Primary Care and VFC Incentive Program



Overview

Effective for services provided January 1, 2013, through December 31, 2014, MHCP reimburses the following services at enhanced rates to eligible providers under the Primary Care and Vaccines for Children (VFC) Incentive Program:

  • • Primary care services (CPT codes 99201 – 99499)
  • • Vaccines for Children (VFC) administration services (CPT codes 90460 – 90461 and 90471 – 90474)

  • Eligible services may be provided to fee-for-service (FFS) MHCP recipients or enrollees covered by DHS-contracted managed care organizations (MCO).

    See Enhanced Rates for information about implementation of the enhanced rates and claims reprocessing.

    Eligible Providers

    Physicians

    To be eligible for enhanced payment of the covered services, physicians must currently practice in one of the following specialties, as defined by the American Board of Medical Specialties (ABMS), American Board of Physician Specialties (ABPS) or American Osteopathic Association (AOA):

  • • Family medicine
  • • General internal medicine
  • • Pediatric medicine
  • • Any subspecialty of the above specialties

  • In addition to practicing in one of the above specialties, an eligible physician must meet one of the following:

  • • The physician is certified by the ABMS, ABPS or AOA in one of the above specialties or subspecialties
  • • At least 60% of Medicaid services for which the physician received payment were for the covered services listed above. The 60% criteria applies to services that were paid by Medicaid (FFS or MCO) during one of the following periods:
  • • For physicians who enrolled as a Medicaid provider on or after January 1, 2013, use all services paid on warrants issued during the calendar month immediately prior to the month the assurance statement (below) is completed
  • • For all other enrolled physicians who submit the assurance statement in 2013, use all services paid during the 2012 calendar year

  • The 60% claims history criteria applies to the physician’s entire scope of practice. The calculation must include all Medicaid services paid to the physician at all locations or practices where he or she provides services.

    Eligible physicians must complete and sign the Physician Primary Care and VFC Incentive Program Applicant Assurance Statement (DHS-5211) and fax to the number listed on the form. Submit only one form per eligible physician.

    Board certified eligible physicians who practice outside the state of Minnesota must submit a copy of their certificate with the form.

    Non-physician Practitioners

    Covered services provided by individually enrolled physician assistants (PAs) and advanced practice registered nurses (APRNs) are eligible for enhanced payment when supervised at all times by a physician who:

  • • Is eligible for the enhanced rates, based on the above criteria
  • • Has submitted the physician assurance statement
  • • Accepts professional responsibility for all services performed by the PA/APRN

  • Both the PA or APRN and the supervising eligible physican must complete and sign the Non-Physician Primary Care and VFC Incentive Program Applicant Assurance Statement (DHS-2649) and fax to the number listed on the form.

    Eligibility Begin Date

    The earliest date of service for which a provider is eligible to receive enhanced rates is determined by the date they submit their assurance statement to MHCP.

  • • For physicians who submit the assurance statement:
  • • Before April 1, 2013, enhanced rates will apply to covered services effective January 1,2013
  • • On or after April 1, 2013, enhanced rates will apply to covered services effective the first day of the month in which MHCP receives the form
  • • For non-physician practitioners (PA or APRN) who submit the assurance statement:
  • • Before August 1, 2013, enhanced rates will apply to covered services effective January 1, 2013.
  • • On or after August 1, 2013, enhanced rates will apply to covered services effective the first day of the month in which MHCP receives the form

  • Provider Review

    MHCP will perform reviews on a statistically valid sample of providers to verify the eligibility criteria. Services retroactively found ineligible for the enhanced payment will be subject to recoupment of the overpaid amount.

    Eligible Provider List

    Use the Ordering/Prescribing Providers list to identify providers who have submitted an assurance statement and are eligible for the enhanced rates. To access the list:

  • 1. Log in to MN–ITS
  • 2. Select Provider Lists from the left menu
  • 3. Select Ordering/Prescribing Providers

  • Eligibility for the enhanced rates is indicated in the Enhanced Service column with the following codes:

  • • P1 – Board certified eligible physician
  • • P2 – Eligible physician meeting 60% claims history criteria
  • • P3 – PA or APRN supervised by an eligible physician

  • The provider’s eligibility begin date for enhanced rates is indicated in the Begin Date column, to the right of the applicable enhanced service code.

    Excluded Providers

    Providers are not eligible for enhanced rates when delivering services under one of the following:

  • • Federally Qualified Health Center (FQHC)
  • • Rural Health Clinic (RHC)
  • • Indian Health Service (IHS)

  • Enhanced Rates

    Enhanced rates are in effect for claims submitted to MHCP fee-for-service on and after August 13, 2013.

    MHCP has not received federal approval for Managed Care Organizations (MCOs) to implement enhanced rates at this time. MHCP will notify providers when MCOs are able to implement the enhanced rates.

    Refer to the MHCP Fee Schedule to view enhanced rates for the covered services. Factor code V indicates the enhanced rate for the procedure code listed.

    The following standard adjustments may affect final payment amounts:

  • • Standard rate reductions for non-physician providers:
  • • 10% reduction for individually enrolled PA or APRN
  • • 35% reduction for physician extender services
  • • Recipient cost-sharing:
  • • Family deductible
  • • Copay
  • • Spenddown
  • • Add-ons, such as:
  • • Community clinic
  • • Public health
  • • MinnesotaCare tax

  • Claims Reprocessing

    For all eligible providers, MHCP reprocessed claims with dates of service back to the provider’s eligibility begin date. Reprocessed claims will appear on the remittance advice for payment date October 22, 2013 and will be paid at the applicable enhanced rate.

    Definitions

    Service – For purposes of calculating the claims history criteria, the term service refers to a single service or session. Examples of how to count different services include:

  • • Sessions or procedures, where units billed indicate separate occurrences or days, count as one per unit paid
  • • Timed services, where units billed indicate time increments for the same session, count as one per procedure code paid, regardless of the units
  • • Procedure codes that do not indicate an additional occurrence, such as prolonged service or enhanced complexity, are not counted in the calculation

  • Legal References

  • • Minnesota Laws, 2013, Regular Session, Ch 108, art 6, sec 28, to be codified MS 256B.76
  • • Social Security Act sections 1902(a)(13), 1902(jj), 1932(f), 1905(dd)
  • • Affordable Care Act
  • • CMS final rule

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