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Rate increase for pediatric primary care

Pediatric primary care providers

The Health Care Authority (HCA) recognizes the importance of access to pediatric health care services for Apple Health (Medicaid) enrolled families. HCA worked with the Legislature to pass Engrossed Substitute Senate Bill 6032. This bill allows HCA to increase primary care provider rates for pediatric care services through a $13.8 million appropriation. The increase is effective for dates of service beginning October 1, 2018 and ending no sooner than June 30, 2019.

Who will be affected?

Both physician and nonphysician practitioners are eligible for these increases.

What are the increases for my provider type?

For providers offering primary care for fee-for-service (FFS) pediatric clients

  • Evaluation and management services (E&M)
    The rate has increased 9.5 percent.
  • Vaccine administration for Vaccines for Children (VFC)
    The rate has increased from its original rate to 77 percent of Medicare administration rates.
  • Vaccine administration for outside of VFC
    The rate has increased from its original rate to 100 percent of Medicare administration rates.

For providers serving clients covered by a contracted managed care organization (MCO)

Contact the individual MCO for the increase percentage.

How did HCA decide to distribute the money?

The funds were distributed by analyzing the historical reimbursement to FFS providers and MCOs and allocating accordingly. Please note that the large increase for vaccines does not represent volume. E&M services are anticipated to receive 77 percent of the FFS dollars.

Next steps

HCA has published the individual codes with the enhanced reimbursement.

Frequently asked questions (FAQs)

Will the enhanced rates apply for the services listed on the enhanced fee schedule as long as the patient is under age 18?

Are there any qualifying criteria around the location of service for these rates (i.e., ED)?

Is there any special credentialing for the provider performing these services?

Does this rate increase require modifiers?
No. You do not have to define a modifier.

Are there any exceptions or limitations on these increases?
Yes. The increase applies only to the listed codes, which are not already enhanced through another program, for clients 0 - 18 years of age.