Medicaid EHR Incentive Program - Eligibility Criteria

This document provides an overview of some of the Medicaid EHR incentive program eligibility criteria.

Please click the appropriate link that is applicable to you/your organization:

 Eligible Professional in an FQHC/RHC

 Eligible Professional in a Non-FQHC/RHC

 Eligible Hospital

For additional information or questions, please contact:

New Hampshire Medicaid EHR Incentive Program

[email protected] or (603) 271-9440

1 Eligible Professional in an FQHC/RHC

A. Eligible Professional (EP) Type

There are five categories of EPs in Federally Qualified Health Centers/Rural Health Centers (FQHCs/RHCs) that are eligible to apply for a Medicaid EHR incentive payment:

 Non-hospital based physicians: those with more than 10 percent of patient encounters outside of places of service equivalent to the CMS 1500 Place of Service codes 21 (inpatient) or 23 (emergency department).

 Dentists

 Nurse Practitioners

 Certified Nurse Midwives

 Physician Assistants practicing in an FQHC/RHC led by a Physician Assistant

B. Practice Predominantly

An EP in an FQHC/RHC must ‘practice predominantly’ in the FQHC/RHC. This means that more than 50% of patient encounters occurred at an FQHC/RHC in a 6-month period during the prior calendar year.

C. New Hampshire Medicaid Provider

An EP in an FQHC/RHC must be actively enrolled in the New Hampshire Medicaid program in good standing and have a New Hampshire Medicaid provider enrollment number.

D. Individual Patient Volume

EPs in FQHCs/RHCs have the option to calculate patient volume based on individual encounters or aggregate encounters at the clinic/group practice level. Refer to ‘E’ below for more information on the aggregate calculation.

Patient volume is the percentage of needy individual patient encounters that an EP provides in any representative, continuous 90-day period in the preceding calendar year. For the individual calculation, each EP must have a patient volume of 30% or more (with the exception of pediatricians that can have 20% patient volume).

Patient volume is based on encounters and is not impacted by, or related to, how providers are billed. One needy individual patient encounter includes all services provided to an individual in a day by a specific provider where:

 Medicaid (including Healthy Kids Gold and out-of-state Medicaid and Medicaid- managed care programs) paid for part or all of the services (including premiums, co- payments, and/or cost-sharing); OR

 CHIP (Healthy Kids Silver) paid for part or all of the services (including premiums, co- payments, and/or cost-sharing); OR

 Services were rendered to an individual on a sliding scale; OR

 Services were uncompensated.

EPs may choose one (or more) clinical sites of practice in order to calculate their patient volume. This calculation does not need to be across all of an EP’s sites of practice. However, at least one of the locations where the EP is adopting or meaningfully using certified EHR technology should be included in the patient volume. In other words, if an EP practices in two locations, one with certified EHR technology and one without, the EP should include the patient volume at least at the site that includes the certified EHR technology. When making an individual patient volume calculation, an EP may calculate across all practice sites or just at the one site.

Use this three-step formula to determine needy individual patient volume:

Step 1

Divide the numerator by the denominator as follows:

 Numerator = total needy individual patient encounters in any 90-day period in the preceding calendar year

 Denominator = total of all patient encounters during that same 90-day period

Step 2

Multiple the result of Step 1 by 100

Step 3

If this percentage is 30% or more (optional 20% for pediatricians), then the EP may be eligible for a Medicaid EHR incentive payment.

Examples of Individual Patient Volume Calculation

Example 1

Dr. Barry, an OBGYN, had 80 needy individual patient encounters out of 200 total encounters in the selected 90-day period.

 Numerator = the sum of all needy individual patient encounters in a continuous 90-day period in the preceding calendar year = 80

 Denominator = the sum of all encounters in the same continuous 90-day period = 200

 [(Numerator / Denominator) X 100]. If the percentage is 30% or higher, then the EP may be eligible for a Medicaid EHR incentive payment:

80/200 X100 = 40% needy individual patient volume. Dr. Barry meets this criterion.

Example 2

Dr. Powers, a primary care physician, had 30 needy individual patient encounters out of 300 total encounters in the selected 90-day period.

 Numerator = 30

 Denominator = 300

 [(30/300) X100] = 10% patient volume. Dr. Powers does NOT meet this criterion.

E. Option to Calculate Aggregate Patient Volume

Clinics and group practices may use the aggregate clinic/group practice needy individual patient volume and apply it to all EPs under three conditions:

 The clinic or group practice's patient volume is appropriate as a patient volume methodology calculation for the EP (for example, if an EP only sees Medicare, commercial, or self-pay patients, this is not an appropriate calculation);

 There is an auditable data source to support the clinic’s patient volume determination; and

 So long as the practice and EPs use one methodology in each year. (In other words, clinics could not have some EPs use their individual patient volume for patients seen at the clinic, while others use the clinic-level data). The clinic or practice must use the entire practice’s patient volume and not limit it in any way.

