Opinion

Extend and Amend the Medicaid Bump

Without congressional action, a provision of the Affordable Care Act designed to increase access to physicians for Medicaid beneficiaries will expire at the end of this year. The American Academy of Neurology supports the extension of the Medicaid bump, section 1202 of the Affordable Care Act (ACA), also known as “Medicaid parity,” as long as it is amended to include all specialists who routinely provide comprehensive, coordinated care for Medicaid patients.

Two significant problems exist with the Medicaid bump, which pays Medicaid providers the Medicare rates, as currently implemented.

First, the Medicaid bump was aimed at providing a payment increase for “primary care services” by physicians labeled as primary care providers. Through regulation, the Centers for Medicare & Medicaid Services (CMS) qualified all subspecialists boarded by the American Board of Internal Medicine (ABIM) when determining who was eligible for the increase. This means that all cardiologists, gastroenterologists, rheumatologists, and nearly 20 other common specialists are receiving the increased payments on certain billing codes. This is good for Medicaid patient access to care as long as the physician they need is certified by the ABIM. It is a big problem if they need a specialist like a neurologist, psychiatrist, or OB/Gyn, all of whom are certified by other medical boards.

The second problem deals with the definition of primary care services. It is important to understand that there are no billing codes set aside especially for primary care services. When any physician—whether primary care, neurologist, or other specialty—has an office visit with a new or returning patient, they all use the exact same evaluation and management (E/M) codes to bill Medicaid.

The Institute of Medicine defines primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” Cognitive care doctors, like neurologists, provide this type of comprehensive care to patients with chronic neurologic diseases and their families every day. The parents of kids with severe epilepsy or autism, patients with mental health problems, or women with complicated pregnancies frequently rely on specialists to provide focused and expert care for their underlying condition as well as for coordination of their routine care needs.

The American Academy of Neurology believes that the Medicaid bump should be extended. But the current rules for the Medicaid bump are unfair to patients with neurological, psychiatric, or obstetric needs. Medicaid participation from specialties is even worse (just 43 percent) than that of primary care (68 percent) making it difficult for patients with chronic or complicated conditions to access the Medicaid program. Medicaid parity needs to be extended with access to all types of physicians who frequently coordinate patient care and bill identical E/M codes, not just those fortunate enough to be certified by a chosen examining board.

Michael J. Amery, Esq., serves as legislative counsel for the American Academy of Neurology

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