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
Higher payment made under the requirements of the regulation is for physicians reimbursed pursuant to a physician fee schedule. Physicians working in a clinic and reimbursed through a physician fee schedule could qualify for higher payments if they are appropriately Board certified or if 60 percent of the services that he or she provides is for the specified primary care services. Since the clinic itself is not eligible, this percentage of services threshold cannot be based on the aggregate of all services provided by all practitioners within the facility, only on services the individual physicians.
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Yes.
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The regular administrative federal match rate is applicable to administrative costs associated with implementation of this rule. Section 1905(dd) of the Social Security Act (the Act) authorizes increased Federal Medical Assistance Percentage (FMAP) only for eligible services provided by eligible providers pursuant to section 1902(a)(13)(C) of the Act
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We addressed the treatment of bonus payments and other incentive arrangements in terms of identifying the 2009 base rate in the final rule and take this opportunity to clarify that such arrangements are similarly excluded from the methodology for determining the rate differential.
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The applicable Medicare rate does effectively become the "floor" for payments to eligible providers for eligible services, but not the "ceiling." Health plans may pay above that rate depending on their specific contractual arrangements with providers.
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While some plans may be able to pay the higher rate prior to receiving state funds, the final rule does not obligate a health plan to pay eligible providers the higher rate until they have been provided the funds to do so.
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The State will issue a communication instructing providers that only those who are board-certified in a specified specialty/subspecialty or who meet the 60 percent threshold of appropriate claims history are eligible to receive the rate increase.
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Each physician must self-attest to being a qualified provider. It is not appropriate for a state to rely on a modifier to a claim for the initial self-attestation. Under the final rule, states are not required to independently verify the eligibility of each and every physician who might qualify for higher payment. Therefore, it is important that documentation exist that the physicians themselves supplied a proper attestation. That attestation has two parts. Physicians must attest to an appropriate specialty designation and also must further attest to whether that status is based on either being Board certified or to having the proper claims history. Once the signed self-attestation is in the hands of the Medicaid agency, claims may be identified for higher payment through the use of a modifier.
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The certification must be current. If it has lapsed but the physician still practices as an eligible specialist the self-attestation would need to be supported with a 60 percent claims history.
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As with all Medicaid services, the state in which the beneficiary is determined eligible (state A) sets the payment rate for services. Therefore, state A would be responsible for paying using the methodology it had chosen with respect to determining the appropriate Medicare rate and would not be required to pay the rate the physician would receive from state B.