Medicaid fees should be set at a rate that is at least 100% equivalent to those in Medicare.

Health plans should use the most current version of CPT codes and adhere to CPT guidelines regarding the use of codes.

Payment for physician services for newborn care should be separately identified as unique and distinct from maternal services and should ensure adequate and clearly identified payment to attending physicians who provide care for newborn infants to ensure consistent and continuous coverage for the neonatal period and for subsequent pediatric care.

All capitated rates should be adjusted for case-mix differences based on age, geographic location, modifiers for children with special health care needs, outlier risk-adjusted methods, more risk-adjusted rating groups, a pediatric diagnostic classification system, or a combination of these. 

As risk-adjustment techniques are developed by payers, it is necessary to incorporate a pediatric focus and involve PCPs and pediatric specialists experienced in private practice in their design. 

Contract provisions about carved-out services, outlier payment, stop-loss provisions, reinsurance or shared-risk arrangements for individual children, and aggregate plan loss or profits should be clearly identified. 

Any additional services (meaningful use reporting, attestations to facilitate data correction, and so forth) to be covered under the capitation rate must be subject to mutual agreement by the health plan and the contracting physician.

When primary care is capitated, contracts should include fee-for-service carve-outs for unexpected or high-cost services, including, but not limited to, neonatal and routine newborn hospital care, immunizations, hospitalization, emergency services, transplant services, and, in the case of adolescents, pregnancy and other reproductive health services.

All recommended preventive services, including pediatric immunizations, must be covered as first-dollar coverage and not be subject to deductibles and/or copayments or any other cost-sharing mechanism under the health plan. 

Payment for preventive care services needs to be in full and not be bundled or considered incidental to the office visit. Appropriate payment can be accomplished by paying for each service reported separately at a level that reflects the total RVUs of all the reported services.

Health plans paying pediatricians for pediatric care on a fee-for-service schedule should use the most current Resource-Based Relative Value Scale as the basis for their fee schedule. The American Medical Association/Specialty Society Relative Value Scale Update Committee RVU values are appropriate for PCPs, pediatric medical subspecialists, and pediatric surgical specialists. 

A single multispecialty, regionally adjusted conversion factor applied to the current-year RVUs (ie, at least 100% of the current year Medicare resource-based relative value scale reimbursement rate) should be incorporated.