Eligibility The final rule:
- Discusses Medicaid EPs and eligible hospitals that may participate. EPs are physicians (primarily doctors of medicine and doctors of osteopathy), dentists, nurse practitioners, certified nurse midwives, and physician assistants practicing in a Federally Qualified Health Center (FQHC) led by a physician assistant or Rural Health Clinic (RHC) that is so led. Eligible hospitals that can participate are acute care hospitals (which include cancer and critical access hospitals) and children’s hospitals;
- Specifies that eligible professionals and hospitals must meet patient volume thresholds, measured by a methodology selected by the state. The two options offered in the final rule include: 1) a ratio where the numerator is the total number of Medicaid patient encounters (or needy individuals) treated in any 90-day period in the previous calendar year and the denominator is all patient encounters over the same period; or 2) a similar ratio where the state may take into account Medicaid patients on a primary care patient panel. For all eligible professionals except pediatricians, the minimum patient volume threshold is 30 percent; for pediatricians, it is 20 percent. Eligible professionals practicing at FQHCs/RHCs must demonstrate that more than 50 percent of their clinical encounters occurred at an FQHC/RHC over a six-month period, and that they had a minimum of 30 percent of their patient volume from needy individuals. Needy individuals are those receiving medical assistance from Medicaid or the Children's Health Insurance Program, individuals who are furnished uncompensated care by the provider, or individuals furnished services at either no cost or reduced cost based on a sliding scale determined by the individual’s ability to pay.
- Reiterates a statutory requirement that EPs must also not be hospital-based; meaning, that the EP provides “substantially all of his or her professional services in a hospital setting.” Substantially all” is defined to mean that 90 percent or more of the services are performed in an inpatient or emergency department setting. The proposed rule aligns the definition of hospital-based with the Medicare definition, but allows states to develop a process to verify that EPs are not hospital-based, and therefore eligible to participate..
- Specifies that an acute care hospital is a primary health care facility where the average length of patient stay is 25 days or fewer. Hospitals with an average length of stay of 25 days or fewer and with a CMS Certification Number (CCN) that has the last four digits in the series 0001 – 0879 or 1300-1399 are eligible. This specification will include short term general hospitals, the 11 cancer hospitals, and critical access hospitals in the United States , District of Columbia , and U.S. territories. Acute care hospitals also must have 10 percent Medicaid patient volume in order to participate..
- For children’s hospitals, specifies that only those hospitals that have CCNs in the 3300-3399 series will be considered children’s hospitals.
- Specifies that entities promoting the adoption of certified EHR technology can be designated by states for EPs to voluntarily assign their incentive payments. The statute allows eligible professionals to assign their incentive payments to their employer or to state-designated "entities that promote the adoption of certified EHR technology." The definition of such an entity requires the entity to enable oversight of the business, operational and legal issues involved in the adoption and implementation of EHR and/or the exchange and use of electronic health information between participating providers, in a secure manner.