Medicaid Primary Care Rate Increase (PCRI)

Managed Care Policy & Procedure Documentation

Policy & Procedure Documentation is also available in portable document format (PDF, 62KB, 10pg.)

1. Authorizing Federal Legislation

The Affordable Care Act established a Medicaid Primary Rate Increase (PCRI) for qualifying providers. The final rule implementing the PCRI was released in November 2012 by the Centers for Medicare and Medicaid Services(CMS) in the Federal Register (see 42 CFR Parts 438, 441, and 447).

Pursuant to 42 CFR, Section 447.400, effective for dates of service on and after January 1, 2013 through December 31, 2014, the New York State Medicaid Program (including its Managed Care Plans) will pay the Medicare rate for specified primary care services to providers who attest to qualification for the PCRI.

The link to the final rule is provided below:

2. Overview of the PCRI Program

States are required to reimburse qualified providers at the rate that would be paid for the primary care service (if the services were covered) under Medicare.

A physician is eligible only if he/she first self-attests to practicing in the designated primary care specialties of Family Medicine, General Internal Medicine or Pediatric Medicine and also to either being:

  • Board certified in the designated specialties/subspecialties; or
  • Having a 60 percent paid claims history of both Evaluation and Management codes and Vaccine administration codes specified in the regulation.

More general information about the PCRI is available on the CMS and eMedNY website.

3. Criteria:

A. Qualifications

The PCRI is applicable to the following procedure codes that are covered by Medicaid fee for service or managed care plans and paid to qualified physicians:

  • Evaluation and Management (99201-99499)
  • Vaccine Administration (90460, 90471, 90472, 90473 & 90474)

Any new covered Evaluation and Management and Vaccine administration codes must be approved through the Medicaid State plan process; once they are approved, they will be eligible for the Primary Care Rate Increase. Updates to Vaccine administration can be found at:

Only physicians practicing in the designated primary care specialties of Family Medicine, General Internal Medicine or Pediatric Medicine providing services to Medicaid managed care and fee for service beneficiaries qualify for the PCRI. This is determined by the practice characteristics of the physician. For example, how the physician represents himself or herself in the community as a family, internal medicine or pediatric practitioner, as evidenced by medical directory listings, billings to other insurers, advertisements, etc.

The PCRI is not available for physicians, nurse practitioners or nurse midwives who are reimbursed through an FQHC, RHC, DTC or a facility´s encounter, visit, or per diem rate or who are not practicing in one of the designated primary care specialties.

Out of State providers meeting the qualifying criteria ae eligible for the PCRI.

The qualified providers defined as eligible to receive payment under the PCRI are:

  • 1. Physicians holding board certification from the American Board of Medical Specialties, the American Board of Physician Specialties or the American Osteopathic Association in pediatrics, internal medicine and family medicine and associated subspecialties, or
  • 2. Physicians who have furnished primary care services that equal at least 60 percent the Medicaid codes paid during the most recently completed calendar year, or for newly eligible providers, the prior month, or
  • 3. Nurse Practitioners and Nurse Midwives practicing under the professional oversight and supervision of a qualified physician (#1 or #2 above).

B. Verification:

  • 1. Two tracks or options for qualified Physicians to verify eligibility:
    • Board Certified in a designated specialty or subspecialty
      • Physicians can verify eligibility by attesting to current board certification from one of the following:

        American Board of Medical Specialties (ABOS)
        American Board of Physician Specialties (ABPS)
        American Osteopathic Association (AOA)

    • 60% paid Medicaid claims history for the designated primary care procedure codes
      • Physicians can verify eligibility by attesting that:
        The majority of the services provided to Medicaid beneficiaries are primary care.
      • This is defined as 60% of Medicaid codes paid for the designated primary care procedure codes for the most recent calendar year.
  • 2. To verify eligibility for Advanced Practice Clinicians (APCs). (Nurse Practitioners and Nurse Midwives):
    • Supervising physician must qualify and attest to their eligibility and name the supervised APCs.
    • The physician must accept professional responsibility and legal liability for the APC, providing personal supervision for the primary care services provided by the APC.
    • The APC submits claims with their NPI

C. Attestation:

The final rule requires that a physician is eligible for the PCRI only if he/she first self-attests to practicing in primary care, supported by either board certification or an appropriate claims history. States cannot pay a qualified provider without evidence of a self-attestation.

