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
No. The extension of Medicaid coverage to the new group of former foster care children up to age 26 (see section 1902(a)(10)(A)(i)(IX)) and to all children age six and older with incomes up to 133 percent of the (FPL) (1902(a)(10)(A)(i)(VII) are required by the Affordable Care Act and were not affected by the Supreme Court's decision. The Medicaid eligibility change for older children eliminates the confusing "stair step" federal eligibility rules that have put low-income children in the same family in different programs depending on their age. As previously indicated in our Medicaid and CHIP eligibility final rule, the CHIP enhanced matching rate will continue to be available for children transferring from separate CHIP programs to Medicaid as a result of eligibility changes in the Affordable Care Act.
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IHS and tribal facilities are often not separately paid for physician services, but instead receive an all-inclusive rate for inpatient or outpatient service encounters. To the extent that a particular claim is made for primary care services furnished by an eligible physician, there is no exclusion from the requirement for provider payment at least equal to the Medicare Part B fee schedule rate. States would continue to receive Federal Medical Assistance Percentage (FMAP) at the 100 percent rate for services received through IHS and tribal facilities and reimbursed through the all-inclusive rate. For other physician services, including Medicaid payments for contract health services, states would receive the regular FMAP for the base payment, and 100 percent for the difference between the state plan rate in effect on July 1, 2009 and the applicable 2013 and 2014 Medicare rates.
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Physicians employed by hospitals whose services are reimbursed by Medicaid on a physician fee schedule must receive the benefit of higher payment. It is the Medicaid agency's responsibility to ensure that hospitals receiving payments on behalf of those physicians comply with all requirements of the program. While hospitals could increase salaries they could also provide additional/bonus payments to eligible physicians to ensure that they receive the benefit of higher Medicaid payment.
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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.