that time, we believe that the state could make payment prospectively from the date of the physician's application as long as this policy is made clear to providers.
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You are correct that the rule does not require the physician to submit a new self-attestation in 2014 although states could impose such a requirement. States can rely on the initial self-attestation for purposes of 2014 payments since we would not expect provider practices to vary significantly from year to year.
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Attestation forms are developed by the State Medicaid agencies. Physicians should contact their state Medicaid agency for information on the process for becoming eligible for higher payment in their state.
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Yes, that is correct.
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Physicians must first self-attest to a primary care designation of internal medicine, family medicine or pediatrics. This attestation signifies that the physicians consider themselves to be eligible specialty practitioners. The self-attestation must then indicate whether the physicians consider themselves to be qualified because of appropriate Board certification or practice history as represented by a 60 percent claims history. Some physicians may be appropriately Board certified and have a 60 percent claims history.
There may be physicians with Board certification in a specialty not recognized for higher payment under the rule who actually practice as pediatricians, family practitioners or internists who would be eligible for higher payment. For example, an Obstetrician/Gynecologist (OB/GYN) who no longer practices in that specialty but practices as a family practitioner could appropriately self-attest to being a primary care provider. Such a provider would need to qualify based on the 60 percent threshold and not Board certification. Physicians that support their initial self-attestation with an attestation of appropriate Board certification can qualify only if they actually have the appropriate Board certification. Practice habits would not be applicable.
There may also be physicians with Board certification in one of the three eligible specialty areas who do not actually practice in those areas. They should not self-attest to being a primary care provider.
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Such a physician would self-attest to a primary specialty designation of family medicine, pediatric medicine or internal medicine and would then attest to, and qualify based on, a 60 percent claims history.
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The Center for Medicare & Medicaid Services (CMS) disseminated the Deloitte fee for service tool to states through the CMS Regional Offices in early January. It permits states to develop rates for each code based on the decisions it makes about site of service and geographic adjustments. The formula used to develop the rate weights each county equally and does not incorporate a weighting factor for population. Using a rate weighted by population is not an option for states to use in developing their fee schedules.
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CMS can produce the fee schedules for states that are unable to run the program. States should contact Christopher Thompson at Christopher.thompson@cms.hhs.gov.