Eligible Providers

Providers eligible for incentives in the Medi-Cal program are: physicians (MD or DO), dentists, nursepractitioners, certified nurse-midwives, and physician assistants who practice in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) that is PA-led.

Eligibility Requirements

Medi-Cal providers qualify if they fall into one of three categories:

  1. 30% of their patient volume is Medi-Cal patients.
  2. Pediatricians will qualify if 20% of their patient volume is Medi-Cal patients. However, pediatricians who fall between 20% and 30% of patient volume will only qualify for 2/3 of the total incentive.
  3. For providers who practice in a FQHC or RHC: 30% of their patient volume is “needy individuals” i.e. Medi- Cal, Healthy Families, sliding scale, or uncompensated care.

Meaningful Use and Reporting

In order to receive provider incentives, providers will have to demonstrate “meaningful use.” In the Medi-Cal
program, providers will report on meaningful use to the State of California.

How the Incentives are Paid

Medi-Cal provider incentives are paid out over six years, beginning with the first year that the provider enters the incentive program. Medi-Cal providers can begin in the EHR incentive program as late as 2016 and receive the maximum provider incentive. The chart below lays out the maximum incentive by year. The top line is the first year that the provider enters the incentive program, and the side axis is the payment by year.

Contrary to the requirement of continuous demonstration of meaningful use in the Medicare program, a Medi-Cal provider could show meaningful use one year, but not the next, with no penalty. For example, a provider could receive an incentive for adoption in 2011, but not demonstrate meaningful use in 2012. That same provider could then achieve meaningful use in 2013, and still receive the maximum incentive.

Adoption, Implementation, or Upgrade

Unlike the Medicare incentive program, Medi-Cal providers are able to access upfront funding to help with the “adoption, implementation, or upgrade” of an EHR. In the first year that Medi-Cal providers expect to receive incentives they do not need to demonstrate meaningful use. Instead, they can attest that they have purchased, implemented, or upgraded their EHR system during the previous year.

Providers can demonstrate “adoption” of an EHR by directly purchasing a system from a commercial vendor. They can also attest that they have access to a system through an employment or contract arrangement, such as in a clinic or medical group. “Implementation” involves any services required for bringing the EHR into the workflow of the practice. This could involve staff training, workflow redesign, or any other functions that a provider needs to implement the EHR in the practice.

Finally, many providers who have existing EHR systems will need to add additional functions to their systems in order to achieve meaningful use. This will qualify as an “upgrade.”

Calculating Patient Volume

Providers can demonstrate that they are eligible for Medi-Cal incentives by tracking their patient volume for a 90-day period of their choosing.  In general, the patient volume requirements are calculated as a percentage of total patient encounters during that 90-day period.  The formula is:

Providers practicing in an FQHC or RHC will use the same formula, but would include all “needy individuals” in the numerator of the fraction.

Special Rules for Medi-Cal Managed Care

Providers who contract with Medi-Cal Managed Care plans will use a slightly different formula for calculating their patient volume.  The Federal Government will allow providers in a managed care arrangement to consider patients assigned to their patient panel by the plan.  The formula providers in this situation will use is:

A provider in an FQHC or RHC would count all needy individuals, not just Medi-Cal recipients, in the numerator of the equation.

Definition of Medi-Cal Patients

For both the fee-for-service and managed care Medi-Cal providers, Medi-Cal patients also includes anyone covered by a state Medi-Cal waiver, such as the Family PACT program and those covered by both Medi-Cal and Medicare (“dual eligibles”).

Providers who are not in an FQHC or RHC cannot count patients covered by Healthy Families, Access for Infants and Mothers (AIM), a county coverage initiative, the County Medical Services Program (CMSP), or any other state or local program.