Find out what these federal changes mean for primary care practitioners who serve OHP members.

• Background
• What providers need to do
• What DMAP is doing
• Resources

Background

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).

Oregon's definition of primary care provider will not change

Oregon is not changing its definition of Medicaid primary care provider. Instead, Oregon will add the CMS definition alongside Oregon's definition in order to identify primary care providers who qualify for the new two-year reimbursement increase.

This is a decision at the federal level. 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 primary care rate.

What providers need to do

Providers who bill the Division of Medical Assistance Programs (DMAP) can now self-attest to meeting the new definition and begin receiving the increased fee-for-service (FFS) reimbursement rate on or after May 1, 2013 (date contingent on federal approval).

• 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.

What DMAP is doing

To make sure increased payments begin on or near May 1, 2013, DMAP is working on the following:

• Oregon Administrative Rule revisions for the General Rules (Division 120) and OHP (MCO and CCO – Division 141) programs;
• System updates that include the ACA-defined primary care rate separate from DMAP's existing FFS primary care rates;
• Coordination with OHP health plans (MCOs and CCOs) to update contracts and address the ACA requirement in how we pay plans; and
• Updated FFS and managed care rate methodology for CMS approval.

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

Resources

Further information about this change

As required by section 1202 of the federal Affordable Care Act, 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.

This provision applies to evaluation and management (E/M) and vaccine administration services delivered to Oregon Medicaid clients by:

• Physicians with a specialty designation of family medicine, general internal medicine, or pediatric medicine; or
• Nurse practitioners, physician assistants, and some other provider types billed through, and working under the supervision of, a qualified physician.

The final rule also updates the interim regional maximum fees that providers may charge for vaccine administration under the Vaccines for Children (VFC) program.

​More resources

• Webinar for OHP health plans – View our video, slides and questions/answers
  
  
• Webinar for OHP providers – View our video, slides and questions/answers
  
  
• Codes eligible for the ACA primary care rate increase - Updated 5/7/2013 (preliminary - pending CMS approval)
  

• Federal Register/ Vol 77, No 215 published on November 6, 2012 and December corrections to the Federal Register, establishing revisions required by ACA Section 1202

Oregon Medicaid fact sheet about the changes required by ACA Section 1202 - Updated 4/17/2013