Eligibility & Volume: Eligible Professionals

  • Physicians - MDs, DOs
  • Advanced Registered Nurse Practitioners (ARNPs)
  • Certified Nurse-Midwives
  • Dentists
  • Physicians Assistants (PA)(i)

Additional Requirements

  • Active status
  • No outstanding state or federal sanctions
  • Not be hospital based (defined as having 90% or more encounters in a year in a hospital or emergency room setting)

Eligible Professional Volume Requirements

In addition to being an eligible provider type and having certified technology, EPs must meet a 30% Medicaid encounter volume threshold over 90 day period. Pediatricians can qualify for the program with 20% Medicaid encounter volume but it results in a maximum reduced payment of $42,500.

  • Volume can be based on a continuous 90 day period in the previous calendar year or from the 12 months preceding attestation.
  • A Medicaid encounter is defined as a service(s)  rendered on any one day to an individual enrolled in a Medicaid program.  Encounters no longer have to be billed and/or paid to be counted. 
  • Medicaid volume thresholds must be met each participation year.
  • The denominator of the volume calculation is all encounters during the 90 day period. 
  • Eligible professionals that practice in a RHC or FQHC at least 50% of the time can count "needy individuals"(ii) to meet their patient volume threshold.
  1. Must be working in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) and the clinic must be led by a PA. The "Attestation for Physician Assistant Led" form must be complete.
  2. Needy individuals are defined in Section 1903(t)(3)(F) of the Social Security Act as individuals meeting any of the following three criteria:
    • They are receiving medical assistance from Medicaid or the Children's Health Insurance Program (CHIP).
    • They are furnished uncompensated care by the provider.
    • They are furnished services at either no cost or reduced cost based on a sliding scale determined by the individual's ability to pay.