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ACA Increased Payments for CHDP Primary Care Physicians

September 12, 2014

The Patient Protection and Affordable Care Act (ACA), as amended by House Resolution 4872-24 Health Care and Education Reconciliation Act of 2010, Section 1202, requires that payments to primary care physicians be increased to the Medicare equivalent for certain Evaluation and Management and Vaccine Administration services.

Interim Payment
An interim payment for eligible Child Health and Disability Prevention (CHDP) services will be issued to providers who have attested to eligibility for ACA enhanced payments. The interim payment will represent estimated increases retroactive to dates of service on or after January 1, 2013. The interim payment will be issued on a Medi-Cal checkwrite in December 2014.

UCR Web Application Coming Soon
To ensure Medi-Cal providers are reimbursed for their services at the maximum allowable payment provided for by state/federal law and policy, a new process has been developed to submit the Usual Customary and Reasonable (UCR) charge of providers, who bill for CHDP services. Claims will be paid at the lesser of the UCR charge or ACA rate for the services that have a UCR charge submitted through the UCR Web application.

Providers who have access to Med-Cal Eligibility Transaction Services can submit the UCR charge for the National Current Procedure Terminology (CPT) codes that correspond to CHDP History and Physical (H&P) and Non-VFC (Purchased Vaccine) Local Service Codes. UCR charges can be submitted for the years 2013 and 2014. Instructions for the UCR Web application will be released in a future Medi-Cal Update.

Providers may view both the Medi-Cal fee-for-service maximum allowable rates and comparable Medicare maximum allowable rates for calendar year 2013 by downloading the ACA 1202 PCP Rate Increase – Child Health and Disability Prevention (CHDP) Code Crosswalk from the ACA Increased Medicaid Payment for Primary Care Physicians page.

ACA Rate Increase for CHDP Services Billed by Group or Clinics
To be eligible for ACA enhanced payments, the following providers who bill for CHDP services, and who have not already attested, must attest that they are eligible to receive the payment increase by completing the online ACA Self Attestation Form Primary Care Physicians.

  • County hospital outpatient
  • Community outpatient hospital
  • Free clinics
  • Community clinics
  • Multispecialty clinics
  • County clinics not associated with a hospital
  • Clinic (otherwise undesignated)
  • Physicians group

Providers may refer to the ACA Increased Medicaid Payment for Primary Care Physicians page of the Medi-Cal website for additional information about the ACA payment increase.