C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES › Subpart B—Physicians and Other Practitioners

42 C.F.R. § 414.80

Incentive payment for primary care services

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(a) Definitions. As defined in this section—

Eligible primary care practitioner means one of the following:

(i) A physician (as defined in section 1861(r)(1) of the Act) who meets all of the following criteria:

(A) Enrolled in Medicare with a primary specialty designation of 08-family practice, 11-internal medicine, 37-pediatrics, or 38-geriatrics.

(B) At least 60 percent of the physician's allowed charges under the physician fee schedule (excluding hospital inpatient care and emergency department visits) during a reference period specified by the Secretary are for primary care services.

(ii) A nurse practitioner, clinical nurse specialist, or physician assistant (as defined in section 1861(aa)(5) of the Act) who meets all of the following criteria:

(A) Enrolled in Medicare with a primary specialty designation of 50-nurse practitioner, 89-certified clinical nurse, or 97-physician assistant.

(B) At least 60 percent of the practitioner's allowed charges under the physician fee schedule (excluding hospital inpatient care and emergency department visits) during a reference period specified by the Secretary are for primary care services.

Primary care services means—

(i) New and established patient office or other outpatient evaluation and management (E/M) visits;

(ii) Initial, subsequent, discharge, and other nursing facility E/M services;

(iii) New and established patient domiciliary, rest home (for example, boarding home), or custodial care E/M services;

(iv) Domiciliary, rest home (for example, assisted living facility), or home care plan oversight services; and

(v) New and established patient home E/M visits.

(b) Payment. (1) For primary care services furnished by an eligible primary care practitioner on or after January 1, 2011 and before January 1, 2016, payment is made on a quarterly basis in an amount equal to 10 percent of the payment amount for the primary care services under Part B, in addition to the amount the primary care practitioner would otherwise be paid for the primary care services under Part B.

(2) The payment described in paragraph (b)(1) of this section is made to the eligible primary care practitioner or, where the physician has reassigned his or her benefits to a critical access hospital (CAH) paid under the optional method, to the CAH based on an institutional claim.

[75 FR 73617, Nov. 29, 2010]
Notes of Decisions
Cited in 5 cases (1 in the last 5 years), 2018–2022 · leading case: Andrew Averett v. United States Dep't of Health & Human Servs., 943 F.3d 313 (6th Cir. 2019).
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Andrew Averett v. United States Dep't of Health & Human Servs., 943 F.3d 313 (6th Cir. 2019). · cites it 2× “42 C.F.R. § 414.80 (a)(i). But the agency gave an altogether different meaning to the phrase “a physician with a primary specialty designation” as used in the Medicaid provision.”
Averett v. U.S. Dep't of Health & Human Servs., 306 F. Supp. 3d 1005 (M.D. Tenn. 2018). · cites it 3× “CMS promulgated the final rule implementing the Medicare Payment Statute, 42 C.F.R. § 414.80 (a), on November 29, 2010 (the "Final Medicare Payment Rule").”
Feiss, M.D. v. United States (Fed. Cl. 2018). · cites it 2× “at 2; see also 42 C.F.R. § 414.80 (2011) (mirroring 42 U.”
Andrew Averett v. United States Dep't of Health & Human Servs. (6th Cir. 2019). · cites it 2× “42 C.F.R. § 414.80 (a)(i). But the agency gave an altogether different meaning to the phrase “a physician with a primary specialty designation” as used in the Medicaid provision.”
Nitta v. Dep't of Human Servs.., 520 P.3d 241 (Haw. 2022). “3d at 317 (citing 42 C.F.R. § 414.80 (a)(i)(A)). The Sixth Circuit determined that the latter was the proper interpretation because, unlike the Rule,9 it did not conflict with the language of the Statute.”
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