Congress Considering Extension of Medicaid Enhanced Payments to Primary Care Physicians Through 2019

by Leonardo M. Tamburello

One of the signature goals of the Affordable Care Act is to increase Medicaid beneficiary access to primary care services.  To that end, Section 1202 of the Healthcare Education and Reconciliation Act of 2010 provided $230 million in federal funding for “Enhanced Payments” to Medicaid primary care providers from 2011 through 2015.  Momentum now appears to be building to extend these Enhanced Payments through 2019.

In the Senate, the “Community-Based Medical Education Act of 2014” would provide $420 million in funding to extend Enhanced Payments until 2019 and expand the definition of “primary care” to include “family medicine, internal medicine, pediatrics, internal medicine-pediatrics, obstetrics and gynecology, psychiatry, general dentistry, pediatric dentistry, or geriatrics.”  Similarly, in the House, Section 304 of “CHIP Extension and Improvement Act of 2014” proposes an extension of Enhanced Payments through 2019.

There has been some confusion regarding Enhanced Payments as they apply to group practices and whether such payments were required to be paid to the rendering employee physician.  Since then, CMS has issued an informal clarification in the form of a “Q and A” sheet which clarifies that that payment increases to the rendering physician are not absolutely mandatory in all cases, saying “where there is an employment agreement between the physician and the employing entity, the employment agreement might account for the payment increase by noting that the physician accepts his or her salary as payment in full, regardless of Medicaid reimbursement levels.”

If Enhanced Payments continue through 2019 as seems likely, this issue should be addressed by practice group managers and individual physicians to avoid any possible misunderstanding regarding their contracts or with Medicaid managed care organizations which administer the Enhanced Payments.