Lawriter - OAC - 5101:3-57-01 Medicaid provider incentive program (MPIP): eligible providers and patient volume requirements.

5101:3-57-01 Medicaid provider incentive program (MPIP): eligible providers and patient volume requirements.

(A) The medicaid provider incentive program (MPIP) is Ohio's program for implementing section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA), Pub. L. No. 111-5, and the published regulations at 42 C.F.R. Part 495 (as in effect on July 28, 2010) that establish a program that permits certain eligible professionals and eligible hospitals participating in medicaid programs to receive incentive payments if they are meaningful users of certified electronic health records (EHR) technology. The incentive payments are not a reimbursement, but are intended to encourage eligible professionals and eligible hospitals to adopt, implement, or upgrade certified EHR technology and use it in a meaningful manner. MPIP incentive payments will only be made as long as federal funds are available.

(B) The following medicaid providers are eligible to participate in MPIP:

(1) Medicaid eligible professionals; and

(2) Medicaid eligible hospitals.

(1) An eligible professional is limited to the following types of providers, consistent with the scope of practice as it is recognized under Ohio law as applicable for each type of professional:

(a) Physicians, including optometrists, in accordance with rule 5101:3-4-01 of the Administrative Code.

(b) Dentist.

(d) Nurse practitioners.

(e) Physician assistants (PA) practicing in a federally qualified health center (FQHC) or a rural health center (RHC) that is so led by a PA. "So led" means the PA is the primary provider in a clinic (for example, when there is a part-time physician and the PA is full-time, the PA will be considered as the primary provider); the PA is a clinical or medicaid director at a clinical site or practice; or the PA is an owner of an RHC.

(2) An eligible professional must, for each year of participation in MPIP:

(a) Be an enrolled Ohio medicaid provider with an active Ohio medicaid provider agreement.

(b) Not be hospital-based.

(i) An eligible professional is considered hospital-based if ninety per cent or more of the eligible professional's medicaid encounters are furnished in an inpatient hospital (place of service code (POS) 21) or an emergency room (POS 23) setting in the calendar year (CY) prior to the payment year.

(ii) The hospital-based exclusion does not apply to a medicaid eligible professional qualifying as practicing predominantly through a FQHC or RHC as defined in paragraph (C)(4)(c) of this rule.

(i) Another state;

(ii) MPIP; or

(iii) The medicare EHR incentive payment program.

(3) An eligible professional must not have a current sanction or exclusion identified at:

(a) The United States department of health and human services, office of inspector general, list of excluded individuals and entities: or

(b) The Ohio list of excluded providers.

(4) An eligible professional must meet one of the following patient volume criteria:

(a) Have a minimum patient volume of thirty per cent attributable to individuals whose medical services delivered were eligible for and reimbursed by medicaid.

(b) Have a minimum patient volume of twenty per cent attributable to individuals whose medical services delivered were eligible for and reimbursed by medicaid if the provider is a pediatrician.

(i) For purposes of MPIP only, a pediatrician means a medical doctor, who diagnoses, treats, examines, and prevents diseases and injuries in children. A pediatrician must hold a doctor of medicine (MD) or doctor of osteopathy (DO) degree and hold a current, in good-standing board certification in pediatrics through the American board of pediatrics, the American board of surgery, the American board of radiology, the American board of urology or the American osteopathic board of pediatrics.

(c) Practice predominantly through a FQHC or RHC and have a minimum thirty per cent patient volume attributable to needy individual encounters (as defined in paragraph (F)(3) of this rule). An eligible professional practices predominantly through an FQHC or RHC if the clinical location for over fifty per cent of his or her total patient encounters over a period of six months in the most recent CY occurs through an FQHC or an RHC.

(D) Medicaid eligible hospitals.

(1) An eligible hospital must be one of the following:

(a) An acute care hospital where the average length of stay is twenty-five days or fewer (acute care hospital's average length of stay will be calculated based on the hospital's fiscal year); and has a federal centers for medicare and medicaid services (CMS) certification number that has the last four digits in the series 0001-0879 or 1300-1399.

