American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Medicare vs Medicaid EHR Programs

To help you determine whether to participate in the Medicare or the Medicaid Electronic Health Record (EHR) Incentive Programs, we have developed a comparison of the two programs. The table below compares the primary components of each one.

 

Medicare

Medicaid

Eligibility linked to patient volume threshold?

No threshold Medicare patient volumes to qualify for Medicare incentives.

Must have patient volume of at least 30 percent attributable to Medicaid patients (for pediatricians, the volume threshold is 20 percent).

Meaningful use required?

Yes. EPs must meaningfully use a certified EHR to receive an incentive payment.

No – in the first year of participation in the Medicaid incentive program, EPs may qualify for an incentive payment by demonstrating any of the following: that they have adopted, implemented, or upgraded a certified EHR.
Yes – in the years subsequent to the first year of participation in the Medicaid incentive program, EPs must demonstrate meaningful use of a certified EHR.

Criteria

The criteria for both the Medicare and Medicaid incentive programs are the same, but states can add additional meaningful use criteria that pertain specifically to public health objectives and data registries.

Reporting period – first year

For the first year an EP applies for and receives an incentive payment, the EHR reporting period is 90 consecutive days beginning and ending within the calendar year.

There is no EHR reporting period for adopting, implementing, or upgrading for a Medicaid EP’s first payment year.

Reporting period – second year

For every year after the first payment year, the EHR reporting period is the entire calendar year.

In their second payment year/first year of demonstrating meaningful use, EPs have a 90-day EHR reporting period.

Reporting period – subsequent years

For every year after the first payment year, the EHR reporting period is the entire calendar year.

In their third payment year/second year of demonstrating meaningful use, EPs have a 12-month EHR reporting period.

Maximum incentive payment in year 1

$18,000

$25,000

Maximum incentives

The maximum incentive payment is $44,000 over a period of five years ($48,400 if the EP is in a HPSA).

The maximum incentive payment is $63,750 over a six-year period; pediatricians with Medicaid patient volume between 20 percent and 29 percent of their total patient volume could receive two-thirds of the maximum amount ($42,500).

Starting year

2011

Likely 2011, but depends on individual states.

Last year to start program, yet still maximize incentives

2012

2016

Incentive Expires

No incentive for those EPs who begin meaningful use after 2014. The last payment will be made in 2016 (for those who began meaningfully using in 2014).

No incentive payment will be made after 2021, or to those EPs who receive the bonus for more than 5 years.

Additional incentive for HPSA

10% additional

None

Linked to allowed charges?

Yes. Medicare incentive payment is based on 75 percent of allowed Medicare charges with a maximum payment in year 1 of $18,000.

No. Medicaid incentive payment not linked to allowed Medicaid charges.

Penalties for not demonstrating meaningful use of an EHR?

Penalty takes effect in 2015 for EPs who are not meaningfully using certified EHRs.

No penalties for not using certified EHRs.

Interaction with other CMS incentive programs

An EP can participate in both the Medicare EHR Incentive Program as well as the Physician Quality Reporting System (PQRS) if they qualify for both programs.

If the EP chooses to participate in the Medicare EHR Incentive Program, he or she cannot participate in the Medicare e-prescribing incentive program simultaneously.

An EP can participate in both the Medicaid EHR Incentive Program as well as the Physician Quality Reporting System (PQRS) if they qualify for both programs.

If the EP chooses to participate in the Medicaid EHR incentive program, he or she can participate in the Medicare e-prescribing incentive program simultaneously.

Note: EPs who meet the eligibility requirements for both the Medicare and Medicaid incentive programs are able to participate in only one program, and must designate which one they wish to participate in. After their initial designation and receipt of an incentive payment, EPs are allowed to change their program selection only once and only for a payment year prior to 2015.

If you have further questions about the Medicare and Medicaid EHR Incentive Program, please contact Sana Gokak at sgokak@facs.org or 202-672-1517.