Horizon NJ Health
210 Silvia Street
West Trenton, NJ 08628
Phone: (609) 718-9001
www.horizonNJhealth.com
October 4, 2013
Re: ACA Enhanced Medicaid Reimbursement
Dear Horizon NJ Health Primary Care Provider:
As you know, under the Affordable Care Act (“ACA”), primary care providers will receive enhanced Medicaid reimbursement for certain services. In July, you received a letter from the New Jersey Department of Human Services, Division of Medical Assistance and Health Services (“DMAHS”) regarding this enhanced payment. This will include Evaluation and Management procedure codes 99201-99499 and vaccine administration codes 90460, 90471, 90472, 90473 and 90474 or their successors, for services provided between January 1, 2013, and December 31, 2014.
According to our records, you are eligible for reimbursement. Note that this payment is in addition to capitation payments; it is not replacing capitation payments. To receive retroactive payment, the ACA Self-Attestation Forms had to be submitted to DMAHS before July 31, 2013, according to the instructions included in their July notice. These providers will continue to receive monthly payments from Horizon NJ Health. Those who missed the July deadline may receive future payments by ensuring that Horizon NJ Health has the appropriate information on file for you.
Providers who are not board certified in an eligible specialty must send Horizon NJ Health a Self-Attestation Form by October 15, 2013, to receive future payments. This form attests that 60 percent or more of your Medicaid billed codes were program-eligible. This 60 percent threshold applies to calendar year 2012 for enrolled physicians and to the month prior to seeking program eligibility for newly enrolled physicians. A copy of the Self-Attestation Form is included in this letter.
Providers who are board certified in an eligible specialty or sub-specialty do not need to complete a Self-Attestation Form, as long as this specialty is identified in the contract and credentialing application you have on file with Horizon NJ Health. These specialties include Family Medicine, Internal Medicine and Pediatrics. To see the full list of eligible sub-specialties, please refer to the first set of FAQs on the following website: www.medicaid.gov/AffordableCreAct/Provisions/Provider-Payments.html.
Advance practice clinicians (APCs) are also eligible for enhanced reimbursement when supervised by an eligible primary care physician. This includes physician assistants and nurse practitioners. Clinical nurse specialists, certified nurse midwives and certified registered nurse anesthesiologists fall within this category. APCs seeking reimbursement must have their eligible supervising physician complete Section IV of the enclosed Self-Attestation Form – APC Information.
Due to the volume of claims impacted by this program, retroactive payments will be phased in over a three-month period. Once all retroactive payments have been made, payments for current periods will continue on a monthly basis two months after the initial claim payment month. Payment methods will follow the usual Horizon NJ Health payment format (e.g. electronic or paper check).
The following is a schedule of how retroactive payments will be processed for those providers who met the board certification eligibility requirement and/or submitted the ACA Self-Attestation form to DMAHS by the July 31, 2013, deadline.
Claim Payment Periods Covered Payment Month Number of Months
January 2013 October 2013 1 month
February through April 2013 November 2013 3 months
May through July 2013 December 2013 3 months
August through October 2013 January 2014 3 months
November 2013 February 2014 1 month
December 2013 March 2014 1 month
We will hold webinars in the coming weeks to further explain the ACA reimbursement process. The dates and times will be announced shortly. If you have any questions, please call the Horizon NJ Health Physician & Health Care Hotline at 1-800-682-9091. Or, you may visit the ACA Enhanced Reimbursement page of our website at www.horizonNJhealth.com. From the homepage, click the For Providers tab, then Programs. A simulated presentation explaining the ACA reimbursement process will also be archived on our website in the near future.
Thank you for being a Horizon NJ Health participating provider.
Sincerely,
George L. Ingram
Director, Provider Contracting & Strategy
Horizon NJ Health
Enclosed: ACA Self-Attestation Form
Payable Codes for ACA Enhanced Rates
ACA Enhanced PCP Reimbursement Overview
ACA Enhanced PCP Reimbursement Frequently Asked Questions
Horizon NJ Health Provider Representatives by County
Independent licensees of the Blue Cross and Blue Shield Association*
Horizon NJ Health, a product of Horizon HMO*