AAFP Summarizes Provisions of Medicaid/Medicare Parity Regulation

The AAFP has released a summary (4-page PDF; About PDFs) of the final CMS Medicaid/Medicare parity regulation (33-page PDF), which was released in the Nov. 6 Federal Register. The AAFP also has created a dedicated Web page to help members better understand how the rule will affect payment for primary care and some preventive health care services provided as part of the Medicaid program.

The final CMS parity rule implements a provision in the Patient Protection and Affordable Care Act that brings Medicaid payments for certain primary care services and some preventive health services up to Medicare levels for the next two years.

"The Affordable Care Act specifies that physicians with a specialty designation of family medicine, general internal medicine and pediatric medicine qualify as primary care providers for purposes of this increased payment," says the summary. "CMS also finalized policy to qualify for higher payment in the same designated services when provided by subspecialists related to the primary care specialists designated in the statute. These subspecialists would be recognized by the American Board of Medical Specialties, American Osteopathic Association and the American Board of Physician Specialties."

The qualification of subspecialists for the enhanced payment came with AAFP objections. Including subspecialists runs counter to the health care reform act and will "only serve to perpetuate existing disparities in physician payment policies," says the AAFP.

The final rule, however, defines the several physician groups as eligible for the enhanced payment:

According to the AAFP summary, an estimated $5.8 billion in 2013 and $6.1 billion in 2014 in new federal funds will be available to help states bolster their Medicaid primary care delivery systems. The regulation also updates maximum fee amounts for vaccine administration. These fees have not been updated since 1994.

"State Medicaid agencies may pay physicians based on their self-attestation alone or in conjunction with any other provider enrollment requirements that currently exist in the state," says the summary. "However, if a state relies on self-attestation, it must annually review a statistically valid sample of physicians who have self-attested that they are eligible primary care physicians."

This is done to ensure that qualifying physicians are either board certified in an eligible specialty or subspecialty or that their billed Medicaid claims meet the 60 percent threshold, according to the summary. The final rule also gives states the flexibility to determine verification when Medicaid services are delivered through a managed care delivery system.

In addition, "CMS will develop and publish rates for eligible E/M codes not reimbursed by Medicare," according to the summary, which notes that CMS is likely to use the 2009 conversion factor, which is approximately $36.07, if that factor "results in rates that are higher than if the 2013 and 2014 conversion factors were used." Practices will need to update their billing systems so they are ready to start billing Medicaid at the higher fee amounts in 2013, says the summary.

CMS also will require states to submit a state plan amendment to reflect the fee schedule rate increases for eligible primary care physicians. The agency is expected to issue a template for states by the end of 2012. According to CMS, the purpose of the requirement is "to assure that when states make the increased reimbursement to physicians, they have state plan authority to do so, and they have notified physicians of the change in reimbursement as required by federal regulations."