Primary care still waiting on ACA Medicaid pay raise

The health reform law authorized boosting Medicaid rates to Medicare levels starting in 2013, but physician organizations report that state administrative procedures are causing delays.

By — Posted March 11, 2013

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Primary care physicians who qualify for higher Medicaid payments under the Affordable Care Act might not see these rate increases as quickly as anticipated this year.

The Medicaid program has had a long-standing reputation for paying doctors at rates far below what Medicare pays for the same services. The ACA aimed to address this problem by directing states to bump rates for primary care services provided by primary care doctors up to 100% of Medicare rates for calendar years 2013 and 2014. Because the final rule on the provision was issued in late 2012 with an effective date of Jan. 1, many family doctors were hoping to see an immediate boost in their claims payments. However, “there could be a lag of several months even from now” for the enhanced Medicaid rates to take effect, said Jeffrey Cain, MD, president of the American Academy of Family Physicians.

Some physician organizations are concerned that states are missing the opportunity to prop up primary care because they aren't moving quickly enough to pay these higher fees.

Several administrative steps are needed first at the state and federal levels, said Neil Kirschner, senior associate of regulatory and insurer affairs for the American College of Physicians. States have until March 31 to modify their Medicaid plans accordingly and submit those changes to the federal government, which then has an additional 90 days to approve the plans. “It's unclear how many states have done that,” he said.

In recent letters to the National Governors Assn. and the National Assn. of Medicaid Directors, the American Medical Association and other organizations representing primary care doctors called on states to enact the pay bump expeditiously and engage in active communication with physicians to notify them about the timing of the pay increase.

With the ACA provision in effect for only two years, any implementation delays will make it harder for the government to collect data to see if patient access is improving by raising Medicaid payments, Kirschner said. The longer states take, the longer physicians must wait for these enhanced payments, which could affect decisions whether to take new Medicaid patients, he said.

Many states are set to expand Medicaid eligibility up to an effective rate of 138% of poverty starting in 2014. “It's one thing to expand Medicaid; it's another thing to get physicians to accept” new Medicaid patients, Kirschner said.

In Washington state, word has come from the health care authority that it won't be able to start calculations for the pay increase until early July for both Medicaid fee for service and managed care, “with subsequent payments being issued in September at the earliest,” said Bob Perna, senior director for health care economics and practice support with the Washington State Medical Assn. The association has told state officials that not receiving those enhanced payments in a timely manner could impose administrative burdens on physician practices, because the adjusted payments will need to be reconciled on patients' accounts when they start arriving later in 2013, Perna said.

States have been working diligently to make this happen, according to the Centers for Medicare & Medicaid Services. A number already have submitted state plan amendments “that will permit federal funding to flow to states for the increases,” CMS said in a statement. “States are also in the process of reprogramming their claims processing systems to pay at the appropriate, higher rates.”

One piece of good news for primary care physicians is that these enhanced payments are retroactive to Jan. 1, Dr. Cain said. That means the delays won't result in doctors missing out on any additional Medicaid dollars due to them.

Doctors must prove primary care status

Another hurdle that awaits physicians hoping for a Medicaid pay boost is the requirement that primary care doctors attest their eligibility for it, Kirschner said.

To qualify, doctors have to be board certified in one of the primary care categories, which are family medicine, general internal medicine and pediatrics — or a subspecialty of one of those categories. Physicians in these specialties who are not board certified must attest that at least 60% of the codes they submitted to Medicaid in 2012 must have been for primary care services.

However, each state must establish an attestation procedure, and not all states have done this, Kirschner said. The ACP has encouraged members to contact their respective state Medicaid offices to find out what the actual attestation process is, and what the timelines are to report eligibility. Some states have set a narrow time period during which attestation must take place, he said.

Ohio showed some flexibility in this area, extending the reporting window by several weeks to Feb. 2 “so that physicians would have more time to attest and be eligible for the full two years of rate increase,” said Reginald Fields, director for communications and external affairs with the Ohio State Medical Assn. Those who successfully attested in Ohio by Feb. 2 will see their rate increases retroactive to Jan. 1. Physicians who waited until after the deadline, however, “were told that their rate increase would start once approved, but not be retroactive to Jan. 1,” Fields said. Rate increases are not expected to begin showing up on payments until April, he added.

Although doctors in some states may protest the lag in obtaining the enhanced payments, “we are not aware of physicians in Ohio being upset or bothered by not yet receiving the rate increase,” Fields said.

Rhode Island primary care physicians are waiting on a Web-based portal through which they can attest their eligibility for the pay increase. The state originally told doctors that the portal would be live by now, but the Rhode Island Medical Society recently had to alert members that the portal wouldn't be operational until March or early April, said Steven DeToy, the society's director of government and public affairs.

Physicians will have 60 days after the portal opens to complete their attestations and receive retroactive enhanced pay for services provided after Jan. 1. However, “if you can't attest that you're eligible, you can't get paid,” DeToy said.

Arkansas is another state that's on track to start paying out the boosted Medicaid rates starting in April. Like many other states, it plans to distribute the increase in the form of a quarterly bonus and not on a rolling fee schedule basis, said William Golden, MD, medical director of the Arkansas Medicaid program. He's also a professor of medicine and public health at the University of Arkansas for Medical Sciences.

Changing the state's Medicaid fee schedule so the enhanced rates showed up with every payment would have been difficult, especially with the short time frame, Dr. Golden said. To ensure that doctors receive the pay increase in a timely manner, “Arkansas implemented the quarterly approach through an 'emergency' regulatory pathway. We are slightly behind schedule but on target to provide the primary care pay bump in April,” he said.

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Medicaid's and Medicare's widening pay gap

The difference between Medicare and Medicaid fees for all services, not just primary care, has become more pronounced during the past five years, according to a December 2012 report. The drop-off in Medicaid rates relative to Medicare, however, was not due to a decrease in Medicaid pay. Average Medicaid fees actually rose during this period, but Medicare fees for the same services went up much higher due to changes in relative value units for office visits.

Service type Medicaid rates as % of Medicare 2008h Medicaid rates as % of Medicare 2012 Cumulative Medicaid fee increase
All 72% 66% 4.9%
Primary care 66% 59% 3.4%

Source: “How Much Will Medicaid Physician Fees for Primary Care Rise in 2013? Evidence from a 2012 Survey of Medicaid Physician Fees,” Kaiser Commission on Medicaid and the Uninsured/Urban Institute, Dec. 17, 2012 (link)

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