(b) Cancer hospitals and critical access hospitals are included in the definition of an acute care hospital and will be eligible for MPIP if they meet the requirements under an acute care hospital described in this rule.

(c) A children's hospital that is separately certified and is either freestanding or a hospital-within-a hospital that has a CMS certification number with the last four digits in the series 3300-3399 and predominantly treats individuals under the age of twenty-one.

(2) An eligible hospital must be an enrolled Ohio medicaid provider with an active Ohio medicaid provider agreement.

(3) An eligible hospital may be dually eligible for both the medicare EHR incentive payment program and MPIP if it meets all of the following criteria:

(a) Is a sub-section(d) hospital in the fifty United States or the District of Columbia, as defined in section 1886(d)(1)(B) of the Social Security Act (2010), 42 U.S.C. 1395ww; and

(b) Has a CMS certification number ending in 0001-0879;

(4) An eligible hospital must not have received a medicaid EHR incentive payment, within the current payment year, from:

(a) Another state; or

(b) MPIP.

(5) An eligible hospital must not have a current sanction or exclusion identified at:

(a) The United States department of health and human services, office of inspector general, list of excluded individuals and entities; or

(b) The Ohio list of excluded providers.

(6) An eligible hospital must meet a minimum patient volume of ten per cent attributable to those individuals whose medical services delivered were eligible for and reimbursed by medicaid. A children's hospital is exempt from meeting a patient volume threshold.

(E) Establishing patient volume.

(1) Patient volume is calculated in accordance with the patient encounter methodology defined in 42 C.F.R. 495.306(c) (as in effect on July 28, 2010).

(2) To calculate patient volume, an eligible professional must divide:

(a) The total medicaid patient encounters (fee-for-service and managed care) in any continuous ninety-day period, beginning on the first day of a month, in the preceding CY; by (b) The total patient encounters in the same ninety-day period.

(3) To calculate needy individual patient volume, an eligible professional must divide:

(a) The total needy individual patient encounters in any continuous ninety-day period, beginning on the first day of a month, in the preceding CY; by

(b) The total patient encounters in the same ninety-day period.

(4) To calculate patient volume, an eligible hospital must divide:

(a) The total medicaid patient encounters (fee-for-service and managed care) in any continuous ninety-day period, beginning on the first day of a month, in the preceding federal fiscal year (FFY); by

(b) The total encounters in the same ninety-day period.

(F) Encounters.

(1) Encounters are defined in accordance with 42 C.F.R. 495.306(e) (as in effect on July 28, 2010).

(2) For purposes of calculating eligible professional patient volume, a medicaid encounter means services rendered to an individual on any one day where medicaid (fee-for-service and managed care):

(a) Paid for part or all of the service; or

(b) Paid for part or all of the individual's premiums, co-payments, and cost sharing.

(3) For purposes of calculating needy individual patient volume, a needy patient encounter means services rendered to an individual on any one day where:

(a) Medicaid (including the state children's health insurance program (SCHIP)) paid for part or all of the service; or

(b) Medicaid (including SCHIP) paid for part or all of the individual's premiums, co-payments, and cost-sharing; or

(c) Services were furnished at no cost; and calculated as being uncompensated or charity care. If an eligible professionals's data are not available on charity care, then the eligible professional may use data on uncompensated care and must include a downward adjustment to eliminate bad debt (as defined in 42 C.F.R. 413.89, as in effect on October 1, 2004); or

(d) The services were paid for at a reduced cost based on a sliding scale and determined by the individual's ability to pay.

(4) For purposes of calculating eligible hospital patient volume, a medicaid encounter means both of the following:

(a) Services rendered to an individual per inpatient discharge where medicaid (fee-for-service and managed care):

(i) Paid for part or all of the service; or

(ii) Paid for part or all of the individual's premiums, co-payments, and cost sharing.

(b) Services rendered in an emergency department on any one day where medicaid (fee-for-service and managed care):

(i) Paid for part or all of the service; or

(ii) Paid for part or all of the individual's premiums, co-payments, and cost sharing.

(5) Out-of-state encounters.

(a) An eligible professional and eligible hospital may use out-of-state medicaid encounters for calculating patient volume.

