The Michigan Department of Community Health (MDCH) recently released a final bulletin (MSA 14-61) that explains how increased payments for Medicaid primary care services (uplifts) rendered by primary care physicians will be paid in 2015. MSMS advocated for practice characteristics (60% of specified evaluation and management codes) to be added as one of the eligibility criteria. We are happy to report that provision was included in the final version.

The current Medicaid primary care uplift was authorized by the Patient Protection and Affordable Care Act (ACA). Because it expired in 2014, the Michigan Legislature included a partial continuation of the Medicaid primary care enhanced rates to Medicare rates beyond December 31, 2014 in the Fiscal Year 2015 MDCH budget (Section 1801 of Public Act 252 of 2014).

This extension will enable physicians with a specialty designation of family medicine, general internal medicine, and pediatric medicine who provide certain primary care services to be reimbursed at approximately 78 percent of Medicare rates for dates of service on and after January 1, 2015. Payments will be made on qualified procedure codes. To be eligible for the adjusted payment, physicians must be board certified or board eligible in one of the three designed primary care specialties recognized by the American Board of Medical Specialties, American Osteopathic Association, and the American Board of Physician Specialists. Non-board certified or non-board eligible primary care physicians may be eligible for the uplift if a review of their billing history demonstrates that at least 60 percent of the physician’s codes paid by Medicaid are for E/M codes specified in the policy.

Physician practitioners whose CHAMPS Provider Enrollment profile information reflects that they provide specialty or subspecialty, (e.g. cardiology, endocrinology, or oncology, etc.) services will not be eligible for the adjusted payment in 2015. Physicians with multiple subspecialties will also not be eligible for the adjusted payment in 2015. Exceptions will be made for practitioners who have subspecialty practices in adolescent and geriatric medicine.

Physicians must update and maintain their primary specialty designations in their Community Health Automated Medicaid Processing System (CHAMPS) enrollment profile. Because the enhanced payment has not been disclosed, please work with the health plans to define the enhanced capitated payment. As you contact the health plans to determine that enhanced capitated payment, please verify with them your specialty as the state will not provide an eligibility roster to the health plans.

Physicians may see the enhanced rates by visiting the MDCH website and scroll down to the Primary Care Rate Increase.

After meeting with Medicaid, MSMS confirmed the increase is intended to be paid to the physician/employer in full. The increase is not to cover administrative costs.

If you have further questions, contact Stacie J. Saylor, CPC, CPB, at (517) 336-5722 or ssaylor@msms.org.