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Five states now offer Medicaid EHR incentives to ODs

May 1, 2012

Optometrists in five states can now participate in Medicaid Electronic Health Records (EHR) Incentive Programs – with optometrists in up to a half-dozen more possibly becoming eligible for Medicaid EHR incentives in the near future, according to the AOA Advocacy Group.

Since the Medicaid EHR Incentive Program was created under the American Recovery and Reinvestment Act (ARRA) of 2009, Alabama, Illinois, Kentucky, Ohio and South Carolina have all taken action to allow optometrists to qualify for EHR incentives. And all five acted in time to allow at least some optometrists to qualify for payments during the first year of the incentive program.

That is important because Medicaid, like other public and private health insurance plans, increasingly encourages the use of EHR technology by health care practitioners, the AOA Advocacy Group noted; however, clinics and practices that serve primarily low-income patients may be relatively less able to pay for it.

Moreover, Medicaid provides substantially higher EHR incentives than its counterpart Medicare EHR Incentive Program.

Under the Medicaid EHR Incentive Program, health care practitioners who demonstrate they have billed at least 30 percent of their insurance claims to Medicaid during a 90-day reporting period can qualify for up to $63,750 in incentives over the six-year life of the program.

The Medicare EHR Incentive Program, by comparison, offers up to $44,000 ($48,400 in federally designated Health Professional Shortage Areas).

The entry of optometrists into state Medicaid EHR Incentive Programs comes as the result of lobbying efforts by the AOA to get the Centers for Medicare & Medicaid Services (CMS) to clarify incentive program rules, as well as successful efforts by state optometric associations to assist state Medicaid departments in filing necessary state Medicaid plan amendments with the CMS to allow participation by optometrists in their incentive programs.

Medicaid EHR Incentive Program rules issued by the CMS in 2009 limit participation to physicians, dentists, certified nurse-midwives, nurse practitioners and physician assistants who are practicing in federally qualified health centers or rural health clinics led by a physician assistant – with “physicians” defined as doctors of medicine or osteopathy.

Optometrists provide medical eye care services under all state Medicaid programs. However, few state Medicaid departments have ever formally amended their state Medicaid plans to acknowledge optometrists as providers of physician services, the AOA Advocacy Group noted.

The federal laws governing Medicaid do not categorically recognize that optometrists provide physician services (as do the laws governing Medicare), instead giving state Medicaid agencies the option to cover two classes of services that can be provided by optometrists: vision care and “optometry services” – the latter being physician services (medical care) provided by optometrists within the scope of optometric practice.

As a result, few state Medicaid departments initially planned to include optometrists when they began launching their EHR incentive programs in early 2011.

However, following discussions with the AOA Advocacy Group, the CMS revised its “Path to Payment” instructions for federal EHR incentive programs (http://tinyurl.com/PathtoPayment), noting that optometrists are eligible for Medicaid EHR incentives when state Medicaid departments officially recognize them as providers of “physician services” and include them in their EHR incentive programs.

AOA Advocacy Group representatives promptly notified state Medicaid agencies in all U.S. states and territories that optometrists could be included in their EHR incentive programs and even provided them a package of information with the document they would need to modify and the contact information for the official at the nearest CMS regional office who would process the document.

The AOA Advocacy Group also sent e-bulletins to all state optometric associations, informing them of a new opportunity to bring optometrists into a potentially important financial incentive program.

At the time, CMS records indicated only four state Medicaid programs – New Jersey, South Dakota, Kansas, and Hawaii – already recognized optometrists as providers of physician services.

However, after receiving the AOA Advocacy Group information package, a half dozen state Medicaid departments expressed interest in officially recognizing optometrists as physician service providers and opening their EHR incentive programs to them.

Some 25 state optometric association executives expressed interest in approaching their state Medicaid agencies on the matter.

State optometric association action

State Medicaid departments commonly file State Plan Amendments (SPAs), the AOA Advocacy Group noted. The plan amendments necessary to include optometrists in EHR incentive programs are relatively simple to make, the AOA Advocacy Group added.

Nevertheless, advice and assistance from state optometric associations has proven a critical factor in all five of the states that have so far included optometrists in their EHR incentive programs, the AOA Advocacy Group noted.

In several cases, action to include optometrists in Medicare EHR programs took on new urgency after the CMS announced it would extend the 2011 incentive filing deadline to Feb. 29, 2012, in about a dozen states and to March 31 in the rest.

The Commonwealth of Kentucky’s Medicaid EHR Incentive Program was the first in the nation to issue an incentive payment to an optometrist.

Commonwealth officials amended their EHR incentive program on May 12 of last year, after the Kentucky Optometric Association (KOA) reminded them that longstanding provider nondiscrimination provisions in the Kentucky Medicaid Law and Regulations defined optometrists as providers of physician services.

KOA representatives in the fall of 2010 met with directors of the Kentucky Health Information Exchange (KHIE) as well officials of the Kentucky Medicaid Department after learning the department had submitted to the CMS an EHR incentive that would not include optometrists. (See AOA News, January.)

South Carolina was actually the first state to include optometrists in its Medicaid EHR Incentive Program, according to South Carolina Optometric Physicians Association (SCOPA) President Philip Flynn, O.D.

The state Department of Health & Human Services specifically included optometrists when it drew up plans for the program in 2010. SCOPA officials became concerned after learning the CMS did not consider optometrists to be eligible providers for the Medicaid EHR incentive program.

However, South Carolina has recognized optometrists as providers of physician services under Medicaid, Dr. Flynn said, and state officials reaffirmed in October 2010 that optometrists would be eligible for the incentive program.

