Medicaid Eligibility and Patient Volumes

Roberta Mullin, HITECH Answers Expert

Medicaid Eligibility for EHR Incentive Program

If eligible professionals qualify for both the Medicare and Medicaid EHR Incentive programs, they must choose which one to participate in when they register. During the life of the programs an EP can switch programs only once after they receive their first incentive payment. For most EPs maximum return will be in the Medicaid program with a maximum incentive of $63,750 over the 6 year program. Medicaid programs are administered by each State and not all State have launched their programs. Although all states and territories have made their intentions to initiate programs. For the most up to date news on Medicaid programs visit he CMS Medicaid State Information page.

Unlike the Medicare eligibility requirements of billed allowable charges, the Medicaid requirements use patient volume to determine eligibility. To participate in the Medicaid program the EP must either meet a volume threshold of 30% Medicaid patients or practice predominantly in an FQHC or RHC where 30% of the patient volume is needy individuals. Pediatricians are the only exception to the 30% threshold, they can participate with only 20% Medicaid patient volume. Any pediatrician that falls short of the 30% threshold will see a reduced incentive with a maximum of $42,500 over the 6 year program.

Calculating Medicaid Patient Volumes

The Medicaid patient volume methodology is ultimately designated by the State Medicaid Agency and approved by CMS. The final rule outlines two acceptable methods for estimating Medicaid patient volumes. These volumes should include individuals enrolled in Medicaid managed care organizations, prepaid inpatient health plans, prepaid ambulatory health plans, and Medicaid medical home programs or Primary Care Case Management.

The two options in the final rule are:

  1. a ratio where the numerator is the total Medicaid patient encounters (or needy individuals) in any representative, continuous 90-day period in the preceding calendar year and the denominator is all patient encounters over the same period
  2. a similar ratio where the EP use the total of their assigned patient panel and those that are Medicaid patients.

The States can choose to incorporate either or both of these methods along with the choice of submitting for review and approval an alternate methodology. The alternate method that is submitted must meet some specific guidelines stated in the final rule. These include the data source has to be auditable, the State has received input from the relevant stakeholder group, and it will not result in fewer providers becoming eligible than the 2 methods outlined in the final rule. Refer to your specific State’s plan to determine how you will calculate your Medicaid patient volumes.

Group practices are also permitted by the final rule to calculate patient volumes of the entire practice with the following limitations:

  1. The practice’s volume is appropriate as a patient volume methodology calculation for an EP (the practice must see Medicaid patients).
  2. There is an auditable data source for the patient volume determination.
  3. All EPs in the practice must use the same methodology per payment year.
  4. The practice uses the entire practice patient volume.
  5. If an EP works part time in the practice,then the patient volume calculation includes only those encounters associated with the practice.

The HITECH Act also allows EPs to participate in the incentive program that meets their patient mix as well as their time frame. EPs in a practice can attest to their individual reporting periods at different times as well as some in Medicare and others in the Medicaid program. But always remember if you are participating in a State Medicaid program your final answers will come from the actual State Medicaid health information plan (SMHP).