CMS Adopts Final Rule Regarding Medicaid Payments for Primary Care Services and Vaccines

by King & Spalding

The Affordable Care Act (ACA) amended the Social Security Act to require State Medicaid agencies to pay for certain primary care services at rates equivalent to the higher of Medicare rates in effect in CYs 2013 and 2014, or at the rates that would be applicable using the CY 2009 Medicare physician fee schedule conversion factor.  It also provided for 100 percent Federal Financial Participation (FFP) for the difference between the amount a state is required to pay under the new law and the Medicaid State Plan rate that was in effect on July 1, 2009.  The ACA mandated that these rates apply to both payments by fee-for-service Medicaid and Medicaid managed care organizations to physicians with specialty designations of family medicine, internal medicine and pediatrics.  With the expansion of Medicaid looming, the government hopes these higher payments will entice primary care physicians to participate in the Medicaid program.  The final rule published November 6, 2012, in the Federal Register specifies which services and physicians qualify for the higher payment and the method for calculating such payments.  The final rule also updates the maximum administration fee that providers may charge a child’s parents or legal guardian for vaccines administered under the Vaccines for Children (VFC) program.   

With respect to the statutory higher payments for primary care services, CMS clarifies that the higher payment is not applicable to physicians reimbursed through a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), health department/clinic encounter or visit rate, or a nursing facility per diem rate.  The agency also permits higher payments for services performed by advance practice clinicians under the personal supervision of physicians and requires that states reimburse advance practice clinicians in CYs 2013 and 2014 in the manner in which the state reimbursed such services as of July 1, 2009.   This means that if the state reimbursed advance practice clinicians at a percentage of the physician fee schedule on July 1, 2009, then it should continue to do so.  CMS also establishes how the higher rates will be calculated and finalizes the proposed list of codes to which the higher statutory payment applies.  As there are codes on the list that some states and managed care organizations do not cover, the agency clarifies that state Medicaid agencies are reimbursed at the higher statutory rate for codes that are covered under the State’s Medicaid Plan or included in a managed care contract.  States and Medicaid managed care organizations are not required to cover services that were not previously otherwise covered. 

With respect to the VCF program, the final rule also adopts the proposed updates to the maximum administration fees that States may permit providers to charge.  Providers continue to have flexibility to determine the administration fee as long as it does not exceed the state’s maximum administration fee and the provider does not deny a vaccine to an eligible child due to the inability to pay the administration fee.  A state is not required to update the maximum administration fee that a provider may charge in its state in light of the final rule, but it must submit an amendment to its State Plan if it chooses to do so. 

Click here to view a copy of the final rule.

Reporter, Kate Stern, Atlanta, +1 404 572 4661,

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

© King & Spalding | Attorney Advertising

Written by:

King & Spalding

King & Spalding on:

Readers' Choice 2017
Reporters on Deadline

"My best business intelligence, in one easy email…"

Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:
Sign up using*

Already signed up? Log in here

*By using the service, you signify your acceptance of JD Supra's Privacy Policy.
Custom Email Digest
Privacy Policy (Updated: October 8, 2015):

JD Supra provides users with access to its legal industry publishing services (the "Service") through its website (the "Website") as well as through other sources. Our policies with regard to data collection and use of personal information of users of the Service, regardless of the manner in which users access the Service, and visitors to the Website are set forth in this statement ("Policy"). By using the Service, you signify your acceptance of this Policy.

Information Collection and Use by JD Supra

JD Supra collects users' names, companies, titles, e-mail address and industry. JD Supra also tracks the pages that users visit, logs IP addresses and aggregates non-personally identifiable user data and browser type. This data is gathered using cookies and other technologies.

The information and data collected is used to authenticate users and to send notifications relating to the Service, including email alerts to which users have subscribed; to manage the Service and Website, to improve the Service and to customize the user's experience. This information is also provided to the authors of the content to give them insight into their readership and help them to improve their content, so that it is most useful for our users.

JD Supra does not sell, rent or otherwise provide your details to third parties, other than to the authors of the content on JD Supra.

If you prefer not to enable cookies, you may change your browser settings to disable cookies; however, please note that rejecting cookies while visiting the Website may result in certain parts of the Website not operating correctly or as efficiently as if cookies were allowed.

Email Choice/Opt-out

Users who opt in to receive emails may choose to no longer receive e-mail updates and newsletters by selecting the "opt-out of future email" option in the email they receive from JD Supra or in their JD Supra account management screen.


JD Supra takes reasonable precautions to insure that user information is kept private. We restrict access to user information to those individuals who reasonably need access to perform their job functions, such as our third party email service, customer service personnel and technical staff. However, please note that no method of transmitting or storing data is completely secure and we cannot guarantee the security of user information. Unauthorized entry or use, hardware or software failure, and other factors may compromise the security of user information at any time.

If you have reason to believe that your interaction with us is no longer secure, you must immediately notify us of the problem by contacting us at In the unlikely event that we believe that the security of your user information in our possession or control may have been compromised, we may seek to notify you of that development and, if so, will endeavor to do so as promptly as practicable under the circumstances.

Sharing and Disclosure of Information JD Supra Collects

Except as otherwise described in this privacy statement, JD Supra will not disclose personal information to any third party unless we believe that disclosure is necessary to: (1) comply with applicable laws; (2) respond to governmental inquiries or requests; (3) comply with valid legal process; (4) protect the rights, privacy, safety or property of JD Supra, users of the Service, Website visitors or the public; (5) permit us to pursue available remedies or limit the damages that we may sustain; and (6) enforce our Terms & Conditions of Use.

In the event there is a change in the corporate structure of JD Supra such as, but not limited to, merger, consolidation, sale, liquidation or transfer of substantial assets, JD Supra may, in its sole discretion, transfer, sell or assign information collected on and through the Service to one or more affiliated or unaffiliated third parties.

Links to Other Websites

This Website and the Service may contain links to other websites. The operator of such other websites may collect information about you, including through cookies or other technologies. If you are using the Service through the Website and link to another site, you will leave the Website and this Policy will not apply to your use of and activity on those other sites. We encourage you to read the legal notices posted on those sites, including their privacy policies. We shall have no responsibility or liability for your visitation to, and the data collection and use practices of, such other sites. This Policy applies solely to the information collected in connection with your use of this Website and does not apply to any practices conducted offline or in connection with any other websites.

Changes in Our Privacy Policy

We reserve the right to change this Policy at any time. Please refer to the date at the top of this page to determine when this Policy was last revised. Any changes to our privacy policy will become effective upon posting of the revised policy on the Website. By continuing to use the Service or Website following such changes, you will be deemed to have agreed to such changes. If you do not agree with the terms of this Policy, as it may be amended from time to time, in whole or part, please do not continue using the Service or the Website.

Contacting JD Supra

If you have any questions about this privacy statement, the practices of this site, your dealings with this Web site, or if you would like to change any of the information you have provided to us, please contact us at:

- hide
*With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name. Or, sign up using your email address.