Each physician completes the form once and the attestation applies to both managed care and fee for service. The attestation form and instructions are available online at the EMedNY website at:

Attestations received prior to August 1, 2013 will result in the enhanced payment for applicable services effective for dates of service on and after January 1, 2013 unless a provider requests a later effective date. As of August 1, 2013 the effective date will be the date the attestation was received.

Providers with a fee for service Medicaid enrollment record will receive a letter informing them that they have received specialty code "031"

The list of all qualified managed care and fee for service PCRI providers will be posted online and updated weekly.

Managed Care plans are encouraged to benchmark to this list for determining qualified providers

The provider list can be found on the Department of Health website at:

Provider attestations are filed and approved, updates will be posted to the Department site. If you would like to be notified of these updates, please sign up for the Listserv on the website located at:

4. Managed Care

The final rule implementing the PCRI also applies to Managed Care Organizations(MCOs) participating in the Medicaid Managed Care program. MCOs are required to provide enhanced payments to eligible providers (including network providers and out of network providers providing services as authorized by the MCO) who provide qualifying primary care services pursuant to those stated in the PCRI regulations.

The regulations apply to both the Medicaid Managed Care and Family Health Plus programs. The enhancement does not apply to stand alone Child Health Plus programs.

The Department has requested a cursory review of all MCO provider enhancement calculation methodology.

MCOs are required to notify each provider of the specific methodology used to calculate the enhancement and expected timing of payments. MCOs may amend their provider contracts to reflect the enhanced payment arrangement or develop a separate process to inform providers of the enhanced reimbursement and the associated payment arrangements.

The State has received approval from CMS to reimburse MCOs for the PCRI through a "lump sum" payment process. At quarterly intervals MCOs will be required to summarize actual PCRI data, in a reconciliation report format, to calculate the total payment that eligible providers would need to be paid for eligible services in order to reach the mandated Medicare payment rates. Under this methodology, the State will continue to pay prospective capitation rates without an adjustment for enhanced primary care payments.

The State will review each MCOs reconciliation and if found reasonable, would pay the MCO the calculated additional "lump sum" payment amount.

The Department will be working with our Fiscal Management Group to provide MCOs with timing and identification of PCRI payments on remittances prior to those payments being made.

MCOs will be required to make all enhancement payments (specific to the reconciliation period) to providers once "lump sum" funds are received.

MCOs may, but are not required to make enhancement payments to providers prior to receiving "lump sum" funds from the State.

Payments must be made at least quarterly as "lump sum" funds are received from the State.

Since MCO's are ultimately responsible for validating the PCRI was passed on to qualified providers, plans will be able request confirmation from provider groups and/or provider facilities to ensure that the PCRI was passed down.

Encounter submission guidance for PCRI was provided to MCOs by the MEDS Compliance Unit. MCOs will be required to report 2013 and 2014 encounter the Total Paid Amount field excluding any incremental amounts required to reimburse qualified providers for qualifying procedures at 100% Medicare.

Additional information will be provided by the Bureau of Managed Care Fiscal Oversight on reporting instructions for the PCRI on the Managed Care Operating Reports(MMCOR).

PCRI Reconciliation-Form Instructions:

In order to receive the "lump sum" reimbursement under this program, MCOs must complete the Primary Care Rate Increase Reconciliation quarterly. The report identifies each qualified provider of applicable primary care services, as well as the reimbursement type, procedure code, procedure type, utilization, base unit cost, and the Medicare fee cost.

The hard copy report must be completed and returned with a signed Certification form, also enclosed. The MCO Name and Submission date must match on both the Excel Report and the Certification form. Do not add any columns to the Excel PCRI reconciliation. However, additional rows may be added if necessary.

