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ACA Increased Medicaid Payment for Primary Care Physicians
Pursuant to the Affordable Care Act (ACA), as amended by the H.R. 4872-24 Health Care and Education Reconciliation Act of 2010, Section 1202, ACA and 42 Code of Federal Regulations (CFR) 447 require state Medicaid agencies to reimburse primary care physicians with a specialty designation of family medicine, general internal medicine or pediatric medicine, at parity with Medicare for specified Evaluation and Management (E&M) and Vaccine Administration services.
The increased minimum payment level applies to specified primary care services and to services rendered by these provider types paid by Medicaid managed care plans that are contracted by states to provide the primary care services. The payment provides for 100 percent federal financial participation for any increase in payment above the amounts that would be due for these services under the provisions of the approved Medicaid state plan, as of July 1, 2009.
The Department of Health Care Services (DHCS) will be increasing managed care capitation payments to include the primary care service increases. Increased payments will be retroactive for dates of service on or after January 1, 2013. Managed care plans are required to begin making the enhanced payments to eligible physicians upon receipt of the associated capitation payments.
Managed Care Plan (MCP) attestation data is currently available in the “Transaction Services” area of the Medi-Cal website. MCPs may access this data by following the directions in the Managed Care Plan Attestation Download Process and Data Element Dictionary.
The State of California – Medi-Cal Managed Care Proposal for Implementation of Affordable Care Act (ACA) Section 1202: Increased Payments for Medicaid Primary Care Services (PDF) document provides information relative to the Managed Care Methodology used by DHCS for implementation of the primary care rate increase.
ACA 1202 Primary Care Physician (PCP) rate increase crosswalks may be accessed by clicking the links below. These tables provide both the Medi-Cal fee-for-service maximum allowable rates and comparable Medicare maximum allowable rates for procedures defined by Section 1202 of ACA.
Rates for calendar year 2014:
- Section 1202 of the Affordable Care Act – 2014 Payments to Primary Care Physicians: Evaluation and Management Codes and Rates Crosswalk (PDF)
- Section 1202 of the Affordable Care Act – 2014 Payments to Primary Care Physicians: Vaccine Administration Codes and Rates Crosswalk (PDF)
- Section 1202 of the Affordable Care Act – 2014 Payments to Primary Care Physicians: CHDP Health Assessment and Immunization Codes Crosswalk (PDF)
Rates for calendar year 2013:
- Section 1202 of the Affordable Care Act – 2013 Payments to Primary Care Physicians: Evaluation and Management Codes and Local Code Crosswalk (Excel)
- Section 1202 of the Affordable Care Act – 2013 Payments to Primary Care Physicians: Vaccine Administration Codes and Rates Crosswalk (Excel)
- Section 1202 of the Affordable Care Act – 2013 Payments to Primary Care Physicians: CHDP Vaccine Administration Codes and Rates (Excel)
The state fee-for-service interim payments will expedite the release of funds to providers, but will not be considered final reimbursement. Child Health and Disability Prevention (CHDP), Independent Non-Medical Practitioners who bill Medi-Cal directly, and crossovers claims are excluded from the interim payment process. Upon completion of necessary system changes, payment increases for geographic-specific rates will be made. Additionally, final settlement of payments owed, but not reimbursed by interim payments, will be made to reconcile the appropriate geographic-specific rate.
Please note that while Neonatal Intensive Care Unit (NICU) and Pediatric Intensive Care Unit (PICU) claims are part of the interim process, most will not receive interim payments due to defaulting to the lowest acuity level rates during this process. Beginning March 2014, NICU and PICU claims may begin using the new ACA modifiers, so that claims can crosswalk to a higher level of acuity and thereby receive an ACA payment increase.
Click to expand the sections below.
To be eligible for the ACA and 42 CFR 447 enhanced payments, the physician rendering or supervising the service must personally attest to be the following:
- A physician, as defined in 42 CFR 440.50 with a specialty designation of family medicine, general internal medicine, pediatric medicine or a subspecialty within one of the listed specialties.
