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Medicaid Payments for Primary Care Services in Parity with Medicare
Overview
On November 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulation which implements Section 1202 of the Affordable Care Act. This section increases Medicaid payments for specified primary care services to Medicare levels for certain primary care physicians in 2013 and 2014.
States will receive an estimated $5.8 billion in 2013 and $6.1 billion in 2014 in new federal funds to bolster their Medicaid primary care delivery systems. Unless Congress acts to extend and fund this provision permanently, a sudden return to disparate and inadequate payment for primary care services needed by Medicaid patients after only two years will again threaten to restrict their access to such needed services.
The final rule provides for higher payment in both the fee for service and managed care settings for specific primary care services furnished by:
The final rule provides for higher payment in both the fee for service and managed care settings for specific primary care services furnished by:
- Practicing physicians who self-attest that they are board certified with a specialty designation of family medicine, general internal medicine and pediatric medicine, or
- Subspecialists related to those specialty categories as recognized by the American Board of Medical Specialties, American Osteopathic Association, or the American Board of Physician Specialties who also self-attest that they are board certified, or
- Physicians related to the specialty categories of family medicine, internal medicine, and pediatrics who self-attest that at least 60 percent of all Medicaid services they bill or provide in a managed care environment are for the specified Evaluation & Management (E&M) and vaccine administration codes.
- Advanced practice clinicians when the services are furnished under a physician’s personal supervision.
The final rule requires state governments to take further action prior to March 31, 2013, to implement this provision. So that low-income, working families and others can immediately benefit from this important provision, the AAFP calls on states to act quickly once CMS issues an anticipated template for a state plan amendment.
In addition to the increases in Medicaid payments, this regulation also updates vaccine administration fee maximums that had not been updated since the Vaccines for Children (VFC) program was established in 1994. CMS will use the Medicare Economic Index (MEI) to update the maximums consistent with inflation.
In addition to the increases in Medicaid payments, this regulation also updates vaccine administration fee maximums that had not been updated since the Vaccines for Children (VFC) program was established in 1994. CMS will use the Medicare Economic Index (MEI) to update the maximums consistent with inflation.
Review the AAFP Fact Sheet on the final regulation.
Learn More
- Joint letter: AAFP to CMS regarding the primary care payment increase - May 7, 2013
- Joint letter: National Governors Association -- January 29, 2013
- Joint letter: National Association of Medicaid Directors -- January 29, 2013
- Letter: Children's Health Group Joint Letter to Congress -- December 12, 2012
- Letter: AAFP to US House of Representatives regarding Medicare/Medicaid Parity -- December 5, 2012
- Letter: AAFP to US Senate regarding Medicare/Medicaid Parity -- December 5, 2012
- AAFP Executive Summary: Medicaid Payments for Primary Care Services in Parity with Medicare & Charges for Vaccine Administration
- ANN article: AAFP Summarizes Provisions of Medicaid/Medicare Parity Regulation
- ANN article: CMS Releases Final Rule on Medicaid/Medicare Payment Parity
- AAFP Statement: AAFP Welcomes Medicaid Payment Parity with Medicare, Expresses Concern About the Short-Lived Payment Equity
Related Links
- CMS FAQ on Increased Medicaid Payments for Primary Care Physicians (Medicaid.gov)
- CMS Press Release, November 1, 2012: "Health Care Law Delivers Higher Payments to Primary Care Physicians" (CMS.gov)
- CMS Fact Sheet: "Increased Medicaid Payment For Primary Care" (CMS.gov)
- Medicaid Provider Payments page, including helpful FAQs and summaries. (Medicaid.gov)
Archive
- AAFP Executive Summary of the changes proposed by CMS - May 2012 Medicaid Payments for Primary Care Services in Parity with Medicare & Charges for Vaccine Administration (4-page PDF; About PDFs)
- AAFP Recommendations to US Congress regarding Medicare Physician Payment Reform - June 2011
Medicare Physician Payment
AAFP's Response to the SGR Proposal, Second Iteration (*PDF file)
AAFP Response to the SGR Proposal (*PDF file)
Joint Letter to the National Association of Medicaid Directors on Medicaid Primary Care Payment Increase (*PDF file)
Joint Letter to the National Governors Association on Medicaid Primary Care Payment Increase (*PDF file)
Endorsements and Letters to Congress
(*PDF file. About PDFs)
