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Primary care reimbursement changes under the Affordable Care Act
 
Providers, plans and partners:
Read our fact sheet and questions and answers
​​​Find out what these federal changes mean for primary care practitioners who serve OHP members.

Learn the basics about the federal primary rate increase

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Answer
Wbat do providers need to do to qualify for the 2013-2014 federal primary care rate increase?

Please attest using the secure attestation form. Only providers who attest using this form will qualify for the increased FFS rate.

Providers who do not attest will not qualify for the increased FFS rate.

Please Note: Providers who only bill an OHP health plan, but not DMAP, must attest with the health plan.
When will DMAP apply the 2013-2014 primary care rate increase?

DMAP will apply the FFS federal primary care rates based on the dates qualified providers submit their attestations. Only services rendered on or after Jan. 1, 2013 qualify for the new rates:

Attestation submitted
Increased FFS rate will apply to
qualifying services rendered on or after:
Jan. 1 to Mar. 31
Jan. 1
Apr. 1 to June 30
Apr. 1
July 1 to Sep. 30
July 1
Oct. 1 to Dec. 31
Oct. 1

Note: DMAP began paying the FFS federal primary care rates in early July. We are planning to reprocess additional eligible claims to retroactively pay the federal rate increase (details to be determined). 
Which provider types are eligible for the 2013-2014 primary care rate increase?

Physicians with a specialty designation of family medicine, general internal medicine, or pediatric medicine; or

Nurse practitioners and physician assistants billed through, and working under the supervision of, a qualified physician.

Where can OHP health plans learn more about the 2013-2014 primary care rate increase?
Where can health care providers learn more about the 2013-2014 primary care rate increase?
Is Oregon's definition of primary care provider changing?

No. Oregon is not changing its definition of Medicaid primary care provider. Instead, Oregon will add the federal definition alongside Oregon's definition in order to identify primary care providers who qualify for the new two-year reimbursement increase.

The CMS definition only determines which providers may qualify for the two-year reimbursement increase; it does not reduce or change reimbursement for other providers or programs. Oregon's primary care providers who meet CMS's definition will receive an enhanced rate for two years, those who do not will receive their existing Oregon primary care rate.​
Why is Oregon increasing reimbursement rates for some primary care providers?

In November, the Centers for Medicare and Medicaid Services (CMS) announced that practitioners who meet their new definition of primary care provider would see an increased Medicaid reimbursement rate for two years under section 1202 of the federal Affordable Care Act (ACA).

CMS revised sections 1902(a)(13), 1902(jj), 1905(dd) and 1932(f) of the Social Security Act to require increased payment for certain Medicaid primary care services provided in calendar years 2013 and 2014.
 
The final rule also updates the interim regional maximum fees that providers may charge for vaccine administration under the Vaccines for Children (VFC) program.
 
What services are eligible for the federal primary care rate increase?

The increase applies to evaluation and management (E/M) and vacc​ine administration services​​ and the administration fee for Vaccines for Children serum​, when delivered to Oregon Medicaid clients by eligible providers.


For more information about the federal primary care rate increase

Rates

2013 federal primary care codes and rates
2014 federal primary care codes and rates
Oregon Medicaid Vaccines for Children administration codes and rates
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Other Resources

Federal Primary Care Reimbursement Fact Sheet
Federal Primary Care Reimbursement webinar slides for plans
Federal Primary Care Reimbursement webinar slides for providers
Questions and answers about federal primary care reimbursement
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