Current through 2024-38, September 18, 2024
A. An Eligible
Professional must meet the requirements established in
42 C.F.R.
§495.304(c) unless
exempt under
42 C.F.R.
§495.304(d).Title
42 C.F.R.§§
495.310(a) through (e)
governs payments to EPs.
B.
Medicaid or Needy Individual threshold requirements
Table 1 lists the minimum percentage of
Medicaid or Needy Individual encounters for each type of Professional for this
Program. See Title
42 C.F.R.
§495.304(c).
|
Types of Professionals that may apply for
the incentive payment program
|
Minimum Medicaid or Needy Individual
encounters
|
|
Physician, certified nurse-midwife, nurse
practitioner, dentist
|
30% Medicaid encounters
|
|
Pediatrician
|
20% Medicaid encounters
|
|
Physician, certified nurse-midwife, nurse
practitioner, or a dentist who practices predominantly in an FQHC or RHC
|
30% Needy Individual encounters
|
|
Physician assistant who practices predominantly
in an FQHC or RHC that is led by a physician assistant
|
30% Needy Individual Encounters
|
C.
Application Process for EPs
1. A Professional must register with CMS
through the CMS National Level Repository (NLR) system.
2. After a Professional registers, CMS sends
an electronic notification to OMS of the registration.
3. Using the contact information from the NLR
registration, OMS will contact the Professional to begin the application
process.
4. A Professional must
establish that he or she is an EP and meet the following requirements:
a. Using the encounter method, establish that
he or she has met the minimum Medicaid patient volume required under
42 C.F.R.
§495.304(c)(1),
or practices predominantly in a Federally Qualified Health Center
(FQHC) or in a Rural Health Clinic (RHC) and has met the minimum Needy
Individual volume under
42 C.F.R.
§495.304(c);
and
b. Attest that he or she has
adopted, implemented or upgraded electronic health records to be eligible for
the first payment year, or that he or she has met Meaningful Use
requirements under the applicable stage to be eligible for subsequent payment
years; and
c. Attest that he or she
uses an EHR that is included on the list of certified EHRs maintained by CMS;
and
d. Attest that he or she has
not received an incentive payment for that year from another state;
and
e. Attest that he or she has
not received an incentive payment under the Medicare incentive payment program
for that year; and
f.
Satisfactorily complete the application process; and
g. Meet the meaningful use reporting
requirement set forth under
42 C.F.R.
§495.312(b).
5. After confirming that the
Professional meets the requirements enumerated in this section 2.04, MaineCare
will notify CMS that a payment is being issued, and will issue a payment to the
EP according to the requirements of
42 C.F.R.
§495.312(e)(1).
6. If the Department determines that a
Professional has not met the requirements of this Section 2.04, it will notify
the Professional in writing within two (2) business days of making that
determination.
D.
Payment Amounts and Schedule
A Professional who meets EP status requirements for all
six years is eligible to receive a total of $63,750 in payments issued as
follows:
1. A first year payment of
$21,250; except that a pediatrician who has between 20% and 30% Medicaid
encounters is limited to a maximum first year payment of $14,167.
2. For years two through six, a payment of
$8,500 for each year that the EP meets the requirements for that year; except
that a pediatrician who has between 20% and 30% Medicaid encounters is limited
for years two through six to a payment of $5,667 for each year.
3. A payment will be issued to the EP unless
the EP reassigns his or her incentive payment pursuant to
42 C.F.R
§495.310(k)(1).
E.
Attestation and
Meaningful Use Documentation
A Professional must have written or electronic
documentation that the Professional meets all of the EP requirements for the
Program and the incentive payment(s).
1. As proof of adopting, implementing or
upgrading a certified electronic health record, the EP must have at least one
of the following properly executed documents:
a. Receipt;
b. Invoice;
c. Contract;
d. License Agreement;
e. Purchase Order; or
f. User Agreement.
2. In accord with
42 C.F.R.
§495.8(c)(2), any
records used to provide information for registration, application or incentive
payments, including attestation that the Professional has adopted, implemented
or upgraded EHR, and meaningful use, must be kept for six years, unless Federal
or State law requires a longer retention period.
2.04-1
COMBATING FRAUD AND ABUSE
A. An EP must submit an electronic or paper
statement supplied by the Department in satisfaction of the requirements of
42 C.F.R.
§495.368(b).
B. If an overpayment is owed to the
Department, the EP shall repay the entire overpayment within thirty (30) days
of the date of the Department's notice to the EP of the overpayment.
C. EPs are subject to the provisions of the
MaineCare Benefits Manual, Chapter 1, Sections 1.12, 1.19 and
1.20 in regard to incentive payments.
D. The Division of Audit or duly authorized
Agents of the Department shall conduct pre-payment reviews and must approve all
payments before issuance. The Division of Audit or duly authorized Agent shall
have the authority to conduct post-payment audits to include desk and on-site
audits under the Department's SMHP and IAPD-U and Chapter 1, Section 1,
§1.16.
2.04-2
HEARINGS AND APPEALS
A. An EP may
appeal the following issues:
1. A
determination that the Professional is not eligible for the HIT Incentive
Payment Program;
2. A determination
that the Professional did not meet attestations of adopting, implementing or
upgrading certified EHRs or Meaningful Use of EHR requirements;
3. An overpayment amount or recoupment as
determined by the Department or CMS; and
4. Audit findings of any of the
above.
B. Appeal rights
and processes are governed by MaineCare Benefits Manual, Chapter 1, Section 1,
§1.21-1.