Reports may also be emailed to the Bureau of Managed Care Reimbursement at: in order to expedite processing by the State. A hard copy of the report must still be included with a signed Certification form.

There are two sections to this report. The first section will be used for the initial request of quarterly "lump sum" funds for a current or prior period. This is the main section of the report.

The second section of the report is for any prior period adjustments. This area was specifically included to adjust procedures that were previously reported on the reconciliation that should not have been paid or to adjust unit pricing on previously paid procedures. The total PCRI is equal to the sum of the current quarter and any prior quarter adjustments.

Complete the Primary Care Rate Increase (PCRI) Report for each quarter as follows:

Header Section

Enter the following information:

  • Type in the correct Calendar Year, 2013 is the default
  • Select the MCO Name from the drop-down list
  • Your MCO ID should populate based on your MCO Name
  • Enter the Report Submission Date
    • Enter current date that the report is being submitted, in mm/dd/yy format.
    • The reconciliation and the signed certification form must have the same date in order to verify that the certification form is for that particular report.
  • If you need additional lines, click on the Add Line(s) to Report Form button

Current Quarter Section and Prior Quarters Adjustment Section

Enter the following information applicable to each qualifying provider and procedure code

  • Quarter
    • Select the correct Quarter reflecting the date of service of the visit from drop-down list.
    • Enter the MMIS ID of the eligible provider. This value must be eight digits long.
  • NPI Number
    • Enter the NPI number of the eligible provider. This value must be ten digits long.
  • Provider Name
    • Enter the eligible Provider Name
  • Provider Reimbursement
    • Select either "F/S" for fee schedule reimbursement or "CAP" for capitation payments from the drop-down list
  • Procedure Code
    • Select the procedure code from the drop-down list. Each procedure code per provider receives a separate line.
  • Type
    • Select either "E&M" for Evaluation and Management procedures or "Vaccine" for Vaccine Administration procedures from the drop-down list. Do not leave blank.
  • Number of Procedures (Utilization)
    • Enter the total number of qualifying procedures paid by the MCO to the provider (Column C).
    • Additional E&M or vaccination administration codes currently not covered under the Medicaid State plan are not eligible for the enhancement.
  • 2013 Base Unit Cost
    • Enter the total dollar actual amount paid by the MCO to the provider for each procedure and the corresponding fee schedule or capitation payment prior to the PCRI enhancement. This is the unadjusted 2013 unit cost.
    • The base unit cost should include all applicable copays and deductibles.
    • If a base unit cost for a provider changes during a reporting period, the MCO must delineate this information with a separate row indicating those procedures paid at a different base rate.
  • 2013 Medicare Part B Fee Cost
  • Unit Increment - (Column J) NO INPUT NECESSARY, this will automatically be calculated.
  • Total Differential - (Column K) NO INPUT NECESSARY, this will be automatically calculated
  • o Total Primary Care Rate Increase Reimbursement Requested - (Last row, Column K) NO INPUT NECESSARY, this will be automatically calculated based on the sum of the Total Differential Column. This will include both the current quarter and any prior quarter utilization and/or adjustments.
  • Unit Increment - (Column J) NO INPUT NECESSARY, this will automatically be calculated.

While the primary care rate increase is automatically calculated based on the information included on the report, it is NOT considered an approved amount. All data is subject to review and verification prior to any PCRI being finalized by the State.

PCRI Certification Instructions:

The Certification Form must be signed and dated by either the Chief Executive Officer and Chief Financial Officer (or the person having charge of the financial records of the plan) certifying that the information is accurate and complete.

Failure to submit these forms by the due date could result in the suspension or delay of Primary Care Rate Increase payments.

The completed forms should be sent directly to the Bureau of Managed Care Reimbursement at the address below:

New York State Department of Health
Division of Finance and Rate Setting
Bureau of Managed Care Reimbursement
One Commerce Plaza, Room 1405
99 Washington Avenue
Albany, NY 12260-2808

Attachment B - Certification

Certification (PDF, 12KB, 1pg.)