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AAFP Summarizes Provisions of Medicaid/Medicare Parity Regulation
Web Page Provides Information on Program to Match Medicaid Payment Rates to Medicare
By News Staff
"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 AAFP has issued a summary of a final regulation that implements a provision in the health care reform law that brings Medicaid payment rates for certain primary care services and some preventive health services up to Medicare levels for the next two years.
- The AAFP summary distills the rule into digestible parts, explaining how the rule will affect family physician payment.
- In the summary, the AAFP also explains what physician groups qualify for the increased Medicaid payment.
- practicing physicians who self-attest they are board certified with a specialty designation of family medicine, general internal medicine or pediatric medicine;
- board-certified subspecialists whose (sub)specialty categories are recognized by the American Board of Medical Specialties, the American Osteopathic Association, or the American Board of Physician Specialties;
- physicians related to the specialty categories of family medicine, internal medicine or 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 and management (E/M) and vaccine administration codes; and
- advanced practice clinicians when their services are furnished under a physician's personal supervision.
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."