Despite Lagging Implementation of Parity Provision, Physicians Will See Full Medicaid Payment Boost

Although many family physicians who see Medicaid patients are due for an increase in payment as of Jan. 1, they may not see those increased payments for a while. That's because most state Medicaid programs are not ready to implement the Medicaid/Medicare parity provision in the health care reform law that brings Medicaid rates for primary care services at least up to Medicare levels for the next two years.

The Patient Protection and Affordable Care Act requires states to submit a state plan amendment outlining how they will implement the parity provision -- whether they will make increased payments on a monthly or quarterly basis, for example. States have until March 31 to submit their plan amendments, and CMS then has 90 days to approve, disapprove or ask for more information about the plans. States are responsible for paying physicians retroactively to Jan. 1, however.

AAFP President Jeff Cain, M.D., of Denver, said the enhanced Medicaid rates (4-page PDF; About PDFs) will increase access to Medicaid services, resulting in higher quality and better controlled costs. "This is one part of the Affordable Care Act that helps primary care practices, improves payment rates and increases access to health care for the underserved," said Cain. "These are priorities for the AAFP."

CMS, meanwhile, has issued two new question-and-answer documents to help physicians and other stakeholders better understand the parity provision. One of the documents (7-page PDF; About PDFs) addresses implementation of the parity provision in the fee-for-service environment, and the other (2-page PDF) focuses on implementation within Medicaid managed care. By presenting the information in a question-and-answer format, CMS is addressing many of the questions the agency has received since publishing the final rule (33-page PDF) on the parity provision in early November.

The document that addresses the provision of primary care services within Medicaid fee-for-service explains who qualifies for the enhanced payments and what eligible physicians and other health care professionals need to do to obtain the enhanced payments.

"The statute specifies that higher payment applies to primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine or pediatric medicine," the document states. "The regulation specifies that specialists and subspecialists within those designations as recognized by the American Board of Medical Specialties, the American Osteopathic Association or the American Board of Physician Specialties also qualify for the enhanced payment."

According to the document, physicians are required to qualify for the increased payments by self-attesting that they are board-certified in family medicine, internal medicine or pediatrics, or they have to show that at least 60 percent of their billing for evaluation and management (E/M) codes is for primary care services.

The document poses and answers other questions as well. For example, it covers the 60 percent threshold for qualifying for the enhanced payment and whether that includes E/M codes and vaccine administration codes.

"The 60 percent threshold can be met by any combination of eligible E/M codes and vaccine administration codes," according to the document.

Another question in the managed care document asks whether managed care plans under contract with a state can use their own definitions of primary care health professionals and services for the purposes of complying with the rule.

"While we recognize that health plans may have unique definitions of primary care providers and services, the availability of the increased (payment) is limited to the scope of eligible primary care providers and primary care services as defined in (the) statute and implemented by this rule," the document states.