As a result of the Patient Protection and Affordable Care Act (PPACA), Texas Medicaid will soon increase Medicaid payments to Medicare parity for select primary care services provided by primary care physicians (PCPs) and related subspecialists. The federal government will pay the entire costs associated with the fee increase, which will apply to services provided from Jan. 1, 2013, through Dec. 31, 2014.
To receive the higher payments, eligible physicians must submit a signed self-attestation form to the state’s Medicaid claims payer, the Texas Medicaid and Healthcare Partnership (TMHP). The state has not set a deadline for returning attestation forms but will do so in the coming months. Physicians who return the attestation form after the deadline will not be eligible for increases retroactive to Jan. 1, 2013 (though they will be eligible for higher payments through the end of 2014).
TMA strongly encourages eligible physicians to attest early to ensure the state receives all the necessary paperwork to qualify.
Who is eligible for the higher payments?
The PPACA specified the higher payments would go to PCPs practicing in pediatrics, family medicine, or general internal medicine. By rule, the Centers for Medicare and Medicaid Services extended the rate increase to the subspecialists of these three specialties as defined by the American Board of Medical Specialties (ABMS), American Board of Physician Specialties (ABPS), or American Osteopathic Association (AOA). (See complete list of eligible physician specialties.)
To qualify for the higher payments, physicians must practice in an eligible primary care specialty AND:
- Be board-certified in an eligible specialty, OR
- Attest that 60 percent of their Medicaid billings are for eligible evaluation and management (E&M) or vaccine administration CPT codes.
Are advanced practice registered nurses and physician assistants eligible for the higher payments?
Yes. The rate increase will apply to services provided by advanced practice registered nurses (APRNs) or physician assistants (PAs) practicing under physician supervision. APRNs or PAs who bill under their own Medicaid Texas Provider Identification (TPI) number will be paid at 92 percent of the Medicaid payment rate as per current Medicaid payment rules.
I am an OB-Gyn who provides primary care services. Am I eligible for the higher payments?
The PPACA provision relating to the fee increase did not encompass OB-Gyns.
An OB-Gyn may qualify for the higher payments if the physician certifies he or she is practicing as a primary care physician and 60 percent of his or her Medicaid billings are for eligible E&M or vaccine administration codes. (See the list of eligible codes.)
I am a board-certified pediatrician but practice in a subspecialty that is not identified as being eligible for higher payments. Since I am board-certified in pediatrics, am I still eligible for the higher payments?
There are two components of the eligibility requirement. First, a physician must be practicing in an eligible specialty. Then, the physician must attest that he or she is either board-certified in that specialty OR declare that 60 percent of his or her Medicaid billings are for eligible E&M and/or vaccine administration codes.
If the physician can attest to meeting the first and second parts of the eligibility requirements, then he or she will be eligible for increased payments.
I am a board-certified subspecialist, but I practice as a PCP instead. Am I eligible for the higher payments?
A physician who is board-certified in a non-PCP specialty, such as dermatology or neurology, but who practices as a primary care physician may qualify. The physician must attest that he or she is practicing primary care and meets the 60-percent billing threshold for E&M and vaccine administration codes.
I am not board-certified, but I estimate that 60 percent of the services I provide to Medicaid patients will qualify. How do I calculate the 60-percent threshold?
Calculate the 60-percent threshold by dividing the number of E&M and vaccine administration codes provided to Medicaid patients by the total number of Medicaid billings for the previous year.
New physicians who do not have a full year’s worth of billing are to attest that they will meet the 60-percent threshold.
What CPT codes are eligible for the higher payments?
E&M codes 99201 to 99499, including new and established patient preventive care codes and behavioral health counseling codes not covered by Medicare, are eligible; as are vaccine administration codes 90460, 90461, 90471, 90473, and 90474.
How long will the higher payments be in effect?
Two years. The higher payments will apply to eligible claims submitted from Jan. 1, 2013, through Dec. 31, 2014.
At the end of 2014, the higher payments will expire unless Congress extends payment beyond that date, or the Texas Legislature opts to make the payments using general state revenue.
What do I need to do to receive the higher payments?
Eligible physicians must complete and sign a self-attestation form posted on the TMHP website:
PCP Payment Increase Attestation Form
An attestation form must be completed for each individual physician Medicaid TPI number, such as for Texas Health Steps or multiple practice locations. A group practice may submit attestation forms on behalf of each individual physician within the practice but cannot attest as a group.
