Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth All Provider Bulletin 235 August 2013 TO: All Providers Participating in MassHealth FROM: Kristin L. Thorn, Acting 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) and 101 CMR 317. Changes This bulletin updates All Provider Bulletin 230, issued in December 2012. The provisions of All Provider Bulletin 230 continue to remain in effect with the following changes. The 60%-of-claims attestation for eligibility to receive Section 1202 rates will be calculated based on claims paid, instead of claims billed. (Please see the “Eligible Physicians” section.) Physicians may no longer attest to eligibility to receive Section 1202 rates through the Provider Online Service Center (POSC), but they may use the POSC to view the specialties and subspecialties in their MassHealth record and check whether they have attested to 60% of claims. (Physician profiles can be viewed on the POSC web page at https://newmmis-portal.ehs.state.ma.us/EHSProviderPortal/appmanager/provider/desktop.) To qualify for Section 1202 payments for retroactive dates of service, all physicians (excluding hospital-based physicians, addressed separately below) must follow the attestation instructions as clarified. (Please see “Eligibility Dates for Section 1202 Rates” section.) (continued on next page) MassHealth All Provider Bulletin 235 August 2013 Page 2 Eligible Physicians To be eligible for Section 1202 rates, a physician must satisfy both of the following requirements. A physician must self-attest that he or she practices in family medicine, general internal medicine, or pediatric medicine or a related subspecialty recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS), or the American Osteopathic Association (AOA); and such physician must also self-attest that: he or she is board certified in a qualified specialty or subspecialty; or for the most recently completed calendar year, at least 60% of the Medicaid codes for which the physician had been paid were for the services eligible for the Section 1202 rates. A newly eligible physician, defined as a physician who does not yet have a full calendar year of paid Medicaid claims, must self-attest based on the Medicaid codes for which he or she was paid during the prior month. For information on how to self-attest to eligible specialty designation or billing history, visit the MassHealth Section 1202 website at http://www.mass.gov/eohhs/provider/insurance/masshealth/section-1202-rates-for-physicians-who-provide-pcs.html. Services provided by nonphysician practitioners, such as physician assistants, nurse practitioners, and nurse midwives, are eligible for payment of 85% of the Section 1202 rates, as follows. Such services must be provided under the personal supervision of an eligible primary care physician, and otherwise be properly billed under the supervising physician’s national provider identifier (NPI). Due to recent CMS guidance, physicians with an Allergy & Immunology specialty board certification from the American Board of Allergy & Immunology and who also practice in an eligible specialty/subspecialty are eligible for the Section 1202 rates. Such physicians should complete the attached Physician and Certification Self-Attestation Form and submit it to MassHealth. MassHealth All Provider Bulletin 235 August 2013 Page 3 Services Eligible for Section 1202 Rates The Section 1202 rates apply to a specific set of services and procedures: E&M codes 99201-99499 Current Procedural Terminology (CPT) vaccine administration codes 90460, 90461, 90471, 90472, 90473, 90474, or their successor codes. For more guidance about the 1202 rates for codes covered by MassHealth, see Administrative Bulletin 13-06 and Subchapter 6 of your Physician Manual. Retroactive Payment Physicians must submit attestations to MassHealth by December 31, 2013, to be eligible to receive Section 1202 payments for dates of service retroactive to January 1, 2013. For completed attestations received on or after December 31, 2013, 1202 payments will be for dates of service that are prospective. MassHealth reserves the right to extend this deadline Hospital-Based Physicians and Group Practices Hospitals and group practices must ensure that the eligible physicians for whom they are billing receive the direct benefit of the payment increase for each of the Section 1202 primary care services. MassHealth will issue a follow-up publication containing additional information on these requirements. MassHealth is developing an implementation process for hospital-based physicians. The follow-up provider bulletin will also contain additional information on the claiming and payment processes for salaried and contracted physicians who provide services in hospitals. Once the process is finalized, hospitals will be able to resubmit claims for services provided by their eligible physicians retroactive to January 1, 2013, or the date the physician is eligible for Section 1202 payments, whichever is later. Physicians Participating in MassHealth-Contracted Managed Care Entities MassHealth is currently determining the implementation process for physicians participating in MassHealth-contracted managed care entities(such as a managed care organization or senior care organization). MassHealth will issue a follow-up provider bulletin containing additional information on the Section 1202 attestation process and any other relevant information for such physicians at a later date. Managed care entities may also issue additional information to assist their providers. (continued on next page) MassHealth All Provider Bulletin 235 August 2013 Page 4 Vaccine Administration Rates Section 1202 increases the regional administration fee for the “Vaccines for Children” (VFC) program. For vaccines administered by 1202-eligible providers under the VFC Program in calendar years 2013 and 2014, a state must pay the lesser of the Regional Maximum Administration Fee or the calculated Medicare rate for code 90460. Vaccine Administration Billing Instructions Please choose the appropriate code based on the following factors: the age of the patient; for patients up to age 18, whether counseling was provided; whether the vaccine was supplied by the state, including vaccines supplied through the VFC program. If state-supplied, append the SL modifier to the claim; whether first vaccine or additional vaccine; and the method of administration. Please refer to the Medicine Regulations at 101 CMR 117.04(4) for descriptions and appropriate usage of vaccine administration codes. 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.