Or. Admin. Code § 410-130-0005 - Federally Qualified Primary Care Provider
(1) Section 1202 of the Affordable Care Act
(ACA) amended sections 1902(a)(13), 1902(jj), 1905(dd) and 1932(f) of the
Social Security Act to require increased Medicaid payment for primary care
services to qualified providers for calendar years 2013 and 2014 as specified
in these rules.
(2) Federally
Qualified Primary Care Services are designated as:
(a) Evaluation and Management (E&M)
Current Procedural Terminology (CPT) codes 99201 through 99499; and
(b) Vaccine administration CPT codes 90460,
90461, 90471, 90472, 90473 and 90474, or their successor codes; and
(c) Administration of vaccines under Vaccines
for Children Program (refer to OAR
410-130-0255).
(3) To qualify for the increased
payment, the individual physician must attest that:
(a) The physician has a primary practice in
family medicine, general internal medicine, or pediatric medicine;
and
(b) One or both of the
following are true:
(A) The physician is
Board-certified in a specialty or subspecialty of family medicine, general
internal medicine, or pediatric medicine by one of the following boards:
(i) The American Board of Medical Specialties
(ABMS);
(ii) The American
Osteopathic Association (AOA);
(iii) The American Board of Physician
Specialties (ABPS);
(B)
The physician can demonstrate that at least 60 percent of the procedure codes
billed and paid in Medicaid claims were qualifying primary care codes described
in section 2 of this rule.
(i) Over the
previous calendar year, if billings exist for this time period; or
(ii) Over the previous month, if billings do
not exist for the previous calendar year.
(4) To qualify for the increased
payment, a Physician Associate (PA) or Nurse Practitioner (NP) must attest that
they work under the direct supervision of a Physician who:
(a) Qualifies for increased primary care
payments as described in these rules; and
(b) Assumes professional responsibility for
the services rendered by the PA or NP.
(5) Providers seeking the reimbursement
increase from the Division of Medical Assistance Programs (Division) must
self-attest with the Division. Providers, not enrolled with the Division,
seeking the increase from OHP health plans (MCO or CCO), must self-attest with
the applicable MCO or CCO.
(6)
Reimbursement: Effective for dates of service on or after January 1, 2013, the
Division shall reimburse primary care providers as follows:
(a) Federally qualified primary care
providers as described in this rule at the rate specified in OAR
410-120-1340(6)(C)(ii);
or
(b) Other primary care
providers, including potentially qualified providers who do not self-attest to
the Division as described in part (3) of this rule, at the rate specified in
OAR 410-120-1340(6)(C)
(iii).
(7) Annual review
of qualifying providers: The Division will review a statistically valid sample
of providers to determine whether they satisfy the criteria described in (3)
and (4) of these rules. Providers reviewed who do not satisfy the criteria will
be required to reimburse the Division for the difference between the rate they
should have received according to OAR
410-120-1340(6)(C)
(iii) and enhanced rate in OAR
410-120-1340(6)(C)(ii).
The sample will include the following providers:
(a) Physicians who have self-attested to
qualifying for the increased rate; and
(b) Providers who have self-attested that
they are under the direct supervision of a qualified physician.
(8) Supplemental information on
primary care reimbursement under the Affordable Care Act is available at
http://www.oregon.gov/OHA/HSD/OHP/Pages/Providers.aspx.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: 414.025 & 414.065
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