ACA Now

Statutory Text

SEC. 1202. PAYMENTS TO PRIMARY CARE PHYSICIANS. (a) IN GENERAL.— (1) FEE-FOR-SERVICE PAYMENTS.—Section 1902 of the Social Security Act (42 U.S.C. 1396a), as amended by section 2303(a)(2) of the Patient Protection and Affordable Care Act, is amended— (A) in subsection (a)(13)— (i) by striking ‘‘and’’ at the end of subparagraph (A); (ii) by adding ‘‘and’’ at the end of subparagraph (B); and (iii) by adding at the end the following new subparagraph: ‘‘(C) payment for primary care services (as defined in subsection (jj)) furnished in 2013 and 2014 by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine at a rate not less than 100 percent of the payment rate that applies to such services and physician under part B of title XVIII (or, if greater, the payment rate that would be applicable under such part if the conversion factor under section 1848(d) for the year involved were the conversion factor under such section for 2009);’’; and (B) by adding at the end the following new subsection: ‘‘(jj) PRIMARY CARE SERVICES DEFINED.—For purposes of subsection (a)(13)(C), the term ‘primary care services’ means— ‘‘(1) evaluation and management services that are procedure codes (for services covered under title XVIII) for services in the category designated Evaluation and Management in the Healthcare Common Procedure Coding System (established by the Secretary under section 1848(c)(5) as of December 31, 2009, and as subsequently modified); and ‘‘(2) services related to immunization administration for vaccines and toxoids for which CPT codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, or 90474 (as subsequently modified) apply under such System.’’. (2) UNDER MEDICAID MANAGED CARE PLANS.—Section 1932(f) of such Act (42 U.S.C. 1396u–2(f)) is amended— (A) in the heading, by adding at the end the following: ‘‘; ADEQUACY OF PAYMENT FOR PRIMARY CARE SERVICES’’; and (B) by inserting before the period at the end the following: ‘‘and, in the case of primary care services described in section 1902(a)(13)(C), consistent with the minimum payment rates specified in such section (regardless of the manner in which such payments are made, including in the form of capitation or partial capitation)’’. (b) INCREASE IN PAYMENT USING INCREASED FMAP.—Section 1905 of the Social Security Act, as amended by section 1004(b) of this Act and section 10201(c)(6) of the Patient Protection and Affordable Care Act, is amended by adding at the end the following new subsection: ‘‘(dd) INCREASED FMAP FOR ADDITIONAL EXPENDITURES FOR PRIMARY CARE SERVICES.—Notwithstanding subsection (b), with respect to the portion of the amounts expended for medical assistance for services described in section 1902(a)(13)(C) furnished on or after January 1, 2013, and before January 1, 2015, that is attributable to the amount by which the minimum payment rate required under such section (or, by application, section 1932(f)) exceeds the payment rate applicable to such services under the State plan as of July 1, 2009, the Federal medical assistance percentage for a State that is one of the 50 States or the District of Columbia shall be equal to 100 percent. The preceding sentence does not prohibit the payment of Federal financial participation based on the Federal medical assistance percentage for amounts in excess of those specified in such sentence.’’

On Apr. 25, CMS released an extensive final rule on Medicaid and CHIP managed care (press release; add’l fact sheets available here under “final rule”) that seeks to acknowledge increased enrollment in managed care delivery systems and – to facilitate beneficiaries’ transitions and care management across product lines – promote cross-market alignment with Marketplace Qualified Health Plans (QHPs) and Medicare Advantage (MA). The final rule addresses these provisions of the ACA.