Medicaid Payment Increases Available to Qualifying Providers

Medicaid payment reaches Medicare payment parity, kind of, for some services, if you apply for it…

The Affordable Care Act of 2010 (ACA) requires states to increase payments for certain primary care services furnished under Medicaid in 2013 and 2014 at a rate not less than 100 percent of the Medicare rate in effect during 2013 and 2014 or, if greater, the payment that would have been applicable in 2009.

Medicaid Primary care services are defined as:

• CPT-4 Evaluation and Management (E&M) codes 99201 through 99499

• Services related to immunization administration for vaccines and toxoids procedure codes 90460, 90461, 90471, 90472, 90473, and 90474

To qualify for the rate increase for primary care services, a physician must have a specialty designation of general internal medicine, family practice, or pediatrics and must attest to one of the following:

• The provider has a certification recognized by the American Board of Medical Specialties (ABMS), American Board of Physician Specialties (AMPS), or American Optometric Association (AOA) and meets the requirements as required by federal and state regulation to receive the increased payment.

• The provider does not have a certification recognized by the ABMS, ABPS, or AOA, but at least 60 percent of the provider’s Medicaid billings for the previous calendar year (or for the previous calendar month if the provider has been enrolled in Medicaid for less than one year) were for the evaluation and management (E/M) and vaccine administration procedure codes as published in the final federal and state regulations and the provider meets the requirement to receive payment.

Note: New providers with no history of Medicaid billings can attest that 60 percent of their Medicaid billing will be for primary care services.

In order to receive this rate increase, providers must attest to eligibility with their states Medicaid program.  

Texas providers can attest using the Texas Medicaid Attestation for ACA Primary Care Rate Increases form. The form must be completed by individual providers.

Payments are to be paid retroactively for all qualifying codes submitted January 1, 2013 or later.

For more information go to http://www.medicaid.gov/AffordableCareAct/Provisions/Provider-Payments.html.