If the EP works in both the clinic and outside the clinic (or with, and outside, a group practice), then the clinic/practice level determination includes only those encounters

associated with the clinic/practice. If an EP works at one or more clinics/group practices, each clinic/group practice should include the encounters made by the EP at its ‘own’ clinic/group-practice in the group calculation. However, the EP can register for only one incentive payment (i.e., the EP cannot register for an incentive payment at every clinic/group practice that uses his/her encounter information in its group calculation).

Example of Aggregate Patient Volume Calculation

Calculate the needy individual patient encounters for all providers in the clinic/group practice (even those not designated as EPs) in the selected 90-day period:

Provider Name Category EP Status Needy Individual Total Patient Patient Encounters Encounters

Dr. Smith MD Yes 80 200

Casey Jones NP Yes 50 100

Jamie Doe RN No 150 200

Logan Shaw PharmD No 80 100

Dr. Moore MD Yes 30 300

Dr. Johnson DDS Yes 5 100

Dr. Hayes DDS Yes 20 200

TOTAL 415 1,200

 Numerator = the sum of all needy individual patient encounters from all Medicaid providers (even those that aren't designated as EPs, and, hence, aren’t eligible for the incentive program) in a continuous 90-day period:

80 + 50 + 150 + 80 + 30 + 5 + 20 = 415

 Denominator = the sum of all encounters from all providers (even those that aren't eligible for the incentive program) in the clinic/group practice in a continuous 90-day period. Note: to use the clinic/group practice calculation, every provider in the practice/organization must provide services to needy individuals:

200 + 100 + 200 + 100 + 300 + 100 + 200 = 1,200

 [(Numerator / Denominator) X 100]. If the percentage is 30% or higher (optional 20% for pediatricians), then the EP may be eligible for a Medicaid EHR incentive payment:

[(415/1,200) X 100] = 35% patient volume clinic/group practice-wide. Since this exceeds the 30% threshold, Dr. Smith, Casey Jones, Dr. Moore, Dr. Johnson, and Dr. Hayes are EPs who meet the patient volume eligibility criterion.

END OF FQHC/RHC SECTION - PLEASE RETURN TO SURVEY

5 Eligible Professional in a Non-FQHC/RHC

A. Eligible Professional (EP) Type

There are four categories of EPs (not practicing in Federally Qualified Health Centers/Rural Health Centers) that are eligible to apply for a Medicaid EHR incentive payment:

 Non-hospital based physicians: those with more than 10 percent of patient encounters outside of places of service equivalent to the CMS 1500 Place of Service codes 21 (inpatient) or 23 (emergency department).

 Dentists

 Nurse Practitioners

 Certified Nurse Midwives

B. New Hampshire Medicaid Provider

An EP must be actively enrolled in the New Hampshire Medicaid program in good standing and have a New Hampshire Medicaid provider enrollment number.

C. Individual Patient Volume

EPs have the option to calculate patient volume based on individual encounters or aggregate encounters at the clinic/group practice level. Refer to ‘D’ below for more information on the aggregate calculation.

Patient volume is the percentage of Medicaid patient encounters that an EP provides in any representative, continuous 90-day period in the preceding calendar year. For the individual calculation, each EP must have a patient volume of 30% or more (with the exception of pediatricians that can have 20% patient volume).

Patient volume is based on encounters and is not impacted by, or related to, how providers are billed. One patient encounter includes all services provided to an individual in a day by a specific provider where:

 Medicaid (including Healthy Kids Gold and out-of-state Medicaid and Medicaid- managed care programs) paid for part or all of the services (including premiums, co- payments, and/or cost-sharing).

EPs may choose one (or more) clinical sites of practice in order to calculate their patient volume. This calculation does not need to be across all of an EP’s sites of practice. However, at least one of the locations where the EP is adopting or meaningfully using certified EHR technology should be included in the patient volume. In other words, if an EP practices in two locations, one with certified EHR technology and one without, the EP should include the patient volume at least at the site that includes the certified EHR technology. When making an individual patient volume calculation, an EP may calculate across all practice sites, or just at the one site.

Use this three-step formula to determine Medicaid patient volume:

Step 1

 Numerator = total Medicaid patient encounters in any 90-day period in the preceding calendar year

Step 2

Step 3

If this percentage is 30% or more (optional 20% for pediatricians), then the EP may be eligible for a Medicaid EHR incentive payment.

Examples of Individual Patient Volume Calculation

Example 1

Dr. Barry, an OBGYN, had 80 Medicaid patient encounters out of 200 total encounters in the selected 90-day period.

 Numerator = the sum of all Medicaid patient encounters in a continuous 90-day period in the preceding calendar year = 80

 [(Numerator / Denominator) X 100]. If the percentage is 30% or higher, then the EP may be eligible for a Medicaid EHR incentive payment:

80/200 X100 = 40% Medicaid patient volume. Dr. Barry meets this criterion.

Example 2

Dr. Powers, a primary care physician, had 30 Medicaid patient encounters out of 300 total encounters in the selected 90-day period.

 Numerator = 30

 Denominator = 300

 [(30/300) X100] = 10% patient volume. Dr. Powers does NOT meet this criterion.

