Medical Services

Medicaid Electronic Health Records Incentive Payment Program

Eligible Professionals

Eligible Professionals include:

  • Physicians (MDs, DOs)
  • Pediatricians
  • Nurse Practitioner (NPs)
  • Dentists
  • Certified nurse mid-wives (CNMs)
  • Physician Assistants (PAs) when practicing at a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) led by a physician assistant

Eligible Professionals must be non-hospital based, except when practicing predominantly in a Federally Qualified Health Center or Rural Health Clinic. Hospital based providers are those providing 90 percent or more of their covered professional services in either an inpatient or emergency department of a hospital. 

Eligible professionals also qualify when practicing predominantly in a Federally Qualified Health Center/Rural Health Clinic (FQHC/RHC). Practicing predominantly means that the FQHC/RHC is the clinical location for over 50 percent of total encounters over a period of six months in the most recent calendar year or 12 months preceding the attestation.

Patient Volume

All eligible professionals must meet a minimum 30 percent Medicaid patient volume threshold in any continuous 90 day period in a calendar year. Exception: Pediatricians must meet a minimum of 20 percent Medicaid patient volume threshold in a calendar year resulting in a lower incentive payment.

Medicaid patient volume is calculated using encounters which are services rendered on any one day to an individual where Medicaid paid for part or all of the service; premiums, co-payments, and/or cost-sharing.

The final rule allows for several options when determining patient volume.  

  • One option is for eligible professionals (EPs) to annually meet patient volume thresholds, measured by a ratio where the numerator is the total number of Medicaid patient encounters over any continuous 90-day period in the most recent calendar year and the denominator is all patient encounters over that same 90-day period.
  • Another option is having a Medicaid recipient on the panel assigned to the EP (for example, primary care case management or medical home) within that representative continuous 90-day period. The methodology for estimating the Medicaid patient volume threshold would use as the numerator the EP’s total number of Medicaid patients assigned through a Medicaid primary care case management, plus all other Medicaid encounters for that EP.

Beginning with Program Year 2013, Children’s Health Insurance Program (CHIP) recipients are included as encounters in the Medicaid patient volume.

EPs practicing in a FQHC or RHC have the option to consider the following when demonstrating patient volume:

  • Medicaid or CHIP recipients,
  • Patients furnished uncompensated care by the provider or furnished services at either no cost or on a sliding scale.

Clinics and group practices have the option to use the practice or clinic level patient volume and apply it to all EPs in their clinic or group under three conditions:

  • The clinic or group practice’s patient volume is appropriate as a patient volume methodology calculation for the EP (for example, if an EP only sees Medicare, commercial, or self-pay patients, this is not an appropriate calculation).

  • There must be an auditable data source to support the clinic’s patient volume determination.

  • The clinic or practice must use only one methodology in each year.

The clinic or practice must use the entire clinic or group practice’s patient volume and not limit it in any way. EP's may attest to patient volume under the individual calculation or the group/clinic proxy in any participation year.

Eligible Professionals who work at multiple locations would need to have 50 percent of their total patient encounters at locations where certified EHR technology is available. Eligible professionals need to attest to the information submitted.

Adopt, Implement, Upgrade or Meaningful Use Requirements

In the first year of participation, eligible providers can adopt (acquire, install), implement (commence utilization of EHR such as training and data entry), or upgrade (expand) to a certified EHR capable of meeting meaningful use requirements.  Eligible providers are not required to demonstrate meaningful use in the first year and no EHR reporting is required.  Eligible providers who have already adopted, implemented or upgraded would still receive a 1st year payment.  For a list of certified EHR technology, visit the Certified HIT Product List.
                              
Eligible providers should demonstrate meaningful use through:

  • Use of certified EHR technology in a meaningful manner such as e-prescribing
  • Use of certified EHR technology for electronic exchange of health information to improve quality of health care
  • Use of certified EHR technology to submit clinical quality measures (CQM) and other measures

Reporting Information

Reporting period is 90 days for first year demonstrating meaningful use. For subsequent years, reporting period is one full calendar year, except for in program year 2014, which requires a 90 day reporting period for all providers attesting meaningful use. . There is no EHR reporting period for adopting, implementing, or upgrading.

Payment Information

Payments are for adopting, implementing, upgrading or meaningful use of a certified EHR technology. Maximum Payment under the Medicaid Incentive Payment Program for eligible professionals is $63,750 over a period of 6 years. The first year payment cap is $21,250 with subsequent payments of $8,500. Eligible Professionals must begin participation by 2016 to receive full incentive payments as incentives are available through 2021. 

An exception is for pediatricians who do not meet the 30 percent patient volume threshold but meet the 20 percent threshold. Pediatricians with 20 percent threshold qualify for reduced payments of $14,167 for the first year and $5,667 for subsequent years not to exceed a total of $42,500 over six years. 

Eligible Professionals who qualify for both Medicare and Medicaid Incentive Programs

The Medicare incentive program is federally run by the Centers for Medicare and Medicaid Services (CMS) while the Division of Medical Services administers the Medicaid incentive program.  

Some Eligible Professionals may qualify for both the Medicare and Medicaid incentive programs. Providers who are eligible for both the Medicare and Medicaid programs must choose one program and are allowed to switch once between the programs before calendar year 2015. 

Registration Information

  • Eligible professionals must initially register with CMS. For the CMS Registration User Guide and additional information, visit the CMS website.
  • After registering with CMS, you can register and attest for the South Dakota Program.