Payments For Services Furnished By Certain Primary Care Physicians and Charges For Vaccine Administration



The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirement of 42 CFR 447.205, gives notice of the following actions regarding payments for services furnished by certain primary care physicians and charges for vaccine administration under the Vaccines for Children Program.

Section 1202 of the Affordable Care Act, requires state Medicaid programs to pay designated primary care providers (PCPs) fees that are no less than the Medicare fee schedule in effect for 2013 and 2014 or the fee schedule rate that would result from applying the 2009 Medicare conversion factor, whichever is greater. These reimbursement requirements apply to payments made January 1, 2013 through December 31, 2014 for certain primary care and vaccine administration services. The provision applies to evaluation and management (E&M) services delivered by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine.  Managed care payments for 2013 and 2014 must be adjusted also to the extent that the capitation as of July 1, 2009 is less than the equivalent fee for service Medicare rate for certain E&M services.


The provision provides for payments to Nurse practitioners (NPs) and physician assistants (PAs) providing services under the supervision of a primary care physician and billing for those services under the supervising physician’s enrollment number by allowing NPs and PAs to qualify as PCPs for purposes of the increased payments.


The provision defines primary care services as any service described by the Current Procedure Terminology© (CPT) Evaluation and Management (E&M) codes 99201 through 99499 covered by Medicare, some additional E&M codes not covered by Medicare, and CPT vaccine administration codes 90460, 90461, 90471, 90472, 90473, and 90474.  The provision recognizes that some E&M codes describe services commonly provided to Medicaid members that are not covered by Medicare and specifically includes those codes as eligible for payment at what would be the Medicare rate if Medicare covered those services. The provision lists CPT codes 99381–99387, 99391–99397, 99401–99404, 99408, 99409, 99411, 99412, 99420, 99429, and 99441–99444 as eligible for increased payment even though these codes are not covered by Medicare.


Higher payments are not available for physicians who are reimbursed through a Federally Qualified Health Center (FQHC), Rural Health Center (RHC), or health department/clinic encounter or visit rate or as part of a nursing facility per diem rate.


Copies of this notice are available at each County Department of Health and Human services office and at www.scdhhs.govfor public review.  Additional information concerning this action is available upon request at the address cited below.

Any written comments submitted may be reviewed by the public at the Department of Health and Human Services, Division of Physician Services, 1801 Main Street, Columbia, South Carolina, Monday through Friday between the hours of 9:00 A.M. and 5:00 P.M.

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                                                Anthony E. Keck, Director

                                                Department of Health and Human Services

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