AAFP Map Tracks Progress on Medicaid Parity Increase by State

November 07, 2013 03:50 pm Jennifer Lubell

The AAFP has created a map family physicians can use to track the progress their state has made in implementing the Patient Protection and Affordable Care Act's Medicaid parity measure for certain primary care services, which went into effect in January. The map indicates that most states have started paying the enhanced rates for Medicaid.

The parity provision in the Affordable Care Act states that family physicians who offer certain primary care services to Medicaid patients are eligible for a boost in payment to at least Medicare levels for 2013 and 2014. To qualify, physicians were required to self-attest that they were board-certified in one of the primary care specialties, such as family medicine, or show that at least 60 percent of the evaluation and management codes they submitted to Medicaid were for primary care services.

In turn, states were required to submit plan amendments on how they would implement the measure to CMS for approval, a process that significantly delayed disbursement of the additional payments.

The new AAFP map, which is based on data from an AMA/AAFP chapter survey, shows that most states now have started paying Medicaid primary care physicians at the enhanced rates, at least in Medicaid fee-for-service programs. But there are at least seven states in which implementation has begun for fee-for-service Medicaid, but not managed care Medicaid programs, and another seven where no payments have been reported.

Story highlights
  • The AAFP has created a map family physicians can use to track the progress their state has made in implementing the Patient Protection and Affordable Care Act's Medicaid parity measure for certain primary care services.
  • The parity provision states that family physicians who offer certain primary care services to Medicaid patients are eligible for a boost in payment to at least Medicare levels for 2013 and 2014.
  • The map shows that most states now have started paying Medicaid primary care physicians at the enhanced rates in Medicaid fee-for-service programs, although Medicaid managed care programs are not so far along.

Medicaid parity is a complicated provision, and it's important to keep in mind that it's "not entirely straightforward who gets defined as a 'primary care provider' and which services get defined that way," said Matt Salo, executive director of the National Association of Medicaid Directors. According to CMS, all state plan amendments now have been approved, with retroactive payments dating back to Jan. 1.

In Illinois, Medicaid-Medicare parity "has moved relatively smoothly," said Carrie Nelson, M.D., president of the Illinois AFP. "Physicians had until June 30 to sign up to have all their primary care visit codes from Jan. 1, 2013, count toward the payment. Physicians signing up afterward will receive payments from the date they sign up through Dec. 31, 2014," and payments will be made quarterly based on claims submitted during the previous quarter, Nelson said.

The enhanced payments have been significant for some Illinois practices, given that in 2012, some primary care Medicaid fee-for-service visit codes were only being paid at 50 percent of Medicare rates and others in the range of 60 percent to 80 percent of Medicare rates, according to Nelson.

California, cited by the map as one of the "no payment" states, will begin interim payment enhancements early this month, according to Norman Williams, deputy director of the California Department of Health Care Services. Amounts for the first interim payment will cover increases that are retroactive to Jan. 1 and "will vary depending upon the service provided. Subsequent weekly interim payments will then be issued until the final settlement of the increased payment owed is disbursed, as early as February 2014," Williams said. Managed care rates also will increase and are scheduled to begin in December, he noted.

Although pleased that payments in his state are forthcoming, Mark Dressner, M.D., president of the California AFP, said he was disappointed that it took until November to receive payment equity that should have started in January.

Peter Anderson, M.D., a Connecticut family physician, said he finally began seeing the enhanced payments in September, but he has no idea how far along these payments are in catching up to the present. "We have no easy way to even know whether we have money that we're entitled to that we don't get, at least for the back claims," said Anderson.

His Medicaid patient base is small, about 3 percent straight Medicaid and 5 percent to 10 percent dually eligible for Medicare and Medicaid, said Anderson. Thus, the Affordable Care Act enhanced payment isn't much of an incentive for him to take on additional Medicaid patients, especially in light of the nine-month rollout delay.

"Medicare rates, while certainly a major improvement, have been essentially frozen for more than 10 years now," said Anderson. "That's hardly generous, especially for a high overhead specialty like family practice." In addition, he noted, subspecialists were largely excluded from the enhanced payments, so access to subspecialty care for Medicaid patients won't necessarily improve. The result is family physicians often are left "holding the bag" for patients with complex or nonemergency surgical problems, said Anderson.

Dressner said certain factors at play in California might deter family physicians from accepting new Medicaid patients. Complicating the long wait for parity is the fact that Medicaid payments in the state are scheduled to drop by 10 percent in 2014. With millions of newly insured patients entering the health care system, questions remain on how willing family physicians are going to be to expand their patient base when they are facing additional cuts the state has imposed.

In Illinois, according to Nelson, implementation of the parity provision might encourage family physicians to see new Medicaid patients, at least to some extent. But she issues that prediction with some caution "due to the limitations in the duration of the parity."

The AAFP has actively advocated that Congress make the Medicaid enhanced payments permanent and has taken steps to move parity forward and educate members on the attestation process.

"Permanently improving payment for Medicaid services will improve access to primary care, which likely will lead to reduced reliance on avoidable emergency room services, improved preventive care, better quality and lower health care costs for our country," said (then) AAFP President Jeff Cain, M.D., of Denver, in an article in AAFP News Now in July.


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