ACA Enhanced Physician Payment Reimbursement Discontinued. Primary Care Fee Schedule Enhancement

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ACA Enhanced Physician Payment Reimbursement Discontinued December 31, 2014

Effective January 1, 2013, the South Carolina Department of Health and Human Services (SCDHHS) implemented a portion of the final rule under the Affordable Care Act (ACA) that increased Medicaid reimbursements for evaluation, management and immunization procedure codes for two years. The increase applied to both fee-for-service (FFS) and Medicaid Managed Care Organizations (MCOs).

The two-year federal program will end December 31, 2014. All Medicaid FFS claims with a date of service on/or before December 31, 2014, which qualified for the enhanced payments will continue to process based on FFS claim processing timely filing rules. SCDHHS will continue to reimburse the MCOs through a quarterly gross level adjustment. All encounters meeting the requirements for the enhanced payment for dates of service on/or before December 31, 2014 will be included in these adjustments. The MCOs will continue to process these quarterly files and pay providers directly for their portion of the encounter records. These payments must be processed within 30 days of SCDHHS' payment to the MCO.

SCDHHS is standardizing the methodology for receiving encounter files and for this reason some providers may see a delay in quarterly payments from some health plans. SCDHHS is currently working to rectify all problems arising from the standardized process and will make corrected payments once we have fully tested and implemented the standardized process.

SCDHHS Primary Care Fee Schedule Enhancement Program

Effective January 1, 2015, SCDHHS will adjust its fee schedule for qualifying providers that deliver primary care services. The policy update will adjust rates for evaluation, management and immunization procedure codes. SCDHHS will use the established 2014 ACA enhanced primary care rate schedule and procedural coding for this program. Providers qualifying for the program include physicians in the following disciplines: family practice, general practice, gynecology, internal medicine, obstetrics, obstetrics & gynecology, pediatrics, psychiatry and child psychiatry. SCDHHS will identify providers for this program based on their current designation with the agency. Higher payments are not available for services that are reimbursed through a FQHC, RHC, health department/clinic encounter or visit rate. The claims that would qualify for inclusion would be those claims that are filed by a FQHC utilizing their "CBP" provider number and the RHC utilizing their "GP" provider number as prescribed in policy. Providers filing claims to the Medicaid FFS program will not need to take any action to qualify for these payments.

In order for South Carolina to operate a compliant managed care program, federal law requires that SCDHHS pay an actuarially sound per member per month (PMPM) capitation payment for the managed care membership. In lieu of making separate payments to MCOs for this fee schedule adjustment, SCDHHS will increase the capitation payments made to its contracted MCOs. MCO payments to qualifying providers are a contractual matter between the MCO and the provider. SCDHHS is attaching the affected procedure codes and the Medicaid FFS schedule that will be implemented January 1, 2015.

Please refer any questions or concerns regarding this bulleting to the Provider Service Center at (888) 289-0709.

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