Shortage Area Bonus Payments


HPSA BONUS PAYMENTS

History

Section 4043 of the Omnibus Budget Reconciliation Act of 1987 established a bonus payment program for physicians who treat Medicare patients in Health Professional Shortage Areas (HPSAs). Beginning in 1989, physicians providing services in rural HPSAs were entitled to a 5 percent bonus payment. Then effective January 1, 1991, the bonus payment was raised from 5 percent to 10 percent and by adding urban HPSAs. Eligibility for receiving the 10 percent bonus payment is based on whether the specific location at which the service is furnished is within an area that is designated (under section 332(a)(1)(A) of the Public Health Services Act) as a HPSA. For example, the service(s) were rendered in the physicians office, therefore, the office must be located in a designated HPSA.  Previously, physicians had to include a modified (QB or QU) to receive the HPSA bonus payment.


New changes to program

Effective January 1, 2005, physicians no longer have to include the QB or QU modifier on claims to receive their HPSA bonus payment, which will be paid automatically, if they provide care in a zip code area that either:

  • Fall entirely in a county designated as a full-county HPSA; or
  • Fall entirely within the county, through USPS determination of dominance;
    or
  • Fall entirely within a partial county HPSA.

However, if the physician provides care in zip code areas that do not fall entirely within a full county HPSA or partial county HPSA, they must continue to enter either the QB or QU modifier on the claim to receive the bonus payment.

 

Are you eligible for the automated HPSA bonus payment?

 

Follow the steps below to determine if you are eligible for the automated payment:

 

Step 1:  Open the file below and look up the zip code where you rendered services.  If the zip code is on the list, STOP.  You do not need to do anything else.  You should automatically receive the HPSA bonus payment.

 

Zip Codes Eligible for Automated HPSA bonus

 

Step 2:  If you are a mental health provider only and the zip code where you rendered services was not in the file above, consult the following file.  If the zip code is on the list, STOP.  You do not need to do anything else.  You should automatically receive the HPSA bonus payment.

 

Additional Zip Codes Eligible for HPSA bonus for Mental Health Services

 

Step 3:  If you provide services in a location within a Geographic HPSA but the zip code is not in the file above, the"QU/QB" modifier must still be used to receive the HPSA bonus.  Click here to view maps of the HPSAs in Kansas. Please note only Whole County (Geographic) HPSAs are eligible for the bonus payment.

 

 

 

PHYSICIAN SCARCITY AREA BONUS PAYMENTS

 

In addition to HPSA bonus payments, effective January 1, 2005, CMS began making additional 5% bonus payments for services rendered in newly-defined Physician Scarcity Areas.  This bonus is only available for physicians (dentists, podiatrists, optometrists, and chiropractors are not eligible).

 

Are you eligible for the automated PSA bonus payment?

 

Step 1:  If you are a physician in general practice, family practice, internal medicine, and obstetrics/gynecology, consult the following table and look up the zip code where you rendered the service.  If you are a physician in a non-primary care specialty, skip to Step 5.

 

Eligible_Zip_Codes_for_Primary_Care_PSA_Bonus.pdf

 

Step 2:  If your zip code is on the list, STOP.  You do not need to do anything else.  You should automatically receive the 5% PSA bonus payment.

 

If your zip code is not on the list, go to Step 3.

 

Step 3:  If you did not find the zip code on that table, you may still be eligible for the bonus.  Consult the table below.

 

Counties_Eligible_for_Primary_Care_PSA_Bonus.pdf 

 

Step 4:  If your county is included on this list (and your zip code was not listed in the file under Step 1), STOP.  You are eligible for the 5% PSA bonus, but will need to use an "AR" modifier to claim the PSA bonus payment.

 

Step 5:  Physicians other than specialists in the designated primary care specialties are also eligible for the 5% bonus for services rendered at sites in a Specialty Care PSA zip code. Consult the following list.

 

Eligible_Zip_Codes_for_Non_Primary_Care_PSA_Bonus.pdf

 

Step 6:  If your zip code is on the list, STOP.  You do not need to do anything else.  You should automatically receive the 5% PSA bonus payment.

 

If your zip code is not on the list, go to Step 7.

 

Step 7:  If you did not find the zip code on that table, you may still be eligible for the bonus.  Consult the table below.

 

Counties_Eligible_for_Non_Primary_Care_PSA_Bonus.pdf

Step 8:  If your county is included on this list (and your zip code was not listed in the file under Step 1), STOP.  You are eligible for the 5% PSA bonus, but will need to use an "AR" modifier to claim the PSA bonus payment.

If you have questions about shortage areas, click here to contact an BCHS staff member.