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Fee-for-Service Medicare Incentive Payment  

Incentive Payment - Calculation

Under FFS Medicare, the payment incentive amount, subject to an annual limit, is equal to 75 percent of an EP’s Medicare physician fee schedule allowed charges submitted not later than 2 months after the end of the calendar year. This means that, for 2011, the EHR incentive payment for an EP would be, subject to an annual limit, equal to 75% of the EP’s Medicare physician fee schedule allowed charges for CY 2011, based on claims for services performed by the EP from January 1, 2011 through December 31, 2011, and submitted to the EP’s Medicare contractor (MAC/carrier) no later than February 29, 2012.

Table 1: Maximum Incentive Payments Based on the First CY in Which an EP Participates in the Program

Calendar YearMaximum Incentive PaymentsMaximum Incentive PaymentsMaximum Incentive PaymentsMaximum Incentive Payments
2011 2012 2013 2014
2011 $18,000
2012 $12,000 $18,000
2013 $8,000 $12,000 $15,000
2014 $4,000 $8,000 $12,000 $12,000
2015 $2,000 $4,000 $8,000 $8,000
2016 $2,000 $4,000 $4,000
Total $44,000 $44,000 $39,000 $24,000

Table 2: Maximum Incentive Payments for an EP Who Qualifies for an HPSA Bonus Payment Based on the First CY in Which the EP Participates in the Program

Calendar YearMaximum Incentive PaymentsMaximum Incentive PaymentsMaximum Incentive PaymentsMaximum Incentive Payments
2011 2012 2013 2014
2011 $19,800
2012 $13,200 $19,800
2013 $8,800 $13,200 $16,500
2014 $4,400 $8,800 $13,200 $13,200
2015 $2,200 $4,400 $8,800 $8,800
2016 $2,200 $4,400 $4,400
Total $48,400
($4,400 increase)
$48,400
($4,400 increase)
$42,900
($3,900 increase)
$26,400
($2,400 increase)


Table 3: Maximum Incentive Payments Based on the First CY in Which the MAO EP Participates in the Program

Calendar YearMaximum Incentive PaymentsMaximum Incentive PaymentsMaximum Incentive PaymentsMaximum Incentive Payments
2011 2012 2013 2014
2011 $18,000
2012 $12,000 $18,000
2013 $8,000 $12,000 $15,000
2014 $4,000 $8,000 $12,000 $12,000
2015 $2,000 $4,000 $8,000 $8,000
2016 $2,000 $4,000 $4,000
Total $44,000 $44,000 $39,000 $24,000

Medicaid EHR Incentive Payment

Incentive Payment - Volume Requirements

To be eligible to participate in the Medicaid EHR Incentive Program, an EP must either: (1) Meet certain Medicaid patient volume thresholds or (2) practice predominantly in an FQHC or RHC where 30 percent of the patient volume is derived from needy individuals.1 One exception to this rule is that a pediatrician may have at least 20 percent Medicaid patient volume and still qualify but at a reduced incentive.

Table 1: Patient Volume Thresholds per Provider Type

EntityMinimum Medicaid Patient Volume ThresholdOr the Medicaid EP practices predominately in an FQHC or RHC with a 30 percent “needy individual” patient volume threshold
Physician 30%
Pediatrician 20%
Dentist 30%
Certified nurse-midwife 30%
Nurse practitioner 30%
Physician assistant when practicing in an FQHC/RHC led by a physician assistant 30%

Incentive Payment - Patient Volume Calculation

The Medicaid patient volume methodology will be designated by the State Medicaid Agency and approved by CMS. Note: The final rule describes acceptable methods for estimating patient volume. In determining patient volume thresholds, EPs should include individuals enrolled in Medicaid managed care organizations, prepaid inpatient health plans, prepaid ambulatory health plans, and Medicaid medical home programs or Primary Care Case Management.

Table 2: Medicaid EHR Incentive Payments by Calendar Year

YearMedicaid EPs Who Adopted InMedicaid EPs Who Adopted InMedicaid EPs Who Adopted InMedicaid EPs Who Adopted InMedicaid EPs Who Adopted InMedicaid EPs Who Adopted In
2011 2012 2013 2014 2015 2016
2011 $21,250
2012 $8,500 $21,500
2013 $8,500 $8,500 $21,500
2014 $8,500 $8,500 $8,500 $21,500
2015 $8,500 $8,500 $8,500 $8,500 $21,500
2016 $8,500 $8,500 $8,500 $8,500 $8,500 $21,500
2017 $8,500 $8,500 $8,500 $8,500 $8,500
2018 $8,500 $8,500 $8,500 $8,500
2019 $8,500 $8,500 $8,500
2020 $8,500 $8,500
2021 $8,500
Total $63,750 $63,750 $63,750 $63,750 $63,750 $63,750

Source: CMS