Eligible Primary Care Physicians Get Medicaid Pay Increase

On May 7, the Texas Medicaid and Healthcare Partnership (TMHP) began issuing retroactive supplemental Medicaid payments for fee-for-service claims submitted by primary care physicians who qualify for the payment increase as authorized by the Affordable Care Act. Supplemental payments will be made weekly until TMHP has paid all retroactive eligible claims. Once caught up, TMHP will then make quarterly payments. 

ACA increased Medicaid payments to Medicare parity for evaluation and management and vaccine administration services provided by pediatricians, family physicians, and general internists, as well as each of their respective subspecialists. The higher payments, paid for entirely with federal funds, apply to claims submitted between Jan. 1, 2013, and Dec. 31, 2014. To receive the higher payments, physicians must attest to their eligibility.

Physicians who attested before April 1, 2014, are eligible for payments retroactive to Jan. 1, 2013. Those who attest after the deadline will receive supplemental payments only for claims submitted after April 1.

Rates were increased to the state fiscal years 2013 and 2014 adjusted Medicare rate for eligible services. Physicians will be paid the difference between the paid Medicaid amount and the minimum payment required under federal law. Federal regulations require Medicare and Medicaid to pay the "lesser of" physicians' billed charges or the allowable amount. The same regulation applies to the Medicaid primary care physician rate increase.  

  • If the physician's billed charges on the original claim are greater than or equal to the state adjusted Medicare rate, he or she may receive a supplemental payment. 
  • If the health professional's billed charges on the original claim are less than the state adjusted Medicare rate, no supplemental payment will be made. 

Earlier this year, Medicaid HMOs began issuing retroactive supplemental payments to eligible primary care physicians within their networks. Those initial payments excluded vaccine administration codes, as well as Texas Health Steps services provided in group practices. 

Beginning in late May or early June, HMOs also will issue retroactive payments for these services. At the same time, the HMOs will reconcile payments to physicians who received retroactive payments for the second quarter of 2013 but not the first quarter because of the timing of their attestation. The reconciliation process also is expected to resolve missing payments for erroneously excluded physicians or services. 

Direct any questions regarding supplemental payments for either HMO or fee-for-service claims to TMHP, the Texas Medicaid administrator, at (800) 925-9126. 

The state calculates the amount of supplemental payments owed to each physician based on HMO encounter data. The state sends the monies to the HMOs, which act as agents of the state and pass the monies along. HMOs are not involved in determining how much each physician should be paid.

Federal regulations prohibit both TMHP and the HMOs from charging an administrative fee to distribute the funds due to physicians. 

Action, May 16, 2014


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