Provider Notice issued 04/14/14

Recoupment of Some Enhanced Payments Made to PCPs under Affordable Care Act (ACA)

Many Primary Care Physicians (PCPs) in the specialties of Internal Medicine, Family Medicine and Pediatrics have received enhanced payments for several services they have provided to Medicaid patients since January 1, 2013 following their required attestation. These additional payments over and above the Medicaid Fee Schedule, provided with 100% funding by the Federal Centers for Medicare and Medicaid Services (CMS), were prescribed by the Affordable Care Act (ACA) for 2 years and are slated to expire December 31, 2014. This department has acted as an intermediary for collection of those funds from the CMS and distribution for qualifying PCP services in accordance with the federal guidance.

The purpose of this notice is to inform participating Primary Care Physicians that the federal guidance, now clarified, limits additional payments for specified services only to those patients who receive Medicaid benefits under Title XIX. A smaller number of patients on Title XXI and some state funded programs are not eligible for enhanced payments under the ACA. Those additional payments made in error on claims received between January 1, 2013 and November 17, 2013 (the date that error was corrected) to patients in Title XXI and state funded programs will therefore need to be recouped according to federal rules. That take-back, although inconvenient and an unfortunate necessity, will only affect 3%-4% of the total enhanced payments made under the program and will be applied only on future vouchers for enhanced ACA payments, until recouped. The department will not recoup against any other type of payment.

On March 10, 2014, the department began issuing remittance advices identifying the erroneous payments with an Adjustment Reason Code 3317, (ACA Pmt Recoup/Client Category Ineligible).

Unfortunately, there is no such reliable system currently available which will allow the participating PCPs to definitively determine in advance whether a patient about to be seen or billed is Title XIX, Title XXI, or State-Funded. However, the participating PCPs will continue to receive enhanced payments for qualified services to a vast majority of patients they see.

Any questions regarding this notice may be directed to a medical assistance consultant in the Bureau of Professional and Ancillary Services (BPAS) at 1-877-782-5565.