CMS clarifies specifics of increased Medicaid payment eligibility
- Copyright © 2012, The American Academy of Pediatrics
The Center for Medicare and Medicaid Services (CMS) on Friday clarified specifics related to the increased Medicaid payment eligibility for primary care physicians, including information about how certain subspecialists may qualify under the Affordable Care Act.
The federal government will begin funding a two-year increase in Medicaid payment rates for certain primary care and immunization services as part of the new federal health care law. Many pediatricians will qualify for increased payments when utilizing the covered billing codes.
CMS released updated information Friday about which subspecialists may qualify under the new rules. Subspecialists will qualify for the new payments if they are either board certified in an eligible specialty or subspecialty and/or if 60 percent of their Medicaid claims for the prior year were for E&M (evaluation and management) codes specified under the rule. Physicians may qualify on the basis of both board certification and claims history.
Physicians who self-attest to a specialty designation of (general) internal medicine, family medicine or pediatric medicine or a subspecialty within those areas may qualify for the increased payments, according to CMS. Physicians who fall into those categories must also be recognized by the American Board of Medical Specialties (ABMS), American Board of Physician Specialties (ABPS) or American Osteopathic Association (AOA). “General internal medicine” encompasses “internal medicine” and all recognized subspecialties, according to CMS.
A physician who maintains one of the eligible certificates but actually practices in a non-eligible specialty should not self-attest to eligibility for higher payment. But a physician board-certified in a non-eligible specialty who self-attests to practicing within one of the covered areas and meets the 60 percent claims history may qualify for the increased payments, CMS said.
The 60 percent threshold can be met by any combination of eligible E&M and vaccine administration codes. Qualifying subspecialties are:
Family Medicine – Adolescent Medicine; Geriatric Medicine; Hospice and Palliative Medicine; Sleep Medicine; Sports Medicine.
Internal Medicine – Adolescent Medicine; Advanced Heart Failure and Transplant Cardiology; Cardiovascular Disease; Clinical Cardiac Electrophysiology; Critical Care Medicine; Endocrinology, Diabetes and Metabolism; Gastroenterology; Geriatric Medicine; Hematology; Hospice and Palliative Medicine; Infectious Disease; Interventional Cardiology; Medical Oncology; Nephrology; Pulmonary Disease; Rheumatology; Sleep Medicine; Sports Medicine: Transplant Hepatology.
Pediatrics – Adolescent Medicine; Child Abuse Pediatrics; Developmental-Behavioral Pediatrics; Hospice and Palliative Medicine; Medical Toxicology; Neonatal-Perinatal Medicine; Neurodevelopmental Disabilities, Pediatric Cardiology; Pediatric Critical Care Medicine; Pediatric Emergency Medicine; Pediatric Endocrinology; Pediatric Gastroenterology; Pediatric Hematology-Oncology; Pediatric Infectious Diseases; Pediatric Nephrology; Pediatric Pulmonology; Pediatric Rheumatology, Pediatric Transplant Hepatology; Sleep Medicine; Sports Medicine.
CMS has a detailed question-and-answers document for review, including a complete list of the ABPA and AOA specialties covered, at http://www.medicaid.gov/State-Resource-Center/Frequently-Asked-Questions/CMCS-Ask-Questions.html. Physicians also can email questions to CMS at .
The AAP has detailed information about the changes at http://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/access-to-care/Pages/Access-to-Care-Medicaid-for-children.aspx. Physicians can also check a summary at http://aapnews.aappublications.org/content/33/12/5.1.full.
To review the complete text of the Medicaid final rule, click http://www.gpo.gov/fdsys/pkg/FR-2012-11-06/pdf/2012-26507.pdf.