Medicare and Medicaid Incentives for EPs
The Medicare EHR Incentive Program for EPs, which began in 2011, will continue through 2016. To receive the maximum EHR incentive payment, Medicare EPs must begin participating by 2012. The last year to begin participating in the program is 2014.
- EPs who demonstrate MU of certified EHR technology for five continuous years can receive up to $44,000. Payments are calculated by multiplying the submitted allowable charges by 75 percent, up to the capped amount for the year. Allowable charges are defined as fee-for-service of Part B claims. See the EHR Payment Tables for more information.
- To qualify for Medicare EHR incentive payments, Medicare EPs must successfully demonstrate MU each year they participate in the program.
- Incentive payments for EPs are based on the calendar year (January to December). The reporting period for the first year is any 90 continuous days during the calendar year. The reporting period for all subsequent years, with the exception of 2014, is the entire calendar year. To allow participants to upgrade to a 2014 certified EHR, all participants in the program during 2014, regardless of their stage in demonstrating meaningful use, will have a 90-day reporting period.
- Beginning in 2015, Medicare EPs who do not successfully demonstrate MU will be subject to a payment adjustment. The payment reduction starts at one percent and increases each year that a Medicare EP does not demonstrate MU (up to a maximum of five percent).
- Medicare EPs who predominantly furnish services in an area designated as a Health Professional Shortage Area (HPSA) will receive a 10 percent increase in their annual EHR incentive payments. (NOTE: This HPSA incentive is not available for EPs who participate in the Medicaid EHR Incentive Program.)
To participate in the Medicaid EHR Incentive Program, an EP must adopt, implement, or upgrade to certified EHR technology during the first participation year. The EP must also meet the minimum patient volume threshold.
The Medicaid EHR Incentive Program, which will continue to pay incentives through 2021, is administered voluntarily by states and territories. EPs can participate for a total of six years and, unlike Medicare, participation years do not have to be consecutive. The last year that an EP can begin participating in the Medicaid EHR Incentive Program is 2016.
- EHR incentive payments for EPs are higher under Medicaid than Medicare. EPs can receive EHR incentive payments up to $63,750 over six years under Medicaid vs. $44,000 over five years under Medicare. See the EHR Payment Tables for more information.
- Medicaid EPs can receive an incentive payment for adopting, implementing, or upgrading certified EHR technology in their first year of participation. In subsequent participation years, Medicaid EPs receive incentive payments for successfully demonstrating MU.
- Unlike Medicare, Medicaid has a patient volume requirement. To meet this requirement, pediatricians must have a Medicaid patient volume of at least 20 percent. All other Medicaid EPs must have a Medicaid patient volume of 30 percent.
- Medicaid EPs that practice predominately at a Tribal/Urban/FQHC/RHC are still required to have a patient volume of 30 percent, but they are allowed to include paid Medicaid claims, zero-paid claims, CHIP, Medicaid enrolled, and uncompensated care patients as part of a "needy individual" calculation.
- Medicaid EPs will not be subject to payment adjustments, but Medicaid EPs who also treat Medicare patients will have a payment adjustment to Medicare reimbursements starting in 2015 if they do not successfully demonstrate MU in 2013
See the EP Incentive Estimator [XLS - 163 KB] for help calculating provider payments under Medicare and Medicaid. (Persons using assistive technology may have limited access to the information in these files. For assistance, contact JoAnne Hawkins at (505) 767-6600, ext. 1525, or Joanne.Hawkins@ihs.gov.)
Meet with your area MU coordinator or MU consultant for details about state-specific Medicaid requirements for demonstrating MU.