Steps Toward Receiving EHR Incentive Payments

Determine Eligibility

Who is Eligible

Eligible Hospitals and critical access hospitals– all IHS hospitals are eligible

Eligible Professionals – individual health professionals at I/T/U clinics and ambulatory care sites in a hospital who meet the requirements

Medicare: physicians, oral surgeons, podiatrists, optometrists, chiropractors

Medicaid: physicians, nurse practitioners, dentists, certified nurse midwives, and some physician assistants (where they work at a federally-qualified health center or rural health center that is PA-led) that meet the Patient Volume requirements. For pediatricians, they must have at least 20% Medicaid Patient Volume. For all other Medicaid Eligible Professionals, it’s 30% Medicaid Patient Volume; unless they practice predominately at an FQHC/RHC then it’s 30% “needy individual” Patient Volume (includes Medicaid, CHIP, sliding scale and uncompensated care)

Determine Eligibility for Medicare and/or Medicaid Incentive Payments

Health Professionals

To qualify for incentive payments health professionals must meet certain eligibility criteria for Year 1.

Medicare	Medicaid
Adopt/Implement/Upgrade a Certified Electronic Health Record Be an Eligible Professional Demonstrate Meaningful Use	Adopt/Implement/Upgrade a Certified Electronic Health Record Be an Eligible Professional Meet Patient Volume

To determine additional requirements for Meaningful Use from the state Medicaid agency, confer with your Meaningful Use coordinator and Meaningful Use consultant.

Qualifying as Eligible Professionals

Eligible professionals can determine if they meet the eligibility requirements for Medicare and Medicaid EHR incentive programs by reviewing the following table. Those who qualify for Medicare and Medicaid programs may only participate in one program. Those eligible to receive Electronic Health Record (EHR) incentive payments under both programs will maximize their payments by choosing the Medicaid EHR Incentive Program. Note that Eligible Professionals who provide care to Medicare beneficiaries must be enrolled with Medicare as Medicare providers.

Medicare	Medicaid
Eligible professionals under the Medicare incentive program include Eligible Professionals who bill the Medicare Physician Fee Schedule for patient services and the following professionals: Doctor of medicine or osteopathy Doctor of oral surgery or dental medicine Doctor of podiatric medicine Doctor of optometry Chiropractor	Eligible Professionals under the Medicaid incentive program include: Physician Dentist Certified nurse-midwife Nurse practitioner Physician assistant practicing in a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) led by a physician assistant

Hospital-based Eligible Professionals are not eligible for incentive payments. An Eligible Professional is considered hospital-based if 90% or more of his or her services are performed in a hospital inpatient (Place of Service code 21) or emergency room (Place of Service code 23) setting.

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Qualifying for an Incentive Payment under the Medicare and Medicaid EHR Incentive Programs

Medicare

Medicaid

For Medicare, there is not a patient volume requirement; however, you must demonstrate Meaningful Use during a consecutive 90-day period in the first calendar year. After year 1 of participation, each remaining year the reporting period will be 365 days.

To be eligible to receive an incentive under the Medicaid EHR, an Eligible Professional must meet one of the following Patient Volume criteria during a consecutive 90-day period in the calendar year. Have at least 30% of your paid services furnished to Medicaid patients in an outpatient setting (20% for pediatricians) OR Practice predominately in an FQHC or RHC with a 30% needy individual Patient Volume threshold. Needy Patient Volume is defined as patients who are enrolled in the Medicaid or Children’s Health Insurance Program (CHIP), receive uncompensated care, or receive care on a reduced fee scale.

Encourage eligible patients to sign up for Medicaid to ensure that required patient volume and eligibility requirements are met. More information.

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Calculating Patient Volume for Medicaid

The calculation of Patient Volume under Medicaid is based on the total number of paid encounters to the Eligible Professional during a consecutive 90-day period in the calendar year prior to the Meaningful Use payment year.

The numerator is the number of encounters during the same time period where Medicaid paid for all or part of the service, co-pay, premium, or cost share. Thus, the patient not only has to be Medicaid eligible, but Medicaid must have paid for some part of the encounter. If your state has an 1115 waiver, you will include both Medicaid and CHIP paid encounters into the numerator.

