ACA Information for Providers

Eligibility

•  Public Notice for DHS' Intent to Implement MAGI-Based Eligibility Requirement EarlyOpens In A New Window
• Application for Section 1115 Waiver Demonstration Program
  

Hospitals 

• Hospital Based Presumptive Eligibility Training
  
• Medical Assistance Bulletin 01-15-32 Revised Presumptive Eligibility as Determined by Hospitals
• Presumptive Eligibility Training Document (text only version)
  
• Presumptive Eligibility Training Document (Participant Notes)
  
• Presumptive Eligibility Desk Guide
  
• 2024 Income Limits for Presumptive Eligibility Groups
  
• Medical Assistance Bulletin 01-20-04 Issued 06/18/2020 Updates to the Procedures for Presumptive Eligibility as Determined by Hospitals
  

Provider Organizations

• Sign-up to get email updates on the ACA Provider Enrollment Screening

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.
• States must verify that the provider is licensed by the State, that the license has not expired and does not have any current limitations.
• Providers must consent to criminal background checks, including fingerprinting.
• States 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.
• States 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,
  • Providers 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.
• States 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.
• States must give providers who are terminated or denied, appeal rights under the State law and regulations.
• States 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.
• States 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.
• States 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.
• States 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.