Healthcare Law Blog

Primary Care Providers – Are you feeling the pinch?

It was nice while it lasted – due to a provision of the Patient Protection and Affordable Care Act (“ACA”), services furnished by certain primary care providers (“PCPs”) were subject to an enhanced payment rate for Calendar Years 2013 and 2014. These PCPs had to have (a) been Board certified in the specialty designation of family medicine, general internal medicine or pediatric medicine or have a subspecialty designation recognized by specific boards or associations, or (b) furnished more than 60% of claims in specific evaluation and management or vaccine administration services under certain codes to have been eligible for these enhanced payments.[1] The payments were raised to the level of the Medicare Part B fee schedule rate (unless the actual billed charge for the service was lower), and providers had until April 1, 2013 to self-attest to being eligible.[2] The increase applied to both fee-for-service and managed care Medicaid plans.

In effect, the federal government supplemented the state Medicaid payment rate, raising it to the Medicare rate for two years, as an inducement for more primary care providers to provide care to Medicaid recipients as the provisions of the Affordable Care Act took full effect. Services provided by non-physician practitioners qualified for this enhanced rate when delivered under the supervision of a qualifying physician.

Sadly, the period for enhanced payment is now over. A six-month claim run-out period was allowed for claims for services in CY 2013-2014 as well as any adjustments or corrections, and the Kentucky Department for Medicaid Services posted an update to their website in mid-September, stating that “[t]he final cycle for the adjusted primary care payment rate, which includes the claim run-out period as well as the reconciliation, will process October 1, 2015.”[3]

For providers who relied on these enhanced payments, the end of this program only brings into sharp relief the crisis in low reimbursement rates under the Medicaid program. The failure of Congress to extend what is referred to as the “Medicaid Primary Care Pay Parity” program may ultimately cause providers to begin to drop Medicaid patients in order to stay afloat. According to the Kaiser Family Foundation, fifteen states have chosen to continue the enhanced payment program out of state coffers, but Kentucky is not among them.[4] Time will tell if the end of enhanced payment rates will affect the quantity of care available to Kentucky Medicaid recipients, but providers in Kentucky are likely already feeling the pinch.

Lisa English Hinkle is a Member of McBrayer law. Ms. Hinkle chairs the healthcare law practice and is located in the firm’s Lexington office. Contact Ms. Hinkle at lhinkle@mcbrayerfirm.com or (859) 231-8780, ext. 1256, or reach out to any of the attorneys at McBrayer.

Services may be performed by others.

This article does not constitute legal advice.

[1] 42 CFR 447.400

[2] 42 CFR 447.405

[3] Kentucky Department for Medicaid Services, http://chfs.ky.gov/dms (Last Accessed September 29, 2015)

[4] Kaiser Family Foundation, “The ACA Primary Care Increase: State Plans for SFY 2015” http://kff.org/medicaid/perspective/the-aca-primary-care-increase-state-plans-for-sfy-2015/ (Oct. 28, 2014, Last Accessed September 29, 2015)