Don't miss out on increased Medi-Cal payments

September 27, 2013

The California Department of Health Care Services (DHCS) will soon be implementing rate increases for primary care physicians who treat Medicaid patients, as authorized under the Affordable Care Act. The increase also applies to services provided by physicians to Medi-Cal managed care patients. In order to see the bump in pay, providers must first attest to their eligibility. According to DHCS, less than half of eligible providers have completed the brief self-attestation process as of September 24.

For purposes of this regulation, primary care is defined as family medicine, general internal medicine, pediatric medicine or related pediatric subspecialties. Pediatric subspecialists must be recognized by the American Board of Medical Specialties, American Board of Physician Specialties or the American Osteopathic Association to receive the increased fees. If a physician is not board certified, eligibility can be determined by the physician’s billing history. Physicians will qualify if 60 percent of the codes they bill are for evaluation and management codes and vaccine administration codes covered by this rule. Physicians can self-attest to their board certification or billing history.

Although the regulations implementing the pay raise were released by the Centers for Medicare & Medicaid Services (CMS) in November 2012, DHCS is still awaiting approval of its State Plan Amendment, which details California's proposed payment methodology for both fee-for-service and managed care payments. DHCS expects to receive approval soon and plans to implement the increase in late October. Once approved, the increases will be retroactive to January 1, 2013.

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 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.

Physicians are encouraged to complete the attestation form, which is available on the Medi-Cal website. The attestation form must be completed 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. However, when the California Medical Association (CMA) queried the major Medi-Cal managed care plans on how their attestation processes would work, all that responded indicated they would utilize the DHCS attestation process. Physicians are encouraged to check with their Medi-Cal managed care plans to confirm, however.

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

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


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