Provider Notice issued 03/04/13

Increased Payment for Primary Care Services

The purpose of this notice is to inform providers that the department is implementing the provision of the Affordable Care Act (ACA) included in section 1202 of the Health Care and Education Reconciliation Act of 2010, which provides increased payments for certain Medicaid primary care services provided by certain qualified primary care providers.

For dates of service January 1, 2013 through December 31, 2014, the department will apply an increased payment rate to enrolled practitioners for primary care services delivered by a primary care physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. The increased payments will apply to services reimbursed by Medicaid fee-for-service, Voluntary Managed Care Organizations and Integrated Care Program Health Plans.

Provider Eligibility

The providers defined as eligible to receive payment are:

• Physicians holding board certification from the American Board of Medical Specialties, the American Board of Physician Specialties or the American Osteopathic Association in pediatric medicine, internal medicine and family medicine and associated subspecialties, or

• Physicians who have furnished primary care services (see procedures on following page) that equal at least 60 percent of the Medicaid codes paid during the most recently completed calendar year, or for newly eligible providers, the prior month.

Primary Care Services

The eligible primary care services are evaluation and management codes (99201-99499) and vaccine administration codes (90460, 90461, 90471, 90472, 90473, and 90474). Since the department does not currently pay vaccine administration using the vaccine administration codes listed, a crosswalk of the department's current vaccine administration procedure codes will be submitted to the federal Centers for Medicare and Medicaid Services (CMS) for their approval with our State Plan Amendment (SPA).

Attestation Form

In order to receive the increased payments, physicians must self attest that they meet at least one of the criteria listed above. The department has created Form HFS 2352, Certification and Attestation for Primary Care Rate Increase for physicians use in self attesting. The HFS 2352 (pdf) is available on the Provider Enrollment Web page.

The department is reviewing the possibility of an online attestation process through the department's Medical Electronic Data Interchange (MEDI) system. Providers will be notified via an informational notice when the online attestation becomes available.

Board Certified Physicians Attestation

Complete and submit a signed HFS 2352 (pdf) attesting that you are currently a Board certified primary care physician with a specialty designation in family medicine, general internal medicine, or pediatric medicine, or a subspecialty recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS) or the American Osteopathic Association (AOA). A copy of the current board certification or verification must be submitted with the HFS 2352 (pdf).

60 % Attestation – Non Board Certified

Complete and submit a signed HFS 2352 (pdf) attesting that:

• You practice in a specialty or subspecialty of family medicine, general internal medicine and pediatric medicine; and

• At least 60% of your billings for services rendered were for E&M and vaccine administration codes during the most recently completed calendar year: or

• A newly enrolled physician at least 60% of your billings for services rendered were for E&M and vaccine during the previous calendar month.

Physicians meeting the criteria and wishing to participate must return the completed and signed HFS 2352 (pdf) and any additional documentation to the following address:

Healthcare & Family Services

Provider Participation Unit (PPU)

P. O. Box 19114

Springfield, Illinois 62794-9114

Once eligibility for this program has been approved, physicians will receive a new Provider information Sheet from the department identifying a new specialty code has been added to the provider database. Physicians, who do not receive a new provider information sheet within thirty (30) days of submittal to the department, may contact PPU by telephone at 217-782-0538 or by sending an e-mail to PPU.

Enhanced Rates for Primary Care

For providers identified as eligible for the rate increase, payment will be made on the qualified procedure codes at the Medicare Physician Fee Schedule rates for calendar year 2013 and 2014 or, if higher, the rate that would be applicable using the calendar year 2009 Medicare conversion factor.

The department has until March 31, 2013, to submit the SPA to CMS. Once the SPA is approved and necessary programming is completed, the department will begin reimbursing eligible providers at the increased rates. The increased rates will be paid as an "add-on" through an adjustment process, and the adjustment will be paid separately from the payment for the service.

The department will publish a separate fee schedule for the two-year rate increase, which will be located on the department's Web site under "Medicaid Reimbursements."

When providing services to a beneficiary who is eligible for both Medicare and Medicaid, enhanced payments will be at the full Medicare rate for CY 2013 and 2014 instead of the customary Medicaid maximum allowable amount.

Payment Schedule

The effective date of the enhanced payments for a physician will be based on the date that the Attestation Form (HFS 2352 (pdf)) is received by the department. The effective date for physicians for whom the Attestation Form is received by the department no later than June 30, 2013, will be January 1, 2013. After June 30, 2013, the effective date for the enhanced payments will be the date the Attestation Form is received by the department. The enhanced rates will be paid for services with dates of service on and after the effective date.

Further details regarding the increased payments will be released in the near future. Any questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa Eagleson, Administrator

Department of Medical Programs