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Section 1202 Overview: Payment Increase for Medicaid Primary Care Physicians

PREPARING FOR THE MEDICAID PRIMARY CARE RATE INCREASE MARCH 30, 2011

Section 1202 ­ Payment to Primary Care Physicians Summary

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Section 1202 of the Affordable Care Act amends section 1902(a)(13) of the Social Security Act to require payment for certain evaluation and management (E & M) services and immunization administration services furnished in calendar years 2013 and 2014 by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine at a rate not less than 100 percent of the payment rate that applies to such services under Medicare. In the case of primary care services provided under Medicaid managed care plans for 2013 and 2014, the payment rates must be adjusted to be consistent with the equivalent fee for service Medicare rate. States will receive 100 percent FMAP for increased expenditures equal to the difference between the CY 2013 and 2014 Medicare rate and the State plan rate in effect on July 1, 2009 for these services.

Section 1202 ­ Payment to Primary Care Physicians

Implementation Issues : Eligible Providers and Services 3

Definition of the physicians eligible for payment at the Medicare rate Are services provided by family medicine, general internal medicine, and pediatric medicine subspecialists eligible for enhanced payment? Should enhanced payment be made for services billed using the physician provider number and provided under his/her supervision but actually rendered by a non-physician? Definition of services eligible for payment at the Medicare rate How should non Medicare reimbursed/covered services be treated? Should CMS specify the code set eligible under section 1202? Which release of the Medicare fee schedule should be used in CY 2013 and CY 2014?

Section 1202 ­ Payment to Primary Care Physicians Implementation Issues: Vaccine Administration 4

Section 1202 affects payment for services related to immunization administration for vaccines and toxoids for certain CPT codes or such billing codes as subsequently modified. In 2011 four billing codes (90465-90468) will be replaced by two codes (90460, 90461). Identification of the rate differential when codes have changed

· How should States identify the rate differential between the bundled

codes used in 2009 and the individual codes used in 2011 for the purpose of claiming 100% Federal financial participation (FFP)? · How does section 1202 payment interact with vaccine administration rate caps set for the Vaccines for Children (VFC) program?

Section 1202 ­ Payment to Primary Care Physicians Implementation Issues: Managed Care 5

Section 1202 also applies to payment for managed care services. States must identify the difference between the Medicare Part B rate and the managed care rate for primary care services in effect as of July 1, 2009. Identification of the managed care rate differential for the purpose of claiming 100% Federal financial participation (FFP) How should States measure the amount of 2009 capitation associated with section 1202 eligible providers and services to determine the rate differential for the purpose of claiming 100% FMAP?

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