D. Option to Calculate Aggregate Patient Volume

Clinics and group practices may use the clinic/group-practice patient volume and apply it to all EPs in their practice under three conditions:

 The clinic or group practice's patient volume is appropriate as a patient volume methodology calculation for the EP (for example, if an EP only sees Medicare, commercial, or self-pay patients, this is not an appropriate calculation);

 There is an auditable data source to support the clinic’s patient volume determination; and

 So long as the practice and EPs use one methodology in each year. (In other words, clinics could not have some EPs use their individual patient volume for patients seen at the clinic, while others use the clinic-level data). The clinic or practice must use the entire practice’s patient volume and not limit it in any way.

If the EP works in both the clinic and outside the clinic (or with, and outside, a group practice), then the clinic/practice level determination includes only those encounters associated with the clinic/practice. If an EP works at one or more clinics/group practices, each clinic/group practice should include the encounters made by the EP at its ‘own’ clinic/group practice in the group calculation. However, the EP can register for only one incentive payment (i.e., the EP cannot register for an incentive payment at every clinic/group practice that uses his/her encounter information in its group calculation).

Example of Aggregate Patient Volume Calculation

Calculate the Medicaid patient encounters for all providers in the clinic/group practice (even those not designated as EPs) in the selected 90-day period:

Provider Name Category EP Status Medicaid Total Patient Encounters Patient Encounters

Dr. Smith MD Yes 80 200

Casey Jones NP Yes 50 100

Jamie Doe RN No 150 200

Logan Shaw PharmD No 80 100

Dr. Moore MD Yes 30 300

Dr. Johnson DDS Yes 5 100

Dr. Hayes DDS Yes 20 200

TOTAL 415 1,200

 Numerator = the sum of all Medicaid patient encounters from all Medicaid providers (even those that aren't designated as EPs, and, hence, aren’t eligible for the incentive program) in a continuous 90-day period:

80 + 50 + 150 + 80 + 30 + 5 + 20 = 415

 Denominator = the sum of all encounters from all providers (even those that aren't eligible for the incentive program) in the clinic/group practice in a continuous 90-day period. Note: to use the clinic/group practice calculation, every provider in the practice/organization must provide services to needy individuals:

200 + 100 + 200 + 100 + 300 + 100 + 200 = 1,200

 [(Numerator / Denominator) X 100]. If the percentage is 30% or higher (optional 20% for pediatricians), then the EP may be eligible for a Medicaid EHR incentive payment:

[(415/1,200) X 100] = 35% patient volume clinic/group practice-wide. Since this exceeds the 30% threshold, Dr. Smith, Casey Jones, Dr. Moore, Dr. Johnson, and Dr. Hayes are EPs who meet the patient volume eligibility criterion.

END OF NON-FQHC/RHC EP SECTION - PLEASE RETURN TO SURVEY

4 Eligible Hospital

A. New Hampshire Medicaid Provider

An Eligible Hospital (EH) must be actively enrolled in the New Hampshire Medicaid program in good standing and have a New Hampshire Medicaid provider enrollment number.

B. Average Length of Stay

An EH must have an average length of stay that is 25 days or fewer. Use this formula to determine average length of stay:

 Numerator = total of all unique inpatient bed days from the Hospital Medicare Cost Reporting period; includes neonatal (NICU) bed days; does not include bed days for nursery, observation, labor and delivery

 Denominator = total of all unique discharges from the Hospital Medicare Cost Reporting period; includes neonatal (NICU) bed days; does not include bed days for nursery, observation, labor and delivery

C. CMS Certification Number

An EH must have a CMS Certification Number (CCN) in which the last four digits are in the series 0001-0879 or 1300-1399

D. Patient Volume

Patient volume is the percentage of Medicaid patient encounters that an EH provides in any representative, continuous 90-day period in the preceding calendar year. Each EH must have a Medicaid patient volume of 10% or more.

Patient volume is based on encounters and is not impacted by, or related to, how providers are billed. One patient encounter includes all services provided to an individual in a day by a specific provider per:

 Inpatient hospital discharge where Medicaid (including Healthy Kids Gold and out-of- state Medicaid and Medicaid-managed care programs) paid for part or all of the services (including premiums, co-payments, and/or cost-sharing).

 Emergency department where Medicaid (including Healthy Kids Gold and out-of-state Medicaid and Medicaid-managed care programs) paid for part or all of the services (including premiums, co-payments, and/or cost-sharing).

1 Eligible Hospital

Use this three-step formula to determine Medicaid patient volume:

Step 1

 Numerator = total Medicaid patient encounters in any 90-day period in the preceding calendar year

Step 2

Step 3

If this percentage is 10% or more, then the EH may be eligible for a Medicaid EHR incentive payment.

Example of Patient Volume

Hospital A had 80 Medicaid encounters out of 200 total encounters in the selected 90-day period.

 Numerator = the sum of all Medicaid encounters in a continuous 90-day period in the preceding fiscal year = 80

 [(Numerator / Denominator) X 100]. If the percentage is 10% or higher, then the hospital may be eligible for a Medicaid EHR incentive payment:

80/200 X100 = 40% patient volume. Hospital A meets this eligibility criterion.

END OF HOSPITAL SECTION - PLEASE RETURN TO SURVEY