Note: This Fact Sheet outlines a Proposed Rule. Any of the specifics of this fact sheet could change based on the promulgation of a Final Rule.

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1 Fact Sheet on Proposed Rule: Medicaid Payment for Services Furnished by Certain Physicians and Charges for Immunization Administration under the Vaccines for Children Program Note: This Fact Sheet outlines a Proposed Rule. Any of the specifics of this fact sheet could change based on the promulgation of a Final Rule. What does the regulation do? For evaluation and management (E/M) CPT codes, sets a floor of payment in the Medicaid system of 100% of the Medicare rate. See below for the list of codes to which this new rate applies. State Medicaid agencies must pay at least the Medicare rates in effect in CYs 2013 and 2014, or if higher, the Medicare rate from 2009, for primary care services by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. The payment increase applies to 2013 and 2014 only. Provides 100% federal funding for the difference between the Medicaid rate in effect on July 1, 2009 and the amount required to be paid under the increase. Payment would reference the Medicare Physician Fee Schedule (MPFS) rate applicable to the site of service and geographic location of the service. (Note: Individual fee schedule amounts for the MPFS are the product of the geographic adjustment, Relative Value Units (RVUs), and Conversion Factor that adjusts RVUs into dollar amounts. Site of service is reflected as an adjustment to the RVUs used to set the rate.) Extends the requirement for payment at the Medicare rate to primary care services paid on a fee for service basis as well as to those paid by Medicaid managed care plans. Proposes to empower the Centers for Medicare and Medicaid Services (CMS) as well as States to review managed care contracts to ensure that this requirement is imposed on managed care plans by the State. Updates Vaccines for Children (VFC) program regional maximum immunization administration fees that have not been updated since the VFC program was established in 1994; proposes to update these rates based on medical inflation as reflected in the Medicare Economic Index (MEI). To which codes does the payment increase apply? Healthcare Common Procedure Coding System (HCPCS) CPT E/M codes These codes include those primary care E/M codes that are not recognized for reimbursement by Medicare, but do have published RVUs associated with them a population not typically served by the Medicare program: New Patient/Initial Comprehensive Preventive Medicine: codes

2 Established Patient/Periodic Comprehensive Preventive Medicine: codes ; Counseling Risk Factor Reduction and Behavior Change Intervention: codes , 99408, 99409, 99411, 99412, and 99429; E&M/Non Face to Face physician Service: codes Medicare sets and publishes RVUs for these codes even though Medicare payment will not be made for the services. The regulation proposes that the rates for these non paid Medicare services would be established using the Medicare conversion factor in effect in CYs 2013 and 2014 (or the CY 2009 CF, if higher) and the RVUs recommended by the AMA/Specialty Society Relative Value Scale Update Committee (RUC) and published by CMS for CYs 2013 and Immunization Administration codes 90460, 90461, 90471, 90472, and or their successors. Which physicians are eligible for the payment increase? Physicians with a primary specialty designation of family medicine, general internal medicine and pediatric medicine are eligible for the Medicaid payment rate increase. Services provided by subspecialists related to the three primary care specialties designated in the statute would also qualify for higher payment. States establish a system to require physicians to identify their specialty or subspecialty to the Medicaid agency before they become eligible for an increased payment. The State will be required to confirm the self attestation of the physician before paying claims at the higher rate. This will be done by verifying that the physician is Board certified in an eligible specialty or subspecialty. If increased payments are made to a physician who is not eligible, the state will recoup the payment from the physician. If the physician is not Board certified, a review of the physician s billing history must be performed by the Medicaid agency. The regulation proposes that at least 60% of the codes billed by the physician for all of CY 2012 must be for the E/M codes and immunization administration codes specified to be eligible for a secondary pathway to the payment increase. CMS is seeking comment on whether 60% or some other percentage threshold would be more appropriate to determine whether a non Board certified physician qualifies for the increased payment. The increased payment for primary care services will also apply to services furnished by non physician practitioners, such as nurse practitioners and physician assistants, under the personal supervision of an eligible physician and billed under that physician s program enrollment number. This increased payment does not apply to Medicaid payments to Federally Qualified Health Centers or Rural Health Clinics as these sites are paid under a different structure.

3 State Requirements States would be required to submit a State plan amendment (SPA) to reflect the fee schedule rate increases in order to assure that when States make the increased payments, they have State plan authority to do so and have notified physicians of the change in payment as required by Federal regulations. Managed care and contract physicians The ACA requires that managed care plans also pay physicians at the increased payment rate. CMS proposes to implement the managed care requirements through a State by State review of managed care contracts and applicable procedures to ensure that the increase in payments are passed directly to the physician, regardless of whether a physician is salaried or receives a fee for service or capitated payment. Both the managed care contracts and States methodology for identifying payment amounts made for each eligible primary care service must be submitted to CMS for review prior to the start of CY CMS will not require that contracts be renegotiated to deal with payments beyond this payment increase required by the ACA. Thus, while rates for primary care services must be renegotiated, managed care companies may keep maintain rates for other services. How does the regulation address vaccines? Sets forth unequivocally that the VFC program statute does not permit payment for each additional vaccine/toxoid component administered in a multi component vaccine. This disallows payment for CPT code Sets forth that physicians participating in the VFC program can only bill for CPT code when administering a multi component vaccine. Proposes to apply a value to CPT code of $0 because the code did not exist prior to CY 2011 when immunization administration codes did not permit additional administration payments for multi component vaccines. In other words, States would be unable to identify the rate differential by comparing payments in CY 2009 to those in CYs 2013 and For CPT code 90460, the regulation proposes that States calculate the CY 2009 rate for the code based on the average payment amount for the immunization administration codes which were replaced in 2011 (90465, 90466, 90467, 90468) weighted by service volume. That is, each of the four CY 2009 rates for immunization administration would be multiplied by their respective percentages of service volume and then added to determine one payment amount. How does the regulation address regional maximum charges? The rule proposes to increase payment of immunization administration fees under the VFC program to either the new 2013 and 2014 VFC regional maximum administration fee (the VFC "ceiling") included in the rule (chart attached), or the geographicallyadjusted Medicare vaccine administration rates for those years. The proposed

4 rule would allow payment according the lesser amount of either program's fee schedule. The 2013 Medicare vaccine administration fees will be released in November Because the VFC ceiling rates were issued on an interim basis in 1994 and have not been changed, they have been updated based on the Medicare Economic Index (MEI), which is a measure of medical practice cost inflation. The rates have increased by around half with variation depending on the state in question. A chart is published in the regulation with each States new regional maximum administration fee. The chart is reproduced below. Regional Maximum Administration Fee by State State Current regional maximum fee Updated regional maximum fee Alabama $14.26 $19.79 Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico

5 New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Please contact Robert Hall, Associate Director of the Washington, DC Office of the American Academy of Pediatrics, with any questions regarding the Proposed Rule. Mr. Hall can be reached at or 202/

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