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PA Bulletin, Doc. No. 14-684



Medical Assistance Program Fee Increase for Select Primary Care Services

[44 Pa.B. 1949]
[Saturday, March 29, 2014]

 The Department of Public Welfare (Department) is announcing the methodology for determining the calendar year 2014 fees for payments for specified primary care services for physicians qualified to receive increased fees.


 Section 1202 of the Patient Protection and Affordable Care Act (Pub. L. No. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. No. 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 Department paid the increased fees in CY 2013 and will continue to pay the increased fee in CY 2014.

 As set forth in 43 Pa.B. 105 (January 5, 2013), 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 must have a specialty designation of family medicine, general medicine or pediatric medicine recognized by the American Board of Physician Specialties, the American Board of Medical Specialties or the American Osteopathic Association and have self-attested to board certification or meeting the 60% billing threshold for the certain primary care services.

 The fee increase applies 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 and managed care delivery systems. Qualified physicians rendering services to non-Medicaid beneficiaries, such as General Assistance MA beneficiaries and physicians rendering services who do not qualify for the primary care fee increase, will be paid the current MA Program Fee Schedule rate.

 The Centers for Medicare and Medicaid Services (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.


 The Federal implementing regulation in 42 CFR 447.405 (relating to amount of required minimum payments) requires states to use the Medicare CF in effect at the beginning of CY 2014, or the CY 2009 CF, if higher, to calculate the fee increase. As the CY 2009 CF is higher than the CY 2014 CF, the revised fees (referred to as follows as computed fees) will be calculated by adjusting the 2014 MPFS to reflect the higher CY 2009 CF, using the following formula:

 Computed fee = (CY 2014 MPFS) ÷ (CY 2014 CF) × (CY 2009 CF)

 (Note: This formula is used to substitute the 2014 CF for the 2009 CF.)

 CMS 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. In accordance with the requirements in 42 CFR 447.405, the Department will continue to pay the mean over all counties of the rate for each procedure code calculated as follows.

 (5 × GPCI 01 rate + 62 × GPCI 99 rate) / 67

 The Department will continue to pay qualifying physicians an enhanced rate of $23.14 per vaccine administration.

 Qualifying physicians will initially be paid using the current 2013 increased primary care services fees. The Department anticipates that the system changes necessary to make payments at the 2014 rate will be completed in April. Qualifying physicians who submitted their self-attestation to the Department by December 31, 2013, will be paid the increased fee retroactive to January 1, 2014. Qualifying physicians who submit their self-attestation to the Department on or after January 1, 2014, will be paid the increased fee for dates of service beginning with the date the self-attestation is received by the Department.

 The Department will issue a MA Bulletin to provide the specified primary care services procedure codes and the corresponding primary care mean Statewide fees for CY 2014 to physicians and will post the codes and fees on the Department's ACA Physician Fee Increases for Primary Care Services web site.

Fiscal Impact

 Due to the availability of 100% FMAP for these primary care services, the Department projects no fiscal impact in CY 2014.

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 for any subsequent revisions of the MA Program Fee Schedule. 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).


Fiscal Note: 14-NOT-856. No fiscal impact; (8) recommends adoption.

[Pa.B. Doc. No. 14-684. Filed for public inspection March 28, 2014, 9:00 a.m.]

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