Medicare and Medicaid EHR incentive programs: What are the key differences?

The American Recovery and Reinvestment Act of 2009 (ARRA) created major incentive programs for clinicians and hospitals that adopt electronic health records and achieve certain Meaningful Use (MU) criteria. Medicare and Medicaid have similar but separate programs. All providers –except certain hospitals– have to choose one program or the other to participate in.

CMS has a useful PDF, which highlights the key differences between the Medicare and Medicaid programs. Some are:

  • Medicare providers receive payment reductions if they don’t achieve MU by 2011, while there is no such provision for Medicaid
  • The maximum bonus for eligible professional is $44,000 for Medicare and $63,750 for Medicaid
  • States can add elements to the MU definition for Medicaid, but Medicare’s definition is national
  • Medicare providers must initiate their program by 2014, while Medicaid providers have until 2016

There are some differences in the programs in the types of clinicians that are eligible:

  • Physicians are generally eligible for either program
  • Dentists are eligible for either but dental surgeons apparently only for Medicare
  • Podiatrists, optometrists, and chiropractors are eligible for Medicare but not Medicaid
  • Nurse practitioners, certified nurse midwives, and certain physician assistants in health centers or rural clinics are eligible for Medicaid but not Medicare

Clinicians can use the handy Eligibility Wizard to figure out what they qualify for.

Medicare-eligible hospitals include:

  • Subsection (d) hospitals in the 50 states or Washington, DC paid under the Inpatient Prospective Payment System
  • Critical access hospitals (CAHs)
  • Medicare Advantage affiliated hospitals

Medicaid-eligible hospitals include:

  • Acute care hospitals (including CAHs and cancer hospitals) with at least 10% Medicaid patient volume
  • Children’s hospitals –regardless of Medicaid patient volume

Some hospitals can actually participate in both programs (they don’t have to choose one or the other). Such hospitals must meet all three of these criteria:

  • Subsection (d) hospital or critical access hospital (CAH)  in the 50 states or Washington, DC; and
  • CMS Certification Number ending in 0001-0879 or 1300-1399; and
  • At least 10% of patient volume from Medicaid encounters

CMS has a comprehensive EHR incentive program site where more information is available.

August 4, 2011

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