Do I need to complete an attestation form for each Medicaid HMO with which I participate?
No. You only need to attest for each individual Medicaid TPI number. TMHP will provide each HMO a list of the HMO’s network physicians who have attested.
Do I need to attest for services provided to children enrolled in the Children with Special Health Care Needs (CSHCN) program?
No. CSHCN is not a part of Medicaid (though a TPI is issued to participate). Thus, no attestation form is needed related to the CSHCN TPI number.
Many group practices use Certifacts for primary source verification, including to confirm board certification. Will the state accept documentation from Certifacts to verify a physician is board-certified or must an actual copy of the board certification be sent?
The practice may submit a copy of the Certifacts profile in lieu of an actual copy of the board certification.
What is the deadline for submitting a signed attestation form?
The state has not yet set a deadline but will impose one within the coming months, most likely in early September. Please regularly check the TMA website for updates.
How will I know if the state received my attestation form?
Texas Medicaid is in the process of developing a system to notify physicians when their attestation form has been received and processed. Additional details will be provided soon.
When will higher payments begin and how will they be made?
Texas anticipates beginning the higher payments in early fall. Eligible claims submitted prior to the implementation date will automatically be adjusted retroactively to Jan. 1, 2013, and paid in a lump sum. Thereafter, physicians will receive quarterly payments through the end of the two years.
Once payments begin, HMOs will disburse payments to network physicians for eligible services provided to their enrollees. TMHP will issue payments for services provided to fee-for-service enrollees.
Is the PCP payment increase linked to the state’s decision to forego Medicaid expansion to low-income adults as authorized by the PPACA?
No. Eligible physicians will be paid the higher fees regardless of whether Texas eventually expands Medicaid.
How will Texas ensure that payments are made only to eligible physicians?
Per the federal regulations, Texas Medicaid will conduct a random, statistically valid audit of physicians receiving the higher payments to ensure the physicians qualify.
If a physician attested to meeting the requirements but is found to not qualify, the state will recover the additional monies paid.
Will the higher payments also apply to Medicaid coinsurance payments for patients who qualify for both Medicare and Medicaid (dual-eligibles)?
Medicaid is responsible for paying the deductible and copayment for low-income Medicare patients known as “qualified Medicaid beneficiaries.” These patients’ low income makes them eligible for both Medicare and Medicaid. Current Texas Medicaid policy limits Medicaid’s portion of a dual-eligible patient’s coinsurance payment to the Medicaid allowable. Thus, if Medicare’s payment for a service exceeds what Medicaid will pay, no additional payment will be made toward the patient’s deductible or copayment. However, when Medicaid begins making the higher PCP payments, the amount Medicaid pays for an E&M service or vaccine administration code will be the same as what Medicare pays. Because Medicaid must pay up to the Medicaid allowable, it will be required to pay the full coinsurance for eligible codes for dual-eligibles for the two years the higher fees are in place.
- Current Medicaid policy:
An established dual-eligible patient visits physician office for routine visit. The 2013 Medicare deductible has been met. Physician bills Medicare CPT code 99213. The Medicare allowable is $69.06. Medicare pays $55.24, 80 percent of the allowable. Physician bills Medicaid for the remaining 20 percent. Medicaid allowable is $33.27. Because the Medicare payment exceeded the Medicaid allowable, no coinsurance will be paid.
- After implementation of the PCP payment increase:
An established dual-eligible patient visits physician office for routine visit. The 2013 Medicare deductible has been met. Physician bills Medicare CPT code 99213. The Medicare allowable is $69.06. Medicare pays $55.24, 80 percent of the allowable. Physician bills Medicaid for the remaining 20 percent. The Medicaid allowable, through the end of 2014, also is $69.06. Because the Medicare payment and the Medicaid allowable are the same, Texas will pay the balance of $13.82.
What is the difference in Medicaid versus Medicare payments?*
Review a comparision of Medicaid to Medicare payments for select office visit codes.
Where can I find more information?
TMA will send you updates on the fee increase in Action and post them on the TMA website. For additional help, call the TMA Knowledge Center at (800) 880-7955 or the TMHP Contact Center at (800) 925-9126.