ACA Information for Providers
The implementation of the Affordable Care Act (ACA) (§ 455.414) requires some changes for health care providers. Please use this page as your resource to determine how these changes may affect your organization. As we move through the implementation of the new law, the department intends to use this page to provide regular updates. Please refer to this page frequently for the information you need. Your questions or concerns about the changes should still go through your regular contacts within the Department of Human Services.
All Providers must revalidate their Medical Assistance enrollment every 5 years. Providers should log into PROMISe™ to check their revalidation date and submit a revalidation application at least 60 days prior.
Providers will need to complete a full new enrollment application for their provider type for each site of service (service location).
If you have already submitted your revalidation application, DHS will send out a change notice when your application is processed and the service location is revalidated.
Changes to Medical Assistance (MA) Provider Enrollment & Screening
- The ACA contains several program integrity provisions for provider screening and enrollment. The requirements are as follows:
- States must require all providers to be screened in accordance with their risk level (limited, moderate, high). For more information, please see Medical Assistance Bulletin 99-16-13, Assignment of ACA Categorical Risk Levels and the Implementation of Site Visits.
must verify that the provider is licensed by the State, that the license has
not expired and does not have any current limitations.
must consent to criminal background checks, including fingerprinting.
must revalidate the enrollment of all providers at least every 5 years. For
more information, please see Medical Assistance Bulletin 99-16-10, Revalidation of Medical Assistance (MA) Providers.
must collect an application fee prior to executing a provider agreement from a
prospective or re-enrolling provider except for the following:
- Individual physicians or non-physician practitioners,
- Providers who are enrolled in Title XVIII of the Act or another state's title
XIX or XXI plan,
that have paid the applicable application fee to a Medicare contractor or
another state. For more information on the application fee, please see the MA Bulletin titled ACA Enrollment Application Fee.
must deny enrollment of any provider that is terminated on or after January 1,
2011, under title XVIII of the Act or under the Medicaid program or CHIP of any other states.
must give providers who are terminated or denied, appeal rights under the State
law and regulations.
must conduct site visits to verify that the information submitted to the State
is accurate and determine compliance with the Federal and State enrollment
requirements. For more information, please see Medical Assistance Bulletin 99-16-13, Assignment of ACA Categorical Risk Levels and the Implementation of Site Visits.
must require any enrolled provider to permit CMS, its agents, its designated
contractors, or the State Medicaid agency to conduct unannounced on-site
inspections of any and all provider locations.
may impose temporary moratoria on enrollment of new providers, or impose
numerical caps or other limits that the State Medicaid agency identifies as
having a significant potential for fraud, waste or abuse and that the Secretary
has identified as being at high risk for fraud, waste, or abuse.
must require all claims for payment for items and services that were ordered or
referred contain the NPI of the provider who ordered or referred such items.
For more information, please see Medical Assistance Bulletin 99-16-07, Enrollment
of Ordering, Referring and Prescribing Providers.