The Centers for Medicare & Medicaid Services (CMS) released regulations in early November 2012 implementing rate increases for primary care physicians who treat Medicaid patients. The goal of the increase is to recruit more physicians to treat low-income patients who will be newly eligible for health coverage under the Affordable Care Act (ACA). Under the ACA, primary care physicians will see their reimbursement rates raised to Medicare levels in 2013 and 2014. According to CMS, states must also incorporate the increased payment rates into their contracts with managed care plans so that primary care physicians contracting with Medi-Cal managed care plans see the higher rates. The increase is financed 100 percent by the federal government.

The rate increase applies to evaluation and management codes 99201 through 99499 and vaccine administration codes 90460, 90461 and 90471 – 90474.

The California Department of Health Care Services (DHCS) had previously indicated that it expected to implement the rate increase in summer 2013, but DHCS now reports a likely implementation date in the fall.

DHCS is currently still waiting for approval from CMS on the State Plan Amendment, which details California's proposed payment methodology for both fee-for-service and managed care payments. Once approved, the increases will be retroactive to January 1, 2013.

To qualify for enhanced payments, providers will first be required to self-attest eligibility. The attestation will be available through the Medi-Cal website (www.medi-cal.ca.gov) in late July. Physicians will be required to complete the attestation online (paper copies will not be accepted).

Medi-Cal managed care plans have the option of either using the DHCS online attestation system or developing their own attestation tools. The California Medical Association (CMA) is in the process of querying the major Medi-Cal managed care plans on how their attestation processes will work.

For more information on which specialties qualify for the increase, see CMA’s Medi-Cal Primary Care Physician Rate Increase FAQs.

Contact: CMA’s reimbursement help line, (888) 401-5911 or economicservices@cmadocs.org.