Information for MassHealth Providers about the ACA Program Integrity Provisions

The Affordable Care Act (ACA) improves government-wide efforts to fight Medicaid fraud and waste through many new initiatives that affect providers

This page will be periodically updated. Below is a description of some of the program integrity provisions that affect MassHealth providers. 

ACA Section 2702: Payment Adjustment for Provider-Preventable Conditions (PPC) including Health Care-Acquired Conditions (HCAC)

Under the rule, providers must report PPCs to state Medicaid agencies, and state Medicaid agencies are prohibited from paying providers for PPCs in violation of the rule. See Appendix V of your provider manual for billing instructions for PPCs.

ACA 6401: Temporary Provider Enrollment Moratorium

The ACA allows states to request a temporary moratorium on enrollment from the Centers for Medicare & Medicaid Services (CMS). CMS granted Massachusetts’ request for moratoriums on Home Health Agencies and Adult Foster Care Providers. Here are the details:

Home Health

  • CMS granted approval for EOHHS and MassHealth to impose a temporary moratorium on the enrollment of new home health agencies in the MassHealth fee-for-service and home- and community-based services waiver programs.
  • This moratorium became effective statewide February 11, 2016, for an initial period of six months. Home health agency provider applications that were not approved before February 11, 2016, are subject to the moratorium.
  • CMS granted approval for EOHHS and MassHealth to extend the temporary moratorium through February 11, 2020.
  • With more than 200 home health agency service locations currently providing services in Massachusetts, MassHealth has determined that current access to home health agency services is adequate, and that this continued moratorium will not adversely affect access to care.
  • MassHealth has identified areas of serious concern through its audit process and is currently working with home health providers through both formal and informal areas to address those concerns. MassHealth is also continuing a process of reviewing and implementing prior authorization requirements to determine appropriate service thresholds in order to ensure that home health agencies provide appropriate, medically necessary services to members and to improve the integrity of the home health program.
  • While CMS may continue to certify and enroll home health agency providers for Medicare enrollment, MassHealth will not be enrolling new Medicaid providers during the moratorium period.

Adult Foster Care 

  • This moratorium became effective statewide April 1, 2017 for an initial period of six months. Adult Foster Care provider applications that were not approved before April 1, 2017, are subject to the moratorium.
  • CMS granted approval for EOHHS and MassHealth to extend the temporary moratorium through April 1, 2020.​
  • With more than 100 Adult Foster Care providers currently providing services in Massachusetts, MassHealth has determined that current access to Adult Foster Care services is adequate, and that this moratorium will not adversely affect access to care
  • MassHealth has identified areas of serious concern through its audit process and is currently working with adult foster care providers through both formal and informal areas to address those concerns. MassHealth is also continuing a process of reviewing and implementing prior authorization requirements to determine appropriate service thresholds in order to ensure that adult foster care providers provide appropriate, medically necessary services to members and to improve the integrity of the adult foster care program.
  • MassHealth has determined that a temporary moratorium on the enrollment of new Adult Foster Care provider agencies is necessary and appropriate to mitigate increasing program integrity risks within the existing Adult Foster Care provider network.

ACA Section 6401: Enhanced provider screening and enrollment requirements

The Affordable Care Act (ACA) mandates additional enrollment, re-enrollment, and revalidation screening for providers based on their risk level. Providers are assigned into one of three categories: limited risk, moderate risk, and high risk.

The final rule for Section 6401 assigned risk levels for provider types that are recognized by Medicare. MassHealth adopted those risk levels and assigned risk levels for Medicaid-only provider types. Enrollment requirements are based on the risk level for a particular provider type or provider.

Limited Risk Providers – verify that the provider complies with applicable federal and state requirements, verify licenses, and conduct database checks.

  • Abortion/Sterilization Clinics
  • Acute Inpatient Hospitals
  • Acute Outpatient Hospitals
  • Adult Day Health Providers
  • Ambulatory Surgery Centers
  • Audiologists
  • Case Management
  • Chiropractors
  • Chronic Inpatient Hospitals
  • Chronic Outpatient Hospitals
  • Community Health Centers (CHC)
  • Day Habilitation Programs
  • Dental Clinics
  • Dental School Clinics-Graduate
  • Dental School Clinics-Undergraduate
  • Dentists
  • DPH Transportation Providers (& DPH waivers)
  • Early Intervention Providers
  • Family Planning Agencies
  • Fiscal Intermediaries (for personal care attendants)
  • Group Practice Organizations (without physical therapists)
  • Health Maintenance Organizations
  • Hearing Instrument Dispensers
  • Home Care Corporations
  • Hospital Licensed Health Centers (HLHC)
  • ICF - MR - State School
  • Independent Living Centers
  • Independent Nurses
  • Indian Health Services
  • Intensive Residential Treatment Programs (IRTP)
  • Nurse Midwives
  • Nurse Practitioners
  • Nursing Facilities
  • Ocularists
  • Opticians
  • Optometrists
  • Optometry Schools
  • Personal Care Management Agencies
  • Pharmacies
  • Physicians
  • Podiatrists
  • Psychiatric Day Treatment Programs
  • Psychiatric Inpatient Hospitals (all ages)
  • Psychiatric Outpatient Hospitals
  • Psychologists
  • Public Health Dental Hygienists
  • Radiation Oncology Treatment Centers
  • Rehabilitation Clinics
  • Renal Dialysis Clinics
  • School-Based Medicaid Providers
  • Semi-Acute Inpatient Hospitals
  • Semi-Acute Outpatient Hospitals
  • Special Programs – Wigs
  • Special Programs – Certified Mastectomy Fitters
  • Speech and Hearing Clinics
  • Substance Abuse Programs
  • State Agency Services
  • Therapists (occupational and speech)
  • Transportation Providers (except for Ambulance Providers)
  • Volume Purchasers

Moderate Risk Providers – activities listed above for limited-risk providers and unannounced site visits that may be conducted by Medicare, MassHealth, or both.

