The long awaited Medicaid rate increase for APNs in Texas is in effect as of March 1, 2006. APNs billing for services provided to fee-for-service or Primary Care Case Management (PCCM) Medicaid recipients are now reimbursed at 92% of the physician’s fee. The rate increase also applies to services reimbursed by the Children with Special Health Care Needs (CSHCN) Program if those service are billed under the APN’s Texas Provider Identifier (TPI) number.
It has not been a fast or easy path to receiving this increase from 85% to 92%. Advanced Practice Nurses began lobbying for the change in 2003, and in 2005 the Texas Legislature included a rider on the Appropriations Bill that created the path to receiving the increase. For more background information, read the article posted in the Legislative section, 2005 Session. Significant hurtles were overcome in achieving this rate increase, including unexpected resistance from some physician groups. However, despite the intervening saga, the agreements forged during the 2005 Legislative Session were ultimately upheld and the result is another win for APNs.
At the time the Appropriations Bill rider was adopted, it seemed the Health and Human Services Commission (HHSC) would have no choice but to end the practice of allowing physicians who delegate prescriptive authority to APNs to bill for the APN’s services. However, HHSC chose to continue allowing physicians to bill for services provided by APNs under certain circumstances. The Medicaid Rule, 1 TAC §354.1062, that allows physician billing for APN services is expected to be revised by early 2007, but early drafts still allow physicians to bill for APN’s services if the physician employs the APN or the physician and APN are employed by the same group.
Based on the requirements in the 2006 Medicaid Provider Manual, physicians who bill for services provided by APNs should attach the modifier “SA” to each applicable procedure code. Physicians using those modifiers should be reassured that they will continue to receive 100% of Medicaid reimbursement.
Those providers reimbursed by Medicaid Health Maintenance Organizations (HMOs) should review the contracts with those HMOs. HMOs pay based upon the provisions in the provider contract. So, if a contract with an HMO states the APN will be paid the Medicaid rate, then the HMO will increase the percentage because the Medicaid rate increased to 92%. However, if an HMO contracted to pay 85% of the physician Medicaid rate for services billed under the APN’s name, then the HMO would not be required to increase the rate it pays APNs. Be advised that before renewing any Medicaid HMO contract, those negotiating the contract should assure that the rate to be paid APNs is 92% or higher.
If you need verification of the change in the Medicaid rate, refer to item #16 in the Texas Medicaid Healthcare Partnership Banner issued on April 17, 2006. The item can be accessed online, www.tmhp.com/File%20Library/File%20Library/Banner%20Messages/2006/041706_BM.pdf
Several APNs have asked if the Medicaid rate increase also applies to Medicare. It does not. Medicare is a federally administered program and the state of Texas has no authority to increase the Medicare payment rate. Also not affected by the increase are other state health care programs not mentioned specifically in the TMHP Banner item, including the Children’s Health Insurance Program (CHIP). APNs should understand that Rider 72 in Article 2 of the 2005 Appropriations Bill only addressed the Medicaid Program rate so any other state programs that also adopt that reimbursement rate are a bonus for Texas APNs.
APNs should also be aware that APNs are paid for many items in the Medicaid Program at 100% of the physician’s rate. This includes well child checkups and immunizations provided under the Texas Health Steps (THS) program, and the costs of any biologicals, medications, laboratory and radiologic services that are administered or provided. If you have questions about APNs and the Medicaid program, contact Lynda Woolbert at lynda@cnaptexas.org.
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