Medicaid Reimbursement


On Nov. 6, 2012, the Centers for Medicare and Medicaid Services (CMS) issued a final rule implementing a section in the Affordable Care Act that requires that Medicaid rates in 2013 and 2014 must not be less than the Medicare rates for those years, or, if greater, the Medicare rates that would be applicable in those years using the 2009 conversion factor.

Effective January 1, 2013 through December 31, 2014, the higher rates will be applied to primary care services furnished by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. The final rule also provides for higher payment for subspecialists related to those specialty categories as recognized by the American Board of Medical Specialties, American Osteopathic Association, and the American Board of Physician Specialties. For example, a pediatric gastroenterologist would qualify for the higher payment if he/she rendered one of the specified primary care services by virtue of that physician’s subspecialty within the qualifying specialty of pediatric medicine.

Additionally, physicians who are in those designated specialties but not Board certified (are Board eligible) can also qualify if at least 60 percent of the codes billed by the physician for all of calendar year 2012 were for the evaluation and management (E&M) codes and vaccine administration codes specified in the final rule. Codes eligible for the higher payment are E&M codes 99201 through 99499 and vaccine administration codes. This includes codes within the specified range that are not currently covered by Medicare.


Our Partners
The Association of Pediatric Gastroenterology and Nutrition Nurses
Help & Hope for Children with Digestive Disorders
Journal of Pediatric Gastroenterology and Nutrition
JPGN Reports