ACA Physician Fee Increases for Primary Care Services
The Department of Human Services (Department) is implementing Section 1202 of the Patient Protection and Affordable Care Act (ACA). Section 1202 of the ACA requires state Medicaid programs to pay increased fees to qualifying physicians that are no less than the Medicare rates in effect in calendar years (CYs) 2013 and 2014, or if greater, the rates that would be applicable in those CYs using the CY 2009 Medicare Physician Fee Schedule conversion factor (CF). As such, the Department will increase fees for certain Evaluation and Management (E&M) and vaccine administration procedure codes to the extent covered by the Department when furnished by a physician, or under the personal supervision of a physician, in the specialties of family medicine, internal medicine or pediatric medicine, effective January 1, 2013 through December 31, 2014. The fee increase applies to qualified physicians in the above-stated specialties or subspecialties rendering primary care services to MA beneficiaries paid through both the MA Program’s fee-for-service and managed care delivery systems.
Provider Quick Tip(s):
Medical Assistance Bulletin(s):
Medical Assistance Program Attestation Form:
Medical Assistance Program Attestation Form (Form to be used when attesting to 60% including the PA MA Vaccine Product Codes) Attestation Form Completion Tutorial for Providers
ACA Primary Care Services Fee for Service Fee Schedule:
Remittance Advice Banner Alert(s):
This virtual classroom training session is designed to provide physicians with information regarding the Department’s implementation of Section 1202 of the ACA relating to MA fee increases for select primary care services.
- Physicians may sign up for virtual classroom training at http://www.DHS.state.pa.us/provider/training/. First, browse to “PROMISe provider education and training” at the bottom right list on the page, then, select “Conference call training”, and from the bottom right list of that page, select “Class offerings on the MA Program’s primary care fee increases.”
ACA-PCS Claim Submission Examples:
Span Billing Examples:
- Dr. Jones, a qualifying physician, provided consecutive inpatient visits on 12/29/2012 through 1/1/2013. The primary care services fee increases to qualified physicians are effective with dates of service on 1/1/2013 through 12/31/2014. Dr. Jones must submit a claim with two detail lines. The first detail line must contain dates 12/29/2012 through 12/31/2012 and reflect three units to account for the three consecutive inpatient visits prior to 1/1/2013. This detail line will pay based on the current (default) MA Program Fee Schedule rate. The second detail line must contain the date of 1/1/2013 and reflect one unit. This detail line will pay at the increased primary care services rate.
- Dr. Smith, a qualifying physician, provided consecutive inpatient visits on 12/29/2013 through and including 1/1/2014. The primary care services increased fees will change on 1/1/2014. Dr. Smith must submit a claim with two detail lines. The first detail line must contain dates 12/29/2013 through 12/31/2013 and reflect three units to account for the three consecutive inpatient visits. This detail line will pay based on the CY 2013 primary care services increased fee. The second detail line must contain the date of 1/1/2014, and will pay based on the CY 2014 primary care services fee. If Dr. Smith submits a claim with a single detail line spanning the calendar years when the primary care services fee changes, the Department will pay based on the current (default) MA Program Fee Schedule rate and Edit 826 will post on the detail line to advise the physician of the required billing instructions for payment based on the primary care services increased fees, as described in this example.
- Dr. Snow submits his Physician Attestation Form attesting to Board certification on 4/17/2013. The Department receives his Physician Attestation Form on 4/20/2013. Dr. Snow is not eligible for the retroactive fee increase and is only eligible for the increased primary care services fees based on the effective date of his Physician Attestation Form, which is 4/20/2013. Dr. Snow provides inpatient visits that span the effective date of his Physician Attestation Form. Dr. Snow provides inpatient visits consecutively on 4/18/2013, 04/19/2013 and 4/20/2013; Dr. Snow is only eligible for the increased primary care services fees for dates of service on and after 4/20/2013. In order to be paid appropriately, Dr. Snow must submit a claim with two detail lines. The first detail line must reflect dates of service 4/18/2013 through 4/19/2013, which pays at the current (default) MA Program Fee Schedule fee. The second detail line must reflect date of service 4/20/2013, which pays at the primary care services increased fee. If Dr. Snow submits a claim with a single detail line for all dates of service, which span the effective date of his Physician Attestation Form, the Department will pay his claim based on the current (default) MA Program Fee Schedule rate and Edit 1055 will post on his claim.
- Physicians must not submit claims using a single detail line that reflects dates of service prior to the effective date of January 1, 2013 when the increased primary care fees begin or when the primary care services increased fees change between CYs 2013 and 2014. In these instances, the physician must reflect the applicable date of service on a separate detail line.
- Physicians must not submit claims using a single detail line that includes dates of service prior to or after the effective date the physician is qualified for the increased primary care services fees.
Centers for Medicare and Medicaid Services’ (CMS) Final Rule published November 6, 2012:
Centers for Medicaid & CHIP Services (CMCS) “Affordable Care Act Questions and Answers”:
Medical Assistance Program Fee Increase for Select Primary Care Services Provider Training