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, that is correct.
Supplemental Links:
Date: February 6, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 94141
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.
Supplemental Links:
Date: February 6, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 94146
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.
Supplemental Links:
Date: February 6, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 94151
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.
Supplemental Links:
Date: February 6, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 94156
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.
Supplemental Links:
Date: February 6, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 94161
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.
Supplemental Links:
Date: February 6, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 94171
Yes.
Supplemental Links:
Date: February 6, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 94176
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.
Supplemental Links:
Date: January 28, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
FAQ ID: 94246
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.
Supplemental Links:
Date: January 28, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 94251
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.
Supplemental Links:
Date: January 28, 2013
Topics:
Affordable Care Act
Subtopics:
Final Rule
Primary Care Services
FAQ ID: 94271