Skip to main content

Medicaid Patient Volume Requirements

Eligibility for MDAAP incentives will be limited to those eligible providers whose Medicaid patient volume is at least 20%, as determined using the calculations below. The definition of Medicaid patient encounter and Medicaid patient volume for MDAAP are as follows, consistent with the standards used for the CMS EHR Technology Incentive Program, 42 CFR Part 495 at the Electronic Code of Federal Regulations (e-CFR). 

  • A patient encounter is any service rendered to an individual on any one day. 

  • A Medicaid encounter is any service rendered to an individual on any one day where: 

    • Medicaid paid for part or all of the service, 

    • Medicaid paid all or part of the individual’s premiums, co-payments, and cost-sharing, or 

    • The individual was enrolled in a Medicaid program at the time the billable service was provided. 

To calculate Medicaid patient volume for MDAAP purposes, a provider must first divide the total Medicaid encounters in any representative, continuous 90-day period in the prior calendar year (M90), or in the 12 months before the provider’s attestation, by the total for all patient encounters in the same 90-day period (A90). Then, multiple by the administrative State Adjustment Factor of 0.9763 to arrive at Medicaid patient volume for MDAAP purposes.  This is  expressed in the following equation: (M90 ÷ A90) x 0.9763 = Medicaid Patient Volume (Medicaid Patient Volume Calculation Template)

  • For many eligible providers, the first quarter of 2023 may contain the highest Medicaid volume since the unwinding of the continuous Medicaid enrollment provision enacted in response to the COVID-19 public health emergency did not begin until the second quarter of 2023. 

  • Medicaid Patient Volume of at least 19.5% will be rounded up to 20% 

  • Providers should not count multiple claims for services for the same patient by the same provider on the same day. The patient volume calculation assesses encounters, not claims, and requires the provider to remove duplicate encounters on the same day for both the numerator (M90) and denominator (A90). 

  • Services rendered to the same patient by different providers on the same day are allowed to be counted discretely by each provider. 

  • Providers participating in MDAAP will attest to program milestones as either a solo provider of a practice (individual) or a group practice or facility (group). Solo practice providers will use an individual Medicaid patient volume calculation. Group practices and facilities will attest as a group and use a group Medicaid patient volume calculation. In either situation, MDAAP incentives will be issued based on the payment information on file in MMIS for the Medicaid provider ID on the approved MDAAP application.  

  • Individual/solo providers may choose one (or more) clinical sites of practice in order to calculate patient volume. This calculation does not need to be across all of a provider’s sites of practice. However, at least one of the locations where the provider is participating in MDAAP must be included in the patient volume and must be within the State of Vermont. A provider may calculate patient volume across all practice sites, or just at one site. 

  • Group practices or facilities will calculate patient volume at the group practice/clinic level, in accordance with all of the following limitations:  

    • The clinic or group practice uses the entire practice or clinic’s patient volume and does not limit patient volume in any way.  

    • If a provider works inside and outside of the clinic or practice, then the patient volume calculation includes only those encounters associated with the clinic or group practice, and not the provider’s outside encounters. 

  • For each provider/practice attesting with Group Patient Volume, a Group Definition must be provided at the time of attestation. The Group Definition must contain:  

    • The complete set of Billing NPIs and Medicaid IDs across all of their client services programs defining the Group. 

    • The calculation/compilation of the Group Patient Volume must incorporate ALL encounters under the practice’s set of billing NPIs and Medicaid IDs.  

As part of initial attestations for the first program milestone, all providers will be required to submit a patient volume spreadsheet with details of their Medicaid patient volume metrics, including the selected 90-day patient volume reporting period, numerator value, denominator value, and overall Medicaid patient volume percentage. The spreadsheet should include each and all of the direct patient encounters which were counted in either the patient-volume numerator or the patient-volume denominator of the attestation (i.e., we need data to support both the numerator and the denominator). The spreadsheet must contain the following fields: 

  • ColumnName: Description 
  • BillNpi: Billing provider NPI. 
  • BillMdId: Billing provider Medicaid ID 
  • Pid: Patient unique ID. (Do not include PHI such as social security numbers, dates of birth, or names.) 
  • Ruid: Medicaid Recipient Unique ID. The Medicaid ID ONLY should populate this column. No other insurance policy number or ID is relevant for this data field. The field should remain blank if the patient was not eligible for Medicaid on the date of service.   
  • MdState: State in which the patient was enrolled in Medicaid. This field should remain blank if the patient was not eligible for Medicaid on the date of service.  
  • EnctrDate: Patient encounter date. 
  • Group: For all group attestations based on a subpart of the billing provider NPI: Clinic name, group practice name, service location, or organizational subpart NPI. You should be prepared to show that a subpart group has an identifiable and distinct physical location or business function within the billing-NPI organization other than for the purpose of establishing minimum Medicaid patient volume for the MDAAP. 

We strongly recommend that providers utilize the Medicaid Volume Calculation template that can be downloaded from this page to calculate Medicaid volume for program eligibility purposes and that participating providers maintain this completed spreadsheet along with other forms of program milestone documentation for a period of six (6) years.