Frequently Asked Questions Medicaid Enhanced Payments for Primary Care Providers 1. Are Medicare Part B claims eligible for the enhanced rate? No 2. Are Nurse Practitioners that are not supervised by a physician on site eligible for the enhanced payment? The enhanced payments are for physicians. Per CMS, it may not be permissible to attest as a nurse practitioner if the supervising physician is not on site. 3. Does the affiliation of a provider to a group/organization affect attestation for enhanced payment? No, eligibility is based on the provider’s taxonomy within the NCTracks provider record. 4. There was a Webinar on ACA payments, where can I find it? The slides and the audio are available on the seminars page of the Division of Medical Assistance (DMA) website at www.ncdhhs.gov/dma/provider/seminars.htm. The direct link is www.ncdhhs.gov/dma/provider/ACA_Payments_030514.ppt. 5. Where is the pseudo fee schedule used for the enhanced payment? The ACA Pseudo Medicare Fee Schedule can be found at www.ncdhhs.gov/dma/fee/. 6. I don’t see a code that Medicare paid for on the pseudo schedule; will I be paid for that code? All of the codes listed on the Pseudo Medicare Fee schedule will be paid at the enhanced rate, unless Medicaid does not cover that code/service. 7. Do I have to attest in 2014 if I attested in 2013? No, if you successfully attested in 2013 you do not need to attest again in 2014. 8. How are attestations validated for eligibility? Attestations are validated based on information in your NCTracks provider record. Providers should review their record and ensure their correct taxonomy is listed. Updated 4-30-14 9. I received the enhanced payment and then it stopped. What should I do? Review your NCTracks provider record to ensure your taxonomy is correct and has not been end-dated. 10. I just attested, what is the effective date for the enhanced payment? The effective date for the enhanced payment is the date of your successful attestation. Attestations for retroactive payments to January 1, 2013 expired on June 30, 2013. 11. Will the payment be backdated to January 1, 2013? For example, if I attest today, will the payments be effective the date of the attestation or January 1, 2013? Payments will be paid for dates of service effective January 1, 2013 and later if the eligible provider attested on or before June 30, 2013. Retroactive pay only applies to providers who attested by June 30, 2013.   12. Is there a Website where I can find accurate information about this program applicable to all states? Yes, that Website is found at http://www.medicaid.gov/AffordableCareAct/Provisions/Downloads/Q-andA-ManagedCare-Increased-Payments-for-PCPs.pdf 13. When will providers know if their attestation was successful? Providers will be able to check the status of their attestation within 5-10 business days. 14. Can providers receive ACA Enhanced Rate Payments for services provided to N.C. Health Choice (NCHC) beneficiaries? Providers are not eligible to receive ACA Enhanced Rate Payments for services provided to State Children’s Health Insurance Programs (SCHIP)/N.C. Health Choice (NCHC) beneficiaries. A system change has been implemented to eliminate any future ACA Enhanced Rate Payments for services provided to SCHIP/NCHC recipients. Prior ACA Enhanced rate payments made to providers for SCHIP/NCHC beneficiaries will be recouped at a future date. Providers will be notified prior to the recovery. DMA is working with CSC to review ACA Enhanced Rate Payments to ensure compliance with the final rule. 15. Medicaid Provider Numbers (MPN) are no longer issued. What should providers do when the attestation process asks for an MPN? As of July 1, 2013, providers who enroll in Medicaid are no longer issued a Medicaid Provider Number. Providers who began their N.C. Medicaid participation after July 1 Updated 4-30-14 should enter first seven digits of NPI under the MPN box and all 10 digits of the NPI under NPI box. 16. How can providers know what the payment is for? Will there be an itemized statement by beneficiary? The enhanced payment will show on the Remittance and Status Report (RA) as a separate line item. 17. How will States and providers know which primary care services will be paid at the higher rate? The regulation at 42 CFR 447.000(c)(1) and (2) specifies Evaluation and Management (E&M) codes 99201 through 99499 and vaccine administration codes 90460, 90461, 90471, 90472, 90473, or their successor codes. 18. Does the 60 percent threshold include both E&M codes and vaccine administration codes? Yes. The 60 percent threshold can be met by any combination of eligible E&M and vaccine administration codes.   