AmeriHealth Caritas Pennsylvania ACA Fee Increase Frequently Asked Questions

The Department of Public Welfare (DPW) is implementing Section 1202 of the Patient Protection and Affordable Care Act (ACA). Section 1202 of the ACA requires states to increase payments to qualified physicians for certain primary care services provided to eligible Medical Assistance (Medicaid) beneficiaries.

The fee increase is effective for dates of service January 1, 2013 through and including December 31, 2014.

The Department of Public Welfare (DPW) submitted a State Plan Amendment to the Centers for Medicare and Medicaid Services (CMS) for approval. CMS has approved DPW's payment plan, including the payment rate.

Rates will be available on the ACA page of DPW's website as a separate PDF titled: FFS ACA Primary Care Services (PCS) Fee schedule.

• Qualified E&M codes
  Note: Only codes that are currently on the Medical Assistance (MA) fee schedule are eligible for the fee increas
• Vaccine administration fee under the specific vaccine toxoid code

Physicians who have submitted the required attestation documents to DPW and are:

• Board-Certified family practice, internal medicine and pediatric physicians and their subspecialties that render primary care services for specific Evaluation and Management (E&M) and vaccine administration procedure codes. Physicians must be board certified by one of the following: American Board of Medical Specialties (ABMS), American Board of Physician Specialties (ABPS), or American Osteopathic Association (AOA);
• Non Board-Certified physicians who have been enrolled in the Medical Assistance (MA) program for the entire calendar year 2012 and provided ACA qualifying E&M and vaccine services equal to 60% or more of their MA billing in calendar year 2012;
• Non-Board Certified physicians who have been enrolled in the MA program for one full calendar month or more but less than a full calendar year and who have provided ACA qualifying E&M vaccine services equal to 60% or more of their MA billing from the date of enrollment through the end of the full calendar month.

Qualifying E&M and vaccine services provided to recipients in certain Medical Assistance (MA) programs are excluded from the ACA fee increases:

• General Assistance MA beneficiaries (package HCB03, HCB05, HCB12)
• Additional State-Funded (package HCB07)
• Health Care Benefit Package 11 (HCB11) – when there is no Medicare/Medicare Advantage coverage/cost sharing

Complete and submit to DPW the Medical Assistance Program Increase for Select Primary Care Services Physician Attestation Form.

Go to the provider section of DPW's website.

Providers who submitted a valid Attestation Form prior to April 2, 2013 are eligible to receive, retroactive to January 1, 2013, the ACA increased fees for qualifying E&M and vaccine procedure codes.

Note: Physicians who are eligible via the 60% threshold option and who did already attest may be eligible for retroactive payments to January 1, 2013 if they submitted a valid Attestation Form by close of business July 1, 2013.

Providers can still submit an Attestation Form. However, ACA increased fees will only apply to eligible claims with date of service as of the receipt date of valid attestations.

Note: Physicians who are eligible via the 60% threshold option and who did not already attest may be eligible for retroactive payments to January 1, 2013 if they submitted a valid Attestation Form by close of business July 1, 2013.

AmeriHealth Caritas Pennsylvania will be paying eligible providers on a fee-for-service basis through the normal claims submission process.

Note: For providers that submitted a valid Attestation Form by April 1, 2013, AmeriHealth Caritas Pennsylvania will make retroactive payments for ACA qualifying E&M and vaccine procedure codes for dates of service beginning January 1, 2013 to providers who attested with DPW by April 1, 2013.

Also, physicians who are eligible via the 60% threshold option and who did not already attest may be eligible for retroactive payments to January 1, 2013 if they submitted a valid Attestation Form by close of business July 1, 2013.

AmeriHealth Caritas Pennsylvania will base a provider's eligibility for the ACA increased fees upon a weekly provider file received from DPW that identifies a provider's eligibility and the effective date of their eligibility. Providers not identified on the file as eligible will not be eligible to receive the ACA increased fees.

Practices that are currently paid through a capitated arrangement will be switched to a fee-for-service payment method. Practices that are currently paid via a fee-for-service arrangement will continue to be paid under that payment methodology.