ACA Enhanced PCP Reimbursement Payments

The Affordable Care Act’s (ACA) expansion of Medicaid eligibility to 16-20 million new beneficiaries beginning in 2014 may generate additional pressure on Medicaid’s already taxed network of primary care providers (PCPs). To encourage broader PCP participation in Medicaid and ensure patient access to primary care, the legislation requires Medicaid agencies to increase PCP reimbursement for both Fee-for-Service and Managed Care members to reach parity with Medicare rates in 2013 and 2014. States will receive up to $8.3 billion in federal funding with the incremental funding financed 100% by the federal government.


Program Eligibility

  • Primary care services provided to Medicaid members must be reimbursed at Medicare rates.
  • This requirement applies only to specific primary care and vaccination procedure codes identified in the ACA.
  • Provider eligibility for enhanced reimbursement depends on board certification or percentage of encounters of practice representing primary care services (those billed with eligible CPT codes).
  • Providers who are board certified in one of the eligible primary care specialties are automatically eligible.
  • If a provider is not board certified in one of the primary care specialties identified in the ACA, the provider must submit to NJ Medicaid and/or Horizon NJ Health an attestation that at least 60% of the services billed by the provider fall within one of the eligible CPT codes.
  • The enhanced reimbursement does not apply to Federally Qualified Health Centers and does not apply to services billed for NJ FamilyCare members.


Program Administration

  • The Centers for Medicare & Medicaid Services (CMS) offered states several ways to implement this requirement. The state of New Jersey chose the option that requires a pass-through of the enhanced reimbursement from CMS through the state and Horizon NJ Health to the provider. As a result, Horizon will only pay the provider when it has received payment from the state.
  • Enhanced payments will be made separately from normal claim payments based on actual submitted claims (including capitated encounters).
  • The enhanced payment must ultimately be paid to the physician rendering the service so the individual physician, not the group practice, is receiving the benefit of the enhanced rate.
  • Enhanced payments will be subject to audit and recoupment by CMS if the provider was not eligible for participation because attestation was found to be inaccurate, or because the underlying initial claim payment was recouped for some other reason.