Increased Payments for Primary Care Services in Medicaid Include Those Provided by Cardiologists

The Centers for Medicare and Medicaid Services (CMS) finalized a rule that will increase payments to certain physicians for evaluation and management services provided to Medicaid patients so that they will equal Medicare rates in the local area. In the current model, many Medicaid programs pay much lower rates than Medicare. Physicians eligible for this program include all subspecialties of internal medicine and pediatrics; therefore, cardiologists will be eligible to receive the increased rates. The ACC strongly supported this proposal earlier this year by pointing out the many facets of primary care provided by specialists to Medicaid patients. Because Medicaid programs are run by states, the implementation schedule and details will differ across the country. This provision of the Affordable Care Act is currently only funded for 2013 and 2014, but efforts to extend these payments are underway. Unlike normal Medicaid payments that are shared between the federal government and states, this additional funding will come entirely from the federal government. 

Physicians who are board certified in internal medicine or pediatrics or a subspecialty of either will automatically be eligible to receive the payments. There is also a pathway for non-board certified primary care physicians to qualify if their claims for the previous year show at least 60 percent of services billed are E&M services. Physicians will self-attest that they qualify under this alternative pathway.

The higher payments will apply to all evaluation and management codes, such as office and hospital visits, including those such as preventive services and some non- face-to-face services that Medicare does not cover if the state Medicaid plan covers those services. CMS will develop a fee schedule for the services Medicare does not cover. Payments for procedures and diagnostic tests will not be affected by this rule.

CMS elected to allow states flexibility about whether and when to change rates if Medicare payments change during the year. Physicians will most likely not begin to receive higher payments on Jan. 1 since states will have until March 31, 2013 to submit the necessary State Plan Amendment to CMS, but the payment increases will be retroactive. In addition, states will have the option of providing the increased payments as either an add-on to each payment or as a lump sum no less than quarterly.

The ACC will continue to monitor the implementation of this important change. We are very interested in hearing from members to learn if this requirement is being implemented as intended. Please contact

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