Payment for Primary Care Services

Recent federal law requires Medicaid payments for primary care services furnished by a primary care practitioner with a primary specialty of family medicine, general internal medicine, or pediatric medicine be paid at parity with Medicare beginning January 1, 2013. The law defines covered services as those Evaluation and Management (E&M) codes and immunization services that are covered by Medicare, as well as primary care codes that Medicare does not currently cover but for which it publishes and sets relative value units. The law provides 100% federal funding for the incremental cost of meeting this requirement. The 100% federal funding of the incremental cost is calculated based on the Medicaid rate as of July 1, 2009.

For more information, see the fact sheet for Proposed Federal Rules for Increased Medicaid Payment for Primary Care Providers.

MO HealthNet Division has been working toward implementing this federal mandate and received authority from the General Assembly during the past legislative session in both the physician and managed care appropriation. It is anticipated that approximately 700 primary care codes utilized by MO HealthNet (Missouri Medicaid) will be affected. The proposed rule referenced in the link above is intended to apply to payment within both Medicaid managed care and fee-for-service delivery systems.