Private Practice Insights: Rate Increase for Primary Care Services

The Federal Affordable Care Act (ACA) requires Medi-Cal to reimburse certain primary care services for eligible physicians at parity with Medicare rates for dates of service in 2013 and 2014. The purpose of this reimbursement rate increase is to acknowledge the importance of physicians in achieving quality outcomes and to increase access in preparation for Medi-Cal expansion in 2014.  CenCal Health has put together this helpful guide to get you started.

Do you qualify for increased payments under ACA?  According to the final rule, physicians must meet the following two criteria to be eligible for increased payments:

1.  A physician with a specialty designation of family medicine, general internal medicine, pediatric medicine or a subspecialty within one of the listed specialties and

2.  Meeting at least one of the following qualifications:

  • Board certified in a specialty or subspecialty listed above. The recognized boards are the American Board of Medical Specialties (ABMS), the American Osteopathic Association (AOA) and the American Board of Physician Specialties (ABPS) or
  • At least 60 percent of the services billed to Medi-Cal for the most recently completed calendar year fall within the Evaluation and Management (E&M) or vaccine administration codes covered by the regulation. Covered services include the following codes:  E&M codes 99201 – 99499 and the vaccine administration code 90471 which is the only vaccine administration code under ACA that is a Medi-Cal benefit.

If yes, then self-attest!  Self-attestation is required in order to receive higher payments.  DHCS has created an online Self Attestation Form which can be found on their website here. This form can be completed by any eligible provider regardless of active status with State Medi-Cal, so even if you have never been certified by Medi-Cal or your Medi-Cal status has become inactive, you can still self-attest through the State’s process. Providers are strongly encouraged to read the Affordable Care Act – Primary Care Physician Self Attestation Form Completion Instructions, also available at the above link, to ensure the form is completed accurately. Physicians are solely responsible for reporting accurate information through this process.

(Source CenCal Health)