19. The Affordable Care Act specifies increased payments for three primary care medical specialties: Family Medicine, General Internal Medicine and Pediatrics. The Final Rule interprets this language to include some subspecialties with a relation to the original three, but does not list the subspecialties. Please identify the subspecialists eligible for higher payment.   Subspecialists that qualify for higher payment are those listed under Family Medicine, General Internal Medicine and Pediatrics as recognized by the American Board of Medical Specialties (ABMS), American Board of Physician Specialties (ABPS) or American Osteopathic Association (AOA). For purposes of the rule, “General Internal Medicine” encompasses “Internal Medicine” and all recognized subspecialties under that heading. The Websites of these organizations currently list the following subspecialty certifications within each specialty designation: • ABMS • Family Medicine – Adolescent Medicine; Geriatric Medicine; Hospice and Palliative Medicine; Sleep Medicine; Sports Medicine. Updated 4-30-14 • • Internal Medicine – Adolescent Medicine; Advanced Heart Failure and Transplant Cardiology; Cardiovascular Disease; Clinical Cardiac Electrophysiology; Critical Care Medicine; Endocrinology, Diabetes and Metabolism; Gastroenterology; Geriatric Medicine; Hematology; Hospice and Palliative Medicine; Infectious Disease; Interventional Cardiology; Medical Oncology; Nephrology; Pulmonary Disease; Rheumatology; Sleep Medicine; Sports Medicine: Transplant Hepatology. • Pediatrics – Adolescent Medicine; Child Abuse Pediatrics; Developmental-Behavioral Pediatrics; Hospice and Palliative Medicine; Medical Toxicology; Neonatal-Perinatal Medicine; Neurodevelopmental Disabilities, Pediatric Cardiology; Pediatric Critical Care Medicine; Pediatric Emergency Medicine; Pediatric Endocrinology; Pediatric Gastroenterology; Pediatric Hematology-Oncology; Pediatric Infectious Diseases; Pediatric Nephrology; Pediatric Pulmonology; Pediatric Rheumatology, Pediatric Transplant Hepatology; Sleep Medicine; Sports Medicine. AOA o Family Physicians – No subspecialties o Internal Medicine – Allergy/Immunology; Cardiology; Endocrinology; Gastroenterology; Hematology; Hematology/Oncology; Infectious Disease; Pulmonary Diseases; Nephrology; Oncology; Rheumatology. o Pediatrics – Adolescent and Young Adult Medicine, Neonatology, Pediatric Allergy/immunology, Pediatric Endocrinology, Pediatric Pulmonology. • ABPS The ABPS does not certify subspecialists. Eligible certifications are: o American Board of Family Medicine Obstetrics o Board of Certification in Family Practice, o and Board of Certification in Internal Medicine. There is no APBS certification specific to Pediatrics. Physicians with a certification in Family Medicine Obstetrics are certified first in family medicine with additional certification in obstetrics. They practice as family practitioners and, therefore, can self-attest to a qualified specialty. This is not true of individuals certified in obstetrics by either the ABMS or AOA. Such specialists do not qualify for higher payment. Updated 4-30-14   20. Would Board certified “general surgeons” qualify for higher payment if they actually practice as general practitioners? The statute specifies that higher payments apply to primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. The regulation specifies that specialists and subspecialists within those designations – as recognized by the American Board of Medical Specialties (ABMS) the American Osteopathic Association (AOA) or the American Board of Physician Specialties (ABPS) – also qualify for the enhanced payment. Under the regulation, “general internal medicine” encompasses “internal medicine” and all subspecialties under that heading which are recognized by the ABMS, ABPS and AOA. In order to be eligible for higher payment physicians must: 1) Self-attest to a covered specialty or subspecialty designation. 2) Specify that they are either: a. Board certified in an eligible specialty or subspecialty and/or, b. 60 percent of their Medicaid claims for the prior year were for the E&M codes specified in the regulation. It is quite possible that physicians could qualify on the basis of both Board certification and claims history. Physicians only qualify if they can legitimately self-attest to a specialty designation of (general) internal medicine, family medicine or pediatric medicine or a subspecialty within those headings as recognized by the American Board of Physician Specialties (ABPS), American Osteopathic Association (AOA) or American Board of Physician Specialties (ABPS). It is possible that a physician might maintain a particular qualifying Board certification but might actually practice in a different field. A physician who maintains one of the eligible certificates, but actually practices in a non-eligible specialty should not self-attest to eligibility for higher payment. However, a physician who is board certified in a non-eligible specialty (for example, surgery or dermatology) who practices within the community as a primary care physician (such as a family practitioner) could self-attest. Such a provider would need to attest based on both a specialty designation of family medicine, internal medicine or pediatric medicine and a supporting 60 percent claims history. In either case, should the validity of that physician’s self-attestation be reviewed by the state as part of the annual statistical sample, the physician’s payments would be at risk if the state finds that the attestation was not true or accurate.   