Nebraska Medicaid Enhanced Primary Care Payments
1-1-2013 to 12-31-2014
****CMS has approved Nebraska Medicaid’s State Plan Amendment regarding paying primary care physicians an enhanced fee.*****
See new Frequently Asked Questions
Notifications to Providers
Attestation Form (updated 06-04-13)
Enhanced Primary Care Provider fee schedule
Information about the Enhanced Primary Care Payments
Effective January 1, 2013, certain physicians who provide eligible primary care services to Medicaid clients are eligible to be paid the Medicare rates in effect in calendar years (CY) 2013 and 2014 instead of their usual state-established Medicaid rates. The enhanced rate is available for providers who are fee for service providers with Nebraska Medicaid as well as eligible providers who are enrolled in the Nebraska physical health managed care program. This enhanced rate will only be available for the limited periods of the calendar years 2013 and 2014. At the end of this period, the enhanced federal funding for this program sunsets and the enhanced rate for Medicaid services will end.
The increased payments will pertain to primary care services delivered by a physician (MD or DO) with a specialty designation of family medicine, general internal medicine, or pediatrics. Physician Assistants (PA) who are supervised by a physician that is eligible for the enhanced rate are also eligible to receive the enhanced rate. The increase will apply to a specific set of services and procedures that Centers for Medicare & Medicaid Services (CMS) designates as “primary care services.”
In order to qualify for the enhanced rates, eligible enrolled Nebraska Medicaid providers must attest to being a primary care physician by one of the following:
Have furnished evaluation & management (E&M) and vaccines services (codes specified by federal regulation) that equal at least 60% of the Medicaid codes billed during the most recently completed fiscal year.
Eligible providers who may qualify for the enhanced rate must complete an Attestation Form to be submitted with the identified documentation to the Medicaid central office. The attestation form is listed above.
Providers can immediately begin sending forms and documentation to the following address:
DHHS- Medicaid and Long-Term Care
Enhanced PCP Rates
P.O. Box 95026
Lincoln, NE 68509-5026
Nebraska Medicaid is currently undergoing programming changes to the Medicaid Management Information System (MMIS) to implement these enhanced payments to primary care providers. Payments will not begin until after January 1, 2013. Implementation is contingent on completing the necessary system changes and approval by CMS of Nebraska Medicaid’s State Plan Amendment. Additional details regarding this initiative and its implementation will be provided in future bulletins.
This enhanced rate will only be available for the limited periods of the calendar years 2013 and 2014. At the end of this period, the enhanced federal funding for this program sunsets and the enhanced rate for Medicaid services will end.
To assist in delivery of information, a dedicated email address has been created for questions and answers specific to this program change. We will gather the questions and responses and place them on our website. The email address is: DHHS.EnhancedPCPRates@nebraska.gov.
When will the Enhanced Primary Care Payments Fee Schedule be published?
The Enhanced Primary Care Fee Schedule for attested providers will be published prior to when payments are ready to be made.
When will we begin receiving payments?
We are currently working with our IT staff to configure our MMIS system to make payments to attested providers on the enhanced primary care codes and adjust claims previously submitted which would qualify for the enhanced rate. Nebraska is anticipating the system will be ready by October 1, 2013.
Are APRN’s eligible for the enhanced primary care payments?
CMS clarified with the following information:
“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 the physician assumes professional responsibility for the services provided under his or her supervision. This normally means that the physician is legally liable for the quality of the services provided by individuals he is supervising. If this is not the case, the practitioner would be viewed as practicing independently and would not be eligible for higher payment.”
We have confirmed with the DHHS Licensure unit that the scope of practice for APRN’s is not in a supervising role nor does the physician assume professional responsibility or liability. Therefore, APRN’s do not qualify for the enhanced payments.
Acknowledgement of Attested Providers
Attested Providers (updated 11/23/15)
Board Certification Lists
Medicaid Managed Care Contractors for Physical Health
Provider Service line for information about general questions about the PCP reimbursement
United Healthcare Provider Service line for more specific contracting questions
CMS Final Rule:
Correction to final rule:
Q and A on Increased Medicaid Payments for PCPs
Q and A on Set II INcreased Payments for PCPs
Q and A on Increased Medicaid Payments for managed care
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