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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, 2020.

Who is affected?

Both physician and nonphysician practitioners are eligible for these increases.

Next steps

HCA has published the individual codes with the enhanced reimbursement.

Frequently asked questions (FAQs)

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

Are there any qualifying criteria around the location of service for these rates (i.e., ED)?
No.

Is there any special credentialing for the provider performing these services?
No.

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.