PURPOSE: This rule sets forth the criteria to be used by the MO HealthNet Division in establishing certain payment rate increases for certain primary care services provided in calendar years 2013 and 2014. Federal law requires certain payment rates by state Medicaid agencies of the Medicare Part B rates in effect in calendar years (CY) 2013 and 2014 or, if higher, the rate that would be applicable using the CY 2009 Medicare conversion factor (CF), for certain primary care services furnished by a physician with the specialty designation of family medicine, general internal medicine, or pediatric medicine. The proposed rule is to encourage physicians to participate in MO HealthNet (Medicaid), and thereby promote access to primary care services for current and new MO HealthNet participants.

1. (1) Definitions. Primary care services are defined as procedure codes for services in the category designated primary care Evaluation and Management (E/M) codes 99201-99499 or their successor codes in the Healthcare Common Procedure Coding System (HCPCS) and services related to immunization administration for vaccines and toxoids for which Current Procedural Terminology (CPT) codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, 90474, or their successor codes apply under such system.

2. (2) Condition of Eligibility to Receive Payment Rate Increase. Physicians with certain specialty and sub-specialty designations (family medicine, general internal medicine, or pediatric medicine) are eligible to receive increases in payment rates when delivering primary care services as defined in section (1).

   1. (A) Sub-specialists within the specialty designations of family medicine, general internal medicine, and pediatric medicine as recognized by the American Board of Medical Specialties, the American Board of Physician Specialties, the American Osteopathic Association, or any other enrolled provider providing primary care services defined by the Centers for Medicare and Medicaid Services (CMS) as eligible for federal financial participation at the one hundred percent (100%) rate may also be eligible for increased payment. To be eligible—

      1. 1. The provider may be board certified;

or

1. 2. If not board certified, at least sixty

percent (60%) of the services billed to MO HealthNet by the physician for CY 2012 must be for primary care E/M codes 99201-99499 or their successor codes and vaccine administration codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, 90474 or their successor codes. Claims data review will be done to ensure the sixty percent (60%) threshold is met.

1. 3. For newly enrolled non-board certi-

fied physicians, a year end review will be done to ensure eligibility criteria are met.

1. 4. If the condition of eligibility to

receive the payment rate increase is not met the payment will no longer be made.

1. (3) Reimbursement. MO HealthNet reimbursement rates for primary care services and services related to immunization administration for vaccines and toxoids will be the lower of the provider’s usual and customary charges to the general public or the MO HealthNet allowable amount based upon the Medicare Part B rates for office site of service using the mean values over all counties. An additional payment for vaccine administration will be made to bring the reimbursement amount up to Missouri’s regional maximum fee of twenty-one dollars and fifty-three cents ($21.53). The reimbursement amount may be referenced at http://dss.mo.gov/mhd/index.htm under Alerts & Notifications.
2. (4) The fee-for-service and managed care payment rate increase applies to certain primary care services defined in section (1) provided in CY 2013 and 2014 only.
3. (5) The Federal Medical Assistance Percentage (FMAP) rate is one hundred percent (100%) of the difference between the Medicaid State Plan rate in effect on July 1, 2009, and the amount required to be paid under section 1902(a)(13)(C) of the Social Security Act. The state will be fully reimbursed for these increased payments for primary care services by the federal government.
4. (6) Primary care services performed by a nonphysician practitioner will be paid at the higher rates if properly billed under the provider number of a physician who is enrolled as one of the specified primary care specialists or subspecialists when provided under the physician’s personal supervision as services of the supervising physician. There is no increase in payment rate for independently practicing non-physician practitioners.
5. (7) The increased payments are available for services claimed under the physician services benefit. Increased payments are not available for federally qualified health centers (FQHCs) or rural health clinics (RHCs).

AUTHORITY: sections 208.152, 208.153, and 208.201, RSMo Supp. 2013.* Original rule filed Oct. 10, 2013, effective April 30, 2014. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978(2), 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007; and 208.201, RSMo 1987, amended 2007.