DEPARTMENT OF
PUBLIC WELFAREMedical Assistance Program Fee Increase for Select Primary Care Services [43 Pa.B. 105]
[Saturday, January 5, 2013]The Department of Public Welfare (Department) is announcing its intent to increase the fees for certain primary care services billed by enrolled qualifying physicians with a specialty designation of family medicine, general internal medicine or pediatric medicine recognized by the American Board of Physician Specialties (ABPS), the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA).
Background
Section 1202 of the Patient Protection and Affordable Care Act (Pub. L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L 111-152) (collectively ACA), requires state Medicaid programs to pay increased fees to qualifying physicians that are no less than the Medicare rates in effect in calendar years (CY) 2013 and 2014, or if greater, the rates that would be applicable in those CYs using the CY 2009 Medicare physician fee schedule (MPFS) conversion factor (CF).
The Centers for Medicare and Medicaid Services (CMS) published the final Federal regulation implementing section 1202 of the ACA at 77 FR 66670 (November 6, 2012).
States are required to increase fees for certain evaluation and management (E&M) and vaccine administration procedure codes to the extent covered by the State when furnished by a physician or under the personal supervision of a physician with a specialty designation of family medicine, general internal medicine or pediatric medicine. To qualify for the increased fees, physicians may self-attest to a specialty or subspecialty designation of family medicine, general internal medicine or pediatric medicine recognized by the ABPS, the ABMS or the AOA.
As set forth in 42 CFR 447.400(a) (relating to primary care services furnished by physicians with a specified specialty or subspecialty), the Department will pay the increased fees to physicians who self-attest to a specialty or subspecialty designation of family medicine, general internal medicine or pediatric medicine recognized by the ABPS, ABMS or AOA and to one or both of the following:
(1) Board certification with a specialty or subspecialty.
(2) Furnishing evaluation and management services and vaccine administration services that equal at least 60% of all Medicaid codes the physician billed during the most recently completed CY or, for newly eligible physicians, in the prior month.
The Department will provide additional information to physicians regarding the self-attestation.
The fee increase will apply to qualified physicians in the previously-stated specialties or subspecialties rendering primary care services to Medicaid beneficiaries in the Medical Assistance (MA) Program's fee-for-service (FFS), including ACCESS Plus and managed care delivery systems. Qualified physicians rendering services to non-Medicaid beneficiaries, such as, General Assistance MA beneficiaries, will be paid the current MA Program Fee Schedule rate; and physicians rendering services who do not qualify for the primary care fee increase will be paid the current MA Program Fee Schedule rate.
CMS, through enhanced Federal Medical Assistance Percentage (FMAP), will pay 100% of the rate in excess of the MA rate for the specified E&M and vaccine administration procedure codes in effect on July 1, 2009, for dates of service on January 1, 2013, through and including December 31, 2014. On January 1, 2015, the Department will revert back to paying the rates for the specified procedure codes listed on the MA Program Fee Schedule as of December 31, 2012.
Discussion
The Federal implementing regulation in 42 CFR 447.405 (relating to amount of required minimum payments) specifies that states pay physicians meeting the requirements in 42 CFR 447.400(a) for the specified primary care services based on one of the following options:
(1) The Medicare Part B fee schedule rate applicable to the site of service.
(2) The office setting rate adjusted for the specific geographic location of the service.
(3) The mean over all counties of the rate for each procedure code.
The Department has opted to set the increased fees, for the FFS including ACCESS Plus, and the managed care delivery systems, based on the mean over all counties of the rate for each procedure code as described as follows.
The Federal implementing regulation in 42 CFR 447.405 requires states to use the Medicare CF in effect at the beginning of CY 2013 or 2014, or the CY 2009 CF, if higher, to calculate the fee increase. As the CY 2009 CF is higher than the CY 2013 CF, the revised fees (referred to as follows as computed fees) will be calculated by adjusting the 2013 MPFS to reflect the higher CY 2009 CF, using the following formula:
Computed fee = (CY 2013 MPFS) ÷ (CY 2013 CF) × (CY 2009 CF)
(Note: this formula is used to substitute the 2013 CF for the 2009 CF)CMS has established two geographic location variations in this Commonwealth for purposes of Medicare payment. Pennsylvania Geographic Practice Cost Index (GPCI) 01 consists of Philadelphia, Bucks, Chester, Delaware and Montgomery Counties; GPCI 99 consists of the remaining 62 counties in this Commonwealth.
The previous calculation was completed for both GPCIs, GPCI 01 for the Philadelphia region and GPCI 99 for the rest of this Commonwealth, for the nonfacility fees. GPCI 01 and GPCI 99 were then blended at 50% each to create the statewide average fee, by procedure code using the following formula:
50% × (GPCI 01 computed fee for non-facility) + 50% × (GPCI 99 computed fee for non-facility) = Statewide average fee by procedure code
The Department uses the vaccine product procedure codes, not the specified vaccine administration procedure codes, for payment of the MA vaccine administration fee. CMS has advised states that the ACA provision does not require states to cover procedure codes that they did not previously cover. For this reason, the Department has sought clarification from CMS regarding whether the ACA requirement applies to its payment for vaccine administration and the methodology to compute the enhanced payment. To the extent the Department is required to make an enhanced payment for vaccine administration, the Department will calculate the enhanced payment consistent with 42 CFR 447.405.
Physicians will initially be paid using the current MA Fee Schedule fees. The Department anticipates the systems changes necessary to make payments at the increased fees will be completed in April 2013. Qualifying physicians who submit their self-attestation to the Department by March 1, 2013, will be paid the increased fee retroactive to January 1, 2013. Qualifying physicians who submit their self-attestation to the Department on or after March 2, 2013, will be paid the increased fee for dates of service beginning with the date the attestation is received by the Department.
The Department will also issue an MA Bulletin to provide further detailed information to physicians and will post the specified primary care services procedure codes covered by the MA Program and the corresponding primary care mean Statewide fees, self-attestation and other related information on the Department's web site.
Fiscal Impact
Due to the availability of 100% FMAP for these primary care services, the Department projects no fiscal impact in CY 2013 and 2104.
Public Comment
Interested persons are invited to submit written comments regarding this notice to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Deputy Secretary's Office, Attention: Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received within 30 days will be reviewed and considered in the development of the final notice. Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
GARY D. ALEXANDER,
SecretaryFiscal Note: 14-NOT-805. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 13-23. Filed for public inspection January 4, 2013, 9:00 a.m.]
