Trojan Horse Or Meaningful Medicaid Reform?

The Centers for Medicare and Medicaid Services (CMS) has outlined its plan to temporarily raise Medicaid rates to Medicare levels for primary care services, and pay states to cover the difference. On May 11, 2012, CMS issued a proposed rule requiring Medicaid payment for primary care services furnished by eligible physicians at rates "not less than the Medicare rates" for fiscal years 2013 and 2014.1 The proposed rule provides for 100% federal matching for any increase in payment above the amounts that would be due under the provisions of a state's plan as of July 1, 2009.2 By increasing Medicaid rates for 2013 and 2014, CMS is implementing certain provisions of the Patient Protection and Affordable Care Act (ACA). CMS hopes the increased rates will encourage sufficient primary care physician participation in the Medicaid program to accommodate the nearly 16 million new patients that will be eligible to receive Medicaid benefits if the ACA survives the Supreme Court's review. The proposed rule does not say, however, what will happen to Medicaid rates – and, more importantly, whether there will be enough physicians to care for the larger Medicaid patient population – after 2014. Nor does the proposed rule say whether the increased rates for primary care services will be applied regardless of the Supreme Court's decision.

What physicians are eligible for reimbursement at the higher Medicare rates?

The increased rates apply to physicians with a specialty designation of either family medicine, general internal medicine, or pediatric medicine (primary care physicians). Significantly, CMS has broadly interpreted the ACA so that subspecialists who provide services sufficiently related to primary care may also be eligible for reimbursement at the higher rates. CMS suggests that states engage in a two-step process to verify a physician's eligibility to receive payment for Medicaid services at the higher Medicare rates. First, a state's Medicaid agency should establish a system to collect physicians' "self-attestations." Self-attestation requires a physician to identify his or her particular specialty (for instance, pediatrics), or subspecialty (for instance, pediatric cardiology) entitling him or her to the increased rates. Second, the state must then confirm the physician's self-attestation by either verifying that the physician is Board certified in an eligible specialty or subspecialty, or reviewing the physician's billing history for 2012. Where...