Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.
Frequently Asked Questions
Community clinics in my state (clinics other than Federally Qualified Health Center and Rural Health Clinic are reimbursed at the same rate as a physician. They do not receive a bundled or encounter rate. Are they eligible for the higher payment under CMS 2370-F? Would they have to attest that 60 percent of the services provided in the clinic are within the qualifying Evaluation & Management (E&M) codes? Are they required to pass through any increased payments in the form of higher wages for the health care professionals they employ?
Higher payment made under the requirements of the regulation is for physicians reimbursed pursuant to a physician fee schedule. Physicians working in a clinic and reimbursed through a physician fee schedule could qualify for higher payments if they are appropriately Board certified or if 60 percent of the services that he or she provides is for the specified primary care services. Since the clinic itself is not eligible, this percentage of services threshold cannot be based on the aggregate of all services provided by all practitioners within the facility, only on services the individual physicians.
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FAQ ID:94171
SHARE URLThe final rule under CMS 2370-F 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 dollars?
The 60 percent threshold is based on the number of billed services as identified by individual billing codes for the primary specialty being asserted. That is, the numerator equals total billed codes for Evaluation & Management (E&M) services for the primary specialty, plus vaccine administration services, and the denominator equals the total number of billed codes. Please note that a state may choose to use paid billing codes/services in place of billed codes.
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FAQ ID:93966
SHARE URLIf a physician does not provide an attestation by a date established by the State, can the State apply the increased payment under CMS 2370-F prospectively only (that is, to dates of services on and after the date of attestation)? If not, are we correct that 42 CFR 447.45(d)(1) applies such that the claim for additional reimbursement is not payable if the attestation is not received within 12 months of the date of service?
States can establish reasonable timeframes regarding the submission of attestations by physicians. We are aware that many states are experiencing delays in implementing the provisions of the regulation and we have also been made aware that there is considerable confusion on the part of providers regarding enrollment. We expect that states will provide physicians with ample notice of the procedures for enrollment that physicians will be given several months to comply with the requirements. If the state sets a reasonable timeframe, such as three months, and physicians do not enroll within that time, we believe that the state could make payment prospectively from the date of the physician's application as long as this policy is made clear to providers.
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FAQ ID:93981
SHARE URLDoes a physician have to self-attest under CMS 2370-F in 2014 as well as 2013? The rule does not indicate that the physician has to self-attest a second time and we don't want to do that, but some who qualified in 2013 (based on 2012 claims history) may not qualify in 2014 (based on 2013 claims history).
You are correct that the rule does not require the physician to submit a new self-attestation in 2014 although states could impose such a requirement. States can rely on the initial self-attestation for purposes of 2014 payments since we would not expect provider practices to vary significantly from year to year.
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FAQ ID:93991
SHARE URLWhat form must a physician use to self-attest and qualify for higher payment under CMS 2370-F under this provision?
Attestation forms are developed by the State Medicaid agencies. Physicians should contact their state Medicaid agency for information on the process for becoming eligible for higher payment in their state.
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FAQ ID:93996
SHARE URLWhile sports medicine is a subspecialty of internal medicine, it is also a subspecialty of non-primary care specialties? We would only qualify a physician for the board certification for the sports medicine subspecialty under CMS 2370-F when it is a subspecialty of internal medicine. Is this correct?
With respect to self-attestation, if a provider only meets the 60 percent threshold or only meets the Board certification under CMS 2370-F, would the provider only have to attest to that one component to be eligible or is it necessary to meet both components?
Physicians must first self-attest to a primary care designation of internal medicine, family medicine or pediatrics. This attestation signifies that the physicians consider themselves to be eligible specialty practitioners. The self-attestation must then indicate whether the physicians consider themselves to be qualified because of appropriate Board certification or practice history as represented by a 60 percent claims history. Some physicians may be appropriately Board certified and have a 60 percent claims history.
There may be physicians with Board certification in a specialty not recognized for higher payment under the rule who actually practice as pediatricians, family practitioners or internists who would be eligible for higher payment. For example, an Obstetrician/Gynecologist (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. Such a provider would need to qualify based on the 60 percent threshold and not Board certification. Physicians that support their initial self-attestation with an attestation of appropriate Board certification can qualify only if they actually have the appropriate Board certification. Practice habits would not be applicable.
There may also be physicians with Board certification in one of the three eligible specialty areas who do not actually practice in those areas. They should not self-attest to being a primary care provider.
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FAQ ID:94016
SHARE URLHow should a physician who is certified in internal medicine, family practice or pediatrics by a Board other than the ABMS, the AOA or the ABPS self-attest under CMS 2370-F?
We received the Deloitte Excel model but have been unable to open some of the files. Can you help?
CMS can produce the fee schedules for states that are unable to run the program. States should contact Christopher Thompson at Christopher.thompson@cms.hhs.gov.
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FAQ ID:94046
SHARE URLWhat federal matching rate will apply for services for which a higher payment is made under CMS 2370-F if the services also qualify for a higher FMAP under the provisions of section 4106 of the Affordable Care Act?
In qualifying states, certain United States Preventive Services Task Force (USPSTF) grade A or B preventive services and vaccine administration codes are eligible for a one percent FMAP increase under section 4106 of the Affordable Care Act (which amended sections 1902(a)(13) and 1905(b) of the Act). Some of these services may also qualify as a primary care services eligible for an increase in the payment rates under section 1202 of the Affordable Care Act. For these services the federal matching rate is 100 percent for the difference between the Medicaid rate as of July 1, 2009 and the payment made pursuant to section 1202 (the increase). The federal matching payment for the portion of the rate related to the July 1, 2009 base payment would be the regular Federal Medical Assistance Percentage (FMAP) rate, except that this rate would be increased by one percent if the provisions of section 4106 of the Affordable Care Act are applicable.
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FAQ ID:91076
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