Under CMS 2370-F, if a physician self-attests to being a primary care provider and supports
No. Verification of current board certification is sufficient.
Under CMS 2370-F, if a physician is board certified in a non-eligible specialty (for example
Since the only evidence of eligibility is the self-attestation and claims history, the state would need to take steps to verify the practice characteristics of the physician. This could be done by determining that the physician represents himself in the community as a family practitioner, as evidenced by medical directory listings, billings to other insurers, advertisements, etc.
In our state, the Medicaid agency instructs Rural Health Centers (RHCs) to bill the Medicaid
Providers such as RHCs and Federally Qualified Health Centers (FQHCs) are reimbursed on the basis of an all-inclusive rate under their own Medicaid benefit categories. As specified in the final regulation, only services provided under the physician benefit and billed using a physician fee schedule are eligible for higher payment.
Under CMS 2370-F, there are several codes for which there are relative value units (RVUs),
When there are RVUs for just one site of service the state should use those RVUs. There is no alternate method for calculation.
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Under CMS 2370-F, we interpret 42 CFR 447.205 to not require public notice of a
CMS agrees that 42 CFR 447.205(b)(1) excepts states from the public notice requirements when a change is being made to conform to Medicare reimbursement. However, states must still ensure that providers are properly notified of the requirements for self-attestation and higher payment through provider bulletins or other mechanisms.
Under CMS 2370-F, are the services of "physician extenders" (defined as physicians who provide services
No. The only services that qualify are those provided directly by physicians (or by non-physician practitioners that they supervise) who self-attest to an eligible primary care designation and whose attestation is supported by evidence of board certification or claims history. Physicians who do not qualify on their own merits cannot receive higher payment by having an eligible physician bill on their behalf. As previously noted, physicians must accept professional responsibility/liability for the services provided by non-physician practitioners under their supervision.
Under CMS 2370-F, are eligible E&M and vaccination codes that are covered by managed care health plans but not under the Medicaid state plan eligible for reimbursement at the enhanced Medicare rate?
No. The only codes that are eligible for reimbursement at the Medicare rate as specified under the final rule are those eligible codes that are identified under the Medicaid state plan. Additional E&M or vaccination administration codes that are being “covered” by a health plan but that are not identified in the state plan cannot be reflected in the rates.
As we are working to implement ACA 1202, we found that we have to pay
The state has two options: (1) it may claim this cost as an administrative expense of the Medicaid program; or, (2) it may require physicians to provide this documentation when they self-attest.
The CMS 2370-F final rule specified that states will need to recoup the enhanced payments
States must require health plans to recoup erroneous payments found through the sampled pools of providers, and in some states, this sample will include both fee-for-service (FFS) and managed care providers.
What methods can states use to execute conversion to modified adjusted gross income (MAGI) as required by the Affordable Care Act?
Effective January 1, 2014, MAGI eligibility rules will be used to determine eligibility for nonelderly, nondisabled eligibility groups. The transition to MAGI also involves converting current net income eligibility standards to MAGI standards. MAGI rules apply regardless of whether a state adopts the new adult eligibility group.