Eligibility & Volume: Eligible Professionals
- Physicians - MDs, DOs
- Advanced Registered Nurse Practitioners (ARNPs)
- Certified Nurse-Midwives
- Dentists
- Physicians Assistants (PA)(i)
Additional Requirements
- Active status
- No outstanding state or federal sanctions
- Not be hospital based (defined as having 90% or more encounters in a year in a hospital or emergency room setting)
Eligible Professional Volume Requirements
In addition to being an eligible provider type and having certified technology, EPs must meet a 30% Medicaid encounter volume threshold over 90 day period. Pediatricians can qualify for the program with 20% Medicaid encounter volume but it results in a maximum reduced payment of $42,500.
- Volume can be based on a continuous 90 day period in the previous calendar year or from the 12 months preceding attestation.
- A Medicaid encounter is defined as a service(s) rendered on any one day to an individual enrolled in a Medicaid program. Encounters no longer have to be billed and/or paid to be counted.
- Medicaid volume thresholds must be met each participation year.
- The denominator of the volume calculation is all encounters during the 90 day period.
- Eligible professionals that practice in a RHC or FQHC at least 50% of the time can count "needy individuals"(ii) to meet their patient volume threshold.
- Must be working in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) and the clinic must be led by a PA. The "Attestation for Physician Assistant Led" form must be complete.
- Needy individuals are defined in Section 1903(t)(3)(F) of the Social Security Act as individuals meeting any of the following three criteria:
- They are receiving medical assistance from Medicaid or the Children's Health Insurance Program (CHIP).
- They are furnished uncompensated care by the provider.
- They are furnished services at either no cost or reduced cost based on a sliding scale determined by the individual's ability to pay.
