Affordable Care Act (ACA) Requirements

To become compliant with the Affordable Care Act (ACA) requirements, the Indiana Health Coverage Programs (IHCP) has made significant changes to provider enrollment policies and procedures. ACA-related requirements are summarized below.

Ordering, Prescribing, or Referring Practitioners

For Medicaid to reimburse for services or medical supplies resulting from a practitioner's order, prescription, or referral, the Affordable Care Act requires that the ordering, prescribing, or referring (OPR) practitioner be enrolled in Medicaid. To address this new requirement and to encourage nonenrolled practitioners to enroll in the IHCP, a new category of enrollment has been created for OPR providers. Practitioners already enrolled as IHCP providers do not need to do anything new. Practitioners not otherwise enrolled as IHCP providers can enroll as OPR providers. This new OPR provider category is appropriate for practitioners who:

  • May occasionally see an individual who is an IHCP member who needs additional services or supplies that will be covered by the Medicaid program; and
  • Do not want to be enrolled as another IHCP provider type; and
  • Do not plan to submit claims to the IHCP for payment of services rendered.

The OPR Provider Packet is a simplified application that asks for minimal information from practitioners who only order, prescribe, and refer IHCP members for services or supplies. The new OPR Provider Packet is posted on the OPR Providers page.

For practitioners who choose to enroll as OPR providers, it is important to remember that an OPR provider cannot submit claims to the IHCP for payment for services rendered. If the practitioner wishes to be able to submit claims, enrollment as another IHCP provider type is required.

Provider Revalidation

Under the Affordable Care Act (ACA), the Indiana Health Coverage Programs (IHCP) is required to revalidate all provider enrollments. The ACA screening criteria apply during revalidation.

Note: Revalidation requirements do not apply to practitioners enrolling only as OPR Providers.

Providers will receive notification letters with instructions for revalidating 90 and 60 days before their revalidation deadline. Providers should not take any steps to revalidate until they receive their notification letters. Providers that fail to submit revalidation paperwork in a timely manner will be deactivated from participation in the IHCP as of the deadline date.

Revalidation of enrollment will occur on a regular schedule. Under the ACA, states are required to revalidate providers at intervals not to exceed every five years. A more frequent three-year revalidation requirement applies to durable medical equipment (DME) and home medical equipment (HME) providers, including pharmacy providers with DME or HME specialty enrollments. Providers will be notified every three or five years when it is time to revalidate their IHCP enrollments.

For more information, see Chapter 4 of the IHCP Provider Manual.

Note: Revalidation of enrollment is not the same as recertification of enrollment credentials. See the Recertify Provider Enrollment Licenses and Other Certifications web page for details about the recertification process.

Application Fee

Certain providers are subject to an application fee. The Provider Type Application Fee and Risk Assignment Matrix (for Non-Waiver and Waiver providers) provides a full list of provider types, and indicates which are subject to the application fee. Generally, the application fee applies to "institutional" providers, as defined by CMS, and not to individual professionals, such as physicians.

Note: The application fee does not apply to practitioners enrolling only as OPR Providers.

For those providers subject to an application fee, the fee is assessed in full for each service location at initial enrollment or with a change of ownership. The application fee is NOT an annual assessment.

Please note: If a provider's service location is enrolled in Medicare or the provider pays an application fee to another state's Medicaid agency for a specific service location, the provider is not required to pay an application fee for that service location to the IHCP.

The Centers for Medicare & Medicaid Services (CMS) sets the application fee amount, which may be adjusted annually. The application fee for enrollments received in 2013 is set at $532. The application fee for enrollments received in 2014 is set at $542.

Payment Options

The application fee can be paid using one of the following electronic methods only. Paper forms of payment are not accepted.

  • Online - Go to the IHCP Bill Pay site and follow the on-screen instructions. You can pay online using a credit card, debit card, or electronic funds transfer from your checking account. When the transaction is complete, you will be given a confirmation number to enter in the appropriate section of your IHCP Provider Packet.
  • By Phone - Contact HP Customer Assistance at (317) 655-3240 in the Indianapolis local area or toll-free at 1-800-577-1278 and select the appropriate option. Please have your credit card, debit card, or checking account information ready. When the transaction is complete, you will be given a confirmation number to enter in the appropriate section of your IHCP Provider Packet.

Providers can download HP's Federal W-9 form from this website for reporting payments on the provider's tax forms.

In rare instances the CMS may agree to waive the application fee based on proof it presents a financial hardship for a provider. Providers requesting a waiver of the fee must submit a letter with their enrollment packet. The letter must make a compelling case for the request, including a description of the ways in which the provider attempted to raise the funds. The final decision to waive the fee is made by the CMS. If a CMS waiver of the application fee was previously granted for the specific provider service location with Medicare or another state's Medicaid program, a copy of the waiver letter can be submitted with the IHCP Provider Packet as proof of financial hardship.

Provider Risk Levels

Providers are categorized by risk level - high, moderate, or limited. This determination is made by the Centers for Medicare & Medicaid Services (CMS), based on an assessment of potential for fraud, waste, and abuse for each provider type. The Provider Type Application Fee and Risk Assignment Matrix (for Non-Waiver and Waiver providers) provides a full list of provider types and their CMS-assigned risk levels, both for enrollment and revalidation. Please note that the risk level assignment of an individual provider may be increased at any time at the discretion of the State. In these instances, the provider will be notified by the State, and the new risk level will apply to processing enrollment-related transactions.

Providers enrolling, revalidating, or changing ownership will be screened according to their assigned risk level. The following table outlines the general screening activities required for each risk category.

Note: Risk level assignments do not apply to practitioners enrolling only as OPR Providers.

Risk Level
Screening Activities
High
  • Fingerprinting and criminal background check for all individuals with ownership in the entity of 5% or more (implementation pending)
  • Unannounced site visits before and after enrollment/revalidation
  • Verification of provider-specific requirements, including but not limited to the following:
    • License verification
    • National Provider Identifier (NPI) check
    • Office of the Inspector General (OIG) exclusion check
    • Ownership/controlling interest information verification
Moderate
  • Unannounced site visits before and after enrollment/revalidation
  • Verification of provider-specific requirements, including but not limited to the following:
    • License verification
    • NPI check
    • OIG exclusion check
    • Ownership/controlling interest information verification
Limited
  • Verification of provider-specific requirements, including but not limited to the following:
    • License verification
    • NPI check
    • OIG exclusion check
    • Ownership/controlling interest information verification

 

Fingerprinting and Criminal Background Check

Implementation Pending