Primary Care Physician Rate Increase (“Bump”)


TO:  All Physician Providers (provider type 31)

A major provision of the Affordable Care Act (ACA) requires Alabama Medicaid reimburse certain primary care physicians at parity with Medicare for services provided between January 1, 2013 and December 31, 2014.


Services eligible for an enhanced payment fall into two categories:

·         Primary care services

·         Vaccine administration service under the VFC program


Primary care services subject to the enhanced payment are Current Procedural Terminology (CPT) Evaluation and Management procedure codes 99201 to 99499.


Vaccine administration services  under the VFC program are 90633, 90636, 90645, 90647, 90648, 90649, 90650, 90655, 90656, 90657, 90658, 90660, 90669, 90670, 90680, 90681, 90696, 90698, 90700, 90702, 90707, 90710, 90713, 90714, 90715, 90716, 90718*, 90721, 90723, 90732, 90733, 90734, 90744, and 90748.  The Alabama Medicaid Agency requires the VFC administration codes to be billed using the specific product code (vaccine codes).  *CPT deleted 90718 effective 12/31/2012; however, this code would still be used in calculating the 60% threshold for CY 2012. 


Under the federal regulations, the physicians qualify for the enhanced rate if:

·        They have a specialty or subspecialty designation in family medicine, general internal medicine, or pediatrics that is recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS), or the American Osteopathic Association (A0A) and they actually practice in these areas.

·    They are not board certified but are practicing in the fields of family medicine, general internal medicine, or pediatrics or a subspecialty under one of these specialties, and 60% of their paid Medicaid procedures billed are for evaluation and management codes 99201 through 99499 and VFC administration services. 

·    NOTE:  To calculate your percentage, divide the total volume of E&M code and vaccine administration codes paid by Medicaid by the total volume of all codes paid by Medicaid.  This calculation must be done for each eligible physician individually and not as a group practice.   Although urinalyses, EKGs, and antibiotic administrations, are commonly provided by primary care physicians, CMS did not include them as primary care services in the numerator when calculating the 60% threshold for the enhanced primary care fee eligibility. Therefore, paid billed codes for ancillary services such as labs, x-rays, injections will cause the percentage threshold to be less. 


Eligible providers must complete the Alabama Medicaid Certification and Attestation for Primary Care Rate Increase Form and submit to HP Enterprise Services (Medicaid’s fiscal agent) for each service location.  A copy of the board certification must be submitted with each completed attestation form.  If a copy of the board certification is not available, a copy of the website verification is acceptable.  The self-attestation form is available for download at:

Qualifying physicians who submit their self-attestation to HPES by March 29, 2013, will be paid the enhanced reimbursement retroactive to January 1, 2013.


Qualifying physicians who submit their self-attestation to HPES on or after April 1, 2013, will be paid the enhanced reimbursement for dates of service beginning with the date the attestation is entered into the system by HPES.

Qualification for the payment increase will end the earliest of either December 31, 2014, or the expiration date of the board certification.  Therefore, physicians whose board certifications expire during the CY 2013 or 2014 must reattest for the program.  Services provided during any lapses in time between board-certification expiration and reattestation will not be eligible for the rate increase. If the board certification is rescinded by the certifying board, the provider must notify HPES within 10 days.  Qualification for the payment increase will end on the date the certification was rescinded by the certifying board.


At the end of each year, the Alabama Medicaid Agency must review a statistically valid sample of physicians who received the higher payments to verify that they met the requirements.  Services retroactively found ineligible for the enhanced payment will be subject to recoupment.



Covered services provided by non-physician practitioners are eligible for enhanced payment when working under the personal supervision of a qualifying physician.  In this case, the physician must assume professional/financial responsibility and is legally liable for the quality of services provided under his or her supervision.

Eligible non-physician practitioners include:

·         Physician Assistants

·         Nurse Practitioners


Eligibility for enhanced reimbursement is based on EACH individual physician meeting the eligibility criteria.



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

·         Federally Qualified Health Center (FQHC)

·         Rural Health Clinic (RHC)

·         Health Departments (ADPH)


Physician specialist certified in areas other than the three specified in the ACA are not eligible for the increased payments even if they otherwise meet the 60% procedure code threshold.  Physicians in these categories (for example:  ER doctors and OB/GYN) should NOT attest.


CMS rules implementing the ACA specifically exclude independently practicing nurse practitioners from the enhanced payment. 



The Alabama Medicaid Agency will reimburse the lesser of the following:

·         The provider’s submitted charge

·         The enhanced fee schedule rate



The enhanced rate is determined by comparing the 2013 Medicare Rate established by CMS to the 2009 Alabama Medicaid rate.  The higher rate will establish the rate of payment for that code.  A separate fee schedule of the enhanced rates will be made available in the near future under the Provider information heading on the Alabama Medicaid Agency website at


The enhanced reimbursement rate for the VFC administration service (for each of the codes listed above under covered services) is $19.79.



Federal regulations were not issued to the states in time to implement the pay increase on January 1, 2013.  For a limited period of time after January 1, 2013, claims will be paid at the regular Medicaid rates.  CMS will not allow enhanced payments to be made until the State Plan Amendment (SPA) is approved and attestation forms are received and processed by HPES. 

To ensure that payments can be made to qualifying physicians as soon as possible, the Alabama Medicaid Agency has taken the following steps: 

1)    Submitted the Tribal Letter Notification,

2)    Published the Public Notice Letter,

3)    Submitted the required SPA to CMS in January, the earliest states could submit a SPA,

4)    Submitted the Change Order for system changes (Medicaid and HPES are working together to make the computer system changes needed to process the payments)  

5)    Developed a process for the self-attestation, and

6)    Mailed a letter to all physicians who are currently enrolled with a primary care specialty or subspecialty designation.

Medicaid cannot make enhanced payments until all three of the following criteria are met:  

·         The Centers for Medicare and Medicaid Services (CMS) approves the State Plan Amendment (SPA).  

·         Medicaid implements the required system changes needed to process claims at the higher payment rate.

·         Eligible physicians return the self-attestation form (along with a copy of the board certification/ website verification if applicable).

·         They complete a self-attestation form to meeting the requirements above.  

Once all these requirements are in place, eligible services with dates of services starting January 1, 2013, will be retroactively adjusted for enhanced payments.

The Alabama Medicaid Agency is working as quickly as possible to finalize a primary rate increase and will keep providers informed of the process and timeline