  • Certified Independent Laboratories
  • Diagnostic Testing Facilities (IDTF)
  • Group Practice Organizations with Physical Therapists
  • Hospice Care Providers
  • Mental Health Clinics
  • Physical Therapists
  • Transportation-Ambulance Providers
  • Durable Medical Equipment Providers & Personal Emergency Response System (PERS) Providers (once enrolled)
  • Home Health Agencies (once enrolled)
  • Orthotics Providers (once enrolled)
  • Oxygen & Respiratory Therapy Equipment Providers (once enrolled)
  • Prosthetics Providers  (once enrolled)

High Risk Providers – activities listed above for limited-risk and moderate-risk providers, and fingerprint based criminal background checks performed by Medicare, MassHealth, or both.

  • Adult Foster Care Providers
  • Durable Medical Equipment Providers & Personal Emergency Response System (PERS) Providers (newly enrolling into MassHealth)
  • Group Adult Foster Care Provider
  • Home Health Agencies (newly enrolling into MassHealth)
  • Orthotics Providers (newly enrolling into MassHealth)
  • Oxygen & Respiratory Therapy Equipment Providers (newly enrolling into MassHealth)
  • Prosthetics Providers (newly enrolling into MassHealth)
  • Any provider in a Limited or Moderate Risk Provider Type who meets federal criteria to be considered High Risk. Such criteria include
    • Providers who had payment suspensions based on a credible allegation of fraud, waste, or abuse on or after August 1, 2015
    • Providers with OIG or another state Medicaid program exclusions within the past 10 years, and
    • Providers with qualified overpayments who are enrolled or revalidated on or after August 1, 2015.
  • Under federal regulations, any newly enrolling MassHealth provider in a provider type previously subject to an enrollment moratorium who applies to enroll during the first 6 months after the moratorium is lifted.

Fingerprint-based Criminal Background Checks

ACA Section 6401 requires MassHealth and/or Medicare to perform a fingerprint-based criminal background check on all High Risk providers and all persons with a 5% or greater direct or indirect ownership interest in such providers. See 42 CFR 455.434 and 455.450.  We will be performing local and national background checks. Fingerprinting is required in order to complete the background checks. Providers who need to be fingerprinted or need to have their owners fingerprinted will be notified by MassHealth. For more information, please see All Provider Bulletin 267 (Fingerprint Based Criminal Background Checks) on the All Provider bulletins page. 

Application fee

If you are applying or reapplying to become a MassHealth provider, you may be required to submit an application fee. The application fee is $569 for Calendar Year 2018 (effective January 1, 2018). Federal law generally requires provider applicants for enrollment or reenrollment into a Medicaid program to pay an application fee. See 42 CFR 455.460 implementing Section 6401 of the Affordable Care Act.

Individual physicians and non-physician practitioners, including dentists, providers of Home- and Community-Based Waiver Services, group practices, and local public health providers participating in MassHealth's Flu Vaccine Program, are exempt. Also exempt are providers who are enrolled in Medicare or another state’s Medicaid program or CHIP, and have paid the application fee to a Medicare contractor or another state’s Medicaid program.

Revalidation of enrollment

The state Medicaid agency must revalidate the enrollment of all providers, regardless of provider type, at least every five years. MassHealth revalidation is currently underway.

For more information, visit the MassHealth Provider Revalidation page. 

Federally required disclosures

State agencies must collect certain required information, such as the date of birth and social security number (or other tax identification number for legal entities) of all persons with an ownership or control interest in an entity applying for enrollment and for enrolled providers, upon reenrollment/revalidation or when certain entity information changes. MassHealth collects this information on the Federally Required Disclosure Form. See Additional Resources, below. 

Additional Resources for

ACA Section 6401(b): Enrollment and NPI of Ordering or Referring Providers

All ordering or referring physicians and other professionals must be enrolled under the State (Medicaid) Plan as an ordering and referring provider or as a servicing provider; and the national provider identifier (NPI) of any ordering or referring physician or other professional must be specified on any claim for payment that is based on an order or referral of the physician or other professional.

 

Additional Resources for

ACA Section 6402: General Program Integrity Provisions

  • Overpayment Requirements – Providers must generally return overpayments within 60 days and report the reason for the overpayment. See All Provider Bulletin 224: Provider Overpayment Disclosure Process in "Additional Resources," below.
  • The provider’s NPI must be included on all enrollment applications and claims (only those who qualify for NPI).
  • Payments to providers must generally be withheld pending the investigation of a credible allegation of fraud and completion of any associated enforcement proceedings. See Transmittal Letter ALL-192: Revised Administrative Regulations in "Additional Resources," below.

Additional Resources for

ACA Section 6507: National Correct Coding Initiative

National Health Care Reform (ACA) requires state Medicaid agencies to incorporate compatible methodologies of the National Correct Coding Initiative (NCCI). NCCI was implemented by CMS to promote national correct coding methodologies and to control improper coding to minimize inappropriate payment.

Refer to All Provider Bulletin 209: Medicaid National Correct Coding Initiative, dated April 2011, and All Provider Bulletin 227: Modifier Coverage and National Correct Coding Initiative (NCCI) Updates, dated July 2012, in "Additional Resources" below. 

Additional Resources for

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