- Meeting at least one of the following qualifications:
- Board certified in a specialty or subspecialty that is recognized by the American Board of Medical Specialties (ABMS), American Board of Physician Specialties (ABPS) or American Osteopathic Association (AOA). Please see the “Related Links” section of this page for links to additional information.
- At least 60 percent of total claim volume for the most recently completed calendar year or, for newly eligible physicians, the prior month, were for E&M (99201 – 99499) and Vaccine Administration (90460, 90461, 90471 – 90474, or their successors) services or local codes that correspond to these E&M and Vaccine Administration codes.
Provider attestation is automatically retroactive to January 1, 2013, except in two circumstances:
- If the provider is eligible based on board certification, but not claim history, the attestation is only retroactive to the begin date of the board certification if that is after January 1, 2013.
- If the provider is newly enrolled in the Medi-Cal program, the attestation would only be retroactive to the date of enrollment.
Providers are automatically considered eligible for payments retroactive for dates of service on or after January 1, 2013. If providers have any period(s) of time in which they are not eligible, they should submit an update to the attestation eligibility date information as described in the Affordable Care Act – Primary Care Physician Self Attestation Form Completion Instructions.
- Filing Period Extended for CHDP ACA Balance Due Requests
- Streamlined Procedure for ACA-Related Appeals
- Important Notices about ACA Payments to CHDP Providers
- Update: ACA Primary Care Rate Increases
- Attestation and UCR Submission Period Extended for CHDP Group Providers to Receive ACA Rate Increase
- CHDP Proprietary Electronic Claim Transaction Format Update
- ACA RAD Code and Correlation Table Additions
- CHDP ACA Updates: UCR Charges, Electronic Claims and Interim Payments
- ACA Primary Care Physician Rate Increase EPC Update
- ACA Primary Care Physician Rate Increase: Retroactive Payments
- ACA Rate Increase for Specified Primary Care Services Implementation Update
- Updates for the ACA Increased Medicaid Payments for Primary Care Physicians
- ACA Increased Medi-Cal Payments Released by SPA Approval
- Update – ACA Increased Medi-Cal Payments for Primary Care Physicians
- ACA Rate Increase to Medicare Equivalent for Specified Primary Care Services
- ACA Self Attestation Form Now Available
- ACA Increased Payments for CHDP Primary Care Physicians – UCR Web Application Instructions (PDF)
- Patient Protection and Affordable Care Act: Retroactive NICU/PICU Claim to ACA Modifier Assignment Instructions (PDF)
- NICU/PICU Claim To ACA Modifier Assignment Spreadsheet template (Excel)
- Medicaid Managed Care Payment for PCP Services in 2013 and 2014 – Technical Guidance and Rate Setting Practices (PDF)
- Implementation of Section 1202 of the Affordable Care Act Primary Care Payment Increase Methodology Approval Letter (PDF)
SELF ATTESTATION FORM
Physicians must self-attest that they are eligible to receive the payment increase by completing the online ACA Self Attestation Form. For detailed field-by-field instructions about completing the ACA Self Attestation Form, please read the Affordable Care Act – Primary Care Physician Self Attestation Form Completion Instructions (PDF).
The NewsFlash article “Update: ACA Primary Care Rate Increases” which published on May 18, 2015, announced that the ACA Self Attestation form would be decommissioned on June 15, 2015. The form has been decommissioned.
- DHCS, Approved State Plan Amendment (SPA) 13-003: Increase Payments for Primary Care Services Provided by Eligible Physicians:
- Centers for Medicaid and CHIP Services (CMCS) ACA Information:
- Centers for Medicare & Medicaid Services (CMS) ACA Final Rule [42 CFR 438, 441 and 447] (PDF):
- Centers for Medicare & Medicaid Services (CMS) ACA Final Rule Q&A (PDF):
- American Board of Medical Specialties:
- American Board of Physician Specialties:
- American Osteopathic Association:
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