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Provider Eligibility


Provider Eligibility


Dr and child

Eligible providers, or Medicaid Eligible Professionals (EP) include:

  • Physicians (MD, DO) - Doctor of Medicine and Doctor of Osteopathy (Pediatricians have special eligibility and payment rules)

  • Nurse Practitioners (NP), including Nurse Practitioner Nurse-Midwives

  • Dentists

  • Physician Assistants (PA) in certain settings*

To be eligible, providers must meet one of the following requirements:

  • Have a minimum 30% Medicaid patient volume (20% for pediatricians) and not be hospital-based. This means at least 30% of services were furnished to Medicaid patients. Hospital-based providers perform 90% or more of their services in an inpatient hospital or emergency room setting.
     
  • Practice predominantly in an FQHC or RHC and have a minimum 30% needy individual patient volume. This means at least 30% of your services were furnished to needy individuals.**

Determining Patient volume:

Providers must have at least 30% Medicaid patient volume (20% for pediatricians) calculated at the individual provider or the group/clinic level. The method to calculate patient volume has changed for program years 2013 and beyond. Medicaid patient volume is calculated using the following formula:


Total Medicaid patient encounters*
Total patient encounters*

*In any representative 90-day period in either the prior calendar year or within the 12 month time frame directly preceding the application date.

 

A Medicaid encounter means services rendered to an individual on any one day where the individual was enrolled in a Medicaid program (or a Medicaid demonstration project approved under the Social Security Act section 1115) or Children’s Health Insurance Program (CHIP) as part of a Medicaid expansion, at the time the billable service was provided.

 

Please note: Oregon's CHIP is not part of Medicaid Expansion so only Medicaid encounters are applicable to that portion of the calculation.  However, the Oregon Health Plan (OHP) includes funding for both Medicaid and CHIP.  Because providers cannot differentiate between the two funding streams, providers must reduce all OHP encounters by 4.4%.  This is Oregon's statewide rate of CHIP encounters (aka "CHIP proxy").  The CHIP proxy is calculated by taking the total OHP encounters for the selected 90-day period and multiplying that number by .956 as shown below.​

 ​

Total Medicaid patient encounters = (Total OHP encounters) x .956​​​​

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Group/Clinic Patient Volume Option: If you are part of a practice or clinic, the patient volume may be calculated on a group level which means the encounters for all practitioners (eligible and non-eligible providers) in a group practice are used to determine patient volume. You will need to individually demonstrate meaningful use of certified EHR technology after your first year and will be eligible for one incentive payment each year, regardless of the number of practices or locations.

 

**Only if you work predominantly in an FQHC or RHC may you use "needy individuals" in the patient volume calculation. To be considered a provider who works predominantly in an FQHC/RHC, over 50 percent of your total patient encounters over a period of six months in either the most recent calendar year or the 12-months directly preceding the application date, must occur at a FQHC/RHC location. Determine whether you practice predominantly by using this worksheet.
 


**Needy individuals include all of the following:

  • Person who is receiving assistance under Title XIX (Medicaid);
  • Person who is receiving assistance under Title XXI (CHIP);
  • Person who is furnished uncompensated care by the provider;
  • Person for whom charges are reduced by the provider on a sliding scale basis based on the individual's ability to pay

The needy individual formula is calculated as:


Total needy patient volume
Total patient encounters

Find out if you are eligible using the CMS Flow Chart or Interactive Tool

EHR EP Decision tool
EHR EP Decision tool

Note: For full effect, play slideshow

Physician Assistants

* Physician Assistants who meet one of the following:

  1. Is the primary provider in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC). (e.g., when there is a part-time physician and full-time PA, the PA is considered to be the primary provider)
  2. Is a clinical or medical director at an FQHC or RHC
  3. Is an owner of an RHC
  • FQHCs: are federally-designated "safety net" providers such as community health centers, public housing centers, outpatient health programs funded by the Indian Health Service, and programs serving migrants and the homeless. The main purpose of the FQHC Program is to enhance the provision of primary care services in underserved urban and rural communities.
     
  • RHCs: are federally-designated clinics to provide care in underserved areas, and therefore, receive cost-based Medicare and Medicaid reimbursements.

Medicaid vs Medicare 
Provider Incentive Amount