That was confirmed late last year when husband-and-wife practitioners John Mason, O.D., and Katie Mason, O.D., of Columbia, S.C., successfully attested compliance with EHR utilization standards and received the maximum incentive payments provided under the program.

Participation in the Medicaid EHR Incentive Program will be particularly important to South Carolina optometrists, Dr. Flynn believes.

The state has become a leader in the implementation of electronic health records and is considered a model by the federal Office of the National Coordinator for Health Information Technology.

As a result, many optometrists in the state already have electronic health records systems. About 25 percent of the state’s population is enrolled in Medicaid. In many optometric practices, Medicaid enrollees represent 50 to 60 percent of the patient base, Dr. Flynn said.

He expects many South Carolina optometrists to receive payments under the Medicaid EHR Incentive Program, including a number of practitioners who are expected to “switch over” from the Medicare EHR Incentive Program.

Illinois last year included optometrists in its Medicaid EHR incentive program, as the result of a hard push by the Illinois Optometric Association (IOA), the AOA and the Illinois Eye Institute (IEI), the not-for-profit clinic operated by the Illinois College of Optometry.

The initiative to change the Illinois State Medicaid Plan was originally launched in an effort to help ensure Medicaid reimbursement for optometrists in the institute’s federally qualified community health centers and rural health centers.

“However, we eventually found out that EHR was the far greater issue,” Michael G. Horstman, IOA executive director, said.

The Illinois Department of Healthcare and Family Services officially filed amendments to its state Medicaid plan with the CMS on July 22, 2011.

The CMS approved the revised Illinois Medicaid State Plan in September 2011 but allowed changes to be retroactive to the filing date.

As this AOA News went to press, some 30 to 50 IEI optometrists were preparing to file for Medicaid EHR incentives, potentially resulting in millions of dollars in payments to the institute.

The Alabama Medicaid Agency received formal approval from the CMS to include optometrists in its EHR incentive program on Dec. 12, 2011, according to Alabama Optometric Association Executive Director Amanda Buttenshaw.

The state Medicaid agency agreed to amend its EHR incentive program following a meeting with Buttenshaw and state Rep. Jim McClendon, O.D., (R) the chair of the Alabama House Health Committee.
The association was still working with the agency to implement program changes in March. However, Alabama optometrists would still have time to attest compliance with EHR meaningful use standards before the program’s extended March 31 filing period deadline and earn incentive payments for 2011, Buttenshaw said.

Efforts to ensure Ohio optometrists a place in the state’s Medicaid EHR Incentive Program began in late 2010 when the Ohio Optometric Association (OOA) learned its members would be omitted from the program.

A series of meetings between Immediate Past President Heath Gilbert, O.D., and the Ohio Office of Medicaid resulted in a pledge by state officials to amend the incentive program.

The effort took on new impetus after OOA member Tom Bobst, O.D., secured a meeting with HHS Secretary Kathleen Sebelius. She emphasized during the meeting that the HHS intends for optometrists to be involved in the Medicaid EHR Incentive Program.

Ohio officials submitted a revised Medicaid EHR Incentive Program plan to the HHS on Nov. 1, 2011. However, given that the CMS normally takes months to approve Medicaid program plan changes, Ohio optometrists would not have enough time to qualify for incentive for the 2011 calendar year, Dr. Gilbert realized.

At the urging of OOA, Ohio Gov. John Kasich (R) took the unusual step of issuing an emergency executive order that, effective immediately, would allow optometrists to take part in the incentive program.

The order took effect Dec. 17, 2011, after Ohio Senate and House of Representatives committees, in an equally unusual move, both unanimously gave required approvals for the order.

“I can tell you Ohio optometrists are now receiving checks from the Medicaid EHR Incentive Program,” an OOA staff member said. One four-practitioner optometric practice recently received a total of $85,000 for their first year of participation in the incentive program, he said.

Ongoing negotiations

Representatives from the AOA Advocacy Group and state optometric associations have held meetings with nine additional state Medicaid departments over recent months.

During virtually all of those meeting, AOA Advocacy Group members have had to emphasize that they are not asking the department to cover additional services but simply allow optometrists who already provide services under Medicaid to participate in the EHR incentive program, noted Brian Reuwer, AOA Advocacy Group associate director for advocacy and affiliate services.

“Every state Medicaid program already reimburses optometrists for medical eye care service,” said Reuwer. “They are simply being asked to officially acknowledge in their state Medicaid plan what they are already doing.”

The “sticking point,” Reuwer said, is generally the term “optometric services,” which Medicaid administrators commonly misinterpret to mean vision care and which many cash-strapped Medicaid plans do not wish to begin offering at this time or be forced to maintain as budgets tighten. Optometric associations have to explain the changes relate only to optometrists providing medical eye care covered under physician services.

“The AOA Advocacy Group is available to work with AOA members in opening additional state Medicaid EHR incentive programs to optometrists,” Reuwer emphasized. “One thing states are having trouble with is the 30 percent Medicaid billing threshold for the incentive. Many optometrists do not bill that much Medicaid, especially if they do not currently have a vision benefit in the program. However, states that have optometry schools with large clinics, community health centers, and other public health entities with integrated optometric services would be the most likely candidates to have optometrists who will reach this threshold and those optometrists could really help their clinic with this incentive money.”

For more information, contact Reuwer in the AOA Washington office at 800-365-2219, ext. 1343 or BReuwer@aoa.org.

Ky OD leads nation 

In July 2011, Alison Overley, O.D., became the first optometrist in the nation to successfully meet the federal government’s Stage 1 EHR utilization requirements and receive payment through the Medicaid EHR incentive program. By the end of last year, more than 30 Kentucky optometrists had met the Stage 1 requirements and qualified for incentive payments through Medicaid.

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