Why PCPs have yet to see their Medicaid pay hike

Delays may be due to difficulty determining how to implement increases

Most primary care physicians (PCPs) still have not seen a Medicaid pay hike guaranteed to them by the Affordable Care Act (ACA), but a federal official says 48 states have received approval to distribute them.


CMS issued a final rule on the Affordable Care Act's (ACA) temporary Medicaid pay bump for PCPs more than seven months ago, but most doctors are still waiting to see an increase.

The two-year pay raise matched Medicaid payments to those paid by Medicare. It was included in the ACA to incent physicians to treat more Medicaid beneficiaries as millions of Americans are added to the program through the Medicaid expansion. Medicaid fees are generally far below those paid by Medicare and private plans, so the move could mean a pay increase of 73% nationally, according to a 2012 study by the Kaiser Family Foundation.

Earlier this year, CMS said that physicians would be able to obtain their pay raises retroactively to Jan. 1. However, many states have established deadlines in April or May for doctors to attest that they qualify for the increase in order to get the retroactive pay bump. Physicians who missed those deadlines will only receive the pay raise once they fill out paperwork evidencing that they practice as a PCP, internist, or pediatrician.

Why have the delays continued?

National Association of Medicaid Directors Executive Director Matt Salo said states are frustrated by the delay. "It's been slow to roll out," he said, adding, "And it will be gone less than 18 months after it starts."

However, a CMS spokesperson said the department has approved 48 state applications—Alaska and California are the only exceptions—which means the states can begin paying the increased rate. (Alaska already pays out the higher rates, and California's application is still being reviewed by the administration.)

According to "Capsules," there have been several reasons for the delay, including:

  • Difficulty determining how to implement the increases;
  • Determining how Medicaid managed care plans—which typically pay physicians a monthly fee per patient—can distribute the additional pay; and
  • State officials needing extra time to enact the change and get federal approval for new rates, after the administration did not release the final rule until November 2012 (Galewitz, "Capsules," Kaiser Health News, 7/16).

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