OAR 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 .