Fees for Primary Care Physicians under the Affordable Care Act


Increased Medicaid Payments for Primary Care

Effective with dates of service on or after January 1, 2013, the South Carolina Department of Health and Human Services (SCDHHS) will implement 42 CFR Part 438, 441, and 447, Increased Medicaid Payments for Primary Care.  This action implements the Affordable Care Act (ACA) requirement that increases payments to physicians with a specialty designation of family medicine, general internal medicine, pediatric medicine, and related subspecialists for specified primary care services and charges for vaccine administration under the Vaccines for Children Program.  Medicaid will reimburse primary care services at 100 percent of Medicare levels in Calendar Years (CY) 2013 and 2014, or, if greater, the 2009 Medicare payment rates. (CY is January 1 to December 31).  This minimum payment level applies to services rendered by these specified provider types who are paid fee-for-service or paid by Medicaid Managed Care Organizations (MCO).  The ACA does not provide continued funding for the enhanced reimbursement past 2014.  If there are no changes to the ACA regulations between now and January 1, 2015 the State will discontinue the enhanced reimbursement. 

The federal government delayed releasing regulations to the State until November 1, 2012 therefore SCDHHS anticipates making the enhanced payments to qualified providers by March, 2013 for Fee for Service (FFS) claims. Retroactive payments will be made to providers for dates of service beginning January 1, 2013. 

SCDHHS anticipates making its first payments to the MCOs for the enhanced payment late in the second quarter of 2013.  Once payments are made to the health plan the health plan will be responsible for the enhanced payments to each of the plan’s qualified providers.  SCDHHS is in the process of finalizing its attestation procedures for providers.  All providers, including providers only participating with MCOs, will need to attest with SCDHHS prior to receiving the enhanced reimbursement.  Retroactive payments will be made to providers for dates of service beginning January 1, 2013.

Primary Care Services Qualifying for Increased Payments

The ACA provision defines primary care services as those described by the Current Procedure Terminology© (CPT) Evaluation and Management (E&M) codes 99201 through 99499, and CPT vaccine administration codes 90460, 90461, 90471, 90472, 90473, and 90474.  Codes currently non-covered by SCDHHS within this range will not be covered for the enhanced reimbursement.  For codes within this range, currently reimbursed by SCDHHS, that do not have a Medicare fee schedule amount, SCDHHS will reimburse at the rate established through a special fee schedule to be developed by CMS.  This includes CPT codes 99381–99387, 99391–99397, 99401–99404, 99408, 99409, 99411, 99412, 99420, 99429, and 99441–99444.

While all vaccine administration codes are eligible for increased payments under the ACA provision, not all of these codes are used by SCDHHS to describe vaccine administrations to children covered by the Vaccines for Children (VFC) program.  SCDHHS will reimburse for the administration using the codes 90460 and 90461.  For vaccines provided under the VFC program, SCDHHS will reimburse at the lesser of the Regional Maximum Administration Fee or the Medicare fee schedule rate.  SCDHHS will process payments for codes included in the ACA provision as long as they are covered by the South Carolina Medicaid State Plan or included in a managed care contract.

Provider Qualification

To qualify for the enhanced rates, a physician must self-attest to his or her specialty designation of family medicine, general internal medicine, pediatric medicine or a subspecialty recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS) or the American Osteopathic Association (AOA).  Any of these physicians with one of the specialty designations must meet one of the following criteria:

  • Board certification and/or
  • Sixty (60) percent of all Medicaid services billed, or provided in a managed care environment in CY 2012 are for E&M codes 99201-99499 and vaccine administration codes 90460, 90461, 90471, 90472, 90473 and 90474.

Physicians located in North Carolina and Georgia within a 25 mile radius of the border who meet the requirements above must also self-attest with SCDHHS to qualify for the increased payment. 

The provision provides for increased payments for primary care services furnished by a nurse practitioner or a physician assistant under the personal supervision of a physician who is one of the primary care specialties or subspecialty types designated in the regulation.  Physicians will be required to attest for the nurse practitioners and/or physician assistants under his/her supervision who would qualify for the increased payments.

All providers, both providers participating with Medicaid FFS and those only participating with MCOs will need to register with SCDHHS and then complete the Primary Care Provider Attestation form to become eligible to receive the enhanced primary care reimbursement rates.  A registration portal will be available beginning January 18, 2012 at www.scdhhs.gov/physicianattestation.  All providers registered prior to February 28, 2013 will receive retroactive payments to January 1, 2013.  Providers enrolled after February 28, 2013 will receive the enhanced reimbursement from the date of enrollment forward from both FFS and MCOs.

This enhanced payment provision does not apply to Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC), Health Departments, and clinics, paid on an encounter or visit rate, or to nursing facility services paid a per diem rate.  

In CY 2013 or 2014, newly enrolled, non-board certified physicians in one of the designated specialties are eligible if they attest to meeting the 60 percent threshold in the prior month.  Providers who are board certified can also attest at the time of enrollment.

Physicians currently enrolled in the SCDHHS Pediatric Sub-Specialty program should not attest for inclusion into this payment methodology.  Attesting will effectively reduce your payment amount for the above referenced evaluation and management codes.

As required by federal regulation, at the end of CY 2013 and CY 2014, SCDHHS will conduct an audit that includes a statistically valid sample of physicians receiving the temporary increased payments to verify that they are either board certified in an eligible specialty or that 60 percent of claims billed are for eligible Medicaid services.  Payments will be recouped from any physicians identified as having not met these requirements.  A similar verification process will be conducted for the MCOs.

This bulletin applies to fee-for-service, medical homes networks and MCOs.  If you have any questions regarding this bulletin, please contact the Provider Service Center at (888) 289-0709.  Thank you for your continued support of the South Carolina Healthy Connections Medicaid Program.

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