Help Desk: Eligibility Q&A
Q: Who is considered a potential "Eligible Provider" (EP) under the Indiana Medicaid Promoting Interoperability (PI) Program?
A: Physicians (MDs & DOs); Nurse Practitioners*; Certified Nurse Midwives; Dentists; and Physician Assistants who lead a Federally Qualified Health Center (FQHC) or a Rural Health Center (RHC).
*In Indiana, Pursuant to 848 IAC 4-1-3, Advanced Practice Nurse (Provider Type 09) includes Nurse Practitioner, Certified Nurse Midwife and Clinical Nurse Specialist. Advance Practice Nurses are inclusive of all types of Nurse Practitioners and all Nurse Practitioners are included under the Advance Practice Nurse designation.
Q: How many Medicaid patients must an EP see per year to be eligible to participate in the program?
A: An EP must meet one of the following criteria:
- Have a minimum of 30% Medicaid patient volume.*
- Have a minimum of 20% Medicaid patient volume, and be a pediatrician.*
- Practice predominantly in a Federally Qualified Health Center (FQHC) or a Rural Health Center (RHC), and have a minimum 30% needy patient volume.
*The Children’s Health Insurance Program (CHIP) does not count toward the Medicaid patient volume criteria
Q: What is the time frame for seeing the Medicaid patients?
A: Volume must be met during one of the following two time frames:
- The previous calendar year (from the program year). Ex.: For Program Year 2016, pull data from CY 2015,
- 12 months preceding attestation date. Ex.: For a Program Year 2016 attestation completion date of Nov. 8, 2016, pull data from Nov. 8, 2015-Nov. 7, 2016
Q: What qualifies as "needy patient volume"?
A: Needy individuals are persons meeting any of the following criteria:
- They are receiving medical assistance from Medicaid or the Children’s Health Insurance Program (CHIP).
- They are furnished uncompensated care by the EP.
- They are furnished services at either no cost or reduced cost based on a sliding scale determined by the individual’s ability to pay.
In addition, an EP is considered to practice predominantly in an FQHC or RHC when an FQHC or RHC is the clinical location for over 50% of the EP’s total encounters over a period of six (6) months in the most recent calendar year.