Updated 4-30-14 21. If a provider only meets the 60 percent threshold OR only meets the Board certification, could the provider attest to that one component or is it necessary to meet both components in order to be eligible? First, the physician must self-attest to a primary care designation of internal medicine, family medicine or pediatrics. This attestation signifies that physicians consider themselves to be eligible specialty practitioners. Physicians must then indicate whether they consider themselves qualified because of appropriate board certification OR practice history as represented by a 60 percent claims history. Some physicians may be both appropriately board certified and have a 60 percent claims history. There may be physicians with board certification in specialties not recognized for higher payment under the rule but who actually practice as pediatricians, family practitioners or internists. As an example, an OB/GYN who no longer practices in that specialty but practices as a family practitioner could appropriately self-attest to being a Primary Care Provider (PCP). Such a provider would need to qualify based on the 60 percent threshold rather than Board certification. Physicians who support their initial self-attestation with attestations of appropriate Board certification, can qualify only if they actually have the appropriate Board certification. Actual practice activities are not be applicable. 22. The final rule clarifies that the 60 percent threshold for eligibility is based on services billed. Are billed services to be defined based on the number of units submitted or dollar amounts billed? The 60 percent threshold is based on the number of billed services as identified by individual billing codes for the primary specialty being asserted. The threshold is based on a fraction in which the numerator equals total billed codes for E&M services for the primary specialty, plus vaccine administration services, and the denominator equals the total number of billed codes.   23. With respect to the use of board certification to confirm a physician’s selfattestation, must the physician’s board status be current or is initial board certification sufficient? The certification must be current. If it has lapsed but the physician still practices as an eligible specialist the self-attestation would need to be supported with a 60 percent claims history. Updated 4-30-14   24. Can mid-level/non-physician practitioners such as nurse practitioners receive the higher payment? The final rule specifies that services must be delivered under the Medicaid physician services benefit. This means that higher payment also will be made for primary care services rendered by practitioners working under the personal supervision of a qualifying physician. The rule makes clear that, while deferring to state requirements regarding supervision, the expectation is that physicians assume professional responsibility for the services provided under their supervision. This normally means that physicians are legally liable for the quality of the services provided by individuals they are supervising. If this is not the case, the practitioner would be viewed as practicing independently and would not be eligible for higher payments. 25. I am having trouble attesting for mid-level providers. Please advise. The problem may be that the supervising physical has not successfully self-attested. Midlevel providers should enter their supervising physicians’ Provider Number and NPI first to see if their supervisors have successfully attested. Only then can midlevel providers enter their own Provider Numbers and NPIs for attestation. 26. We have a total of 59 hospitalists in our hospital - what if I attest for a provider that doesn't qualify? The system will validate the qualifying ACA providers and reject the ones that are not qualified based on type and specialty. You can check the status of your attestation on the following State Business day after submission. Simply resubmit the form as if you are planning to self-attest. You should receive a reply which states “Attestation Successful” and “You successfully attested on (date) and (time).” A list of state holidays can be found here: www.ncdhhs.gov/dma/provider/2013_State_Holiday_Schedule.pdf Updated 4-30-14