(b) "Out-of-state encounters" are services rendered by an eligible professional or eligible hospital to a non-Ohio resident that meets the definitions of an encounter as defined in paragraph (F) of this rule.

(c) If out-of-state medicaid encounters are included in the numerator then all out-of-state encounters, for the same representative time period, should be included in the denominator.

(d) Eligible professionals and eligible hospitals are required to provide documentation to support the use of out-of-state encounters and must report each state's out-of-state encounters separately through the MPIP system, in a manner specified by the Ohio department of job and family services (ODJFS).

(G) Group practice or clinic patient volume proxy.

(1) A group practice or clinic will be permitted to calculate patient volume at the group practice or clinic level, but only in accordance with all of the following limitations defined in 42 C.F.R. 495.306(h) (as in effect on July 28, 2010):

(a) The group practice or clinic's patient volume is appropriate as a patient volume methodology calculation for the eligible professional.

(b) There is an auditable data source to support the group practice's or clinic's patient volume determination.

(d) The group practice or clinic must use the entire practice's or clinic's patient volume and not limit patient volume in any way.

(e) If an eligible professional works inside and outside of the group practice or clinic, the patient volume calculation includes only those encounters associated with the group practice or clinic, and not the eligible professional's outside encounters.

(2) To calculate patient volume at the group practice or clinic level, all medicaid eligible professionals, (as defined in paragraph (C) of this rule), of the group practice or clinic must:

(a) Have a valid, current Ohio medicaid provider agreement; and

(b) Have rendered and billed medicaid for at least one medicaid covered service with a date of service in the ninety-day period associated with the calculation of patient volume, and has been reimbursed for that service.

(3) Each group practice or clinic must confirm in writing, in a manner specified by the ODJFS, from each eligible professional in the group practice or clinic, that the eligible professional is consenting to one of the following:

(a) Attesting as a member of the group practice or clinic and permitting the group practice or clinic to use his or her encounters in the group practice or clinic patient volume proxy calculation; or

(b) Not attesting as a member of the group practice or clinic but will permit the group practice or clinic to use his or her encounters in the group practice or clinic patient volume proxy calculation.

(4) Evidence of an eligible professional's consent must be provided for processing through the MPIP system and must include the following information:

(a) The group practice or clinic name and medicaid ID number;

(b) The name and medicaid ID number of each eligible professional in the group; and

(c) Must specify if each eligible professional is consenting to the use of his or her encounters as defined in paragraphs (G)(3)(a) and (G)(3)(b) of this rule.

(5) If an eligible professional is not attesting as a member of a group practice or clinic but will permit a group practice or clinic to use his or her encounters in the patient volume proxy calculation for the group practice or clinic, the non-participating eligible professional cannot use those encounters toward his or her individual patient volume calculation.

(6) If any eligible professional within the group practice or clinic does not provide written consent for the group practice or clinic to use his or her encounters in the patient volume proxy calculation for the group practice of clinic, the group practice or clinic is precluded from using a group practice or clinic patient volume proxy.

(7) Supporting documentation must be provided for processing through the MPIP system of the attested patient volume proxy and include the medicaid encounters, total encounters, name and medicaid ID of all medicaid practitioners used in the group practice or clinic patient volume proxy calculation. This information shall be provided in a manner specified by ODJFS.

(8) Eligible professionals must be employed by the group practice or clinic at the time of attestation in order to use the group practice's or clinic's patient volume proxy.

(H) SCHIP adjustment.

(1) Eligible professionals (except for eligible professionals practicing predominantly through a FQHC/RHC) and eligible hospitals (except for children's hospitals) in counties with children covered by virtue of Title XXI of the Social Security Act, will be subject to a federally required SCHIP adjustment to patient volume. This adjustment is a reduction equal to the value of the lesser of the average statewide per cent of children covered by virtue of Title XXI or by the per cent of children covered by virtue of Title XXI in the county that serves as the primary location for the eligible professional or eligible hospital.

(2) The SCHIP adjustment will be made by the MPIP system at the time of registration when the eligible professional or eligible hospital selects the county that serves as the primary location for the eligible professional or eligible hospital.

Effective: 01/01/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.0215
Rule Amplifies: 5111.0215