Medicaid Fee Hike Requires Eligibility Confirmation

Primary care physicians who treat Medicaid patients will receive fee increases for 2013 and 2014 under the Patient Protection and Affordable Care Act, but only if they sign an attestation form confirming they're eligible for the raise, state officials say.

Although the state received the final federal rules too late to begin the higher payments on Jan. 1, the Texas Medicaid & Healthcare Partnership (TMHP) will make retroactive payments to that date. The state anticipates beginning payments in midsummer.

Under federal rules, physicians will qualify for the rate increase if:

  • They practice family medicine, general internal medicine, pediatrics, or a subspecialty within those designations recognized by the American Board of Medical Specialties, the American Osteopathic Association, or the American Board of Physician Specialties, and
  • They are board certified in an eligible specialty or subspecialty designation and practice in primary care, or more than 60 percent of the services they provide are primary care services eligible for the rate increase. Specifically, the increase will apply to evaluation & management codes 99201 through 99499 and vaccine administration codes 90460, 90461, 90471, 90472, 90473, and 90474. Preventive care codes for new and established patients also will be included in the increase even though Medicare does not cover them.

New physicians with no history of Medicaid billings can attest that 60 percent of their Medicaid billing will be for primary care services, the Texas Health and Human Services Commission (HHSC) said.

HHSC has not yet set a deadline for filing the attestation form but says it will continue to keep physicians informed of the timeline. However, TMA encourages physicians to complete and return the form as soon as possible.

The higher payments will benefit physicians who participate in both Medicaid fee-for-service and Medicaid HMO plans, says Helen Kent Davis, director of government affairs for TMA. Further, the rate increase will significantly help those physicians hurt by the cut in payment for the Medicare Part B coinsurance enacted in 2012. Currently, for those patients, Texas will not pay the 20-percent coinsurance if what Medicare pays is more than the Medicaid allowable for the same services. However, once the rate increase takes effect, eligible physicians will be paid the full coinsurance because the Medicare and Medicaid allowable for the service will be the same.

Payments for eligible services provided by physician assistants or advanced practice nurses also will increase if patients receive the service under physician supervision. If midlevel providers bill under their own Medicaid numbers, they will be paid 92 percent of the higher rate, the same discount that applies to their services today.

For more information, call the TMHP Contact Center at (800) 925-9126.


Action, May 1, 2013


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    Provision for expanding the increased reimbursement for the care of Medicaid patients with dermatological problems is needed because there are some horrible life threatening diseases that initially present as dermatological findings. With very few exceptions there are no pediatric dermatologists that see only or mostly Medicaid patients so exceptions must be made to allow for the increased payments to them.

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