Pursuant to the Affordable Care Act (ACA) and 42 CFR 447, State Medicaid agencies are required to reimburse Primary Care Physicians with a specialty designation of Family Medicine, General Internal Medicine, or Pediatric Medicine or related pediatric sub-specialties, at parity with Medicare for specified Evaluation and Management (E&M) and Vaccine Administration services. On average, Medi-Cal reimbursement is at 51% of the Medicare rate for all services. Reimbursement for primary care is even lower, at 43%. In order to be eligible for enhanced payment, the physician rendering or supervising the service must personally attest to be the following: Physician, as defined in 42 CFR 440.50 with a specialty designation of Family Medicine, General Internal Medicine, or Pediatric Medicine or a sub-specialty within one of the specialties listed on the Medi-Cal’s website. …AND… Meet at least ONE of the following qualifications:

  • Board Certified in a specialty or sub-specialty recognized by the:
    • American Board of Medical Specialties, or
    • American Board of Physician Specialties, or
    • American Osteopathic Association.
  • At least 60% of total codes billed or paid for the most recently completed calendar year or for newly eligible physicians, the prior month, were for E&M (99201 – 99499) and Vaccine Administration (90460, 90461, 90471 – 90474, or their successors) services.
  • In order to see the bump in pay, providers must first attest to their eligibility. According to California’s Department of Health Care Services (DHCS), less than half of eligible providers have completed the brief self-attestation process as of September 24.

     → Attest Here ← 

    Although the regulations implementing the pay raise were released by the Centers for Medicare & Medicaid Services (CMS) in November 2012, DHCS is still awaiting approval of its State Plan Amendment, which details California’s proposed payment methodology for both fee-for-service and managed care payments. DHCS expects to receive approval soon and plans to implement the increase in late October. Once approved, the increases will be retroactive to January 1, 2013. The goal of the increase is to recruit more physicians to treat low-income patients who will be newly eligible for health coverage under the ACA. Under the ACA, primary care physicians will see their reimbursement rates raised to Medicare levels in 2013 and 2014. According to CMS, states must also incorporate the increased payment rates into their contracts with managed care plans so that primary care physicians contracting with Medi-Cal managed care plans see the higher rates. Physicians are encouraged to complete the attestation form, which is available on the Medi-Cal website. The attestation form must be completed online (paper copies will not be accepted). Medi-Cal managed care plans have the option of either using the DHCS online attestation system or developing their own attestation tools. It is anticipated that the managed care plans would utilize the DHCS attestation process as well. Physicians are encouraged to check with their Medi-Cal managed care plans to confirm, however. Reference: http://kff.org/medicaid/state-indicator/medicaid-to-medicare-fee-index/#map https://www.medi-cal.ca.gov/acaattest/certform1.aspx

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