Medicaid PCP Rate Increase and VFC Changes Information for Providers March 11, 2013

Affordable Care Act (ACA) primary care fee increase MD implementation vs. other states – policy differences Eligible services Eligible and ineligible providers MCO Responsibilities Importance of attestation – claiming Federal funds Next steps – provider responsibilities Resources and staying informed Overview 2 of 13

What? – As part of the ACA, all States must reimburse certain primary care practitioners at 100% Medicare rates for certain evaluation and management (E&M) and vaccine codes Why? – To encourage greater participation in Medicaid heading into Health Reform When? – Effective for dates of services January 1, 2013 through December 31, 2014 How? – Fee-for-service (FFS) Medicaid and managed care organizations (MCOs) will pay providers the increased rate as part of routine claims payment ACA Primary Care Fee Increase 3 of 13

Maryland is handling the Medicaid payment increase for E&M codes differently from every other state: o MD is paying the increased rate to most Medicaid providers who bill for these important primary care services, including specialists and nurse practitioners. o Providers will not have to attest before receiving the payment increase; however, Maryland still needs its primary care physicians to attest in order to claim federal funds. Maintain current methodology for billing Vaccines for Children (VFC) administration codes. Maryland Implementation vs. Other States 4 of 13

Eligible Services The following services are eligible for the increased rate: Current Procedural Terminology (CPT) E&M codes through o Maryland will pay the increased rate for previously covered codes within this range Vaccine Administration o Providers in Maryland must continue to bill for VFC administration using –SE modifier o Rate will increase to $23.28 o Maryland will not reimburse for vaccine administration for adults, maintaining current policy 5 of 13

Eligible Providers While Maryland Medicaid and MCOs will pay most providers billing eligible codes at the increased rate, Maryland can only claim federal matching dollars for physicians who meet the following criteria: Physicians with a specialty or subspecialty in family medicine, general internal medicine, or pediatric medicine; AND meet one of the following requirements: o Is Board certified as a specialist or subspecialist in family medicine, general internal medicine, or pediatric medicine from a qualifying Board*; OR o Attests that at least 60% of codes billed to Medicaid fee-for-service (FFS) and/or MCOs during last calendar year were for eligible E&M and/or VFC administration codes. *As recognized by American Board of Medical Specialties (ABMS), American Osteopathic Association (AOA) or American Board of Physician Specialties (ABPS) 6 of 13

Ineligible Providers The following providers are not eligible for the fee increase: Providers who submit specialty mental health claims through ValueOptions; Out-of-network specialists (contact MCO to find out how to join the network for higher rates) Federally Qualified Health Centers (FQHCs); Rural Health Clinics (RHCs); and Tribal health centers. 7 of 13

MCO Responsibilities MCOs are required to reimburse their panel providers, including in-network specialists, at least the 100% Medicare rate for eligible services. MCOs are also required to pay the 100% Medicare rate for: o Out-of-network primary care and self-referred providers delivering eligible services (e.g., school-based health centers, ER doctors) and o FQHCs providing services for Primary Adult Care (PAC) recipients. As necessary, the MCOs and the fee-for-service program will re-adjudicate provider claims for the increased E&M codes or VFC administration delivered between January 1 st, 2013 and mid-March to make sure providers receive the increased payment. 8 of 13

Drawing Federal Matching Funds Maryland only receives enhanced federal funds for eligible providers who self-attest that they meet the conditions on the previous slide. Provider Attestation The Department developed an online attestation form for all eligible physicians – it’s quick and easy! Attestation will ensure the State receives Federal match on eligible services. Providers need to submit their attestation by April 15 th. All primary care physicians, regardless of whether they bill MCOs and/or Medicaid fee-for-service, should use the Maryland online form. Providers need only self-attest once to receive the increase rate for services provided between January 1, 2013 and December 31, of 13

Why should you complete the self- attestation form? Again, Maryland only receives enhanced federal funds for providers who complete this form. In order to make sure the program doesn't have to cut other rates or services, we need as many primary care physicians as possible to complete the online Provider Attestation by April 15 th. Nurse Practitioners and physicians who practice a specialty other than family medicine, general internal medicine, or pediatric medicine do not need to complete the primary care attestation form in Maryland. 10 of 13

Next Steps for You Please complete the primary care self-attestation form online by April 15 th. You can find the form at: – Please share this link with other primary care colleagues. It is OK for your office assistant to complete this form on your behalf. –If you have more than 10 physicians in your practice and would like to complete an excel sheet with all information at once, please 11 of 13

Resources and Staying Informed If you would like to know more about the primary care fee increase, here are a few additional resources: Sign up for one of two webinars if you want to learn more: Friday, 3/29 from 11-12pm: Thursday, 3/21 from 10-11am: Go to for: Federal notices regarding ACA Section 1202 Transmittal PT re: PCP fee increase Physicians’ Services Fee Manual Physicians’ Fee Schedule 12 of 13

Additional Questions? For additional information on the PCP Fee Increase in Maryland, please 13 of 13