Who is eligible for Medicare incentive payments?

• Doctor of medicine or osteopathy
• Doctor of oral surgery or dental medicine
• Doctor of podiatric medicine
• Doctor of optometry
• Chiropractor

Note: Medicare EPs cannot be hospital-based. EPs are defined as hospital-based if 90 percent or more of their services are provided in the following place of service (POS) codes: 21—Inpatient Hospital; 23–Emergency Room.

Who is eligible for Medicaid incentive payments?

• A physician (including pediatricians)
• A nurse practitioner
• A certified nurse-midwife
• A dentist
• A physician assistant practicing in an FQHC or RHC led by a physician assistant

Medicaid EPs also cannot be hospital-based. The table below outlines the Medicaid patient volume requirements by provider type.

How is a 30% Medicaid patient volume calculated?

Since the Medicaid programs are run on the state level, it could vary by state. You can visit your state's Medicaid website for tools and details to determine your Medicaid patient volume.

As an example, here is how California Medicaid defines Medicaid encounters. http://www.dhcs.ca.gov/provgovpart/Documents/OHIT/Understanding_Medi-Cal_Encounters.pdf

Note: All information provided is intended to be a helpful overview.  Please visit the CMS website for the written law and regulations.