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Medicare and Medicaid Incentives for EPs

Medicare 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 is the entire calendar year. All participants in the program during 2015 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 PI (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.)

Medicaid EPs

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 PI.
  • 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 PI in 2013

Meet with your area PI coordinator or PI consultant for details about state-specific Medicaid requirements for demonstrating PI.