The Massachusetts Form ACA 1202 is an annual insurance statement that is used to report information about the health insurance coverage that was provided to individuals in Massachusetts during the previous calendar year. This form must be filed by all Massachusetts employers, regardless of size, who provide health insurance coverage to their employees. The deadline for filing this form is March 31st of each year. Filing this form late can result in penalties. If you are a Massachusetts employer and you provided health insurance coverage to your employees during the last calendar year, you must file the Massachusetts Form ACA 1202 by March 31st of this year. The form must be filed even if you did not have any employees covered by health insurance during the last calendar year.
Below, you'll discover quite a few details about massachusetts form aca 1202 PDF. You'll have the assumed time you may need to fill in the form and a few extra details.
Question | Answer |
---|---|
Form Name | Massachusetts Form Aca 1202 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names |
Commonwealth of Massachusetts
Executive Oice of Health and Human Services www.mass.gov/masshealth
SECTION I: Instructions
Physician Certification and Attestation Form
for ACA Section 1202 Rates for Physicians Who Provide Primary Care Services
For calendar years 2013 and 2014, Section 1202 of the federal Affordable Care Act requires Medicaid agencies to provide payment for certain primary care services delivered by eligible physicians consistent with rules set forth in 42 CFR Part 447, Subpart G (Section 1202 rates) and 101 CMS 317.
If you are a physician and would like to be eligible for Section 1202 Rates, please complete the information in Sections II and IV, sign and return completed forms by fax to
Only completed forms will be accepted. Questions about this form can be addressed to CST. All information is subject to audit. Note: You may view your Section 1202 eligibility in your physician profile online at the MassHealth Provider Online Service Center
(POSC) at
SECTION II: Physician Information
|
NAME |
|
BUSINESS NAME (If applicable) |
|
|
|
|
|
|
|
|
|
|
|
STREET ADDRESS |
|
CITY |
|
STATE |
ZIP CODE |
|
|
|
|
|
|
|
|
BUSINESS TELEPHONE NO. |
BUSINESS FAX NO. |
BUSINESS |
|||
|
|
|
|
|
|
|
|
CONTACT NAME |
CONTACT PHONE NUMBER |
CONTACT |
|||
|
|
|
|
|
|
|
|
MASSHEALTH PROVIDER ID |
INDIVIDUAL PROVIDER NPI |
INDIVIDUAL SSN |
|||
|
|
|
|
|
|
|
Are you enrolled in the MassHealth Primary Care Clinician Program? . . . . . . . . . . . . . . . . . . . .
Yes
No
Are you currently enrolled with a |
|
Yes |
|
No |
If yes, please provide the name of each managed care entity with which you contract and your health plan provider number under that managed care entity.
SECTION III: Information
In order to be eligible for the Section 1202 Rates, a physician must satisfy both of the following requirements:
(1)A physician must
(2)such physician must also
(a)he or she is board certified in a qualified specialty or subspecialty; or
(b) for the most recently completed calendar year, at least 60% of the Medicaid codes for which the physician had been paid were for the services eligible for the Section 1202 Rates. (Newly eligible physicians must
*Note that ABMS recognizes certification in Allergy & Immunology with the American Board of Allergy & Immunology (ABAI) as an eligible subspecialty.
The following billing codes are eligible for the Section 1202 Rates.
•E&M codes
•Current Procedural Terminology (CPT) vaccine administration codes 90460, 90461, 90471, 90472, 90473, 90474, or their successor codes
For more guidance about the 1202 rates for codes covered by MassHealth, see Administrative Bulletin
Please also see 101 CMR 317.00 and All Provider Bulletins 230 and 235 for additional guidance on Section 1202.
SECTION IV: Attestation
By completing this Section IV, you are providing the
Part 1
Complete this Section IV, Part 1 if you are practicing in family medicine, general internal medicine, or pediatric medicine, and are attesting that you are certified by the ABMS, ABPS, or AOA in one of the following specialties/subspecialties.
A. Practice Area
Check the box of your practice area(s):
B. Board Certification
family medicine
general internal medicine
pediatric medicine
Check the box for specialties in which you have board certification:
family medicine general internal medicine pediatric medicine
or list any subspecialties under family medicine, general internal medicine, or pediatric medicine in which you have board certification:
Check the box for the certifying board: |
ABMS* |
ABPS |
Provide the date of such certifications: ___ / ___ / |
______ |
AOA
*ABMS recognizes certification in the Allergy & Immunology with ABAI as an eligible subspecialty. If you have this subspecialty, please indicate that on the subspecialty line above.
Part 2
Complete this Section IV, Part 2 only if you are attesting that you are practicing in family medicine, general internal medicine, or pediatric medicine; you do not have a certification from the ABMS, AOA, or ABPS; and at least 60% of your total Medicaid claims paid are for evaluation and management (E&M) services and
A. Practice Area
Check the box of your practice area(s):
family medicine |
|
general internal medicine |
B. 60% Paid Claims
pediatric medicine
Physicians (those that have a full previous calendar year of paid Medicaid claims)
I attest that at least 60% of my total Medicaid claims paid for the previous calendar year were for the E&M and
New Physicians only (those that do not have a full previous calendar year of paid Medicaid claims)
I attest that at least 60% of my total Medicaid claims paid during the previous month are for qualified E&M and
I certify under the pains and penalties of perjury that the information on this form and any attached statement that I have provided has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.
Printed legal name of physician
Physician’s signature (Signature and date stamps, or the signature of anyone other than the provider, is not acceptable) |
Date |