The denominator is all patient encounters for the same Eligible Professional over the same 90-day period. For example, if the Eligible Professional had 100 encounters and 30 were paid in full or in part by Medicaid, they would have a 30% Patient Volume. The calculation formula is: [Total (Medicaid) paid patient encounters in any representative continuous 90-day period in the preceding calendar year/Total patient encounters in that same 90-day period] *100

There is an option to calculate or aggregate Patient Volume for the entire facility and then each Eligible Professional would use the facility's Patient Volume as a proxy for their individual Patient Volumes. However, in this case you would count encounters for all providers - not just Eligible Professionals - when you calculate the group rate. Thus, if you have providers who see a lot of patients but those encounters are not paid for by Medicaid, it can lower your group rate. The opposite also could be true.

Calculating Incentive Payments for Medicare and Medicaid

Tools are available to help you calculate provider payments under Medicare and Medicaid. See Eligible Professional Incentive Estimator [XLS-163KB].

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Hospitals

To qualify for incentive payments, hospitals must meet certain eligibility criteria for Year 1.

Medicare	Medicaid
A/I/U of a Certified EHR Be an Eligible Hospital Demonstrate Meaningful Use	A/I/U of a Certified EHR Be an Eligible Hospital Acute Care Hospitals and Critical Access Hospitals (CAHs) (must meet Patient Volume)

Confer with your Area Meaningful Use Coordinator to determine additional requirements for Meaningful Use from the state Medicaid agency.

Qualifying as Eligible Hospitals

Eligible Hospitals can determine if they meet the eligibility requirements for Medicare and Medicaid EHR Incentive Programs by reviewing the following table. Hospitals that qualify for Medicare and Medicaid programs may participate in both programs.

Medicare	Medicaid
Hospitals eligible under Medicare: Acute care hospitals (Subsection (d) hospitals in the 50 states or DC that are paid under the Inpatient Prospective Payment System). Critical access hospitals (CAH) Medicare Advantage (MA-Affiliated) Hospitals	Hospitals eligible under Medicaid: Acute care hospitals (including CAHs and cancer hospitals) with at least 10% Medicaid Patient Volume Children’s hospitals (no Medicaid Patient Volume requirements)

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Qualifying for an Incentive Payment under the Medicare and Medicaid EHR Incentive Programs

Medicare	Medicaid
To qualify for an incentive under the Medicare EHR, there is not a Patient Volume requirement; however, Eligible Hospitals must demonstrate Meaningful Use for 90 consecutive days within the first Federal fiscal year (FFY) of participating in the program.	To qualify for an incentive under the Medicaid EHR, acute care hospitals must have at least 10% Medicaid Patient Volume during a consecutive 90-day period in the preceding Federal fiscal year (FFY) of participating in the program.

For 2015 and later, Medicare Eligible Hospitals and CAHs that do not successfully demonstrate Meaningful Use will have a payment adjustment in their Medicare reimbursement. More information .

Calculating Patient Volume for Medicaid

The calculation of Patient Volume under Medicaid is based on the total number of Medicaid paid patient encounters to the Eligible Hospital during a consecutive 90-day period in the preceding fiscal year prior to the Meaningful Use payment year.

The numerator is the number of encounters during the same time period where Medicaid paid for all or part of the service, co-pay, premium, or cost share. Thus, the patient not only has to be Medicaid eligible, but Medicaid must have paid for some part of the encounter. If your state has an 1115 waiver, your facility will include both Medicaid and CHIP paid encounters into the numerator.

The denominator is all patient encounters for the same Eligible Hospital over the same 90-day period. For example, if the Eligible Hospital had 100 encounters and 10 were paid in full or in part by Medicaid, they would have a 10% Patient Volume.

The calculation formula is: [Total (Medicaid) paid patient encounters in any representative continuous 90-day period in the preceding fiscal year/Total patient encounters in that same 90-day period] *100

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Calculating Incentive Payments for Medicare and Medicaid

Tools are available to help the hospital calculate payments under Medicare and Medicaid. See Hospital Incentive Estimator [XLS-151KB].

Assess Your Readiness

Use standardized tools to assess your readiness and to define corrective actions.

A Meaningful Use readiness assessment tool is being administered to facility staff to evaluate its readiness and progress toward meeting Meaningful Use requirements and adopting a certified Electronic Health Record (EHR).

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