(a) States pay for services furnished by a physician as defined in § 440.50 of this chapter, or under the personal supervision of a physician who self-attests to a specialty designation of family medicine, general internal medicine or pediatric medicine or a subspecialty recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS) or the American Osteopathic Association (AOA). Such physician then attests that he/she:
(1) Is Board certified with such a specialty or subspecialty and/or
(2) Has furnished evaluation and management services and vaccine administration services under codes described in paragraph (b) of this section that equal at least 60 percent of the Medicaid codes he or she has billed during the most recently completed CY or, for newly eligible physicians, the prior month.
(b) At the end of CY 2013 and 2014 the Medicaid agency must review a statistically valid sample of physicians who received higher payments to verify that they meet the requirements of paragraph (a)(1) or (2) of this section.
(c) Primary care services designated in the Healthcare Common Procedure Coding System (HCPCS) are as follows:
(1) Evaluation and Management (E&M) codes 99201 through 99499.
(2) Current Procedural Terminology (CPT) vaccine administration codes 90460, 90461, 90471, 90472, 90473 and 90474, or their successor codes.
(d)(1) The state must submit to CMS, in such form and at such time as CMS specifies, information relating to participation by physicians described in paragraph (a) of this section and the utilization of E&M codes described in paragraph (c) of this section (whether furnished by or under the supervision of a physician described in paragraph (a)) of this section for the following peri—s—
(i) As of July 1, 2009, and
(ii) CY 2013
(2) As soon as practicable after receipt, CMS will post this information on www.Medicaid.gov.
[77 FR 66700, Nov. 6, 2012, as amended at 77 FR 74382, Dec. 14, 2012]
Notes of Decisions
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. § 447.400 (a). B. The plaintiffs in this case are 21 physicians who practice family medicine in Tennessee, mostly in rural areas, and who received increased payments in 2013 and 2014 under the Medicaid provision described above.”
Nitta, M.D. v. Dep't of Human Servs.., 508 P.3d 1209 (Haw. App. 2022).
· cites it 5× “42 C.F.R. § 447.400 . Requiring board certification or a sixty-percent billing threshold, CMS's Final Medicaid Payment Rule provided: (a) States pay for services furnished by a physician as defined in § 440.”
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 Medicaid Payment Statute, 42 C.F.R. § 447.400 (a), on November 6, 2012 (the "Final Medicaid Payment Rule").”
Nitta v. Dep't of Human Servs.., 520 P.3d 241 (Haw. 2022).
· cites it 4× “Nitta he was ineligible because he did not meet specialty requirements for Program participants as set forth in a federal administrative rule, 42 C.F.R. § 447.400 2 ** FOR PUBLICATION IN WEST’S HAWAIʻI REPORTS AND THE PACIFIC REPORTER ** (“the Rule”).”
Andrew Averett v. United States Dep't of Health & Human Servs. (6th Cir. 2019).
· cites it 2× “42 C.F.R. § 447.400 (a). B. The plaintiffs in this case are 21 physicians who practice family medicine in Tennessee, mostly in rural areas, and who received increased payments in 2013 and 2014 under the Medicaid provision described above.”
Antonio Selliman v. Jeffrey J Colton Md (Mich. 2024).
“es under the GI Bill, and numerous state medical boards); Department of Health and Human Services, Centers for Medicare & Medicaid Services, Medicaid Program; Payments for Services Furnished by Certain Primary Care Physicians and Charges for Vaccine Administration Under the…”
Est. of Linda Horn v. Michael J Swofford Do (Mich. 2024).
“es under the GI Bill, and numerous state medical boards); Department of Health and Human Services, Centers for Medicare & Medicaid Services, Medicaid Program; Payments for Services Furnished by Certain Primary Care Physicians and Charges for Vaccine Administration Under the…”
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