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Who is eligible to receive EHR Incentive Program payments?

There are two categories of providers that are eligible for incentive payments under the EHR Incentive Program: eligible professionals and eligible hospitals.  

Eligible professionals under the Medicaid EHR Incentive Program include:

  • Physicians
  • Nurse Practitioners (NPs)
  • Certified Nurse-Midwives (CNMs)
  • Dentists
  • Physician Assistants (PAs) who practice medicine at a FHQC or RHC that is led by a PA

Hospital-based eligible professionals do not qualify for Medicaid or Medicare EHR incentive payments.  Eligible professionals are considered “hospital-based” if more than 90 percent of their services are performed in an inpatient hospital or emergency room.  

In addition to being one of the designated eligible practitioner types, Medicaid eligible professionals must have at least 30 percent of all patient encounters attributable to Medicaid.  This percent calculation includes Medicaid fee-for-service patients and those enrolled in Medicaid managed care organizations, prepaid inpatient health plans, and prepaid ambulatory heath plans.  (Children’s Health Insurance Program (CHIP) patients do not count.) Patient encounters are measured over any continuous, representative 90-day period within the most recent calendar year prior to reporting.

There are two exceptions to the 30 percent rule:  

  1. The threshold is lower for pediatricians; their patient volume need only be at least 20 percent Medicaid to qualify.
  2. Eligible professionals working in an FQHC or RHC must have a minimum of 30 percent of encounters attributable to needy individuals.  In addition to Medicaid individuals, those considered “needy” include those receiving assistance from CHIP, those receiving uncompensated care, or those receiving care at no cost or reduced cost based on an income-based sliding scale.  

Eligible professionals who practice predominantly in an FQHC or RHC are eligible to receive incentive payments.  “Practicing predominantly” in an FQHC or RHC is defined as when more than one-half of the eligible professionals’ total patient encounters take place at the FQHC or RHC.  These encounters would be counted over the period 6 months prior to the reporting period.  

FQHC and RHCs are not eligible to receive incentive payments as an entity.  However, FQHC and RHC providers who meet the criteria for eligible professionals can receive incentive payments as individuals, and may reassign their payment to their employer (the FQHC or RHC).  Each eligible professional may only reassign the entire amount of the incentive payment to one employer or entity.

Eligible hospitals under the Medicaid EHR Incentive Program include:  

  • Acute care hospitals (including Critical Access Hospitals) with at least 10 percent  Medicaid patient volume
  • Children’s hospitals (no minimum Medicaid volume is required)

An acute care hospital is defined as a health care facility where the average length of patient stay is no more than 25 days.  A children’s hospital is defined as a separately certified children's hospital, either freestanding or hospital-within-hospital, and which predominantly treats individuals under the age of 21.

Note that eligible professionals are allowed to participate in only one EHR incentive program (either Medicaid or Medicare).  If you are eligible for both the Medicare and Medicaid Incentive Programs, you must choose one in which to participate.  Before 2015, you are allowed to switch one time between programs.  Some hospitals will be eligible to receive EHR incentive payments from both Medicaid and Medicare.  

Medicaid eligible professionals and hospitals can begin participation in the program as soon as their State offers the program.  Some States will begin offering the program in January 2011, so check your State’s Medicaid website and the CMS registration and attestation webpage for information.  Eligible professionals must begin their participation in the Medicaid Incentive Program by 2016 to receive the maximum incentive payment; eligible hospitals must begin their participation by 2016.  Participation does not need to be consecutive; an eligible provider can start in one year, postpone their participation another year, then participate again.  Medicaid providers may only register with a single State program (you cannot receive incentive payments from more than one State).  

Related Resources:

EHR Incentive Program Final Rule – Federal Register announcement of CMS’ Final Rule for Meaningful Use, published July 28, 2010. This announcement provides an in-depth explanation of Stage 1 program requirements and a summary of public comments on the proposed preliminary regulations.
EHR Incentive Program, Eligibility – CMS’ details of eligibility for Meaningful Use.
EHR Incentive Program, Hospital Eligibility – CMS’ description of hospital eligibility for Meaningful Use.
Meaningful Use 101 for the Safety Net Community go to exit disclaimer– Webinar hosted by HRSA OHITQ offers tips to help providers demonstrate meaningful use of EHR systems and comply with the EHR Incentive Programs.
Tips for Conducting Meaningful Use Gap Analysis within the Safety Net Community go to exit disclaimer– Webinar hosted by HRSA OHITQ offers tips to help HRSA grantees and safety net providers assess their current health IT capabilities and evaluate gaps in Meaningful Use.
The American Recovery and Reinvestment Act of 2009: Frequently Asked Questions go to exit disclaimer– The National Association of Community Health Centers’ (NACHC) explanation of the funding available for community health centers through ARRA and which government agencies are in control of these funds.

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