Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth All Provider Bulletin 230 December 2012 TO: All Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Section 1202 Rates for Physicians Who Provide Primary Care Services Background For calendar years 2013 and 2014, Section 1202 of the federal Affordable Care Act requires Medicaid agencies to provide payment for certain primary care services delivered by eligible physicians consistent with rules set forth in 42 CFR Part 447, Subpart G (Section 1202 Rates). Section 1202 Rates will be established effective January 1, 2013, pursuant to regulations that will be promulgated by EOHHS. Eligible Services The Section 1202 Rates apply to a specific set of services and procedures that the Centers for Medicare & Medicaid Services (CMS) designate as “primary care services.” They apply to billing codes for a specific set of evaluation and management (E&M) services, and certain vaccine administration services. The following codes are eligible for Section 1202 Rates. Healthcare Common Procedure Coding System (HCPCS): . E&M codes 99201-99499 (Providers should refer to Subchapter 6 of the Physician Manual for the list of Common Procedure Terminology (CPT) codes in this code range that are not payable under MassHealth.); and . CPT vaccine administration codes 90460, 90461, 90471, 90472, 90473, 90474, or their successor codes (Please note that the Section 1202 Rate does not apply to the 90461 code, when billed in connection with the Vaccines for Children Program.) Eligible Physicians The Section 1202 Rates apply to these primary care services when provided by physicians who specialize in family medicine, general internal medicine, and/or pediatric medicine, or a subspecialty recognized by the American Board of Medical Specialties (ABMS), the American Osteopathic Association (AOA), or the American Board of Physician Specialties (ABPS). These physicians are also paid Section 1202 Rates for services provided by advanced practice professionals practicing under the designated physician’s personal supervision. (continued on next page) MassHealth All Provider Bulletin 230 December 2012 Page 2 Eligible Physicians In order to be eligible for the Section 1202 Rates, such physicians must self-attest that they are either board certified in one of the qualified specialties or subspecialties, and/or that 60% of the Medicaid codes he or she has billed during the most recently completed calendar year were for the services eligible for the Section 1202 Rates. Newly eligible physicians must provide self-attestation based on the Medicaid codes billed provided during the prior month. Current MassHealth Providers MassHealth has been working with the Massachusetts Board of Registration in Medicine (BORIM) to obtain specialty attestation information concerning MassHealth-enrolled physicians. As a result, MassHealth may already have your updated specialty information in your provider file. Because BORIM accepts ABMS or AOA board-certification information, but not ABPS information, MassHealth will not have information about ABPS certifications. In such cases, you can attest to an eligible specialty designation online at the Provider Online Service Center (POSC) at: https://newmmisportal. ehs.state.ma.us/EHSProviderPortal/appmanager/provider/desktop. You can also attest to an eligible specialty designation by completing Part 1 of Section V of the Physician Certification and Attestation Form. The form can be found online at www.mass.gov/masshealth. Scroll down the page and click on MassHealth Provider Forms in the lower right panel. A sample form is attached to this bulletin. Completed forms may be faxed to (617) 988-8974 or mailed to the following address. MassHealth Customer Service Attn: Provider Enrollment PO Box 9118 Hingham, MA 02043 Enrolled physicians electing to attest to billing at least 60% of the designated codes can do so by completing Part 2 of Section V of the Physician Certification and Attestation Form in order to receive the payment increase. The form can be found online at www.mass.gov/masshealth. Scroll down the page and click on MassHealth Provider Forms in the lower right panel. A form is attached to this bulletin. Completed forms may be faxed to (617) 988-8974 or mailed to the following address. MassHealth Customer Service Attn: Provider Enrollment P.O. Box 9118 Hingham, MA 02043 (continued on next page) MassHealth All Provider Bulletin 230 December 2012 Page 3 Current MassHealth Providers (cont.) All physician attestations concerning specialty designation and 60% claiming are subject to an audit to ensure the validity of the facts underlying the attestation. MassHealth will issue a follow-up publication containing additional information on the claiming and payment processes. Enrollment for Providers In Entity-Based Relationships For salaried and contracted physicians who provide services in a facility, MassHealth will contact facilities to obtain the necessary information to make Section 1202 Rate payments to facilities retroactive to January 1, 2013, or the date on which the physician became eligible for Section 1202 Rate payments, whichever is later. MassHealth will issue a follow-up publication containing additional information on the claiming and payment processes. Providers Who Are Not Physicians Primary care services provided by nonphysician practitioners (e.g., physician assistants, nurse practitioners) under the personal supervision of an eligible physician are also eligible for Section 1202 Rates. In order for those services to be eligible for Section 1202 Rates, nonphysician providers must provide services under the personal supervision of an eligible primary care physician and the supervising physican may bill for those services. Services performed by nonphysician providers and billed under the supervising physician will receive 85% of the Section 1202 Rate. Eligibility Dates for Section 1202 Rates The section 1202 Rates described above are available for dates of service in calendar year 2013 and calendar year 2014. For those physicians attesting to a certified specialty, the physician is eligible for the Section 1202 Rates for such services provided as of the date he or she became certified in the qualifying specialty. Physicians with previous billing history attesting to 60% billing based on the previous year are eligible for payment back to the beginning of the calendar year during which the physician submits his or her self-attestation. Newly eligible physicians attesting to 60% billing based on the previous month are eligible for payment for the period they have been an eligible provider. (continued on next page) MassHealth All Provider Bulletin 230 December 2012 Page 4 Questions If you have any questions about the information in this bulletin, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to (617) 988-8974. Document ends.